Hematologic adverse effects induced by piperacillin-tazobactam: a systematic review of case reports

Piperacillin/tazobactam-induced sudden severe thrombocytopenia in a patient with a pressure ulcer: a case report

The standard treatment for an infected pressure ulcer (PU) with osteomyelitis is debridement, wound coverage and antibiotic administration. However, systemic administration of antibiotics in patients with osteomyelitis is controversial, and the optimal treatment duration for chronic osteomyelitis has not been standardised. We report a case of sudden severe thrombocytopenia induced by piperacillin/tazobactam (PIPC/TAZ) in a patient with PU-related osteomyelitis. A 57-year-old male patient with paraplegia, using a wheelchair full-time, presented to our plastic surgery department with infection of a stage IV hard-to-heal ischial PU. We surgically debrided the necrotising tissue and raised an ipsilateral biceps femoris musculocutaneous propeller flap for wound coverage. Polymicrobial infections, including Pseudomonas aeruginosa, were detected in the bone biopsy sample; therefore, systemic PIPC/TAZ was administered for the osteomyelitis. Unexpectedly, during the next 12 days of antibiotic administration, the patient's platelet count acutely dropped to 1×103/μl over three days. Based on a series of examinations, PIPC/TAZ was suspected to be the most likely cause of the severe thrombocytopenia. After drug discontinuation, the thrombocytopenia gradually improved. PIPC/TAZ is one of the most widely used antibiotic combinations in the plastic surgery field; it is conventionally administered for hard-to-heal wounds such as PUs and diabetic foot. The present case suggests that surgeons must take special precautions for patients undergoing PIPC/TAZ treatment. In this report, PIPC/TAZ-induced thrombocytopenia and the efficacy of antibiotic treatment for PU-related osteomyelitis are discussed in light of the available literature.

Adverse reactions of piperacillin: A literature review of case reports

Aim

This study aimed to summarize case reports of adverse drug reactions (ADRs) caused by piperacillin and explore their effects on human organs in real-world settings.

Method

Case reports of piperacillin ADRs were collected by searching databases such as PubMed, Embase, Web of Science, CNKI, WanFang, and VIP from inception to December 2022.

Results

A total of 170 patients were ultimately included. The results revealed that ADRs caused by piperacillin were primarily associated with the entire body, followed by the blood system, skin and soft tissues, and the nervous system. The most frequently reported cases included anaphylactic shock, drug fever, rash, and thrombocytopenia. The most severe ADRs were identified as anaphylactic shock and bullous epidermal necrolysis. Furthermore, a comparison was made between systemic adverse reactions caused by piperacillin as a single drug and two composite preparations of piperacillin/β-lactamase inhibitor. ADRs not mentioned in the instructions included convulsions or hallucinations and Kounis syndrome (KS).

Conclusion

This review suggests that the most severe ADRs associated with piperacillin are toxic epidermal necrolysis and anaphylactic shock. Rare ADRs caused by piperacillin, such as myoclonic jerks, hallucinations, and KS, were identified. The most common symptom with domestic preparations of piperacillin/sulbactam and piperacillin sodium was dyspnea.

Piperacillin‑tazobactam‑induced myocardial injury with heart failure: A case report

Piperacillin-tazobactam is a clinically used antibiotic consisting of the semisynthetic penicillin piperacillin and the β-lactamase inhibitor tazobactam. Piperacillin-tazobactam is a broad-spectrum antibiotic used clinically to treat infections caused by gram-positive and gram-negative aerobic and anaerobic bacteria. The most common adverse reactions are gastrointestinal symptoms and skin reactions. There have been a few reported cases of possible drug hypersensitivity, with thrombocytopenia as the most commonly observed adverse event. The present article reported a rare case of myocardial injury with heart failure following treatment of pneumonia with piperacillin-tazobactam in a 75-year-old female patient. Specifically, this patient presented with fever, chills, flushing and tachypnea, in addition to elevated leukocyte, neutrophil, cardiac enzyme and brain natriuretic peptide levels. This patient also presented with a mild ST-segment elevation on the electrocardiogram following piperacillin-tazobactam treatment. Improvements in the aforementioned adverse reactions were observed and the underlying infection didn't come back following the discontinuation of piperacillin-tazobactam treatment. Therefore, the present observations suggest that piperacillin-tazobactam may have induced myocardial injury and heart failure. Possible occurrence of similar adverse reactions in the heart should be considered before choosing piperacillin-tazobactam as treatment in clinical practice.

Development and validation of a risk prediction model for linezolid-induced thrombocytopenia in elderly patients

OBJECTIVES

Linezolid is the first oxazolidinone antimicrobial agent developed for treating multi-drug-resistant gram-positive bacterial infections. The study aimed to investigate the risk factors of linezolid (LI)-induced thrombocytopenia (LI-TP) and to develop and validate a risk prediction model to identify elderly patients at high risk of developing LI-TP during linezolid therapy.

