Ceftriaxone-associated biliary pseudolithiasis in children: do we know enough?

Clinical and biochemical characteristics, and outcome in 33 patients with ceftriaxone-induced liver injury

PURPOSE

To summarize the clinical and biochemical characteristics of patients with ceftriaxone-induced liver injury and guide the selection of safe medication.

METHODS

Retrieved domestic and foreign databases from inception to October 2023, collected case data conforming to ceftriaxone-induced liver injury, and statistically analyzed the data.

RESULTS

A total of 617 articles were retrieved, and 16 articles with 33 cases (10 children, 23 adults) were included. Males represented 60% (18/30), with a male-to-female ratio of 1.5:1. The age of onset ranged from 2 days to 96 years, with 15 of 23 adults (65%) over 55 years old. The time from ceftriaxone use to liver injury fluctuated between 0.5 and 47 days. Only 9 patients (27.3%, 9/33) had clinical symptoms, and the clinical classification was dominated by cholestatic injury (46.2%, 12/26). There was a significant difference in the clinical classification of ceftriaxone-induced liver injury between children and adults (P = 0.0126), with hepatocellular injury predominating in children and cholestatic injury predominating in adults. The severity of liver injury was mainly mild (66.7%, 12/18). Peak values of alanine aminotransferase ranging from 228.5 to 8098 U/L, aspartate aminotransferase ranging from 86.7 to 21575 U/L, alkaline phosphatase ranging from 143 to 2434 U/L, and total bilirubin ranging from 3.35 to 66.1 mg/dL. There was a significant difference in peak values of alkaline phosphatase between children and adults (P = 0.027), with a higher peak value of alkaline phosphatase in adults (1039 ± 716.4 U/L vs. 257 ± 134.9 U/L). Patients with normal imaging examinations accounted for the majority (61.5%, 7/13). The prognosis of 32 patients (97%, 32/33) was good, and one child with sickle cell anemia who developed immune hemolysis, progressive renal failure, and acute liver injury after using ceftriaxone died in the end.

CONCLUSION

Ceftriaxone-induced liver injury can occur at any age, with a higher risk in the elderly, and age may be related to the clinical classification. Although the clinical manifestations are not specific, close monitoring of liver biochemical indicators during the use can detect liver injury early. Most cases have a good prognosis, but for people with concomitant sickle cell anemia, it is necessary to be vigilant about the occurrence of severe hemolytic anemia.

Diseases of bile duct in children

Several diseases originate from bile duct pathology. Despite studies on these diseases, certain etiologies of some of them still cannot be concluded. The most common disease of the bile duct in newborns is biliary atresia, whose prognosis varies according to the age of surgical correction. Other diseases such as Alagille syndrome, inspissated bile duct syndrome, and choledochal cysts are also time-sensitive because they can cause severe liver damage due to obstruction. The majority of these diseases present with cholestatic jaundice in the newborn or infant period, which is quite difficult to differentiate regarding clinical acumen and initial investigations. Intraoperative cholangiography is potentially necessary to make an accurate diagnosis, and further treatment will be performed synchronously or planned as findings suggest. This article provides a concise review of bile duct diseases, with interesting cases.

Key CT and MRI findings of drug-associated hepatobiliary and pancreatic disorders

Obtaining an imaging diagnosis of various hepatobiliary and pancreatic disorders caused by certain drugs can often be challenging. Familiarity with these conditions may improve diagnostic accuracy and patient management. This review aimed to describe the imaging findings of drug-associated hepatobiliary and pancreatic disorders and identify suggestions for obtaining a correct diagnosis. We focused on relatively common disorders or those that can present with characteristic imaging findings, such as drug-induced acute hepatitis, sinusoidal obstruction syndrome, focal nodular hyperplasia-like lesions, hepatocellular adenoma, pseudocirrhosis, chemotherapy-associated steatohepatitis, amiodarone deposition in the liver, secondary iron overload, drug-induced pancreatitis, pancreatic enlargement after epoprostenol therapy, ceftriaxone-associated gallbladder pseudolithiasis, immune-related adverse events, and methotrexate-associated lymphoproliferative disorders.

