Acute hepatitis associated with the use of levofloxacin

Hepatoprotective Effect of Ethanolic Pomegranate Peel Extract Against Levofloxacin via Suppression of Oxidative Stress, Proinflammation, and Apoptosis in Male Rats

One of the fluoroquinolone antibiotics, levofloxacin (LEV), is used to treat a variety of illnesses leading to oxidative stress and cellular damage. Peel from Punica granatum is a waste product abundant in phytochemicals with various biological activities. This study aimed to evaluate P. granatum peel extract's (PGPE) potential to mitigate oxidative stress, inflammation, apoptosis, and liver damage caused by LEV. There were four groups of rats: control, PGPE, LEV, and PGPE + LEV, respectively, and they were orally administered their daily treatments for 2 weeks. Results revealed that PGPE has a large number of phytochemical components with high antioxidant activity. PGPE intake alone enhanced the antioxidant status and decreased oxidative stress. On the other hand, pretreatment of the LEV group with PGPE restored oxidative stress, antioxidant enzymes, glutathione content, liver function biomarkers, and hematological parameters. Also, normalization of gene expressions (cyclooxygenase-2, transforming growth factor-beta1, caspase-3, heme oxygenase-1, B cell lymphoma-2, interleukin [IL]-10, and IL-1) and improvement in liver architecture, and immunohistochemical alpha-smooth muscle actin, were seen in comparison to the LEV group. Conclusively, PGPE exhibits strong anti-inflammatory, antiapoptotic, and antioxidant properties that shield rat liver from the damaging effects of LEV and offer a fresh viewpoint on the application of fruit waste products.

A systematic review of the drug-drug interaction between Statins and Quinolones

BACKGROUND

Statins are widely used in cardiovascular disease (CVD) as a common lipid-lowering drug, while quinolones are widely used for the treatment of infectious diseases. It is common to see CVD in combination with infectious diseases, therefore it is often the case that statins and quinolones are used in combination. Data suggest combinations of statin and quinolone may be associated with potentially life-threatening myopathy, rhabdomyolysis and acute hepatitis. This systematic review aims to characterize data regarding patients affected by the statin-quinolone interaction.

METHODS

The purpose of this systematic review was to collect and evaluate the evidence surrounding statin-quinolone drug interactions and to discuss related risk mitigation strategies. The following databases were searched: PubMed (Medline), Embase, Scopus, and Cochrane Library. The systematic electronic literature search was conducted with the following search terms. In this study, three types of search terms were used: statins-related terms, quinolones-related terms, and drug interactions-related terms.

RESULTS

There were 16 case reports that met the criteria for qualitative analysis. Patients were involved in the following adverse reactions: rhabdomyolysis (n = 12), acute hepatitis (n = 1), muscle weakness (n = 1), hip tendinopathy (n = 1), or myopathy (n = 1). In the included literature, patients vary in the dose and type of statins they take, including simvastatin (n = 10) at a dose range of 20-80 mg/d and atorvastatin (n = 4) at a dose of 80 mg/d. There were 2 patients with unspecified statin doses, separately using simvastatin and atorvastatin. The quinolones in combination were ciprofloxacin (n = 9) at a dose range of 800-1500 mg/d, levofloxacin (n = 6) at a dose range of 250-1000 mg/d, and norfloxacin (n = 1) in an unspecified dose range. 81% of the case patients were over 60 years of age, and about 1/3 had kidney-related diseases such as diabetic nephropathy, post-transplantation, and severe glomerulonephritis. Nearly two-third of the patients were on concomitant cytochrome P450 3A4 (CYP3A4) inhibitors, P-glycoprotein (P-gp) inhibitors, or organic anion transporting polypeptide 1B1 (OATP1B1) inhibitors.

CONCLUSION

Patients treated with statin-quinolone combination should be monitored more closely for changes in aspartate aminotransferase or creatine kinase (CK) levels, and muscle symptoms, especially in patients with ciprofloxacin or levofloxacin, with simvastatin and high-dose atorvastatin, over 60 years of age, with kidney-related diseases, and on concomitant CYP3A4 inhibitors.

