MOJ ISSN: 2379-6162MOJS

Surgery
Proceeding
Volume 2 Issue 4 - 2015
Case Presentation & Tygacil (Tigecycline) Usage
Kamel Al Mashaqi*
Department of General Surgery, The Islamic Hospital, Jordan
Received: June 25, 2015 | Published: August 19, 2015
*Corresponding author: Kamel Al Mashaqi, General Surgery Resident (PGY 4), TIH, Jordan, Email:
Citation: Mashaqi KAl (2015) Case Presentation & Tygacil (Tigecycline) Usage. MOJ Surg 2(4): 00026. DOI: 10.15406/mojs.2015.02.00026

Case 1 – Mr. Rassam

  • 24 year’s old, male, and medically free, from Yemen.
  • Admitted on 8/4/2014
  • With a 1-month Hx. of Gunshots to Chest/Abdomen that was operated on in Yemen.
  • After 1-month post laparotomy + Lt Nephrectomy + Splenectomy + Rt Nephrostomy + Tracheostomy patient.
  • Was treated with unknown medications & unknown antibiotics.

O/E

    • CAO* 3
    • Temp 37.5 – Pulse 125/m – RR 16/m – BP 123/70 – O2% 97%
    • Ill Looking, cachectic, Pale, Jaundiced.
    • Tracheostomy in situ.
    • Bilateral Harsh Breathing Sounds + Decreased AEB.
    • Soft Abdomen with previous midline incision of previous surgery & 3 drains:-
  • Lt UQ à Bile
  • Rt Loin à Urine
  • Lt Loin à Empty

Admission Labs

Lab

Value

Lab

Value

CRP

58.9 ↑

Urine Analysis

Prt + 1

ESR

44 ↑

 

Glu + 3

PO4

4.3

 

Bld + 3

Mg

1.42 ↓

 

Pus - Numerous

Ca

9

 

Red - Numerous

Nasal Cx

Acinetobacter

Bld Cx

-ve

Sputum Cx

Acinetobacter

Urine Cx

-ve

Additional Admission Labs

Chest + abdomen + pelvic CT scan (oral contrast)

  • Bilateral pleural effusion & more on RT side associated with atelectasis & ground glass opacities bilaterally with peri-bronchial thickening & LT fissural effusion.
  • Translucent tubular shadow from LT lung extending to the SC tissue (fistula). Drainage tubes in upper abdomen (1st one @ porta hepatis, 2nd one @ sub diaphragmatic region).
  • Ascites.
  • Double J Catheter in RT Kidney -UB.

Management of case

  • NPO + IV Fluids (Resuscitation)
  • TPN Protocol
  • I/O Charting
  • Bld + Urine + Sputum + Nasal Cx
  • Labs & Radiology (CXR+ Pan CT Scan + Nephrostogram)
  • Pre-Op assessment & evaluation (PRBCs + FFP)
  • Contact Isolation
  • IV Medications (Tygacil + Meropenem + Diflucan + Nexium + Clexane + Hydrocortisone + Perfalgan)

Consultations to

  • Cardiologist
  • Nephrologist
  • Pulmonologist
  • Urologist Surgeon
  • Infectious Disease Specialist

10/4/2014 (2 days post admission)
1st Surgery (Redo exploratory laparotomy with LT thoracotomy approach)

  • LT Lung decortication + LT Lung Bullet injury repair.
  • Gastro-Pleuro-Cutaneous Fistula excision.
  • Primary repair (double layer) of stomach.
  • LT hemicolectomy + End Ileostomy formation.
  • Feeding Jejunostomy Tube Insertion.
  • Pancreatic Necrosectomy.
  • LT Chest Tube + 2 free abdominal drains insertion.

10/4/2014 (2 days post admission)
1st Surgery (Urology Surgery)

  • RT Ureteroscopy
  • DJ Insertion

Post Op Day (0) to Day (3)

  • Patient transferred back to ICU-Surgical with same pre-op management.
  • Patient started on Enteral feeding by (Jejunostomy tube) with ensure milk.
  • Patient remained (Tachycardiac + Feverish).

