Linezolid-induced pure red cell aplasia in a patient with Staphylococcus epidermidis infection after allogeneic stem cell transplantation

Adverse drug events associated with linezolid administration: a real-world pharmacovigilance study from 2004 to 2023 using the FAERS database

Introduction: Linezolid is an oxazolidinone antibiotic that is active against drug-resistant Gram-positive bacteria and multidrug-resistant Mycobacterium tuberculosis. Real-world studies on the safety of linezolid in large populations are lacking. This study aimed to determine the adverse events associated with linezolid in real-world settings by analyzing data from the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS). Methods: We retrospectively extracted reports on adverse drug events (ADEs) from the FAERS database from the first quarter of 2004 to that of 2023. By using disproportionality analysis including reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), along with the multi-item gamma Poisson shrinker (MGPS), we evaluated whether there was a significant association between linezolid and ADE. The time to onset of ADE was further analyzed in the general population and within each age, weight, reporting population, and weight subgroups. Results: A total of 11,176 reports of linezolid as the "primary suspected" drug and 263 significant adverse events of linezolid were identified, including some common adverse events such as thrombocytopenia (n = 1,139, ROR 21.98), anaemia (n = 704, ROR 7.39), and unexpected signals that were not listed on the drug label such as rhabdomyolysis (n = 90, ROR 4.33), and electrocardiogram QT prolonged (n = 73, ROR 4.07). Linezolid-induced adverse reactions involved 27 System Organ Class (SOC). Gender differences existed in ADE signals related to linezolid. The median onset time of all ADEs was 6 days, and most ADEs (n = 3,778) occurred within the first month of linezolid use but some may continue to occur even after a year of treatment (n = 46). Conclusion: This study reports the time to onset of adverse effects in detail at the levels of SOC and specific preferred term (PT). The results of our study provide valuable insights for optimizing the use of linezolid and reducing potential side effects, expected to facilitate the safe use of linezolid in clinical settings.

Effect of Platelet Parameters on Linezolid-Related Thrombocytopenia in Hospitalized Patients

Background

Linezolid-induced thrombocytopenia incidence varies considerably. Linezolid-related thrombocytopenia in patients has received few studies which have investigated risk factors including platelet parameters except for platelet counts. The study aims to analyze the effect of platelet parameters, including mean platelet volume and platelet large cell ratio, on linezolid-related thrombocytopenia in patients.

Methods

The effect of platelet parameters on linezolid-related thrombocytopenia was identified by univariate and multivariate logistic regressions. A Kaplan-Meier survival analysis was carried out to compare the survival of patients who developed linezolid-related thrombocytopenia with patients who did not.

Results

Thrombocytopenia occurred at a rate of 41.5% (66/159) after linezolid therapy in hospitalized patients. Platelet parameters, including the difference in mean platelet volume (MPV/fL=0.08 (-1.2-0.9)vs-0.5 (-1.5-0.3), (OR, 0.459; P = 0.001), the difference in platelet large cell ratio (PLCR/fL=0.9 (-5.1-6.2)vs-3.8 (-8.6-2.4), (OR, 1.156; P = 0.001), baseline platelet counts (OR, 0.995; P = 0.006) and duration of linezolid therapy≥10d (OR, 1.346; P = 0.007), were significantly associated with linezolid-related thrombocytopenia in hospitalized patients. In addition, other risk factors which also are associated with linezolid-related thrombocytopenia include baseline red blood cells, co-medication with parecoxib and co-medication with caspofungin. Accumulated in-hospital mortality of patients with thrombocytopenia was significantly higher than that of patients without thrombocytopenia during linezolid treatment (19.7% vs 8.6%, P = 0.003).

Conclusion

The difference in mean platelet volume, the difference in large platelet ratio, baseline platelet counts and duration of linezolid therapy≥10d significantly affected the development of linezolid-related thrombocytopenia in hospitalized patients.

Linezolid induced hypoglycemia and anemia: A case report

Key Clinical Message

Linezolid (LZD) is an efficient addition antibiotic against multidrug-resistant strains. However, clinicians should pay attention to the adverse reactions such as hypoglycemia and anemia in using LZD, especially in elderly patients and patients with abnormal liver and kidney function who need to use LZD for a long time.

