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Drewett GP, Copaescu A, DeLuca J, Holmes NE, Trubiano JA. Asystolic cardiac arrest following liposomal amphotericin B infusion: anaphylaxis or compliment activation-related pseudoallergy? Allergy Asthma Clin Immunol 2021; 17:80. [PMID: 34325715 PMCID: PMC8323293 DOI: 10.1186/s13223-021-00582-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 07/20/2021] [Indexed: 01/05/2023] Open
Abstract
Allergic reaction to liposomal amphotericin B is rare. We report a case of cardiac arrest in a 64-year-old woman following liposomal amphotericin B infusion, requiring resuscitation. We also present the results of subsequent skin prick and intradermal testing to liposomal amphotericin on the patient and three healthy controls, highlighting the need for further research into the immunopathogenesis of this reaction.
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Affiliation(s)
- George P Drewett
- Department of Infectious Diseases, Austin Health, Heidelberg, Australia. .,Department of Drug and Antibiotic Allergy Services, Austin Health, Heidelberg, Australia.
| | - Ana Copaescu
- Department of Drug and Antibiotic Allergy Services, Austin Health, Heidelberg, Australia.,Department of Clinical Immunology and Allergy, McGill University Health Centre, Montréal, Canada
| | - Joseph DeLuca
- Department of Drug and Antibiotic Allergy Services, Austin Health, Heidelberg, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Australia
| | - Natasha E Holmes
- Department of Infectious Diseases, Austin Health, Heidelberg, Australia.,Department of Drug and Antibiotic Allergy Services, Austin Health, Heidelberg, Australia.,Data Analytics Research and Evaluation (DARE) Centre, Austin Health and University of Melbourne, Heidelberg, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Australia.,Department of Drug and Antibiotic Allergy Services, Austin Health, Heidelberg, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Australia
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Sanches BF, Nunes P, Almeida H, Rebelo M. Atrioventricular block related to liposomal amphotericin B. BMJ Case Rep 2014; 2014:bcr-2013-202688. [PMID: 24907206 DOI: 10.1136/bcr-2013-202688] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Atrioventricular block can occur in normal children, young adults or athletes. It is also associated with underlying heart disease or occurs as a drug adverse effect. Amphotericin B is used in the treatment of invasive fungal infections. Cardiac toxicity is a rare adverse reaction. We report the case of a 9-month girl, admitted in the paediatric intensive care unit with cytomegalovirus pneumonitis. During hospitalisation the patient developed a systemic fungic infection and was medicated with liposomal amphotericin B. On the third day of treatment she began repeated episodes of bradycardia with spontaneous reversion. The investigation revealed a second-degree atrioventricular block. We excluded the misplacement of the central catheter, myocarditis or structural cardiomyopathy and suspended amphotericin. After 8 days, the bradycardia episodes ceased what was consistent with the drug's half-life. Amphotericin cardiotoxic mechanism is still unclear. It may be related with alteration of myocardial membrane depolarisation.
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Affiliation(s)
| | - Pedro Nunes
- Department of Pediatric Intensive Care Unit, Hospital Professor Doutor Fernando Fonseca, Lisbon, Portugal
| | - Helena Almeida
- Department of Pediatric Intensive Care Unit, Hospital Professor Doutor Fernando Fonseca, Lisbon, Portugal
| | - Mónica Rebelo
- Department of Pediatrics, Hospital Professor Doutor Fernando Fonseca, Lisbon, Portugal
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Burke D, Lal R, Finkel KW, Samuels J, Foringer JR. Acute amphotericin B overdose. Ann Pharmacother 2006; 40:2254-9. [PMID: 17090724 DOI: 10.1345/aph.1h157] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report the clinical course of a woman with cryptococcal meningitis and no previous cardiac disease who developed a fatal cardiac arrhythmia after an acute overdose of amphotericin B and to review its toxicity. CASE SUMMARY A 41-year-old woman with a history of proliferative glomerulonephritis from systemic lupus erythematosus was admitted with a diagnosis of cryptococcal meningitis. Liposomal amphotericin B was prescribed at the standard dose of 5 mg/kg/day; however, amphotericin B deoxycholate 5 mg/kg was inadvertently administered (usual dose of the deoxycholate formulation is 0.5-0.8 mg/kg/day). The patient developed cardiac arrhythmias, acute renal failure, and anemia. The medication error was noticed after she had received 2 doses of amphotericin B deoxycholate, and it was then discontinued. Despite treatment in the intensive care unit, the woman died on the sixth day after admission. DISCUSSION Amphotericin B deoxycholate has been reported to produce significant cardiac toxicity, with ventricular arrhythmias and bradycardia reported in overdoses in children and in adults with preexisting cardiac disease, even when administered in conventional dosages and infusion rates. Use of the Naranjo probability scale indicated a highly probable relationship between the observed cardiac toxicity and amphotericin B deoxycholate therapy in this patient. CONCLUSIONS Given the fulminant course of amphotericin B deoxycholate overdosage and lack of effective therapy, stringent safeguards against its improper administration should be in place.