Are children with gallstone disease more overweight? Results of a matched case-control analysis

INTRODUCTION

Gallstone disease (GD) is increasingly common among children, possibly caused by an unhealthy food environment and the associated unhealthy lifestyle. In this study, we investigate the association between body weight and gallstone risk in a cohort of prospectively recruited children with GD.

METHODS

We analysed 188 children with gallstones (50.0% girls, median age 9.8 years) and 376 children without stones who were age- and gender-matched to cases in a ratio of 2:1. Cases were prospectively recruited at three Polish university centres (Warsaw, Katowice and Bialystok). Gallstones were diagnosed by either abdominal sonography or by a history of cholecystectomy. Matched controls without gallstones were selected from 22,412 children taking part in nationally representative Polish health surveys (OLA and OLAF studies) which provided height and weight data for randomly selected pre-school (2.5-6 years) and school aged (7-18 years) children and adolescents.

RESULTS

Analysis of the age- and gender-matched cases and controls demonstrated that patients with GD had significantly higher BMI (P = 0.02) and BMI z-score (P < 0.01) than children without stones. Children with gallstones were more frequently overweight (35.6%, P < 0.01) and obese (12.2%, P < 0.01) than controls (18.4% and 6.7%, respectively). Regression analyses showed that BMI, BMI z-score, overweight and obesity were all associated with increased GD risk (all P < 0.05).

CONCLUSIONS

Overweight and obesity are common in children with cholelithiasis. Given the epidemic of obesity in children we should expect an increasing prevalence of gallstones and stone-related complications in youths and in adults.

Validated HPLC method for ceftriaxone from dried blood spots for pharmacokinetic studies and therapeutic drug monitoring in neonatal population

Background: Pharmacokinetic evaluation is essential for the precise dosing of ceftriaxone in neonates. There is a need for developing a sensitive, affordable and convenient analytical method that can estimate ceftriaxone from dried blood spot (DBS) samples of neonates. Method: An HPLC-UV method was developed and validated as per ICH M10 for ceftriaxone from DBS and plasma using an Inertsil-ODS-3V column with gradient elution. DBS samples were extracted with methanol. Clinical validation was performed using neonatal samples. Results: The developed plasma- and DBS-based-HPLC method were linear from 2-700 μg/ml and 2-500 μg/ml, respectively, for ceftriaxone. Bland-Altman analysis indicated a strong interconvertibility between the plasma and DBS assays. Conclusion: Observed concentrations in clinical samples were comparable to the predicted concentrations, proving the clinical validity of the method.

Ceftriaxone Administration Associated with Lithiasis in Children: Guilty or Not? A Systematic Review

Lithiasis is a known side effect of ceftriaxone administration in children. Sex, age, weight, dosage, and duration of intake have been reported as risk factors for the formation of calcification or stones in the bile and urine excretory systems of children who received ceftriaxone. The purpose of this systematic review is to investigate the reported effects of ceftriaxone administration in pediatric patients who were admitted to a hospital due to infection, the likelihood of gallstones, nephroliths, or precipitations in both the biliary and urinary systems, as well as investigate the relationship with their mother's history during pregnancy. Original studies and literature reviews from the PubMed database were included in the study. No time limit related to research or publication was set for the articles. The results were evaluated, aiming to understand the outcomes and identify any predisposing factors relevant to this side effect. Of the 181 found articles, 33 were appropriate for inclusion in the systematic review. The administered dose of ceftriaxone presented variability. Symptoms, such as abdominal pain and vomiting, were associated with ceftriaxone-related lithiasis in many cases. It was noted that most of the results were the outcomes of retrospective observation and not of prospective randomized research. Definitively, more randomized control studies with long-term outcomes are needed to identify the exact association between ceftriaxone and lithiasis in children.

