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We describe a recent case of Stevens-Johnson Syndrome. A 49-year-old man was admitted to the Intensive Care Unit of an Anaesthesia and Resuscitation Department because of a Fournier gangrene that derived in a sepsis, ventilator-associated pneumonia, and renal failure. He was under treatment with cefepime and suffered a generalized status epilepticus, so started treatment with phenytoin. The next day he developed a "maculous cutaneous eruption in trunk and lower limbs" compatible with a Stevens-Johnson Syndrome. Stevens-Johnson Syndrome is a very severe and potentially fatal multiorganic disease, especially when present in critically ill patients, with a strong drug-related etiology, especially with antiepileptic drugs.

Background Selective decontamination of the digestive tract has been proven to be the best measure to prevent ventilator associated pneumonia (VAP) and the only one that has demonstrated modest reductions in mortality. The preparations are typically non-absorbable, topical admixtures of antibiotics with broad spectrum activity administered either orally and/or enterally applied as an oropharyngeal paste (OP), or as a suspension (decontamination of the digestive tract suspension, DDS). Purpose The purpose of this study was to analyse the composition, costs of acquisition or elaboration at the pharmacy department (PD) of these preparations to determine the most cost effective option and the annual economic impact of the implementation of this new measure at the anaesthesia critical care unit (ACCU). Material and methods We conducted a literature research and analysed if the preparations could be acquired through a regular provider (A) or had to be made at the PD (B). To determine the costs if the preparations were made at the PD, we considered the total costs of raw materials, packaging materials, consumables and staff time. Results We found that antibiotics commonly used were tobramycin, colistin and anfoterincin B (or nystatin instead), and vancomycin was added in the case of methicillin resistant Staphylococcus aureus . We agreed with the ACCU for the PD to provide tobramycin, colistin and nystatin. Preparation costs/acquisition were: OP: €1.43/g A; €0.12/g B; and for DDS: €4.42/10 mL A; €0.70/10 mL B. Regarding the annual consumption, estimating the average of intubated patients per day and the dosage (10 mL DDS every 8 hours and 5 mL orally every 8 hours, equating to 4.58 g B and 1.6g A), we estimated the costs on: €1.556 if we made it and €36.234 if we acquired it. We agreed with the ACCU for the PD to provide these preparations as it may result in estimated annual saving of €24 678. Conclusion After analysing the composition, costs of acquisition or elaboration at the PD, we concluded that the elaboration of OP and DDS at the PD significantly saved costs compared with the acquisition of both preparations already commercialised. This implies optimisation of resources, one of the main objectives of healthcare management. References and/or acknowledgements Klompas M, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol2014;35:S133–54. No conflict of interest

Objective: To describe a recent case of suspected interaction between oral cyclosporine modified and iron. Case Summary: A 33-year-old man underwent urgent cardiac transplantation for refractory cardiogenic shock caused by acute myocarditis. The patient had persistently low levels of cyclosporine despite a dose increase of the drug after the change of administration route from intravenous to oral. Spacing the administration of cyclosporine modified from oral iron resolved the problem. This drug interaction was reported as “probable” as determined by a Drug Interaction Probability Scale score of 7. Using this scoring system, the patient experienced a probable drug interaction between cyclosporine and iron both administered orally, and we surmise that the mechanism is that iron physicochemically destabilizes the cyclosporine microemulsion when both are administered concurrently. Discussion: This may be because of the interaction between cyclosporine microemulsion and iron because this cation can destabilize the immunosuppressant dosage form. Conclusions: Taking into account that joint administration of oral iron and cyclosporine modified can generate a physicochemical interaction that involves a decrease in the absorption of cyclosporine modified, we believe that it is necessary to recommend spacing administrations of both drugs as well as monitoring levels of cyclosporine in order to ensure optimal levels of immunosuppression.