Ceftriaxone associated nephrolithiasis: a prospective study in 284 children

Ceftriaxone-induced severe hemolytic anemia, renal calculi, and cholecystolithiasis in a 3-year-old child: a case report and literature review

Ceftriaxone is widely used in pediatric outpatient care for its efficacy against respiratory and digestive system infections, yet its increasing association with severe immune hemolytic reactions requires heightened vigilance from pediatricians. This report details a rare and severe case of ceftriaxone-induced severe immune hemolytic anemia (IHA), hemolytic crisis, myocardial injury, liver injury, renal calculi, and cholecystolithiasis in a previously healthy 3-year-old child. The child, treated for bronchitis, experienced sudden pallor, limb stiffness, and altered consciousness following the fifth day of ceftriaxone infusion, with hemoglobin (Hb) levels precipitously dropping to 21 g/L. Immediate cessation of ceftriaxone and the administration of oxygen therapy, blood transfusion, intravenous immunoglobulin (IVIG), and corticosteroids led to a gradual recovery. Despite initial improvements, the patient's condition necessitated extensive hospital care due to complications including myocardial injury, liver injury, renal calculi, and cholecystolithiasis. After a 12-day hospital stay and a 3-month follow-up, the child showed complete normalization of Hb and liver function and resolution of calculi. In children, ceftriaxone infusion may trigger severe, potentially fatal, hemolytic reactions. Pediatricians must promptly recognize symptoms such as pallor, limb stiffness, and unresponsiveness, indicative of ceftriaxone-induced severe IHA, and immediately discontinue the drug. Effective management includes timely blood transfusion, respiratory support, IVIG administration, and corticosteroids when necessary, along with rigorous vital signs monitoring. Continued vigilance is imperative, even after cessation of ceftriaxone, to promptly address any residual adverse effects.

Nephrotoxicity of Amoxicillin and Third-Generation Cephalosporins: An Updated Review

Because of their broad-spectrum bactericidal activity, amoxicillin (AMX) and third-generation cephalosporins (TGC) are widely used for the prophylaxis and treatment of established infections. They are considered relatively safe, but several recent reports have suggested substantial nephrotoxicity, especially with AMX use. Considering the importance of AMX and TGC for clinical practice, we conducted this up-to-date review, using the PubMed database, which focuses specifically on the nephrotoxicity of these molecules. We also briefly review the pharmacology of AMX and TGC. Nephrotoxicity of AMX may be driven by several pathophysiological mechanisms, such as a type IV hypersensitivity reaction, anaphylaxis, or intratubular and/or urinary tract drug precipitation. In this review, we focused on the two main renal adverse effects of AMX, namely acute interstitial nephritis and crystal nephropathy. We summarize the current knowledge in terms of incidence, pathogenesis, factors, clinical features, and diagnosis. The purpose of this review is also to underline the probable underestimation of AMX nephrotoxicity and to educate clinicians about the recent increased incidence and severe renal prognosis associated with crystal nephropathy. We also suggest some key elements on the management of these complications to avoid inappropriate use and to limit the risk of nephrotoxicity. While renal injury appears to be rarer with TGC, several patterns of nephrotoxicity have been reported in the literature, such as nephrolithiasis, immune-mediated hemolytic anemia, or acute interstitial nephropathy, which we detail in the second part of this review.

Ceftriaxone Administration Associated with Lithiasis in Children: Guilty or Not? A Systematic Review

Lithiasis is a known side effect of ceftriaxone administration in children. Sex, age, weight, dosage, and duration of intake have been reported as risk factors for the formation of calcification or stones in the bile and urine excretory systems of children who received ceftriaxone. The purpose of this systematic review is to investigate the reported effects of ceftriaxone administration in pediatric patients who were admitted to a hospital due to infection, the likelihood of gallstones, nephroliths, or precipitations in both the biliary and urinary systems, as well as investigate the relationship with their mother's history during pregnancy. Original studies and literature reviews from the PubMed database were included in the study. No time limit related to research or publication was set for the articles. The results were evaluated, aiming to understand the outcomes and identify any predisposing factors relevant to this side effect. Of the 181 found articles, 33 were appropriate for inclusion in the systematic review. The administered dose of ceftriaxone presented variability. Symptoms, such as abdominal pain and vomiting, were associated with ceftriaxone-related lithiasis in many cases. It was noted that most of the results were the outcomes of retrospective observation and not of prospective randomized research. Definitively, more randomized control studies with long-term outcomes are needed to identify the exact association between ceftriaxone and lithiasis in children.