Post Op Day (4) - 14/4/2014

  • We discovered wound dehiscence with fluid discharge from abdominal wound.
  • 2nd Surgery (2nd laparotomy + Wound Repair with Component separation closure technique).
  • Tissue Cultures obtained & (+ve for Staphylococcus spp – Coagulase Negative) & ONLY sensitive to tigecycline.

Post Op Day (4) - 14/4/2014

  1. Patient transferred back to ICU-Surgical Intubated on Ventilator (atelectasis of LT lung & poor expansion with bad ABG’s).
  2. Patient kept on same protocol (IV Fluids + TPN Protocol + Enteral feeding + I/O Charting + IV Medications (Tygacil + Meropenem + Diflucan + Nexium + Clexane + Perfalgan).
  3. We added (Octreotide) to our list of medications for 5 days.
  4. Patient remained (Tachycardiac + Feverish).

Post Op Day (10) - 20/4/2014

  • We discovered (by clinical & radiological evidence) a leak at the site of feeding Jejunostomy tube.
  • 3rd Surgery (laparotomy + Repair).
  • Same Pre-Op management but stopped the enteral feeding for few days.
  • Patient remained (Tachycardiac + Feverish).

Post op day (18) - 28/4/2014

  • Patient fully extubated with Spontaneous Breathing after several trials over the past few days.
  • Multiple interval blood & other Cx came back –ve.
  • Oral fluid feeding resumed for the 1st time from initial trauma with success.
  • Vital signs were near NORMAL for 48 hours.
  • Patient was able to ambulate for 1st time from initial trauma.

 Post op day (19) - 29/4/2014

  • Ventilator stopped & Tracheostomy removed.
  • Tygacil with Meropenem stopped & patient Started on Piperacillin/Tazobactam.
  • Kept on Vancomycin.
  • Stopped feeding by Jejunostomy tube.
  • Kept in ICU – Surgical with oral fluid feeding & observation of multiple spikes of fever & Tachycardia.

Post op day (23) - 03/05/2014

  • Jejunostomy feeding tube removed.
  • CT Chest/Abdomen/Pelvis (Normal Study).
  • Kept in ICU – Surgical with oral fluid feeding & observation of multiple spikes of fever & Tachycardia.

Post op day (24) - 04/05/2014

  • Non ionic contrast meal (Normal Study).

Post op day (27) - 07/05/2014

  • Piperacillin/Tazobactam changed to Tienam.
  • TPN stopped & Full regular diet given.
  • CT Pulmonary Angio done (Normal Study).
  • Kept in ICU – Surgical with oral fluid feeding & observation of multiple spikes of fever & Tachycardia.

Post op day (32) - 12/05/2014

  • Patient transferred to floor.
  • Regular diet (High Protein) & Oral medications.
  • Fully ambulating.

Post op day (44) - 24/05/2014

  1. Patient discharged home.
  2. Patient came back to near normal level of activity & independence.
  3. V/S was normal for > 48 hrs.
  4. WBC & CRP went down to near normal levels.
  5. All Cx came back –ve.
  6. All Radiological Studies came back as normal studies.

Case 2 – Mr. Qannaff

  1. 20 year’s old, male, and medically free, from Yemen.
  2. Admitted on 04/02/2014 – NO formal Hx – Per Reports
  3. With a 1-week Hx. of High Velocity Gunshots to Abdomen that was operated on in Yemen.
  4. After 1-week post laparotomy + 2 drains found inside abdominal cavity with multiple visceral injuries (liver/pancreas/duodenum/gastric/IVC vs. Portal??).
  5. Was treated with unknown medications & unknown antibiotics.