5-Alpha Reductase Inhibitors and the Risk of Anemia among Men with Benign Prostatic Hyperplasia: A Population-based Cohort Study

BACKGROUND

5-alpha reductase inhibitors (5αRIs) are effective for the treatment of benign prostatic hyperplasia (BPH). However, 5αRIs could lower levels of hemoglobin, increasing the risk of anemia.

OBJECTIVE

To compare the rate of anemia between new users of 5αRIs and α-blockers in the United Kingdom (UK).

METHODS

We conducted a matched, active comparator, new-user cohort study using the Clinical Practice Research Datalink. The study population consisted of men aged 40+ years with incident BPH who initiated 5αRIs between 1998 and 2019 and were matched 1:1 on propensity score to new users of α-blockers. Anemia was defined by a measured hemoglobin < 130 g/l. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for anemia.

RESULTS

Our study cohort included 9,429 new users of 5αRIs and 9,429 matched new users of α-blockers. Their median durations of follow-up were 136 days (interquartile range [IQR]: 54-336 days) and 77 days (IQR: 58-236), respectively. A total of 2,865 5αRIs users and 2,407 α-blocker users developed incident anemia, representing rates of 37.3 (95% CI: 33.6-41.3) and 42.0 (95% CI: 38.1-46.2) per 100 person-years, respectively. The use of 5αRIs was not associated with an increased risk of anemia compared to the use of α-blockers (HR: 0.95, 95% CI: 0.90-1.00). Similarly, we did not observe an increased risk of mild, moderate, or severe anemia.

CONCLUSION

The use of 5αRIs was not associated with an increased risk of anemia compared to the use of α-blockers among men with BPH.

Hepatotoxicity Secondary to Levofloxacin Use

Levofloxacin is a broad-spectrum antibiotic that is used in the treatment of many infections. A rare adverse drug reaction following the use of levofloxacin is drug-induced liver injury. The exact mechanism behind fluoroquinolone-induced liver injury is unknown, but many severe, sometimes fatal hepatotoxicity cases are reported. Current recommendations advise clinicians to discontinue levofloxacin immediately if the patient develops signs and symptoms of hepatitis. This case report presents a 79-year-old male who was prescribed levofloxacin 500 mg by mouth daily for seven days. The patient had a past medical history of dementia, seizures, cerebral vascular accident, pulmonary fibrosis, and chronic kidney disease. Upon admission, the patient began to show signs and symptoms of liver injury. We hereby present a case report and a review of significant literature on levofloxacin-induced liver injury.

Ameliorative effects of Moringa oleifera leaf extract on levofloxacin-induced hepatic toxicity in rats

Fluoroquinolones are some of the most common antibiotics used by clinicians all over the world. Levofloxacin, a fluoroquinolone, is used therapeutically in numerous countries; however, it can cause an increase in liver function tests and liver dysfunction. The current study was designed to determine the effect of Levofloxacin (40 mg/kg body weight (b.wt.) daily for 2 weeks) on rat liver function and oxidative stress markers as well as to evaluate the potential hepatoprotective effects of Moringa oleifera leaf extract as a known antioxidant herb. M. oleifera leaf extract was found to improve the hepatic dysfunction induced by Levofloxacin by recovering liver enzymatic activities (alanine aminotransferase [ALT], aspartate aminotransferase [AST] and gamma-glutamyl transferase [GGT]) to normal levels. The extract also reversed the antioxidant imbalance as measured by catalase and superoxide dismutase activities as well as by reduced glutathione and malondialdehyde levels. Moreover, M. oleifera leaf extract induced anti-inflammation by improving the production of interleukin (IL)-10. Additionally, its presence attenuated the downregulation of IL-1 induced by Levofloxacin alone from hepatic tissue. It can be concluded that M. oleifera extract can help reduce the side effects caused by Levofloxacin administration.

