Unnecessary complications of an unnecessary procedure Albert J Mifsud

Mr Travers* 56 year old civil engineer working in various locations in central Europe for previous 5 years presented to his general practitioner with symptoms of bladder outflow obstruction Prostate specific antigen (PSA) performed: 4.9ng/ml Referred to urology clinic in local DGH * fictitious name

Initial presentation: April 12 Presented to his general practitioner with symptoms of bladder outflow obstruction Prostate Specific Antigen (PSA) performed: 4.9ng/ml Referred to urology clinic in local DGH Returned to Romania

Urology Clinic, July 2012 Symptoms On examination urinary frequency (increasing over several months) reduced flow (increasing over years) some perineal discomfort (new) On examination apyrexial Sl. tender mildly uniformly enlarged prostate

Investigations MSU (microscopy) PSA 35WBCs No growth PSA 4.8ng/ml In view of persistently elevated PSA, listed for prostate biopsy

Prostate biopsy: November 12 Pre-assessment penicillin allergy documented 5th November (09:30hrs) : biopsy performed under LA Ciprofloxacin 500mg commenced 2hrs prior to biopsy Prescription for Ciprofloxacin 500mg bd 3days issued

Do you agree with this course of action? Co-ordinator prompts Should investigation and treatment for prostatitis been undertaken (avoid as outside scope of this topic)? Is ciprofloxacin an appropriate agent to be used for prophylaxis for TRUS (avoid as outside scope of this topic)?

Post-biopsy course Circa 18hrs post biopsy (03:00hrs, 6th Nov) developed rigors felt unwell temp: 39.8oC pulse rate: 110bpm bp: 135/70mmHg Admitted under urology team (04:00hrs) diagnosis of sepsis post TRUS biopsy + SIRS

What would you do now? Co-ordinator prompts (1) Further history Elucidation of nature of allergy Nature of symptoms (with respect to prostatitis) Investigations Routine Blood culture / rpt. MSU

Co-ordinator prompts (2) Severity assessment Assessment of need for supportive care Antibiotics: Discussion around nature of allergy and antibiotics advised / contra-indicated

Initial management Blood cultures collected Treatment decision: ‘IV antibiotics: Tigecycline as allergic to Amoxil’ 100mg loading dose (within 30mins), 50mg bd FBC, U&E, CRP: largely normal

Do you agree with this approach? September 2010: US FDA safety communication April 2011: UK MHRA safety warning (I have written a briefing note previously, but should be checked)

Progress, 6th November 15:20hrs, while on Tigecycline: further rigors microbiology contacted. Notes state - repeat blood / urine cultures single dose of gentamicin (600mg) later (untimed): temp 40.8oC haematuria

7th November 01:00hrs 13:00hrs temp 38.2oC; pulse rate 112bpm; BP 79/47mmHg urinary retention (catheterised) resuscitation with fluids reviewed by ITU team 13:00hrs Blood cultures: Gram negative rods

8th November Progress: Blood culture result: Pyrexia, tachycardia settled Hypotension persisted (80-100mgHg systolic) Blood culture result: E.coli ESBL pattern, S gent, imipenem, tigecycline Microbiologist advice (telephone) : continue tigecycline 48hrs, switch to imipenem if no improvement

Do you agree with this approach?

9th– 18th November Initial improvement, but interspersed with hypotensive periods Microbiology advice (telephone) 9th Nov: Continue gent (but incorrect info provided) Switch to imipenem, ‘with caution’ due to allergy However, tigecycline continued Eventual improvement: discharged (18/11) after 12d course of tigecycline

Selected blood results Date time WCC (x109/L) Neuts Plats Creat μmol/L Urea mmol/L CRP (mg/L) 6/11 04:24 6.9 6.4 101 93 5.0 5 7/11 00:55 10.9 10.5 58 178 8.5 106 7/11 08:55 13.6 12.8 49   8/11 03:33 8.6 7.6 28 144 11.1 231 9/11 09:02 16.8 14.6 43 92 8.2 215 9/11 21:38 15.7 12.9 57 96 7.9 147 10/11 09:28 14.1 11.2 62 90 6.1 114 11/11 16:00 12.2 88 87 6.6 61 12/11 16:00 15.6 148 14/11 11:39 19.1 14.5 352 98 7.3 15/11 09:02 11.6 8.3 354 16/11 09:07 435

Relapse, December 2012 1st December (i.e. 8 days later) presented with 2 day history of dysuria, frequency and shivering. On examination: temp 37.8oC, tachycardic (120bpm) but normotensive (115/70mmHg) Drug chart: ‘ penicillin  headache’ Re-started on tigecycline

What would you do now? Co-ordinator prompts Meets SIRS / Sepsis criteria? Further investigations / considerations? Antibiotic choices?

Progress (2nd day) Next day developed pyrexia (38.4oC), but remained haemodynamically stable Discussed with microbiology (telephone): gentamicin advised Remained pyrexial: MI scan showed multiple abscesses within prostate Blood cultures, urine from 2/12: coliform with sens pattern as previously Microbiologist advised gent + metronidazole

Subsequent progress Rapid recovery ensued over next 24hrs Microbiologist advice (telephone): ‘only option is full 14day course of gentamicin plus metronidazole’. Meticulous monitoring of gentamicin levels with Hartford nomogram undertaken.

Outcome Presented to GP 1 wk later with unsteadiness Diagnosis of vestibular failure due to gentamicin made.

Lessons learnt Co-ordinator prompts: Importance of investigating claimed allergies True risks of use of penicillins and beta-lactams in such patients Alternatives in apparently-true Type I hypersensitivity