Hepatitis from intravenous high-dose oxacillin therapy: findings in an adult inpatient population

Frequency of drug-induced liver injury in children receiving anti-staphylococcal penicillins

INTRODUCTION

Anti-staphylococcal penicillins (ASPs) are among the most commonly prescribed antibiotics in children and are associated with a risk of drug-induced liver injury (DILI). Despite the frequent use of ASPs in children, there is no consensus on whether liver function tests (LFTs) should be routinely monitored during treatment.

OBJECTIVES

To review the literature on the frequency of ASP-related DILI in children to determine the incidence, risk factors and outcomes of hepatotoxicity.

METHODS

PubMed, MEDLINE and Embase were searched in January 2022 for original studies of children who received cloxacillin, dicloxacillin, flucloxacillin, methicillin, nafcillin or oxacillin that included ≥10 children aged up to 18 years, and presented data on the incidence of DILI in children exposed to ASPs.

RESULTS

Overall, two studies of oral flucloxacillin, two of intravenous (IV) methicillin, three of IV nafcillin and four of IV oxacillin were included. The mean onset of DILI ranged between 7.0 and 19.0 days following commencement of antibiotic treatment and all episodes resolved between 14.2 and 16.0 days after drug discontinuation, with no specific treatment required. This review found that the incidence of DILI in children was 1 in 50 000 for oral flucloxacillin and ranged from 1 in 3 to 13 for IV oxacillin, methicillin and nafcillin.

CONCLUSIONS

This review found that routine LFT monitoring is not required in children receiving low dose oral flucloxacillin in a primary care setting, although pharmacovigilance is critical. For IV preparations, the existing data support routine LFT monitoring in those receiving treatment for at least 7 days.

The safety of antimicrobials for the treatment of community-acquired pneumonia

Introduction: Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide, and its prevalence continues to increase. Despite the efficacy of antimicrobials, their safety and tolerability remain topics of interest and concern for clinicians and patients alike.Areas covered: This review outlines the main antimicrobial classes recommended for the empirical treatment of CAP in current guidelines, together with a potential new class. Each pharmacological group underwent a safety evaluation based on all available data about drug-related toxicities. The authors also present their mechanisms of action, their pharmacokinetic and pharmacodynamic properties, and the main clinical studies.Expert opinion: Overall, antimicrobials currently marketed for the treatment of CAP are well tolerated and generally safe. However, unusual and sometimes serious adverse effects can occur in susceptible populations. Attention should be paid to identifying patients at risk of developing drug-related toxicities because, although most effects are transient, some could be disabling, permanent, or even fatal. Post-marketing surveillance remains crucial for gathering data to overcome the limitations of preclinical and clinical studies in estimating the true prevalence of drug-related adverse events.

Nafcillin-Induced Allergic Eosinophilic Cholestatic Hepatitis

A 71-year-old female with no history of liver disease or antibiotic allergy developed jaundice with elevated liver enzymes and eosinophilia following treatment with nafcillin for septic arthritis. Further workup demonstrated hepatocellular dysfunction and liver biopsy showed expansion of portal tracts by lymphocytes and eosinophils consistent with a hypersensitivity reaction. Nafcillin and related antibiotics were withdrawn, and her symptoms resolved 3 months later. We searched PubMed using terms of "nafcillin cholestasis" and "nafcillin hepatitis", and a review of the literature showed other reports of nafcillin-induced hepatitis and cholestasis. Avoidance and on occasion the guarded use of glucocorticoids can lead to recovery from the insult. This case report shows that while rare, nafcillin can cause cholestatic hepatitis through a likely eosinophil-mediated hypersensitivity reaction. Further studies are needed to elucidate the mechanism of this reaction.

Systematic overdosing of oxa- and cloxacillin in severe infections treated in ICU: risk factors and side effects

Background

Oxacillin and cloxacillin are the most frequently used penicillins for the treatment of severe methicillin-susceptible Staphylococcus aureus infections in intensive care units (ICUs), especially endocarditis. International recommendations do not suggest any adaptation of the dosage in case of renal impairment. We wanted to assess the risk factors for overdosing in ICU and the related observed side effects.

