Antibiotic agranulocytosis: association with cephalothin and carbenicillin

A 65-year-old woman developed agranulocytosis on two separate occasions following prophylactic administration of antibiotics before cardiac surgery. In the first leukopenic episode, large doses of cephalosporin derivatives were the only drugs implicated, and in the second, carbenicillin was believed responsible. Life-threatening septicemia occurred with Pseduomonas aeruginosa and later with Escherichia coli. Erythrocytes, platelets, and lymphocytes were not affected during these granulocytopenias. Bone marrow examination revealed an arrest of maturation in the granulocytic series. Review of the hematologic complications of cephalosporins, particularly agranulocytosis, suggests an interesting association between carbenicillin-induced neutropenia and previous administration of cephalosporins.

Grand rounds: autoimmune hemolytic anemia

Autoimmune hemolytic anemia (AHA) may be either primary (ie, "idiopathic," one third of all patients) or secondary (ie, associated with underlying illness, two thirds of all patients). A positive Coombs antiglobulin test is the most important criterion for diagnosis of AHA, and characterization of RBC coating (as to whether it is by IgG alone, by IgG plus complement, or by complement alone) may be valuable in ruling out certain underlying illnesses as causative in selected patients. Many limitations to the antiglobulin test must be kept in mind. As routinely performed, a positive result requires greater than 500 molecules of IgG per RBC. Red blood cells from normal subjects have less than 35 molecules of IgG per RBC. Up to 2% to 5% of patients with AHA will have RBC coating in the 50 to 500 molecules per cell range and may therefore have "false"-negative antiglobulin tests. Apparent failures of strength of antiglobulin reactions to correlate with severity of in vivo RBC destruction may result from technical factors or may reflect intrinsic differences among autoantibodies (eg, IgG subclass, affinity). A likely mechanism of in vivo RBC destruction in AHA has been demonstrated in immune-mediated in vitro RBC "rosette" formation about macrophages and lymphocytes bearing specific receptors for subclasses of IgG and for subcomponents of complement. Increased avidity of macrophages for coated RBCs in response to such stimulus as infection may play an additional role. Treatment involves control of underlying disease and the judicious use of adrenal steroids, splenectomy, and immunosuppressive agents. Transfusions, while life-saving in life-threatening anemia, carry substantially increased risks in AHA patients. Their use should be strictly limited.

Pharmacokinetic study of cefazaflur compared to cephalothin and cefazolin

A single 1-Gm dose of cefazaflur, a new semisynthetic cephalosporin derivative, was compared in a crossover study to the same dose of cephalothin and cefazolin by intramuscular injection in seven healthy volunteers. Serum concentrations were measured at several time intervals during 6 hours following each administration. The mean peak serum levels obtained after 30 minutes were 25.2, 17.2, and 62.3 mug/ml, respectively, for cefazaflur, cephalothin, and cefazolin. In each of the seven subjects, serum concentrations were higher at each sampling time with cefazolin than with the other two cephalosporins. The percentage of total administered dose recovered in urine in a microbiologically active form for the 0-24-hour collection was, respectively, 92.7, 59.2, and 94.9 per cent with cefazaflur, cephalothin, and cefazolin, the largest part being excreted during the first 6 hours. Neither drug appeared to have any pronounced effect on various laboratory tests. Local reactions at the site of intramuscular injection were minor with cefazaflur and cefazolin, but were more pronounced with cephalothin.

Double-blind study to investigate methods to prevent cephalothin-induced phlebitis

Methods which might be useful in preventing cephalothin-induced phlebitis following intravenous administration of the buffered drug were investigated. One hundred and twenty adult orthopedic patients were assigned randomly to either a control group or one of five treatment groups. The treatment regimens studied were: addition of hydrocortisone phosphate 10 mg to each liter of intravenous fluid; addition of heparin 1,000 units to each liter of intravenous fluid; addition of heparin 500 units and hydrocortisone phosphate 1 mg to each liter of intravenous fluid; addition of heparin 1,000 units and hydrocortisone phosphate 10 mg to each liter of intravenous fluid; and filtration of intravenous solutions through a 0.22-mum inline filter. All patients in the study received intravenous buffered cephalothin at a dosage of 1 g every six hours for a minimum of 48 hours. Phlebitis was assessed every 12 hours according to predetermined criteria. Significant differences were found in the incidence of phlebitis at 48 hours between the control group and the last three study groups (see above). It is concluded that postinfusion phlebitis following cephalothin administration can be reduced by the concomitant addition of heparin and hydrocortisone to the intravenous solution or by the use of an inline 0.22-mum final filter.