Yenidoğanlarda seftriakson kullanımının yan etkilerinin değerlendirilmesi

Amaç: Seftriakson yan etkileri nedeniyle yenidoğanda sınırlı kullanıma sahiptir. Yenidoğan enfeksiyonlarında kullanımı ile ilgili sınırlı sayıda çalışma vardır. Bu çalışma ile setriakson alan yenidoğanlarda seftriakson sonrası oluşabilecek yan etkilerin değerlendirilmesi amaçlanmıştır. Gereç ve Yöntem: Çukurova Üniversitesi Tıp Fakültesi Balcalı Hastanesi Yenidoğan Yoğun Bakım Ünitesi’nde, 2015-2016 yılları arasında yatan bebeklerin seftriakson tedavisi öncesi ve sonrası klinik ve laboratuvar verileri retrospektif olarak incelenmiştir. Bulgular: Çalışmaya 30 olgu alınmıştır. Bu bebeklerin ortalama gebelik yaşı 37 ± 3,1 (30-41) hafta, seftriakson aldığı süre 7,2 ± 2,2 (2-12) gün bulunmuştur. 30 olgudan alınan idrar kültürlerinde; 17 (%56,6) bebekte üreme saptanmıştır. Bunların 11’inde (%36,6) Escherischia coli (E. coli), 5’inde (%16,7) diğer bakteriler üremiştir. Olguların seftriakson öncesi ve sonrası laboratuvar verilerinde kan üre azotu (BUN), total bilirubin (TB) ve hematokrit değerlerinde anlamlı düşüş saptanmıştır. Seftriakson kullanımına bağlı herhangi bir yan etki izlenmemiştir. Sonuç: Çalışmamızda seftriakson sonrası komplikasyon görülmemiş olması term veya terme yakın yenidoğanlarda seftriakson kullanımı için cesaret verici olabilir. Fakat, yenidoğanda seftriaksonun yan etkilerinin ve sıklıklarının kesinleştirilmesi ve yenidoğanda kullanılan diğer antibiyotiklere karşı alternatif olup olamayacağının belirlenmesi için daha fazla araştırmalara ihtiyaç vardır.

Concomitant Ceftriaxone and Intravenous Calcium Therapy in Infants

OBJECTIVE

To determine if increased mortality could be detected with the administration of ceftriaxone and IV calcium in infants through an analysis of a large repository of electronic health records.

METHODS

Patients were split into 3 groups: 1) neonates, 2) infants, and 3) infants <1 year whose age was not specified. Deaths were classified into mutually exclusive categories based on the administration and timing of ceftriaxone and IV calcium. Crude death rates were calculated, and logistic regression modeling was used to calculate adjusted relative odds of death with associated covariates.

RESULTS

A total of 259,149 infants were identified. Of 79,038 neonates, the proportion of patients that received ceftriaxone and IV calcium within 48 hours who died was 3.8%, compared with 1.95% (IV calcium), 0.3% (ceftriaxone), 1.54% (IV fluids), and 2.03% (parenteral nutrition). For 102,456 infants, the proportions of deaths were 5.47% (ceftriaxone and IV calcium within 48 hours), 0.45% (IV calcium), 0.15% (ceftriaxone), 0.39% (IV fluids), and 5.5% (parenteral nutrition). Multivariate analysis showed increased odds of death in infants who received ceftriaxone and IV calcium within 48 hours, regardless of age, and propensity score-matched analysis showed a more than 2-fold increased risk for death.

CONCLUSIONS

The increased risk for death following ceftriaxone and IV calcium administration was noted not only in neonates, but among older infants as well.

Safety of ceftriaxone in paediatrics: a systematic review

OBJECTIVE

To determine the safety of ceftriaxone in paediatric patients and systematically evaluate the categories and incidences of adverse drug reactions (ADRs) of ceftriaxone in paediatric patients.

METHODS

We performed a systematic search in Medline, PubMed, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, International Pharmaceutical Abstracts and bibliographies of relevant articles up to December 2018 for all types of studies that assessed the safety of ceftriaxone in paediatric patients aged ≤18 years.

RESULTS

112 studies met the inclusion criteria involving 5717 paediatric patients who received ceftriaxone and reported 1136 ADRs. The most frequent ADRs reported in prospective studies were gastrointestinal (GI) disorders (37.4 %, 292/780), followed by hepatobiliary disorders (24.6%, 192/780). Serious ADRs leading to withdrawal or discontinuation of ceftriaxone were reported in 86 paediatric patients. Immune haemolytic anaemia (34.9%, 30/86) and biliary pseudolithiasis (26.7%, 23/86) were the two major causes. Haemolytic anaemia following intravenous ceftriaxone led to death in 11 children whose primary disease was sickle cell disease. Almost all biliary pseudolithiasis are reversible. However, the incidence was high affecting one in five paediatric patients (20.7%).

CONCLUSIONS

GI ADRs are the most common toxicity of ceftriaxone in paediatric patients. Immune haemolytic anaemia and biliary pseudolithiasis are the most serious ADRs and the major reasons for discontinuation of ceftriaxone. Immune haemolytic anaemia is more likely in children with sickle cell disease and may cause death. Ceftriaxone should be used with caution in children with sickle cell disease.

