Hemodialysis as a Risk Factor for Ceftriaxone-Associated Pseudolithiasis in Adults

Clinical Approach to Nosocomial Bacterial Sepsis

Bacterial sepsis and septic shock are associated with a high mortality, and when clinically suspected, clinicians must initiate broad-spectrum antimicrobials within the first hour of diagnosis. Thorough review of prior cultures involving multidrug-resistant (MDR) pathogens along with other likely pathogens should be performed to provide an appropriate broad-spectrum empiric antibiotic coverage. The appropriate antibiotic loading dose followed by individualized modification of maintenance dose should be implemented based on the presence of hepatic or renal dysfunction. Use of procalcitonin is no longer recommended to determine need for initial antibacterial therapy and for de-escalation. Daily reevaluation of appropriateness of treatment is necessary based on the culture results and clinical response. All positive cultures should be carefully screened for possible contamination or colonization, which may not represent the true organism causing the sepsis. Culture negative sepsis accounts for one-half of all cases, and de-escalation of initial antibiotic regimen should be done gradually in these patients with close monitoring.

Ceftriaxone-associated pseudolithiasis in hemodialysis patients: a case series study

Background

Ceftriaxone, a third-generation cephalosporin, is widely used to treat bacterial infections in patients undergoing dialysis because it has a long half-life and broad spectrum of action and does not require dose reduction. However, renal dysfunction is a risk factor for ceftriaxone-associated pseudolithiasis that has rarely been reported in patients undergoing hemodialysis. This study aimed to present the detailed clinical manifestations of, and susceptibility to, ceftriaxone-associated pseudolithiasis in hemodialysis patients.

Methods

Seventy-seven hemodialysis patients received ceftriaxone between February 2011 and June 2019, and 33 patients underwent abdominal computed tomography within 1 year of receiving the drug. Among these 33 patients, 11 have developed ceftriaxone-associated pseudolithiasis. We retrospectively reviewed these patients’ medical records. We also compared the medical records of ten patients who underwent computed tomography scans within 60 days of ceftriaxone administration and developed ceftriaxone-associated pseudolithiasis with those of patients who did not develop this adverse event.

Results

Pseudolithiasis tended to develop when patients received ceftriaxone for longer periods or at a higher total dosage. However, the ceftriaxone dose and the disease severity were not significantly correlated. Most patients improved within several months; however, the condition persisted for 10 months in a patient with a spinal cord injury. There were no significant differences in patient characteristics, prevalence of diabetes mellitus or cerebrovascular disease, being bed-bound, fasting, serum albumin, calcium, intact parathormone, or dose per unit body mass between the two groups. However, patients who developed pseudolithiasis had received ceftriaxone for significantly longer and at a higher total dose than those who did not develop pseudolithiasis (12 days; interquartile range [IQ], 8.3–14 vs. 4 days, IQ, 2–8, P = 0.00872; 12.5 g, IQ, 9.3–14 vs. 4 g, IQ, 2–8, P = 0.00476, respectively).

Conclusions

Ceftriaxone-associated pseudolithiasis may be relatively common in patients undergoing hemodialysis, especially in those who receive a higher total quantity of drug or for a longer duration. It is important to be aware of the possibility of pseudolithiasis developing in hemodialysis patients who receive ceftriaxone. These patients should be monitored during, and for up to 1 year after, its administration.

Ceftriaxone-associated Pseudolithiasis in Elderly People: Frequency and Risk Factors

Objective Ceftriaxone (CTRX) is a widely used antibiotic because of its long plasma half-life and good tissue transmission. Many of the reported studies on CTRX-associated pseudolithiasis were performed in children. Although some studies have been published in adults, there are no studies limited to elderly people. The present study investigated CTRX-associated pseudolithiasis and explored its risk factors in the elderly. Methods We retrospectively reviewed 133 elderly patients (≥65 years old) treated with CTRX. Pseudolithiasis was defined as stones or sludge newly appearing in the gallbladder, as detected by computed tomography after the administration of CTRX. We evaluated the risk factors for pseudolithiasis using multivariate regression and inverse probability of treatment weighting analyses. Results Among the 133 patients, 24 (18%) developed CTRX-associated pseudolithiasis. In a multivariate analysis, the CTRX dose [odds ratio (OR) 4.54, 95% confidence interval (CI) 1.36-15.07, p=0.012] and CTRX treatment duration (OR 2.80, 95% CI 1.06-8.04, p=0.043) were significantly associated with pseudolithiasis formation. The cut-off value of the total CTRX dose associated with pseudolithiasis formation was 19 g. A propensity analysis determined that the frequency of pseudolithiasis was increased in patients treated with >19 g total CTRX compared with those who received ≤19 g in total (OR 4.06, 95% CI 1.45-11.32, p=0.008). Conclusion The incidence rate of CTRX-induced pseudolithiasis is high in elderly people, and the CTRX dose and CTRX treatment duration are significant risk factors for pseudolithiasis. A total dose of >19 g increases the likelihood of pseudolithiasis formation in elderly people treated with CTRX.