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Peter Zed. Sean Gorman. Juan Ronco. However, this patient was diagnosed with an allergy to imipenem following exposure earlier in his hospitalization in addition to a positive penicillin skin test. Thus, we attempted rapid desensitization to imipenem using a continuous infusion protocol. The patient was desensitized within 4 hours and was successfully treated for 21 days with a continuous infusion of imipenem combined with daily amikacin.

He experienced no adverse reaction during the desensitization process or the remainder of his treatment course. We assumed that a more gradual escalation of the dose in our modified protocol would prevent the occurrence of adverse events, thereby resulting in more rapid desensitization.

Rapid desensitization was necessary in this patient due to the presence of a life-threatening infection. The lower total daily dose of imipenem was in response to impaired renal function. An option of last resort is to desensitize the patient using a rapid administration protocol. Our modified rapid imipenem desensitization protocol was successful and allowed for effective treatment of life-threatening pneumonia. Ann Pharmacother ; Published Online, 20 Feb , www.

Many of the microor- agents. We report a case of imipenem sistant to antimicrobial therapy and have been associated desensitization for the successful treatment of VAP sec- with worse outcomes in the critically ill patient population.

Potential multidrug-resistant MDR gram-negative organ- isms encountered in the intensive care unit ICU include Case Report Pseudomonas aeruginosa, Stenotrophomonas maltophilia, and Acinetobacter baumannii. A year-old white man with no previous medical history or drug al- lergy history was admitted to our ICU with acute respiratory failure and baumannii occurred in our ICU in Fortunately, hemorrhagic shock following a motorcycle accident. He sustained multi- imipenem, a carbapenem antibiotic combined with cila- ple injuries including a mesenteric artery rupture, splenic capsular tear, statin, has retained very good activity against A.

Immediately upon ar- rival, the patient underwent an urgent laparotomy and open reduction and internal fixation of his fractures. On postoperative day 3, he was em- Author information provided at the end of the text. VAP was suspected in the presence of a new infiltrate on steadily improved, resulting in weaning from the mechanical ventilator chest X-ray, new fever, leukocytosis, and purulent secretions suctioned and discharge from ICU on day 20 of therapy day 90 of second ICU ad- from the endotracheal tube.

Seventy-two hours after initiation of imipen- mission. A complete blood weeks of treatment, and he was transferred out of the hospital to a reha- cell count revealed a normal proportion of eosinophils. The rash began bilitation institution shortly thereafter. Based on the Naranjo prob- ability scale, it is probable that the rash was due to imipenem. Prior to com- Imipenem was the first carbapenem antibiotic devel- plete resolution of the rash, the patient underwent an intradermally ad- oped.

The major complication of this lengthy second mately 2 months prior to initiating the desensitization pro- admission was septic shock secondary to rectal abscesses, methicillin-re- tocol, this patient had been challenged with imipenem and sistant Staphylococcus aureus MRSA bacteremia, and VAP.

Other developed a rash within 48 hours of initiation. Further- medical problems included acute renal failure and heparin-induced thrombocytopenia. On day 60 of the second ICU admission, he was diag- more, he developed extension of cutaneous erythema nosed as having VAP secondary to A.

It is possi- antibiotics. However, we feared that his ad- We applied a modified imipenem desensitization protocol following verse reaction to imipenem would worsen and therefore informed consent Table 1. Imipenem was deemed the risk unacceptable.

The minibags correct terminology for the dosing protocol we used would were clearly labeled and numbered consecutively in the correct order for have been gradual dosage escalation instead of desensitiza- use during the desensitization protocol. The protocol was modified to achieve desensitization over a much shorter time frame than that of the tion. Desensitization was accomplished within 4 hours ized. An infusion of imipenem plus intermittent amikacin was contin- erance during drug desensitization depends on achieving ued for 21 days without evidence of systemic or cutaneous reactions.

His antigen-specific mast cell desensitization. There is a high likelihood that cross-de- 60 0. If rash or flushing occurs, return to previous step for 30 minutes and sion rates increased 3. However, call physician. Imipenem concentrations prepared and supplied by Vancouver Gen- the patient developed numerous episodes of pruritus and eral Hospital CSU Pharmaceutical Sciences. We did not have the likelihood of clinical failure.

Due to our baumannii. However, since the risk of inducing untoward reactions. Our patient did not infusion rates have to be adjusted for each step in this pro- develop adverse reactions to imipenem after the desensiti- tocol, there may be potential for medication administration zation, which may have been the result of a significantly errors. One suggested method to minimize this possibility slower infusion rate.

For example, if a constant rate of 1. Due to its limitations, desensitization to ically and bacteriologically successful using a continuous imipenem should be performed only after all other thera- infusion of imipenem. There is a paucity of literature ad- peutic modalities have been employed.

First, achievable concentrations at the Professor, Faculty of Pharmaceutical Sciences, University of British site of action, such as the lung, may be inadequate for Columbia, Vancouver killing of the organism. Ventilator-associated pneumonia.

Arch Intern 60 0. Impact of a rotating empiric antibiotic schedule on infectious 0. Crit Care Med ; Hospital antibiogram. Vancouver, Canada: Vancouver General Hospital 0. Hospital-acquired pneumonia in adults: diagnosis, assessment of severi- 0. A consensus 0. Dosage reduction for renal dysfunction. If rash or flushing occurs, return to previous step for 30 minutes and method for estimating the probability of adverse drug reactions.

Clin call physician. Pharmacol Ther ; Allergy ; Lyon JA. Drug In- tell Clin Pharm ; Drug Saf ; Am J Med ;78 suppl 6A J Allergy Clin Immunol ; amikacina. Adkinson NF Jr. Drug allergy. Allergy: principles and practice. Louis: Mosby-Year Book, Sullivan TJ. En este caso, el protocolo modificado de tice. St Louis: Mosby-Year Book, Imipenem-cilastatin sodium. In: Trissel LA, ed. Antimicrobial desensitization: a re- view of published protocols. Hospital Pharm ; Continuous infusion of beta-lactam antibi- otics.

Clin Pharmacokinet ; N Engl J Med ; Moellering RC Jr. Principles of anti-infective therapy. In: Mandell GL, respirateur. Philadelphia: Churchill Livingstone, Related Papers. By Mathias W Pletz. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. By Sheldon Magder. Levofloxacin in the treatment of ventilator-associated pneumonia.



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