O/E

    1. CA but disoriented.
    2. Paraplegic
    3. Temp 37.2 – Pulse 120/m – RR 31/m – BP 132/90 – O2% 98%
    4. Ill looking, cachectic, Pale but NOT Jaundiced.
    5. Bilateral Harsh Breathing Sounds + Decreased AE @ Basal Rt.
    6. Tender Abdomen + previous midline incision of previous surgery + bullet inlet @ RT Para midline + outlet @ LT lumbar & 2 drains:-

Rt loin à Bile
Rt Loin à Bile


Admission Labs

Lab

Value

Lab

Value

Mg

1.9 ↓

Urine Analysis

Prt + 1

Ca

7.4 ↓

 

Glu + 1

 

 

 

Bld + 4

 

 

 

Pus - 4 -6

 

 

 

Red - Numerous

Nasal Cx

ESBL

Bld Cx

-ve

Sputum Cx

ESBL

Urine Cx

-ve

Additional Admission Labs

    1. Chest + abdomen + pelvic CT scan (triple contrast)

 

Lumbosacral MRI

  1. L2 vertebral fracture with injury to cord.

Management of case
Intubation + Full Sedation

  1. NPO + IV Fluids (Resuscitation)
  2. TPN Protocol
  3. I/O Charting
  4. Bld + Urine + Sputum + Nasal Cx
  5. Labs & Radiology (CXR+ Pan CT Scan)
  6. Pre-Op assessment & evaluation (PRBCs + FFP)
  7. Contact Isolation
  8. IV Medications (Meropenem + Nexium + Clexane)

Consultations to

  1. Neurosurgeon
  2. Pulmonologist
  3. Infectious Disease Specialist
  4. ENT Surgeon

05/02/2014 (1 days post admission)

  1. 1st Surgery (Exploratory laparotomy) with
  1. Resection of distal stomach + duodenum + head of pancreas.
  2. Retroperitoneal exploration & evacuation of multiple bilomas.
  3. CBD Tube drainage.
  4. 2 free abdominal drains inserted with 2 VAC dressings.
  5. Multiple packs inserted.
  1. Findings (Type V complex pancreatic – duodenal injuries).

Post Op Day (0) to Day (2)

  1. Patient transferred back to ICU-Surgical with same pre-op management.
  2. Blood transfused with FFP in regular basis.
  3. Vancomycin added to Rx regimen.
  4. Sandostatin added to Rx regimen.
  5. Clexane changed to Hibor.
  6. Patient remained (Tachycardiac + Feverish).

Post Op Day (3) - 08/02/2014

  1. 2nd Surgery (Laparotomy + Removal of Packing + Gastrojejunostomy + choledochojejunostomy + pancreaticojejunostomy).
  1. Patient transferred back to ICU-Surgical Intubated on Ventilator.
  2. Patient kept on same protocol (IV Fluids + I/O Charting + IV Medications (Meropenem + Vancomycin + Nexium + Hibor).
  3. Patient remained (Tachycardiac + Feverish).

Post Op Day (7) - 12/02/2014

  1. 3rd Surgery (Wound Exploration + Debridement + Dressing + Removal of VAC Dressing).
  2. Sputum Cx (+ve for Acinetobacter)

Post Op Day (11) - 16/02/2014

  1. 4th Surgery (Wound Exploration + partial closure with vicryl mesh + component separation technique).

D/C drains (2)

Post Op Day (13) - 18/02/2014

  1. 5th Surgery (Exploratory Laparotomy + Retroperitoneal drainge of subpancreatic fluids + Dressing + progressive closure).
  1. Tissue Cx (+ve for Acinetobacter)
  2. Colistin added to the Rx regimen.
  3. Extubated on O2 mask.
  4. Patient remained (Tachycardiac + Feverish).

Post Op Day (15) - 20/02/2014

  1. Patient started on (Ensure Milk by NGT + Apple Juice).

Post Op Day (17) - 22/02/2014

  1. 6th Surgery (Closure of abdominal wall).
  2. Blood Cx (+ve for Acinetobacter) & Tygacil added to the Rx regimen.
  3. Re-intubated due to Respiratory Distress.

Post Op Day (18) - 23/02/2014

  1. Enteral feeding started.
  2. D/C Chest Tube.
  3. Meropenem stopped.
  4. Flagyl added to the Rx regimen.
  5. Patient remained (Tachycardiac + Feverish).

