Compassionate use of a novel ß-lactam enhancer-based investigational antibiotic cefepime/zidebactam (WCK 5222) for the treatment of extensively-drug-resistant NDM-expressing Pseudomonas aeruginosa infection in an intra-abdominal infection-induced sepsis patient: a case report.

Infections in critically-ill patients caused by extensively-drug-resistant (XDR)-Pseudomonas aeruginosa are challenging to manage due to paucity of effective treatment options. Cefepime/zidebactam, which is currently in global Phase 3 clinical development (Clinical Trials Identifier: NCT04979806, registered on July 28, 2021) is a novel mechanism of action based ß-lactam/ ß-lactam-enhancer combination with a promising activity against a broad-range of Gram-negative pathogens including XDR P. aeruginosa. We present a case report of an intra-abdominal infection-induced sepsis patient infected with XDR P. aeruginosa and successfully treated with cefepime/zidebactam under compassionate use. The 50 year old female patient with past-history of bariatric surgery and recent elective abdominoplasty and liposuction developed secondary pneumonia and failed a prolonged course of polymyxins. The organism repeatedly isolated from the patient was a New-Delhi metallo ß-lactamase-producing XDR P. aeruginosa resistant to ceftazidime/avibactam, imipenem/relebactam and ceftolozane/tazobactam, susceptible only to cefepime/zidebactam. As polymyxins failed to rescue the patient, cefepime/zidebactam was administered under compassionate grounds leading to discharge of patient in stable condition. The present case highlights the prevailing precarious scenario of antimicrobial resistance and the need for novel antibiotics to tackle infections caused by XDR phenotype pathogens.

A case series of melioidosis: An underdiagnosed infection.

Melioidosis is an infection caused by Burkholderia pseudomallei. It is a non notifiable disease and is not included in Integrated Disease Surveillance Program by National Center of Disease Control. India is predicted to have highest burden of disease with an estimated mortality of 32,000 per year. Melioidosis presents with a wide range of clinical manifestations like pneumonia, liver and splenic abscess, septicemia etc. This wide spectrum of presentation and mimicry with other infections leads to its misdiagnosis or underdiagnosis. The only source of disease burden in India is few case reports and the true burden and distribution of disease still needs to be assessed. We, hereby, report a case series of four cases aged 28 years, 53 years, 33 years and 22 years. All cases had different clinical presentation ranging from abdominal wall abscess to septicemia and neurological manifestations making the diagnosis challenging. Three of the four cases were discharged after complete recovery while one case went leave against medical advice. To our knowledge this is the first series describing complete recovery of three out of four cases. This case series will help the physicians to raise their index of clinical suspicion of melioidosis in high risk patients presenting with various findings thus improving the chances of correct diagnosis and treatment.

The estimation of minimum effective volume of 0.5% ropivacaine in ultrasound-guided interscalene brachial plexus nerve block: A clinical trial.

BACKGROUND AND AIMS: Interscalene brachial plexus block (ISB) is the most commonly used mode of anesthesia for upper limb surgeries. Higher volume of local anesthetic used in ISB is associated with increased incidence of side effects, particularly phrenic nerve palsy. The aim of this study was to determine the minimum effective volume of 0.5% ropivacaine in 90% patients (MEV90) in ISB. MATERIAL AND METHODS: With target of 45 successful cases, phase 1 clinical trial was conducted based on the principles of biased coin design up-and-down method. After obtaining Ethical Committee's approval and patient's consent, patients with American Society of Anesthesiologist physical status (ASA PS) I and II, aged 18-60 years of either sex, undergoing upper arm surgery were recruited into the study until 45 successful cases. A 7 ml of 0.5% ropivacaine was used as starting dose, with patients receiving a higher or lower dose depending on previous patient's response. R package, SPSS 23, and Microsoft Excel were used for statistical analysis. RESULTS: MEV90 of 0.5% ropivacaine for ISB was determined as 8.64 ml [confidence interval (CI) 95%, 8.28-9.02 ml]. Time for onset of sensory block and motor block was 5 min (5-15 min) and 10 min (5-20 min), respectively, while duration of analgesia was observed as 8.2 (4.8-12.5) h. CONCLUSIONS: This study observes that surgical anesthesia can be accomplished with 8.64 ml (95% CI: 8.28-9.02 ml) of 0.5% ropivacaine with ultrasound-guided ISB with multiple injection technique, without clinical deterioration in block onset and duration of analgesia.

Comparison of 0.5% Ropivacaine and 0.5% Levobupivacaine for Sciatic Nerve Block Using Labat Approach in Foot and Ankle Surgery.

OBJECTIVE: Compared to ropivacaine, levobupivacaine is more lipophilic and a more potent vasoconstrictor. The study was conducted to compare the effect of 0.5% ropivacaine and 0.5% levobupivacaine in sciatic nerve block using conventional Labat approach in foot and ankle surgery. METHODS: A prospective double-blind, randomised study was carried out in 100 patients of either sex, aged between 20 to 60 years, and American Society of Anesthesiologist (ASA) grades I and II. Patients were randomly allocated into groups R and L of 50 each with 0.5% ropivacaine and 0.5% levobupivacaine, respectively, for sciatic nerve block using the Labat approach. We assessed the onset and duration of sensory and motor block, duration of analgesia, consumption of analgesic, and any untoward effect over 24 hours. RESULTS: Both the groups were comparable with regard to demographic variables and onset of sensory and motor block (p>0.05). Group L compared to group R had significantly longer median (95% confidence interval) duration of sensory block (647.50 min [624.99-674.41] vs. 535 min [524.77-559.83], respectively; p<0.0001) as well as motor block (1065.0 min [1054.5-1068.90] and 945 min [947.13-1013.30], respectively; p<0.0001). Postoperative analgesia also lasted significantly longer in group L compared to group R (1320 min [1273.4-1321.8] vs. 840 min [759.23-812.77]; p<0.0001]). Patients in group L had significantly better visual analogue scale (VAS) score and lesser consumption of analgesics (p<0.0001). None of the groups developed any adverse effect over the observation period. CONCLUSION: Levobupivacaine provides prolonged postoperative analgesia in sciatic nerve block with reduction in postoperative analgesic consumption.