METHODS

A retrospective cohort study was performed at Zhongshan Hospital, FuDan University, China. The study involved elderly Chinese patients aged ≥65 years administered with linezolid (600 mg) twice a day between January 2015 and April 2021. We collected the patients' clinical characteristics and demographic data from electronic medical records, and compared the differences between LI-TP patients and those who had not developed thrombocytopenia (NO-TP) after linezolid treatment. The risk prediction model was developed based on the regression coefficient generated from logistic regression model.

RESULTS

A total of 343 inpatients were enrolled from January 2015 to August 2020 and were used as the training set. Among them, 67 (19.5%) developed LI-TP. Multivariate logistic regression analysis revealed that baseline platelet counts <150×109·L-1 (odds ratio (OR)=3.576; p<0.001), age ≥75 years (OR=2.258; p=0.009), estimated glomerular filtration rate (eGFR <60 mL·(min·1.73 m2)-1 (OR=2.553; p=0.002), duration of linezolid therapy ≥10 d (OR=3.218; p<0.001), intensive care unit (ICU) admittance (OR=2.682; p=0.004), concomitant piperacillin-tazobactam (OR=3.863; p=0.006) were independent risk factors for LI-TP in elderly patients. The LI-TP risk prediction model was established using a scoring method based on the regression coefficient and exhibited a good discriminative power, with an area under the curve (AUC) of 0.795 (95% confidence interval (CI) 0.740 to 0.851) and 0.849 (95% CI 0.760 to 0.939) in the training set (n=343) and validation set (n=90) respectively.

CONCLUSIONS

These findings indicate that duration of linezolid therapy, age, eGFR, ICU admittance, baseline platelet counts, concomitant piperacillin-tazobactam were significantly associated with LI-TP in elderly patients. A risk prediction model based on these risk factors showed a good discriminative performance and may be useful for clinicians to identify patients at high risk of developing LI-TP.

Piperacillin-tazobactam induced immune hemolytic anemia led to increased renal impairment and eventual death from multiple organ failure in a patient with hypertensive nephropathy: case report and literature review

BACKGROUND

Piperacillin is one of the most common drugs that cause drug-induced immune hemolytic anemia, but a complete description of the serological features and course of the disease is rare. This study completely describes the serological characteristics and course of a patient with hypertensive nephropathy who developed drug-induced immune hemolytic anemia and worsened renal function during repeated administration of piperacillin-tazobactam.

CASE PRESENTATION

A 79-year-old male patient with hypertensive nephropathy who developed severe hemolytic anemia and worsened renal function during intravenous piperacillin-tazobactam anti-infective treatment due to lung infection. Serological tests showed that the result of the direct antiglobulin test for anti-IgG was positive (4 +) and anti-C3d was negative, and the irregular red blood cell antibody screening test was negative. Plasma samples collected at different times from 2 days before to 12 days after the discontinuation of piperacillin-tazobactam administration were incubated with piperacillin solution and red blood cells of O-type healthy blood donors at 37 °C, IgG piperacillin-dependent antibodies were detected, and the highest titer was 128. However, no tazobactam-dependent antibody was detected in any plasma samples. Therefore, the patient was diagnosed with piperacillin-induced immune hemolytic anemia. Although blood transfusion and continuous renal replacement therapy were given, the patient died of multiple organ failure 15 days after the administration of piperacillin-tazobactam was stopped.

CONCLUSION

This is the first complete description of the disease course and serological changes of piperacillin-induced immune hemolytic anemia, which is bound to help deepen the understanding of drug-induced immune hemolytic anemia and draw profound lessons from it.

Evaluation of the safety of piperacillin-tazobactam extended infusion in pediatric cystic fibrosis patients

BACKGROUND

Patients with cystic fibrosis (CF) may be treated with piperacillin-tazobactam (PZT) for acute pulmonary exacerbations. Extending the infusion of PZT is one strategy to increase efficacy. Direct comparison, with respect to the incidence of acute kidney injury (AKI), between these two strategies has not been evaluated in pediatric patients with CF. The primary objective of this study was to compare the incidence of AKI in pediatric CF patients receiving extended infusion (EI) PZT versus traditional infusion (TI).

METHODS

This IRB-approved, retrospective analysis included patients ages 30 days to 18 years that received PZT for at least 48 h between January 1, 2008, and January 1, 2020. PZT was infused over 30 min (TI group) or 4 h (EI group).

RESULTS

Two hundred and four patients were included (TI: 109, EI: 95). Median age was 8 years (4-13) and 7 years (3-12) in the TI and EI groups (p = 0.15). The groups did not differ significantly in their baseline characteristics. There were 12 (11%) AKIs in the TI group and 8 (8.4%) in the EI group (p = 0.53). There was one occurrence of serum sickness in the TI group and none in the EI group. The incidence of thrombocytopenia was similar between the two groups. Median treatment duration was 8 days (5-11) and 9 days (5-13) for the TI and EI groups, respectively (p = 0.24).

CONCLUSIONS

There was no significant increase in AKI in pediatric patients with CF receiving PZT by EI compared with TI. EI may be utilized to optimize the pharmacokinetics of PZT in pediatric CF patients.