TRIAL REGISTRATION NUMBER

CRD42017055428.

Ceftriaxone-associated biliary pseudolithiasis in children: do we know enough?

Ceftriaxone is an antibiotic agent frequently used in paediatric hospital practice for the treatment of severe bacterial infections. The use of this agent can result in cholelithiasis and/or biliary sludge, more commonly in children than in adults. This systematic review was aimed at analysing available literature concerning ceftriaxone-associated biliary pseudolithiasis in paediatric patients, with a special emphasis on the clinical aspects. A literature analysis was performed using Medline and Embase electronic databases (articles published in English up to December 2019), with the search terms and combinations as follows:'ceftriaxone', 'cholelithiasis', 'biliary sludge' 'gallstones' 'neonates' 'children' 'clinical aspects' 'management'. Several case reports, case series and prospective/retrospective studies have documented a relationship between ceftriaxone treatment and biliary pseudolithiasis in the paediatric population, even though literature data regarding neonates and infants are scarce. Ceftriaxone-associated biliary pseudolithiasis is dose-dependent and usually asymptomatic but, sometimes, it may present with abdominal pain, nausea and emesis. Abdominal ultrasonography should be performed when this complication is suspected. Generally, ceftriaxone-associated cholelithiasis resolves over a variable period of time (days to months) after cessation of therapy. Therefore, a conservative approach to this condition is advocated, but a prolonged follow-up may be necessary. A personalized assessment of factors predisposing to ceftriaxone-associated biliary pseudolithiasis before prescribing the drug can allow to minimize the risk of developing it, with significant advantages in terms of human and economic costs.

Drug-Induced Urolithiasis in Pediatric Patients

Drug-induced nephrolithiasis is a rare condition in children. The involved drugs may be divided into two different categories according to the mechanism involved in calculi formation. The first one includes poorly soluble drugs that favor the crystallization and calculi formation. The second category includes drugs that enhance calculi formation through their metabolic effects. The diagnosis of these specific calculi depends on a detailed medical history, associated comorbidities and the patient's history of drug consumption. There are several risk factors associated with drug-induced stones, such as high dose of consumed drugs and long duration of treatment. Moreover, there are some specific risk factors, including urinary pH and the amount of fluid consumed by children. There are limited data regarding pediatric lithogenic drugs, and hence, our aim was to perform a comprehensive review of the literature to summarize these drugs and identify the possible mechanisms involved in calculi formation and discuss the management and preventive measures for these calculi.

Evaluation of hypercalciuria in patients receiving intravenous Cefotaxime

Introduction:

Cefotaxime is one of the third generation cephalosporins, which is used against many infections. This drug has a urinary excretion and potentially may have nephrotoxic effects. Hypercalciuria can cause important complications, including the formation of kidney stones. In the recent study, we decided to evaluate hypercalciuria in children receiving cefotaxime.

Materials and Methods:

This case-control study was conducted in Amirkabir hospital (Arak, Iran), where 30 children received intravenous cefotaxime were placed in the case group and 30 children without intravenous administration of cefotaxime were included in the control group. The ratio of calcium to creatinine was measured in both groups. Data were analyzed by SPSS software version 23.

Results:

This study showed that the ratios of male and female children in both the groups were 19 (63.3%) and 11 (36.7%) respectively, the mean age of children in the case group was 2.36 years with a standard deviation of 0.71 and the mean age of the children in the control group was 5.18 years with a standard deviation of 3.31. The ratios of urine calcium to creatinine in the case and control groups were 0.90 with a standard deviation of 1.79 and 0.37 with a standard deviation of 0.44 (P value = 0.003).

Conclusion:

According to the above results, it is concluded that receiving intravenous cefotaxime may increase calcium to creatinine ratio in children.

Ceftriaxone-associated nephrolithiasis and gallstone in adults

Background

Ceftriaxone (CTX) is widely used for the treatment of bacterial infections; however, side effects such as gallstone and nephrolithiasis have been reported in children. There is limited information about urinary tract calculi as CTX side effects in adults. Therefore, the present study was aimed to evaluate the incidence of gallstone and nephrolithiasis following CTX administration.

Methods

The present study was conducted in the Vali-e-Asr Hospital. Eighty-four patients with various infectious diseases with different daily treatment (mean ± SD: 4.19±2.54) were included in this study, consisting of 49 females and 35 males. The mean of total doses used in patients was 10.2143 (SD: 5.8585). To detect possible gallstone, gallbladder sludge, and urolithiasis, patients were evaluated by serial ultrasound before and after CTX treatment. Patients with renal and hepatobiliary dysfunction were excluded from the study and did not receive any nephrotoxic drugs during this study. Demographic parameters including age, sex, body mass index, dosage of CTX, as well as the duration of treatment and hospitalization were determined. Statistical significances were determined using Fisher’s exact test and independent t-test.