Ticarcillin in combination with cephalothin or gentamicin as empiric antibiotic therapy in granulocytopenic cancer patients

Ticarcillin was used in combination with either cephalothin or gentamicin as initial empiric antibiotic therapy for 127 patient trials of suspected infection in granulocytopenic cancer patients. Bacteremia was present in 20%, nonbacteremic microbiologically documented infections in 21%, clinically documented infections in 23%, and possible infections in 5%; infection was doubtful in 31%. Although Staphylococcus aureus was the most common single organism isolated (23%), gram-negative bacilli accounted for 54% of all pathogens. Both antibiotic regimens were highly efficacious, with complete resolution in 46% of bacteremias, 88% of nonbacteremic microbiologically documented infections, and 95% of clinically documented infections. Among bacteremias, 8 of 9 caused by S. aureus but only 4 of 15 (27%) caused by gram-negative bacilli were completely resolved with these antibiotic combinations. Reasons for nonresponse in bacteremias were persistent granulocytopenia, mixed infection and, in two patients, antibiotic-resistant organisms. Toxicities other than hypokalemia were minimal. Although the rate of further infections was high overall (18/127), only one occurred among the 39 patients with <4 days of antibiotic therapy. Ticarcillin in combination with either cephalothin or gentamicin was effective as initial empiric therapy of suspected infection in granulocytopenic cancer patients.

Clinical studies of cefazolin in the surgical field

A double-blind study with volunteers was performed to determine the incidence and severity of thrombophlebitis associated with cephalothin, cephapirin, cefamandole, and a water control. Although there were no statistical differences in the incidence of thrombophlebitis, cephalothin resulted in significantly more severe thrombophlebitis compared with the other agents.

[Haemolytic anaemia and acute renal failure associated with cephalothin and furosemide therapy (author's transl)]

A case report is presented of a 79 year old patient with a bilateral brochopneumonia. Four days after beginning the therapy with cephalothin and furosemide an acute renal failure appeared and six days later a haemolytic anaemia was observed. The modificated Coombs test was positive. The post mortem histiological examination of the kidneys revealed cloudy swelling, necrosis of tubuli, containing protein cylinders ("chromoproteid kidney").

Phlebitis associated with the intravenous use of cephalothin and cephapirin

The frequency and severity of phlebitis associated with cephalothin and cephapirin was compared in a double-blind study in 82 surgical patients with 149 different infusion sites. After treatment with the coded drug products, the status of each patient's veins was evaluated daily by i.v. therapists. Cephapirin was associated with a slightly lower rate of phlebitis, but the difference was not significant. For both drugs, the duration of therapy did not appear to have an effect on the rate of phlebitis. Scalp vein needles were associated with a lower rate of phlebitis than plastic catheters, but the difference was not significant.

Double-blind comparison of phlebitis associated with cefazolin and cephalothin

In a double-blind, crossover study in 28 patients having infections susceptible to cephalosporins (mostly Staphylococcus or Streptococcus), phlebitis developed in twice as many patients (46.4%) receiving intravenous cephalothin within 48 hours, as in patients (21.4%) receiving intravenous cefazolin over the same time period. Likewise, drug therapy had to be discontinued more frequently with cephalothin (39%) than with cefazolin (21%), and the percentage of patients reporting pain or discomfort scores of 1+ or higher was greater with cephalothin (46.4%) than with cefazolin (21.4%). In our study, the intravenous administration of cefazolin was associated with a lower incidence of phlebitis than was cephalothin.

