1. Unnecessary complications of an unnecessary procedure
Albert J Mifsud

2. 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

3. 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

4. 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

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

6. 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

8. 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)?

9. 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

10. 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

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

12. 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

13. 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)

14. 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

15. 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

16. 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

17. Do you agree with this approach?

18. 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

19. 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

20. 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

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

22. 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

23. 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.

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

25. 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