Severe neutropenia associated with ticarcillin therapy

Agranulocytosis induced by vancomycin or ticarcillin/clavulanate

OBJECTIVE

To reacquaint clinicians with a reportedly rare adverse event of agranulocytosis occurring after long-term administration of vancomycin and ticarcillin/clavulanate, with a subsequent review of other reported cases in the literature.

CASE SUMMARY

A 45-year-old white woman with spina bifida developed agranulocytosis (2.7 x 10(3)/mm3 white blood cells with only 3% polymorphonuclear leukocytes and no reported eosinophils or basophils) after long-term administration of vancomycin and ticarcillin/clavulanate for decubitus ulcers and chronic osteomyelitis. Consequently, the cell counts rebounded rapidly on discontinuation of both medications and returned to normal within 1 week.

DISCUSSION

The incidence of vancomycin-associated neutropenia is presumably rare, but the increased use of vancomycin may disclose a more frequent occurrence. It is suggested that the mechanism for the reaction is immunologically mediated, yet this remains unclear. Although it is difficult to determine the causative agent in this case, vancomycin was most suspect clinically. Ticarcillin/clavulanate is less likely because our patient has since been readmitted and treated with oxacillin, imipenem/cilastatin, and amoxicillin/clavulanate without affecting the white blood cell count. In that regard, it could be reasoned that an immunologic reaction to ticarcillin would have resulted in a similar outcome with other penicillins.

CONCLUSIONS

This case serves as a reminder to clinicians that patients receiving long-term treatment with vancomycin should have their white blood cell count monitored at least weekly.

Agranulocytosis associated with semisynthetic penicillins and cephalosporins. Report of 7 cases

Within one year we observed in the same intensive care unit seven severely polytraumatized patients with agranulocytosis (AG) associated with treatment by semisynthetic penicillins or cephalosporins combined with aminoglycosides. Antibiotics were given because of severe bacterial respiratory or generalised infections. Five patients died, four of them without haematological remission. Bone marrow aspirates showed hypoplasia of granulopoiesis due to a lack of mature cells. Leukocyte and granulocyte counts in the blood declined continuously over a period of 8 to 11 days. In average, minimal granulocyte counts occurred after 21 days of hospitalisation and 14 days of antibiotic drug exposure. Beside the incriminated antibiotics all patients were treated sporadically with other agents of which may cause AG. Granulocyte kinetics and serial bone marrow examinations of one patient suggest a phenothiazine type of AG, which is caused by a toxic damage of granulopoiesis. Declining absolute granulocyte counts in the blood together with persisting high temperatures during antibiotic treatment should give rise to the suspicion of a beginning AG.