Methods

All patients with a therapeutic drug monitoring of oxa- or cloxacillin between 2008 and 2014 were included. The target range of trough concentration for total antibiotic activity was considered to be 20–50 mg/L. Data concerning the infection, the given treatment, the renal function, and the attributed side effects of overdosing were collected. A logistic regression model was used to compute the measured trough concentrations.

Results

Sixty-two patients were included in this study. We found a median trough plasma concentration of 134.3 mg/L (IQR 65.3–201 mg/L). Ten patients (16.1%) reached the target concentration; all other patients (83.9%) were overdosed. Eleven patients (17.7%) experienced neurological side effects attributed to a high antibiotic concentration, i.e. persistent coma and delirium. When adjusted on the dosage used, the risk of overdosing was significantly associated with a creatinine clearance <10 mL/min (with or without hemodialysis).

Conclusion

With the suggested dose of 12 g/day for cloxacillin treatment in case of endocarditis and severe infections occurring in ICU, 83.9% of patients are largely overdosed. Considering the observed side effects, doses should be accurately monitored and reduced, particularly when renal replacement therapy is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0255-8) contains supplementary material, which is available to authorized users.

Antimicrobial-related severe adverse events during treatment of bone and joint infection due to methicillin-susceptible Staphylococcus aureus

Prolonged antimicrobial therapy is recommended for methicillin-susceptible Staphylococcus aureus (MSSA) bone and joint infections (BJI), but its safety profile and risk factors for severe adverse events (SAE) in clinical practice are unknown. We addressed these issues in a retrospective cohort study (2001 to 2011) analyzing antimicrobial-related SAE (defined according to the Common Terminology Criteria for Adverse Events) in 200 patients (male, 62%; median age, 60.8 years [interquartile range {IQR}, 45.5 to 74.2 years]) with MSSA BJI admitted to a reference regional center with acute (66%) or chronic arthritis (7.5%), osteomyelitis (9.5%), spondylodiscitis (16%), or orthopedic device-related infections (67%). These patients received antistaphylococcal therapy for a median of 26.6 weeks (IQR, 16.8 to 37.8 weeks). Thirty-eight SAE occurred in 30 patients (15%), with a median time delay of 34 days (IQR, 14.75 to 60.5 days), including 10 patients with hematologic reactions, 9 with cutaneomucosal reactions, 6 with acute renal injuries, 4 with hypokalemia, and 4 with cholestatic hepatitis. The most frequently implicated antimicrobials were antistaphylococcal penicillins (ASP) (13 SAE/145 patients), fluoroquinolones (12 SAE/187 patients), glycopeptides (9 SAE/101 patients), and rifampin (7 SAE/107 patients). Kaplan-Meier curves and stepwise binary logistic regression analyses were used to determine the risk factors for the occurrence of antimicrobial-related SAE. Age (odds ratio [OR], 1.479 for 10-year increase; 95% confidence interval [CI], 1.116 to 1.960; P = 0.006) appeared to be the only independent risk factor for SAE. In patients receiving ASP or rifampin, daily dose (OR, 1.028; 95% CI, 1.006 to 1.051; P = 0.014) and obesity (OR, 8.991; 95% CI, 1.453 to 55.627; P = 0.018) were associated with the occurrence of SAE. The high rate of SAE and their determinants highlighted the importance of the management and follow-up of BJI, with particular attention to be paid to older persons, especially for ASP dosage, and to rifampin dose adjustment in obese patients.

Prolonged severe cholestasis induced by oxacillin derivatives. A report on two cases

Two patients with osteomyelitis who developed reversible cholestatic jaundice during treatment with oxacillin derivatives are described. The clinical course as well as the biochemical pattern and the investigation of liver biopsy specimens enabled us to establish the diagnoses of drug-induced canalicular and hepatocanalicular cholestasis.