Effect of ceftriaxone on intestinal transit time

Ceftriaxone reduces gallbladder and ileal contractility. Many studies have shown that ceftriaxone causes biliary sludge and pseudolithiasis. However, its effect on intestinal transit time has not been investigated. This study aimed to investigate the effect of ceftriaxone on intestinal transit time. Sixteen rats were examined in two groups: The study group (group A, n = 8) was administered with 100 mg/kg ceftriaxone intramuscularly for 7 days. The control group (group B, n = 8) was administered with intramuscular distilled water for 7 days. On the seventh day, a mixture of 2 ml barium and saline was given orally to both groups. Barium transit was evaluated using serial digital X-ray images. The stomach was full and the transition into the small intestine loop was observed in all rats at 45 min in both groups. At the 2nd hour, colonic transition was observed in two rats in group A (2/8, 25%) and in seven rats in group B (7/8, 87.5%). At the 4th hour, five (62.5%) rats in group A had transverse colonic transition, and all rats in group B (8/8, 100%) had transverse and/or left colonic transition. At the 6th hour, no rat in group A had rectal transition, and all rats in group B (8/8, 100%) had complete passage of colonic contrast material. Ceftriaxone significantly prolongs the small intestine transit time, large intestine transit time, and total intestinal transit times.

The Etiology of Cholelithiasis in Children and Adolescents-A Literature Review

The incidence of gallstone disease has increased in recent years. The pathogenesis of cholelithiasis is not fully understood. The occurrence of the disease is influenced by both genetic and environmental factors. This article reviews the literature on cholelithiasis in children, with the exception of articles on hematological causes of cholelithiasis and cholelithiasis surgery. The aim of this review is to present the latest research on the pathogenesis of gallstone disease in children. The paper discusses the influence of all factors known so far, such as genetic predisposition, age, infections, medications used, parenteral nutrition, and comorbidities, on the development of gallstone disease. The course of cholelithiasis in the pediatric population is complex, ranging from asymptomatic to life-threatening. Understanding the course of the disease and predisposing factors can result in a faster diagnosis of the disease and administration of appropriate treatment.

Treatment options for neonatal infections in the post-cefotaxime era

INTRODUCTION

: Cefotaxime has been used for the management of neonatal infections since the 1990s for suspected meningitis and to mitigate gentamicin-associated renal injury. Its shortage in 2015 and subsequent removal from the U.S. pharmaceutical market forced providers to consider alternatives. Ceftriaxone, a cephalosporin with an identical antibacterial spectrum of activity to cefotaxime, is contraindicated in neonates due to its risk of biliary pseudolithiasis. Ceftazidime was recommended as an alternative by the American Academy of Pediatrics but is inequivalent.

AREAS COVERED

: This article addresses indications for cephalosporin use and considerations when selecting an alternative to cefotaxime. Differences among cefotaxime, ceftriaxone, ceftazidime, and cefepime are discussed and compared to the standard-of-care presumptive regimen, ampicillin and gentamicin. The authors consider the data behind the neonatal contraindication to ceftriaxone and provide recommendations for their application to practice.

EXPERT OPINION

: The data against ceftriaxone use in neonates remain poor, particularly in the context of the cefotaxime shortage and lack of an equivalent alternative. Ceftriaxone could be considered in low-risk neonates without hyperbilirubinemia or exposure to calcium-containing fluids on a case-by-case basis. Ceftazidime monotherapy for presumptive management of neonatal infections is inappropriate; cefepime should be more frequently utilized in neonates who are poor candidates for ceftriaxone.

Acute necrotizing calculous cholecystitis after treatment with ceftriaxone in an elderly patient: a case report

BACKGROUND

Ceftriaxone, a third-generation cephalosporin antibiotic with a long plasma half-life, is widely used to treat various infections. The use of ceftriaxone can sometimes induce biliary sludge or stone formation. Although most cases of ceftriaxone-induced pseudolithiasis are asymptomatic or mild and resolve with discontinuation of the drug, we experienced an elderly case of severe acute necrotizing calculous cholecystitis after administration of ceftriaxone.