Results

Results from our study showed that the incidence of gallstone and nephrolithiasis were 8.8% and 1.5% following CTX administration, respectively. Surprisingly, we found a significant correlation in terms of age between patients with and without gallstone (P=0.03).

Conclusion

Our findings suggest that the patients’ age might play a role in the development of such a complication. This indicates the need for a close monitoring of CTX-treated patients to assess the possible formation of gallstone and nephrolithiasis.

Drug-Induced Kidney Stones and Crystalline Nephropathy: Pathophysiology, Prevention and Treatment

Drug-induced calculi represent 1-2% of all renal calculi. The drugs reported to produce calculi may be divided into two groups. The first one includes poorly soluble drugs with high urine excretion that favour crystallisation in the urine. Among them, drugs used for the treatment of patients with human immunodeficiency, namely atazanavir and other protease inhibitors, and sulphadiazine used for the treatment of cerebral toxoplasmosis, are the most frequent causes. Besides these drugs, about 20 other molecules may induce nephrolithiasis, such as ceftriaxone or ephedrine-containing preparations in subjects receiving high doses or long-term treatment. Calculi analysis by physical methods including infrared spectroscopy or X-ray diffraction is needed to demonstrate the presence of the drug or its metabolites within the calculi. Some drugs may also provoke heavy intra-tubular crystal precipitation causing acute renal failure. Here, the identification of crystalluria or crystals within the kidney tissue in the case of renal biopsy is of major diagnostic value. The second group includes drugs that provoke the formation of urinary calculi as a consequence of their metabolic effects on urinary pH and/or the excretion of calcium, phosphate, oxalate, citrate, uric acid or other purines. Among such metabolically induced calculi are those formed in patients taking uncontrolled calcium/vitamin D supplements, or being treated with carbonic anhydrase inhibitors such as acetazolamide or topiramate. Here, diagnosis relies on a careful clinical inquiry to differentiate between common calculi and metabolically induced calculi, of which the incidence is probably underestimated. Specific patient-dependent risk factors also exist in relation to urine pH, volume of diuresis and other factors, thus providing a basis for preventive or curative measures against stone formation.

Unravelling Pathophysiology of Crystalline Nephropathy in Ceftriaxone-Associated Acute Kidney Injury: A Cellular Proteomic Approach

BACKGROUND

Previous studies showed that ceftriaxone can cause acute kidney injury (AKI) in the pediatric population. This study proposed a cellular model of crystalline nephropathy in ceftriaxone-associated AKI and explored the related pathophysiology by using a proteomic approach.

METHODS

Ceftriaxone was crystallized with calcium in artificial urine. Madin-Darby Canine Kidney (MDCK) cells, a model of distal renal tubular cell, were cultured in the absence (untreated control) or presence of ceftriaxone crystals for 48-h (n = 5 each). MDCK cells were harvested and subsequently analyzed by proteomic analysis. Protein bioinformatics (i.e., STRING and Reactome) was used to predict functional alterations, and subsequently validated by Western blotting and cellular studies. p < 0.05 was considered statistically significant.

RESULTS

Phase-contrast microscopy showed increased intracellular vesiculation and cell enlargement as a result of ceftriaxone crystal exposure. Proteome analysis revealed a total of 20 altered proteins (14 increased, 5 decreased and 1 absent) in ceftriaxone crystal-treated MDCK cells as compared to untreated cells (p < 0.05). Protein bioinformatics and validation studies supported heat stress response mediated by heat shock protein 70 (Hsp70) and downregulation of annexin A1 as the proposed pathophysiology of crystalline nephropathy in ceftriaxone-associated AKI, in which impaired proliferation and wound healing of crystal-induced distal tubular cells were outcomes.

CONCLUSIONS

This study, for the first time, used the in vitro model of crystalline nephropathy to investigate the underlying pathophysiology of ceftriaxone-associated AKI, which should be investigated in vivo for potential clinical benefits in the future.

Comparative evaluation of ceftriaxone- and cefotaxime-induced biliary pseudolithiasis or nephrolithiasis: A prospective study in 154 children

Background:

Biliary lithiasis, or sludge, and nephrolithiasis have been reported as a possible complication of ceftriaxone therapy. However, no study related to cefotaxime-induced biliary pseudolithiasis or nephrolithiasis was observed in the literature. Therefore, we investigated the comparative formation of biliary pseudolithiasis and nephrolithiasis after cefotaxime and ceftriaxone therapies.

Methods:

The patients treated with ceftriaxone or cefotaxime were enrolled during the study period. Ultrasound imaging of the biliary and urinary tract was performed in all patients before and after the treatment. The patients with a positive sonographic finding at the end of treatment were followed up with monthly ultrasonography for 3 months.