Reversible oxacillin-associated hepatitis in a 9-month-old boy

Herein we present a case of a 9-month-old boy admitted to our hospital for acute femoral osteomyelitis and hip septic arthritis treatment. Acute hepatitis with concomitant skin rash developed on the sixth day of intravenous oxacillin therapy. No other known virus- or drug-related skin eruption or hepatitis was suspected. The boy recovered completely after antibiotics were shifted to teicoplanin, and no sequelae were noted. To our knowledge, this boy is the youngest case of reported oxacillin-related hepatitis in the literatures.

Adverse reactions to oxacillin in hospitalized children: a prospective study

OBJECTIVES: follow-up of children exposed to oxacillin during hospitalization focusing on adverse reactions. METHODS: patients were selected from the pediatric wards of two hospitals in Fortaleza (Hospital Universitário Walter Cantídio-HUWC and Hospital Infantil Albert Sabin-HIAS) from the first oxacillin prescription with a prospective cohort study between October, 2000 and July, 2001 (HUWC) and July/2001 and March, 2002 (HIAS). Patients' follow-up was performed by daily visits to the wards and medical charts and prescription analysis. Suspected oxacillininduced adverse reactions (OxAR cases) were notified and classified according to causality and severity. Related statistic tests were completed. RESULTS: of the 130 patients exposed to oxacillin, 27 had OxAR (20.8%). Fever was the most frequent reaction (50%) followed by rash (35.7%). The majority of reactions were considered Probable, for oxacillin was the only medication involved and 92.6% of the cases had Moderate severity with the need of therapeutic interventions caused by OxAR. A significant relation between oxacillin exposure time and OxAR was determined as well as hospitalization time and the appearance of adverse reactions. Exposure time over 14 days to oxacillin was established as a risk factor for OxAR (relative risk = 5.49). CONCLUSIONS: careful administration of oxacillin in children is recommended with established treatment duration. Empiric and prolonged use must be avoided.

Hepatotoxicity of antibiotics and antifungals

Hepatotoxicity associated with any antibiotic is rare. With the wide-spread use of antimicrobial agents, however, hepatic injury is not an infrequent occurrence. Penicillins remain a widely used class of antimicrobials with a well defined record of low hepatotoxicity. The combination of clavulanate with amoxicillin may be associated with the greatest risk for liver injury from any antimicrobial agent. Significant hepatotoxicity also may occur with sulfamethoxazole/ trimethoprim and combination regimens used to treat tuberculosis. An autoimmune-like hepatitis may result from minocycline or nitrofurantoin exposure and most often resolves with cessation of therapy. Treatment with high doses of tetracycline and oxacillin may be associated with severe hepatotoxicity. Early suspicion of hepatocellular injury in the setting of antimicrobial exposure should prompt cessation of therapy and avoidance of rechallenge.

Antimicrobial treatment of chronic osteomyelitis

Chronic osteomyelitis has been a difficult problem for patients and the treating physicians. Appropriate antibiotic therapy is necessary to arrest osteomyelitis along with adequate surgical therapy. Factors involved in choosing the appropriate antibiotic(s) include infection type, infecting organism, sensitivity results, host factors, and antibiotic characteristics. Initially, antibiotics are chosen on the basis of the organisms that are suspected to be causing the infection. Once the infecting organism(s) is isolated and sensitivities are established, the initial antibiotic(s) may be modified. In selecting specific antibiotics for the treatment of osteomyelitis, the type of infection, current hospital sensitivity resistance patterns, and the risk of adverse reactions must be strongly appraised. Antibiotic classes used in the treatment of osteomyelitis include penicillins, beta-lactamase inhibitors, cephalosporins, other beta-lactams (aztreonam and imipenem), vancomycin, clindamycin, rifampin, aminoglycosides, fluoroquinolones, trimethoprim-sulfamethoxazole, metronidazole, and new investigational agents including teicoplanin, quinupristin/dalfopristin, and oxazolidinones. Traditional treatments have used operative procedures followed by 4 to 6 weeks of parenteral antibiotics. Adjunctive therapy for treating chronic osteomyelitis may be achieved by using beads, spacers, or coated implants to deliver local antibiotic therapy and/or by using hyperbaric oxygen therapy (once per day for 90-120 minutes at two to three atmospheres at 100% oxygen).