Post op day (20) - 25/02/2014

  1. 7th Surgery (Wound lavage under GA + Dressing).
  2. CXR à white LT lung due to collapse.
  3. Patient is still intubated.
  4. Blood Cx (-ve).
  5. Sputum Cx (+ve Acinetobacter).
  6. TPN Started.
  7. Patient remained (Tachycardiac + Feverish).

 Post Op Day (22) – 27/02/2014

  1. Trial of Extubation à Failed.
  2. 8th Surgery (Tracheostomy + DUGA).

Post Op Day (24) – 01/03/2014

  1. D/C Ventilator.
  2. V/S was normal for > 48 hrs.
  3. All Cx came back –ve.

Post op day (26) - 03/03/2014

  1. Patient discharged to Yemen, AMA by MEDEVAC.
  2. Patient is considered a HIGH risk for non-professional management with risk of death but AMA.

Why tygacil?

  1. Tygacil (tigecycline) has in vitro activity against a wider range of pathogens
  2. Resistant Gram +v: Enterococcus faecalis (VRE), Enterococcus faecium (VRE), Staphylococcus aureus (MRSA), Staphylococcus epidermidis (MRSE)
  3. Resistant Gram –ve: Acinetobacter baumannii, E. Coli, Klebsiella pneumoniae, Stenotrophomonas maltophilia, Tygacil is not affected by (ESBLs).
  4. Atypicals: New- Legionella pneumophila.

Tygacil (tigecycline) has in vitro activity against a wider range of pathogens

  1. Anaerobes: Bacteroides (distasonis, fragilis, ovatus, thetaiotaomicron, uniformis, vulgatus), Clostridium perfringes, others
  2. Gram +ve: Enterococcus (avium, casseliflavus, faecalis, faecium, gallinarum), Staphylococcus (aureus, epidermidis, haemolyticus), Streptococcus (pyogenes, agalactiae, anginosus grp)
  3. Gram –ve: Aeromonas hydrophila, Citrobacter (freundii, koserr), Enterobacter (cloacae, aerogenes), E.Coli, Klebsiella (oxytoca, pneumoniae) Serratia marcescens, Pasteurella multocida

Tygacil (tigecycline) has in vitro activity against a wider range of pathogens

  1. Gram +ve: New- Streptococcus Pneumoniae, including cases with concurrent bacteremia
  2. Gram –ve: New- Haemophilus influenzae & Parainfluenzae.

 

Tygacil

3rd 4th Cephalosporin

Carbapenems

Fluroquinolones

Pipa/Tazo

Gram +ve

Gram -ve

Atypicals

0

0

0

Anaerobes

0

0

R. Gram +ve

0

0

0

0

R. Gram -ve

0

0

0

Pseudomonas

0

0

0

Why Tygacil?

  1. Clinical coverage: Expanded broad-spectrum coverage including resistant gram positive, resistant gram negative, and anaerobes
  2. Efficacy: Proven as empiric mono therapy in patients with cIAI.
  3. Dosing Regimen: Does not require dosage adjustments for patients with renal impairment regardless of severity. No adjustments with mild-to-moderate hepatic impairment.
  4. Drug Interactions: Low potential for drug-drug interactions
  5. Results: Efficacy in treatment
  6. Convenient: Q 12 hr dosing

IV Antibiotic choice

 2009 Infectious diseases society of america guidelines for treatment of cIAI
Optimal dosing: To ensure maximum efficacy & minimal toxicity & to reduce antimicrobial resistance, for empiric Rx of cIAI, guidelines suggest 100 mg initial dose of tigecycline, followed by 50 mg every 12 hrs.
cIAI: community acquired infections: Guidelines recommend tigecycline as single-agent Rx for initial empiric Rx in adults with infections of mild-to-moderate severity & perforated or abscessed appendicitis.
Treatment duration: a) According to guidelines, antimicrobial therapy should be limited to 4-7 days, unless it is difficult to achieve adequate source control.

  1. The recommended duration of Rx with Tygacil for cIAI is 5 to 14 days.
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