Results:

The present study showed that abnormal biliary sonographic findings were demonstrated in 18 children (20.9%) treated with ceftriaxone, 13 (15.1%) had biliary lithiasis, 5 (5.8%) had biliary sludge and 1 (1.2%) had nephrolithiasis. Abnormal biliary sonographic findings were demonstrated in only four (5.9%) children treated with cefotaxime who had biliary sludge and only one (1.5%) had nephrolithiasis. It was observed that older age was at significantly higher risk of developing biliary sludge or stone formation. Receiver operating characteristic analysis was performed to determine the residual risk and analysis found that 4.5 years was the cut-off value for age.

Conclusions:

The present study is unique in the literature for reporting for the first time gall bladder sludge and nephrolithiasis associated with cefotaxime use. Therefore, patients treated with cefotaxime should be monitored for serious complications like patients treated with ceftriaxone. Nevertheless, if third-generation cephalosporin is used, cefotaxime is recommended to be used rather than ceftriaxone.

Hypercalciuria following ceftriaxone a fact or myth

Introduction: Nephrolithiasis is a common worldwide problem both in children and adults. Ceftriaxone as a widely used antibiotic can contribute to the formation of renal stones and hypercalciuria.

Objectives: To find the effect of ceftriaxone, a widely used antibiotic, on urinary calcium excretion rate in children.

Patients and Methods: 84 infants and children over 3 months admitted to hospital for non-renal problems. They were all previously healthy children affected with a condition mandating hospitalisation. They were randomly divided into 2 groups; those who received ceftriaxone according to their physician decision as the case group and those who did not receive antibiotics as the control group. The patients urinary calcium excretion was determined as calcium to creatinine ratio in a random urine sample in the first and third day of their admission. All data was expressed by mean ± SD and analysed by t independent and chi-square tests by SPSS 16. P P value less than 0.05 was significant.

Results: Eighty-four cases were analysed. Calcium excretion in received and non-received ceftriaxone groups was 0.13 ± 0.06 and 0.14 ± 0.02 respectively at first day of admission ( P = 0.1). After 3 days, the urine calcium to creatinine ratio increased to 0.27 ± 0.2 and 0.26 ± 0.08 in received and non- received ceftriaxone groups ( P = 0.8).

Conclusion: In children, urinary calcium excretion increases 2 times in average in a short time after admission because of gastroenteritis, and ceftriaxone is not different to other antibiotics for increase urinary calcium excretion in 3 days after admission.

Ceftriaxone and acute renal failure in children

OBJECTIVE

Our aim was to evaluate the clinical profile, treatment, and outcome of ceftriaxone-associated postrenal acute renal failure (PARF) in children.

METHODS

We retrospectively studied 31 consecutive cases from 2003 to 2012 for PARF after ceftriaxone treatment. There was no past history of urolithiasis or nephropathy in these children.

RESULTS

The average time of ceftriaxone administration before PARF was 5.2 days. The major symptoms apart from anuria included flank pain (>3 years old, 25/25), excessive crying (<3 years, 6/6), and vomiting (19/33). Ultrasound showed mild hydronephrosis (25/31) and ureteric calculi (11/31). Nine children recovered after 1 to 4 days of pharmacotherapy. Twenty-one children who were resistant to pharmacotherapy underwent retrograde ureteral catheterization. After catheterization of their ureters, normal urine flow was observed, and the symptoms subsided immediately. Catheter insertion failed in 1 child who subsequently underwent 3 sessions of hemodialysis before normal urination was restored. Ceftriaxone was verified to be the main component of the calculi in 4 children by tandem mass spectrometric analysis. The recovery was complete in all cases.

CONCLUSIONS

Ceftriaxone therapy in children may cause PARF. Early diagnosis and prompt pharmacological therapy are important in relieving the condition. Retrograde ureteral catheterization is an effective treatment of those who fail to respond to pharmacotherapy.

Possible function of urinary pH and citrate on the ceftriaxone-induced nephrolithiasis

OBJECTIVE

To test whether urinary pH and citrate is associated with ceftriaxone-induced kidney stone formation and if acidified urine could dissolve this kind of stone using an in vitro crystallization model.

METHODS

Crystallization was induced by mixing ceftriaxone at the standard therapeutic urinary concentration to artificial urine. The response of different physiological pH and citrate on ceftriaxone-induced crystallization was measured by the depletion ratio of ceftriaxone in the process. Compositions of formed crystals were qualitatively and quantitatively analyzed. The effect of acidifying urine on dissolving of ceftriaxone-induced crystal was determined by the surplus ratio of ceftriaxone in the process.

RESULTS

Compositional analysis showed that ceftriaxone-induced crystals were composed of calcium and ceftriaxone with a ratio of 1:1. Compared to the response to pH 6.0, ceftriaxone-induced crystallizations in artificial urine at pH 4.5 and 5.0 for 4 hours were significantly decreased, and more acid urine resulted in less crystallization. However, it made no significant change when pH increased to 6.5 and 7.0. In addition, ceftriaxone-induced crystals formed at pH 6.0 for 4 hours could be dissolved significantly when artificial urine was acidified to pH 5.0 and 4.5 for 1, 2, and 4 hours; and more time of dissolution and more degree of acidifying resulted in more dissolution.