CASE PRESENTATION

A 72-year-old male patient was admitted to our hospital because of acute diverticulitis in ascending colon. Ceftriaxone was administered at a dose of 2 g/day for 6 days. Although he recovered after therapy, he was readmitted about 2 weeks later because of severe pain with rebound tenderness in the right upper quadrant. An abdominal imaging study revealed stones and sludge in the gallbladder that were not observed before starting ceftriaxone therapy. Therefore, antibiotic treatment with flomoxef 2 g/day was indicated. However, on the fifth day of readmission, the peritoneal irritation symptoms in the right upper quadrant worsened, and elevated inflammatory response and liver dysfunction were observed. Cholecystectomy was performed based on these findings. The resected inflamed gallbladder showed acute necrotizing cholecystitis with sand granular gallstones. A comparative analysis of the infrared spectroscopic pattern of the composition of gallstones collected during surgery with that of the ceftriaxone powder revealed that both have very similar infrared spectroscopic patterns.

CONCLUSIONS

Ceftriaxone-related pseudolithiasis is generally reversible and mainly observed in children. Here, we report a rare case of ceftriaxone-related acute necrotizing cholecystitis in an elderly patient. We confirmed that the stones in the gallbladder are composed of ceftriaxone. The older age, dehydration, fasting, and long-time bed rest during the administration of high-dose ceftriaxone were the potential risk factors for gallstone formation.

Ceftriaxone-induced cholestatic hepatitis in a child: A case report and a review of the literature

Ceftriaxone, a third-generation cephalosporin, is commonly used in pediatric patients and is generally well tolerated. Its more frequent adverse effects are biliary pseudolithiasis, urolithiasis, and hemolytic anemia. On the other hand, ceftriaxone-induced acute cholestatic hepatitis is a very rare condition, especially in children. Here, we describe a case of this condition in a young male child to highlight the importance of suspecting this drug-induced liver injury to achieve a prompt diagnosis.

Central nervous system infections and antimicrobial resistance: an evolving challenge

PURPOSE OF REVIEW

Antimicrobial resistance is an increasing threat to patients also in nosocomial central nervous system (CNS) infections. The present review focusses on optimizing intravenous treatment in order to achieve sufficient concentrations of antibiotics in the different compartments of the CNS when the causative pathogens have reduced sensitivity to antibiotics or/and the impairment of the blood-cerebrospinal fluid (CSF) and blood-brain barrier is mild.

RECENT FINDINGS

Experience has been gathered with treatment protocols for several established antibiotics using increased doses or continuous instead of intermittent intravenous therapy. Continuous infusion in general does not increase the average CSF concentrations (or the area under the concentration-time curve in CSF) compared to equal daily doses administered by short-term infusion. In some cases, it is postulated that it can reduce toxicity caused by high peak plasma concentrations. In case reports, new β-lactam/β-lactamase inhibitor combinations were shown to be effective treatments of CNS infections.

SUMMARY

Several antibiotics with a low to moderate toxicity (in particular, β-lactam antibiotics, fosfomycin, trimethoprim-sulfamethoxazole, rifampicin, vancomycin) can be administered at increased doses compared to traditional dosing with low or tolerable adverse effects. Intrathecal administration of antibiotics is only indicated, when multiresistant pathogens cannot be eliminated by systemic therapy. Intravenous should always accompany intrathecal treatment.

Risk factors, manifestations, diagnosis and treatment of cholelithiasis in children

Cholelithiasis in children refers to cholelithiasis or choledocholithiasis in newborns, infants and adolescents, including a series of symptoms and complications related to stones. The incidence rate of cholelithiasis in children is far lower than that in adults. However, the detection rate of cholelithiasis in children has risen in recent years. The aetiology of cholelithiasis in children is complex, and the pathogenesis is still unclear. According to existing studies, cholelithiasis in children may be related to sex and hormones, obesity, drugs, haemolytic diseases, genetic factors, chemokines, abnormal biliary tract formation, ileal surgery, total parenteral nutrition and other factors. In addition, there is a large occurrence of idiopathic cholelithiasis in children with unknown aetiology. The clinical manifestations of cholelithiasis in children are not completely the same as those in adults, mainly due to the different ages and causes. At present, there is no consensus on the clinical treatment of cholelithiasis in children. Follow-up and observation, drug dissolution and surgical treatment are all treatment methods for children with cholelithiasis. This study reviewed the related literature reports of cholelithiasis in children and summarized the risk factors, clinical manifestations, diagnosis and treatment of cholelithiasis in children to improve the understanding, diagnosis, and treatment of cholelithiasis in children.