Piperacillin-Tazobactam Induced Rapid Severe Thrombocytopenia Without Known Exposure

Thrombocytopenia is one of the commonly encountered laboratory abnormalities in the inpatient setting. The process of excluding life-threatening causes can be daunting and may result in overlooking iatrogenic sources such as medications. Antibiotics are known culprits; however, there are limited reports of rapid and severe onset thrombocytopenia following piperacillin-tazobactam (TZP) that were frequently observed in critically ill or immunocompromised patients with previous exposure to the antibiotic. This case describes a patient being treated for a soft tissue infection with vancomycin and TZP. Initiation of antimicrobial therapy resulted in severe thrombocytopenia and a platelet nadir of approximately 4,000 within 24 hours of the first doses. Thrombocytopenia resolved within three days of TZP withdrawal. To the best of our knowledge, there have not been any cases described of rapid drug-induced thrombocytopenia without previous exposure to the medication. Medications should always be reviewed when evaluating a patient with rapid and severe thrombocytopenia, which can obviate the need for unnecessary invasive or non-invasive treatments.

Glucose-6-phosphate dehydrogenase deficiency and hydroxychloroquine in the COVID-19 era: a mini review

The coronavirus disease 2019 (COVID-19) is until today a global health emergency. In an immense effort, effective drugs against COVID-19 are searched and intensive researches on possible repurposing of antiviral agents are performed. Since chloroquine (CQ) and hydroxychloroquine (HCQ) have shown in vitro anti- COVID-19 activities, the potential effect of CQ/HCQ to treat and/or prevent COVID-19 infection has caused global attention. However, concern regarding possible hemolysis in G6PD-deficient COVID-19 patients exists and for this reason, the association between HCQ and G6PD deficiency (G6PDD) is back in the limelight. This study aims to answer the question raised by Mastroianni et al. "Hydroxychloroquine: Culprit or Innocent Bystander in G6PD-Deficient Patients with COVID-19?", reporting all cases of HCQ in G6PD deficient COVID-19 patients published on PubMed (pubmed.ncbi.nlm.nih.gov), in addition to the Mastroianni's patient. In our opinion, after an accurate revision of these cases and responding the question raised by Mastroianni et al., we believe that it is difficult to reach a final verdict about the definitive role of HCQ in these patients. The COVID-19 pandemic has reopened attention on HCQ use and G6PDD. G6PD status is extremely important in modulating the level of reactive oxygen species and many cellular immune responses such as enhanced production of the pro-inflammatory cytokine and inflammasome activation. Since these processes are involved in COVID-19 infection, acute hemolytic anemia, a severe complication of the G6PDD, can occur in these patients. In this context, the role of HCQ, usually effective, safe, and well tolerated in G6PD deficient patients, must be redefined in these patients with COVID-19.As consequence, answering the question: "Hydroxychloroquine: Culprit or Innocent Bystander in G6PD-Deficient Patients with COVID-19?", we state that it is risky to believe that HCQ may be an "innocent bystander" in G6PD-deficient COVID-19 patients.

Serious adverse events with novel beta-lactam/beta-lactamase inhibitor combinations: a large-scale pharmacovigilance analysis

The purpose of this study is to characterize adverse events (AEs) of clinical interest reported with ceftolozane-tazobactam and ceftazidime-avibactam, as an aid in monitoring patients affected by severe multidrug-resistant Gram-negative infections. We queried the worldwide FDA Adverse Event Reporting System (FAERS) and performed disproportionality analysis, selecting only designated medical events (DMEs) where ceftolozane-tazobactam and ceftazidime-avibactam were reported as suspect. Serious neurological AEs were further investigated. The reporting odds ratios were calculated, deemed significant by the lower limit of the 95% confidence interval (LL95% CI) > 1. All other drugs/events recorded in FAERS and cephalosporins showing clinical evidence of neurological AEs were respectively selected as comparator for analysis of DMEs and neurotoxicity. Qualitative analysis including case-by-case assessment and deduplication was also performed. Overall, 654 and 506 reports mentioning respectively ceftolozane-tazobactam and ceftazidime-avibactam were found, with DMEs accounting respectively for 13.1% and 10.9% of cases. Agranulocytosis (N = 12; LL95% CI = 12.40) and pancytopenia (14; 6.18) emerged as unexpected AEs with ceftolozane-tazobactam, while acute pancreatitis (7; 8.63) was an over-reported unexpected DME with ceftazidime-avibactam. After deduplication, four unequivocally different cases of agranulocytosis with ceftolozane-tazobactam were retained, occurring on average after 8.8 days. Causality was probable and possible respectively in three and one case. Among neurological AEs exhibiting significant disproportionality, encephalopathy with both antibiotics and mental status changes with ceftazidime-avibactam were retained in at least three cases after deduplication. Although rare, clinicians should monitor high-risk patients (i.e. individuals affected by haematological malignances, HIV infection, or treated with concomitant myelotoxic agents) for early unexpected occurrence of agranulocytosis with ceftolozane-tazobactam.