CONCLUSION

Our study suggests that urinary pH and citrate are probable factors associated with ceftriaxone-induced nephrolithiasis. On one hand, alkaline urine and hypocitraturia predispose ceftriaxone nephrolithiasis, and vice versa. On the other hand, acidifying urine could dissolve ceftriaxone-induced stones.

Outpatient parenteral antimicrobial therapy with ceftriaxone, a review

BACKGROUND

More than 30 years since it was developed for clinical use, the third-generation cephalosporin ceftriaxone remains the most commonly used agent for outpatient parental antimicrobial therapy (OPAT). Recent antimicrobial stewardship programmes have tended to restrict ceftriaxone use in hospitals to control antibiotic resistance and outbreaks of Clostridium difficle infection (CDI). Considering the expansion of OPAT programmes both in the UK and worldwide, revisiting the role of ceftriaxone in OPAT in the context of changing antimicrobial prescribing practices is timely.

AIM OF THE REVIEW

To identify the evidence base for OPAT, review current and historical data on indications for, and safety of ceftriaxone within the OPAT setting, and to provide some perspectives on the future role of ceftriaxone.

METHOD

We searched PubMed and Scopus for articles published in English, and hand searched reference lists. We also conducted a complementary descriptive analysis of prospectively acquired data on the use of ceftriaxone in more than 1,300 OPAT episodes over a 10-year period in our UK centre.

RESULTS

Ceftriaxone has an excellent safety profile in the OPAT setting, and its broad spectrum of activity makes it an established agent in a wide range of clinical infection syndromes, such as skin and soft-tissue infection, bone and joint infection, streptococcal endocarditis and several others. Intriguingly, in contrast to the inpatient setting, liberal use of ceftriaxone in OPAT has not been strongly linked to CDI, suggesting additional patient and environmental factors may be important in mediating CDI risk.

Increased urinary calcium excretion caused by ceftriaxone: possible association with urolithiasis

The administration of ceftriaxone is known to be associated with biliary pseudolithiasis, although the development of urolithiasis has only rarely been reported. We treated a young male with bacterial meningitis complicated by urinary precipitates composed of ceftriaxone-calcium salt, which prompted us to study whether ceftriaxone administration predisposes children to the formation of urinary precipitates. The case-control study reported here included 83 children with bacterial pneumonia aged from 3 months to 8.9 years. The children were divided into one group of 43 children who received ceftriaxone (group A) and a second group of 40 children who received amoxicillin (group B). Paired samples of serum and urine before and after treatment were obtained from the patients in each group. There were no significant differences in demographic characteristics and blood biochemistry between the groups. However, the mean urinary calcium to creatinine ratio (uCa/Cr; mg/mg) was significantly higher in group A patients than in group B patients after treatment (0.19 vs. 0.09, respectively; p < 0.001), and analysis of the paired urine samples revealed that the uCa/Cr significantly increased after treatment only in group A patients(p < 0.001). There was a weak but non-significant relationship between the dose of ceftriaxone and the uCa/Cr in group A (p = 0.10, r = 0.24). Our results are the first to demonstrate that ceftriaxone has the potential to significantly increase urinary excretion of calcium, which may be linked to ceftriaxone-related urolithiasis or sludge. We therefore suggest that it is worthwhile monitoring the uCa/Cr levels in patients on ceftriaxone as they may be at greater risk for developing large stones and renal damage.

Urinary sludge caused by ceftriaxone in a young boy

It is known that ceftriaxone administration is associated with biliary pseudolithiasis, although the development of urolithiasis has been rarely reported. We encountered a young male with bacterial meningitis complicated by urinary precipitates composed of ceftriaxone-calcium salt which is confirmed by high-performance liquid chromatography. This patient suggested that ceftriaxone significantly increased urinary excretion of calcium, which may be linked to ceftriaxone-related urolithiasis or sludge. It is therefore worthwhile to monitor the levels of urinary calcium to creatinine ratio in patients on ceftriaxone, as they may be at greater risk for developing large stones and renal damage.

Simultaneous determination of 12 beta-lactam antibiotics in human plasma by high-performance liquid chromatography with UV detection: application to therapeutic drug monitoring

A rapid and specific high-performance liquid chromatography method with UV detection (HPLC-UV) for the simultaneous determination of 12 beta-lactam antibiotics (amoxicillin, cefepime, cefotaxime, ceftazidime, ceftriaxone, cloxacillin, imipenem, meropenem, oxacillin, penicillin G, piperacillin, and ticarcillin) in small samples of human plasma is described. Extraction consisted of protein precipitation by acetonitrile. An Atlantis T3 analytical column with a linear gradient of acetonitrile and a pH 2 phosphoric acid solution was used for separation. Wavelength photodiode array detection was set either at 210 nm, 230 nm, or 298 nm according to the compound. This method is accurate and reproducible (coefficient of variation [CV] < 8%), allowing quantification of beta-lactam plasma levels from 5 to 250 μg/ml without interference with other common drugs. This technique is easy to use in routine therapeutic drug monitoring of beta-lactam antibiotics.