Endoplasmic reticulum stress precedes oxidative stress in antibiotic-induced cholestasis and cytotoxicity in human hepatocytes

Endoplasmic reticulum (ER) stress has been associated with various drug-induced liver lesions but its participation in drug-induced cholestasis remains unclear. We first aimed at analyzing liver damage caused by various hepatotoxic antibiotics, including three penicillinase-resistant antibiotics (PRAs), i.e. flucloxacillin, cloxacillin and nafcillin, as well as trovafloxacin, levofloxacin and erythromycin, using human differentiated HepaRG cells and primary hepatocytes. All these antibiotics caused early cholestatic effects typified by bile canaliculi dilatation and reduced bile acid efflux within 2h and dose-dependent enhanced caspase-3 activity within 24h. PRAs induced the highest cholestatic effects at non cytotoxic concentrations. Then, molecular events involved in these lesions were analyzed. Early accumulation of misfolded proteins revealed by thioflavin-T fluorescence and associated with phosphorylation of the unfolded protein response sensors, eIF2α and/or IRE1α, was evidenced with all tested hepatotoxic antibiotics. Inhibition of ER stress markedly restored bile acid efflux and prevented bile canaliculi dilatation. Downstream of ER stress, ROS were also generated with high antibiotic concentrations. The protective HSP27-PI3K-AKT signaling pathway was activated only in PRA-treated cells and its inhibition increased ROS production and aggravated caspase-3 activity. Overall, our results demonstrate that (i) various antibiotics reported to cause cholestasis and hepatocellular injury in the clinic can also induce such effects in in vitro human hepatocytes; (ii) PRAs cause the strongest cholestatic effects in the absence of cytotoxicity; (iii) cholestatic features occur early through ER stress; (iv) cytotoxic lesions are observed later through ER stress-mediated ROS generation; and (v) activation of the HSP27-PI3K-AKT pathway protects from cytotoxic damage induced by PRAs only.

Levofloxacin-induced hepatotoxicity and death

Drug-induced hepatotoxicity is a major cause of hepatocellular injury in patients admitting to emergency services with acute liver failure. Hepatic necrosis may be at varying degrees from mild elevations in transaminases to fulminant hepatitis, and even death. The case of a 53-year-old female patient with toxic hepatitis due to levofloxacin and multiple organ failure secondary to toxic hepatitis is presented. Patient suffered itching, redness, and rash after receiving a single dose of 750 mg of levofloxacin tablets for pulmonary infection 10 days ago. Skin lesions had regressed within 3 days, but desquamation formed all over the body. After the fifth day of drug intake, complaints of abdominal pain, vomiting, and yellowing in skin color had started. The patient was referred to our emergency department with these complaints 10 days after drug intake. Patient was thought as a candidate for liver transplant, but cardiopulmonary arrest occurred, and the patient died before she could be referred to a transplant center. This case is important because hepatotoxicity and death due to levofloxacin is uncommon in the literature.

Antibiotic induced liver injury: what about children?

Antimicrobial agents are important causes of drug-induced liver injury. They are responsible for about 45% of cases of drug hepatotoxicity. Hepatic damage mechanisms are intrinsic or idiosyncratic. Usually, antibiotics are responsible for idiosyncratic toxicity. This review summarizes the rate of incidence and clinical features of hepatotoxicity due to antibiotics and chemotherapics, with particular attention to data regarding paediatric population. Liver injury features have been systematically evaluated for the most commonly administered antibiotics and chemotherapics in adults, even though there is little information about other widely used compounds, as cephalosporine or clarithromycin, and about antibiotics active against multi-resistant bacteria, as carbapenems, vancomycin, clindamycin, and linezolid. By contrast, there is an abundance of case reports in paediatrics, but very few structured studies have been carried out in children. Children are an important class of antibiotic users, with specific metabolic characteristics, so more studies on them should be carried out.

The combined use of edaravone, diuretics, and nonsteroidal anti-inflammatory drugs caused acute kidney injury in an elderly patient with chronic kidney disease

The purpose of this study was to draw attention to the fact that the combined use of edaravone, diuretics, and nonsteroidal anti-inflammatory drugs (NSAIDs) may lead to acute kidney injury. This study was a case report of acute kidney injury resulting from the combined use of the aforementioned types of drugs. A 77-year-old male patient with chronic kidney disease (third stage) who was treated with a combination of edaravone, diuretics, and NSAIDs showed significantly increased blood urea nitrogen and creatinine. Interestingly, the blood urea nitrogen and creatinine levels returned to pretreatment levels after the medications were stopped. The patient's score on the Naranjo Adverse Drug Reaction Probability Scale was a nine, and the score on the Drug Interaction Probability Scale was a five. For elderly patients with chronic kidney disease, the combined use of edaravone, diuretics, and NSAIDs should be avoided.