Gentamicin- and cephalothin-associated rises in blood urea nitrogen

Standardized rates of drug-attributed rises in blood urea nitrogen were 8.6%, 2.9%, and 9.3%, respectively, in patients receiving gentamicin alone, cephalothin alone, and both drugs together. These results provide evidence against a substantial synergism between the two drugs in the production of impaired renal function.

Problems in pre-transfusion tests related to drugs and chemicals

Ingestion of drugs can cause patients or blood donors to have a positive direct and sometimes indirect antiglobulin test. The most common cause of these positive reactions and immune hemolytic anemia due to drugs is the formation of red cell autoantibodies. These autoantibodies will react with the patient's own red cells and usually most other normal red cells in vitro without the drug being present. The prototype drug causing this type of reaction is alpha methyldopa (Aldomet). Other drugs cause positive antiglobulin tests by three different mechanisms, the drug antibodies reacting with red cells in vitro only in the presence of the drug. The first of these mechanisms causes positive reactions because the drug binds firmly to the red cell membrane, and antibody against the drug will combine with the drug on the membrane leading to IgG-sensitized red cells. The prototype drug for this mechanism is penicillin. The second mechanism involves chemical modification of the red cell membrane by the drug so that it takes up many proteins nonspecifically; the cephalosporins are the only group of drugs known to react in this fashion. The final mechanism involves the formation of an immune complex by the drug and its specific antibody. This immune complex will attach to cell membranes, usually activating complement in the process. Examples of drugs thought to operate by this mechanism are phenacetin, quinine, and quinidine. Some individuals have antibodies present in their serum that will react with chemical added to commercial blood bank reagents. Examples of these are antibodies to dyes added to ABO typing sera, antibodies to sodium caprylate in bovine albumin, and antibodies to chemicals added to red cell diluents, e.g., chloramphenicol, neomycin, and hydrocortisone. If these antibodies are present they can create problems in pretransfusion testing; in particular, they can present anomalies in ABO, Rh grouping, and antibody detection.

Significant reduction in the incidence of phlebitis with buffered versus unbuffered cephalothin

Cephalothin (1 g every 2 h), buffered cephalothin, and diluent alone (5% dextrose in water) were each administered for 4 days intravenously to 12 volunteers in a double-blind crossover study. The incidence of phlebitis with buffered cephalothin was significantly lower than that with unbuffered drug (P < 0.01) and almost identical to the incidence with diluent alone.

Association of renal injury with combined cephalothin-gentamicin therapy among patients severely ill with malignant disease

There is a high incidence of primary renal tubule damage among patients with malignant disease who die following recent treatment with combinations of cephalothin and gentamicin. Administration of this combination of antibiotics appears to make the patient appreciably more susceptible to severe renal injury if an additional, often minor, insult to the renal tubules is superimposed. In the present study, significant blood loss or bacterial infection not promptly controlled by the antibiotic combination were two factors that provided this additional insult to many patients; the renal injury in these patients could not be attributed to bleeding or infection alone. The combination of cephalothin plus gentamicin carries the potential of causing renal tubule injury and places the patient severely ill with malignant disease at risk for renal failure from many clinical complications which are commonly associated with their primary illness.

Comparison of phlebitis produced by cephapirin and cephalothin

In a single-blinded study involving 120 patients neither the incidence nor severity of phlebitis observed with cephapirin and cephalothin was significantly different.

Comparative incidence of phlebitis due to buffered cephalothin, cephapirin, and cefamandole

Buffered cephalothin, cefamandole, and cephapirin were compared with respect to their tendency to produce phlebitis. Two grams of each agent was administered every 6 h for 4 days to 12 healthy volunteers in a double-blind crossover fashion. Approximately 50% of intravenous sites developed mild (grade 1) phlebitis and 25% developed moderate (grade 2) phlebitis. The frequency of grade 1 inflammation did not differ significantly among the three cephalosporins. The proportion of individuals eventually exhibiting grade 2 phelebitis was highest with cefamandole, lowest with cephalothin (P = 0.07), and intermediate with cephapirin; however, cephapirin required a substantially greater number of doses to produce grade 2 phelebitis than did the other two drugs. These findings, together with the results of other reports, suggest that interpretation of the phlebitogenic potential of these antibiotics must be made with caution.