Abstract

Severe hypoglycemia and anemia caused by linezolid (LZD) are rare, with potentially serious adverse effects. The report of LZD-induced hypoglycemia and anemia is extremely rare. Thus far, this is the first report. We presented LZD-induced recurrent hypoglycemia and anemia in a 93-year-old patient who has been prescribed LZD 600 mg once daily for 42 days for treatment of tuberculosis (TB) pleurisy and pneumonia. The patient began to experience recurrent hypoglycemic episodes and anemia 5 days and 2 weeks after LZD medication, respectively. Using Naranjo's Adverse Drug Reaction Assessment Scale, the patient scored 8 points with the category of "probable". His hypoglycemia and anemia gradually improved 1 month after LZD withdrawal. Clinicians should pay attention to the adverse reactions such as hypoglycemia and anemia in using LZD, especially in elderly patients and patients with abnormal liver and kidney function who need to use LZD for a long time. Patients should regularly monitor blood routine, blood glucose, and liver and kidney functions during LZD exposure, which may avoid adverse reactions and improve their prognosis.

Linezolid-Induced Pure Red Cell Aplasia: A Case Report

Linezolid (LZD) has been widely used for treating the infections of multidrug-resistant gram-positive organisms. As we know, anemias induced by Linezolid (LZD) are common. However, LZD-induced pure red cell aplasia (PRCA) is very rare. In this paper, we report on a 68-year-old woman with intravascular stent infection who developed PRCA after treatment with LZD. The patient presented to our hospital with a 6-month history of fever after stent implantation for aneurysms in both lower limbs. Bone culture grew methicillin-resistant Staphylococcus hemolyticus (MRSH). She received LZD after developing adverse reactions to initial antibiotics. Although her infective symptoms were improved by LZD, progressive thrombocytopenia was observed 23 days after LZD therapy. Her platelets declined to 66*10⁹/L and hemoglobin level was 10.1 g/dL. Thrombocytopenia recovered 12 days after cessation of LZD. LZD was administered again due to recovered fever. 57 days after LZD administration, her hemoglobin level was 4.1 g/dL and reticulocytes were 0.2%. Bone marrow smear revealed active granulocyte proliferation and markedly decreased erythropoiesis with vacuolar degeneration. 12 days after cessation of LZD, her hemoglobin and reticulocyte levels rose to 9.6 g/dL and 5.1%, respectively. LZD was used for the third time as fever and inflammatory markers progressively increased, but Hb was reduced to 6.7g/dL 15 days after LZD therapy. 12 days after cessation of LZD, the hemoglobin level rose to 11.9 g/dL. In summary, we suggest complete blood count and reticulocyte count should be monitored to detect bone marrow suppression during long-term LZD therapy, especially in patients aged over 58 and/or with pre-existing anemia, chronic infections, and renal insufficiency.

Linezolid-induced pure red cell aplasia: a case report and literature review

Linezolid (LZD) is the first oxazolidinone with excellent safety and efficacy profiles against refractory infections caused by gram-positive organisms. Hematological toxicities such as thrombocytopenia, anemia, and leukocytopenia are common in LZD therapy; however, LZD-induced pure red cell aplasia (PRCA) is rare. An 83-year-old man diagnosed with pleural empyema caused by Staphylococcus aureus received LZD after developing resistance to multiple antibiotics. Although his infection-related symptoms were improved by LZD, progressive anemia was noticed after LZD therapy was initiated. Eight weeks after LZD administration began, his hemoglobin level was 5.7 g/dL and reticulocyte proportion was 0.36%, while his white blood cell and platelet counts remained unchanged since admission. Bone marrow examination revealed markedly decreased erythropoiesis with cytoplasmic vacuolation of erythroblasts. Anemia resolved by 14 days after cessation of LZD. It is important to increase the awareness among clinicians about the potential for the hematological effects associated with LZD, particularly for older patients with pre-existing anemia and treatment courses longer than 14 days. To detect bone marrow suppression, including PRCA, we suggest monitoring the complete blood count and reticulocyte count periodically in patients receiving long-term LZD therapy.