Nafcillin-associated hepatotoxicity. Report of a case and review of the literature

Nafcillin is a semisynthetic penicillin that is generally well tolerated with few side effects. Hepatic complications are rare but have a potential for serious liver dysfunction. This unusual complication causes a predominantly cholestatic injury, which can persist for prolonged periods even after discontinuing the medication. The pathophysiology may include direct cytotoxicity or an immune-mediate hypersensitivity. Treatment is generally supportive, except for severely symptomatic patients who may require steroids. We report a case of nafcillin-associated hepatotoxicity and review the literature of this disorder.

Flucloxacillin associated cholestatic hepatitis. An Australian and Swedish epidemic?

The clinico-pathological entity of flucloxacillin-associated cholestatic hepatitis is described and the recognition and documentation of cholestasis associated with flucloxacillin and with related isoxazolyl-penicillins (cloxacillin, dicloxacillin) is examined on an international basis, with particular reference to Australia. Data were obtained from the literature, from the Australian adverse drug reaction monitoring agency and from the Collaborative Centre for International Drug Monitoring (World Health Organisation) in Sweden. Approximately 600 cases of flucloxacillin-associated cholestatic hepatitis were collected, as well as 164 cases associated with other isoxazolyl penicillins. Jaundice and pruritus may first appear several weeks after administration of the drug has ceased and typically are severe and protracted. Liver tests may be abnormal for months after symptomatic recovery. Death is uncommon. Liver pathology shows centrizonal bile stasis with portal tract inflammation and variable loss of bile ducts. Approximately 1 in 15,000 users of flucloxacillin will develop the reaction. Increasing age (> 55 years) and prolonged intake (> 14 days) are particular risk factors. Cholestasis associated with cloxacillin/dicloxacillin appears to be similar in nature but is less well defined. Recognition and reporting of the reaction have been uncommon in the United Kingdom inter alia and high in Sweden and Australia, although estimates of risk have been similar. In Australia, the remarkably high rate of reports appears to be the result of sustained publicity for the reaction. There is only a trickle of reports of cholestatic hepatitis in association with the use of cloxacillin and dicloxacillin from the USA and Canada. The high level of awareness of the reaction and consequential regulatory action so far have not resulted in a diminution of its occurrence in Australia.

Jaundice associated with cephalosporin therapy

Two cases of cephalosporin-induced hepatotoxicity with associated jaundice are presented. Both patients developed jaundice and liver enzyme abnormalities soon after injectable cephalosporin therapy was started. Other possible causes were ruled out, including TPN and allopurinol hepatoxicity, and additional medical illnesses associated with hepatoxicity. Both patients recovered fully from the episode of jaundice. Review of the literature suggests a possible hypersensitivity reaction similar to liver toxicity of the penicillin antibiotics.

Flucloxacillin-induced cholestatic liver damage

Two female patients (75 and 68 yr old) developed jaundice 4 and 7 weeks respectively after treatment with flucloxacillin. Liver biopsies showed intrahepatic cholestasis. After cessation of the drug, the liver tests became normal.

Cholestatic jaundice caused by cloxacillin: macrophage inhibition factor test in preventing rechallenge with hepatotoxic drugs

Severe intrahepatic cholestasis occurred in a patient after taking nitrofurantoin, ampicillin, and cloxacillin. As only nitrofurantoin was known to cause cholestasis she was given cloxacillin again two years later. The cholestasis reappeared at once. A macrophage inhibition factor test confirmed that cloxacillin was the offending drug. Cloxacillin should be added to the growing list of drugs causing cholestasis. Inadvertent rechallenge with hepatototoxic drugs might be prevented by routine use of the macrophage inhibition factor test.

Common adverse effects of antibacterial agents on major organ systems

Antibiotics contribute significantly to the management of the surgical patient. However, their potential for adverse effects, both toxic and allergic, must always be kept in mind. We have reviewed the major adverse reactions to antibiotics, so that side effects may be promptly recognized and treated. Armed with this information, the surgeon can more effectively utilize this valuable class of drugs for the benefit of the patient.