Synthesis, spectral, thermal and antimicrobial studies of some new tri metallic biologically active ceftriaxone complexes

Iron, cobalt, nickel and copper complexes of ceftriaxone were prepared in 1:3 ligand:metal ratio to examine the ligating properties of the different moieties of the drug. The complexes were found to have high percentages of coordinated water molecules. The modes of bonding were discussed depending on the infrared spectral absorption peaks of the different allowed vibrations. The Nujol mull electronic absorption spectra and the magnetic moment values indicated the Oh geometry of the metal ions in the complexes. The ESR spectra of the iron, cobalt, and copper complexes were determined and discussed. The thermal behaviors of the complexes were studied by TG and DTA techniques. The antimicrobial activities of the complexes were examined and compared to that of the ceftriaxone itself.

Sonographic Assessment of Ceftriaxone-Associated Biliary Pseudolithiasis in Chinese Children

In this randomized, single-blind, case-controlled, prospective study, the incidence and outcome of ceftriaxone-associated biliary pseudolithiasis in Chinese children was evaluated via ultrasonography. A total of 108 children diagnosed with hepatobiliary infection or pneumonia were randomized to receive ceftriaxone or ceftazidime. Serial gallbladder sonograms were obtained on days 1, 5 − 7 and 10 − 14 of therapy. Gallstones were detected in 43.10% of patients in the ceftriaxone-treated group and in 2.00% of the ceftazidime-treated group. The incidence of pseudolithiasis was significantly higher in the ceftriaxone-treated than the ceftazidime-treated group. Biliary precipitation abnormalities appeared after 2 − 7 days of treatment. After gallstones were found, the drug was stopped and symptoms resolved within 1 − 2 days. This study suggests that the risk of ceftriaxone-associated biliary pseudolithiasis should be considered when treating Chinese children.

Assessment of the role of renal organic anion transporters in drug-induced nephrotoxicity

In the present review we have attempted to assess the involvement of the organic anion transporters OAT1, OAT2, OAT3, and OAT4, belonging to the SLC22 family of polyspecific carriers, in drug-induced renal damage in humans. We have focused on drugs with widely recognized nephrotoxic potential, which have previously been reported to interact with OAT family members, and whose underlying pathogenic mechanism suggests the participation of tubular transport. Thus, only compounds generally believed to cause kidney injury either by means of direct tubular toxicity or crystal nephropathy have been considered. For each drug, or class of agents, the evidence for actual transport mediated by individual OATs under in vivo conditions is discussed. We have then examined their role in the context of other carriers present in the renal proximal tubule sharing certain substrates with OATs, as these are critical determinants of the overall contribution of OAT-dependent transport to intracellular accumulation and transepithelial drug secretion, and thus the impact it may have in drug-induced nephrotoxicity.

Concomitant ceftriaxone and high-concentration intravenous calcium therapy in adult critical care patients: a matched cohort study

BACKGROUND

Based on case reports in infants, the safety of concomitant use of ceftriaxone and intravenous calcium in all ages has recently come under challenge. Systematic population-based data to guide clinicians with respect to this risk are, however, lacking.

OBJECTIVE

To determine whether concomitant administration of ceftriaxone and intravenous calcium was associated with the occurrence of severe cardiorespiratory events or death in critically ill adults.

METHODS

We performed a matched-cohort study from retrospective data of adults admitted to intensive care units (ICUs) in Calgary, Canada, who were provided continuous high-dose intravenous calcium. Those who received ceftriaxone while on continuous renal replacement therapy were considered exposed. Up to 3 unexposed patients were selected by matching on a number of prognostic factors from the remaining subjects not concurrently exposed to ceftriaxone and calcium. Univariate methods and multivariate conditional logistic regression were used for statistical analysis.

RESULTS

We identified 142 patients exposed to the implicated combination who could be matched to at least one unexposed patient. Hospital mortality was 66% in the exposed versus 63% in unexposed patients (p = 0.442). ICU length of stay, ICU mortality, hospital length of stay, and the frequency of acute oxygenation events were all similar by univariate analysis. Multivariate conditional logistic regression modeling failed to find a significant association between exposure and hospital mortality (adjusted OR 1.15, 95% CI 0.65 to 2.04) or other relevant outcomes.

CONCLUSIONS

In this high-risk group, administration of high concentrations of calcium and concurrent ceftriaxone was not significantly associated with greater mortality or adverse outcomes compared to matched unexposed patients. Although this was an underpowered study and rare adverse effects from the interaction of these 2 compounds cannot be completely excluded, these data provide overall reassurance of the safety of this combination in the majority of critically ill adults.

Diagnostic examination of the child with urolithiasis or nephrocalcinosis

Urolithiasis and nephrocalcinosis are more frequent in children then currently anticipated, but still remain under- or misdiagnosed in a significant proportion of patients, since symptoms and signs may be subtle or misleading. All children with colicky abdominal pain or macroscopic hematuria should be examined thoroughly for urolithiasis. Also, other, more general, abdominal manifestations can be the first symptoms of renal stones. The patients and their family histories, as well as physical examination, are important initial steps for diagnostic evaluation. Thereafter, diagnostic imaging should be aimed at the location of calculi but also at identification of urinary tract anomalies or acute obstruction due to stone disease. This can often be accomplished by ultrasound examination alone, but sometimes radiological methods such as plain abdominal films or more sensitive non-enhanced computed tomography are necessary. Since metabolic causes are frequent in children, diagnostic evaluation should be meticulous so that metabolic disorders that cause recurrent urolithiasis or even renal failure, such as the primary hyperoxalurias and others, can be ruled out. The stone is not the disease itself; it is only one serious sign! Therefore, thorough and early diagnostic examination is mandatory for every infant and child with the first stone event, or with nephrocalcinosis.

Pediatric urolithiasis

PURPOSE OF REVIEW

We review the recent literature on pediatric urolithiasis and present up-to-date findings on epidemiology, diagnosis, and medical and surgical management.

RECENT FINDINGS

There are surprisingly few reliable data on pediatric urolithiasis incidence, but widespread anecdotal and single-center reports suggest that more children with stones are being seen. The contamination of Chinese infant formula with melamine caused urolithiasis and other renal problems in hundreds of thousands of infants in the region, underlining the role of environmental factors in urolithiasis. Efforts continue to determine normal metabolic parameters in children, but have been hampered by variations among regions, races, and ethnicities. The Bonn Risk Index may prove to be a useful tool for assessing risk of urolithiasis in children. Children with recurrent urolithiasis are more likely to have detectable metabolic abnormalities. Surgical approaches to urolithiasis in children continue to evolve, with robotic-assisted laparoscopy being perhaps the most significant new technique. Finally, clinicians and radiologists must be aware of the potential for dextranomer/hyaluronic acid (Deflux) implants to mimic distal ureteral stones on computed tomography (CT) scan.

SUMMARY

Pediatric urolithiasis is an expanding field, due in part to the apparent increase in cases. Research continues, seeking to refine the appropriate diagnostic and therapeutic approaches in these unfortunate children.

Nephrolithiasis caused by ceftriaxone in a 3-year-old child with ureteropelvic junction obstruction

We report the case of a 3-year-old boy with urinary tract malformation (left sided stenosis of the ureteropelvic junction) which was precipitating factor for ensuing nephrolithiasis of the left kidney during the therapy with ceftriaxone. The treatment with spasmolytics was initiated, together with the forced parentheral hydration. After 3 weeks, there was no evidence of calculi in the urinary tract.

Nephrotoxicity as a cause of acute kidney injury in children

Many different drugs and agents may cause nephrotoxic acute kidney injury (AKI) in children. Predisposing factors such as age, pharmacogenetics, underlying disease, the dosage of the toxin, and concomitant medication determine and influence the severity of nephrotoxic insult. In childhood AKI, incidence, prevalence, and etiology are not well defined. Pediatric retrospective studies have reported incidences of AKI in pediatric intensive care units (PICU) of between 8% and 30%. It is widely recognized that neonates have higher rates of AKI, especially following cardiac surgery, severe asphyxia, or premature birth. The only two prospective studies in children found incidence rates of 4.5% and 2.5% of AKI in children admitted to PICU, respectively. Nephrotoxic drugs account for about 16% of all AKIs most commonly associated with AKI in older children and adolescents. Nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, amphotericin B, antiviral agents, angiotensin-converting enzyme (ACE) inhibitors, calcineurin inhibitors, radiocontrast media, and cytostatics are the most important drugs to indicate AKI as significant risk factor in children. Direct pathophysiological mechanisms of nephrotoxicity include constriction of intrarenal vessels, acute tubular necrosis, acute interstitial nephritis, and-more infrequently-tubular obstruction. Furthermore, AKI may also be caused indirectly by rhabdomyolysis. Frequent therapeutic measures consist of avoiding dehydration and concomitant nephrotoxic medication, especially in children with preexisting impaired renal function.

Lithiasis and Risk Factors

Nephrolithiasis is a worldwide disease with high clinical and economic costs. The increasing incidence in industrialized countries seems to be related to several risk factors, which are partly inherited and partly acquired. Although risk factors in urolithiasis are still under discussion, their identification would provide a notable gain for the patient in terms of stone episodes, and for the health service in terms of costs. This article presents an easy classification of risk factors based on clinical background.