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Affiliation(s)
- Douglas Burke
- Division of Renal Diseases and Hypertension, The University of Texas Medical School, Houston, TX 77030-0708, USA
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Wood JE, Mahnensmith MP, Mahnensmith RL, Perazella MA. Intradialytic administration of amphotericin B: clinical observations on efficacy and safety. Am J Med Sci 2004; 327:5-8. [PMID: 14722389 DOI: 10.1097/00000441-200401000-00002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Amphotericin B is used commonly to treat fungal infections. Unfortunately, little information exists regarding the use of intravenous amphotericin B in patients with end-stage renal disease (ESRD). METHODS We retrospectively reviewed the clinical course of patients receiving amphotericin B during hemodialysis (HD). Twenty-five episodes of systemic fungal infection occurring in 24 patients with ESRD treated with parenteral amphotericin B administered during HD were noted. Patients received a maintenance dose of 0.5 to 1.0 mg/kg amphotericin B intravenously thrice weekly during HD sessions. Twenty-three patients received either 500 or 1000 mg of amphotericin B, whereas 1 patient with AIDS received a total of 6,500 mg. RESULTS Intradialytic hypotension developed in 27.7% of HD sessions during treatment with amphotericin B compared with 28.8% of 20 HD sessions evaluated before initiation of amphotericin B therapy. Four patients exhibited a temperature rise greater than 38.8 degrees C during drug infusion (1 episode per patient). Increases in heart rate and ventricular ectopy were rare. Serum potassium concentrations as well as Kt/V and urea reduction ratio did not change significantly. All patients (except the patient with AIDS) resolved their respective fungal infections. CONCLUSIONS Intradialytic administration of amphotericin B was generally well tolerated. Our observations suggest that amphotericin B is effective and safe for outpatient intradialytic therapy when administered according to protocol.
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Affiliation(s)
- James E Wood
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
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Abstract
We describe six children with acute decreases in heart rate temporally related to amphotericin B administration. All patients had achieved their maximal dose within 3 to 4 days. Heart-rate drops occurred as early as day 3 but could be delayed up to day 7 after start of therapy. The mean heart rate dropped from 104 +/- 8/min (range 96 to 114) to 62 +/- 8/min (range 48 to 72) (P = 0.0001). A slower heart rate than baseline was noted during the entire duration of drug administration, from 60 minutes of starting the infusion to 220 minutes (mean 120 +/- 40) after discontinuation of the infusion. This reaction was noted in six of 90 (6.7%) patients who had amphotericin. These six children were compared with six age-matched children who received the drug but in whom such changes in heart rate did not develop. The method of administration of amphotericin B was similar in both patients and controls, starting with 0.25 mg/kg/day and increasing by 0.25 mg/kg/day up to 1 mg/kg/day. Children with heart-rate drop received amphotericin for 4.6 +/- 1.8 days, significantly shorter than their controls (12.6 +/- 6.9 days) (P = 0.02), suggesting that this adverse effect has led to early discontinuation of amphotericin therapy. Physicians and nurses caring for children receiving amphotericin B should be aware of this potential adverse effect, which can be serious in a patient with an underlying heart condition or in a patient who is already on heart-rate-lowering drugs.
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Affiliation(s)
- M Levy
- Division of General Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
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Abstract
OBJECTIVE To review the data examining the use of rapid infusion of amphotericin B in dextrose infusions. DATA SOURCES A MEDLINE search of the English-language literature and review of pertinent references' bibliographies was used to identify articles evaluating the effect of amphotericin B infusion rates on the incidence of adverse reactions. STUDY SELECTION AND DATA EXTRACTION Controlled and uncontrolled studies involving humans are reviewed; emphasis is placed on recent comparative trials. Pertinent information, as judged by the authors, was selected for discussion. DATA SYNTHESIS Amphotericin B, a polyene antifungal agent with significant toxicity, remains the agent of choice for many serious fungal infections. The potential benefits of rapid administration of amphotericin B in reducing the incidence and/or severity of adverse reactions were noted soon after its introduction. Recent studies have examined the tolerability of rapid (0.75-1 h) amphotericin B infusions. Results of studies assessing the tolerability of rapid amphotericin B infusions suggest that tolerance to infusion-related reactions develops during therapy. Comparative trials have obtained variable results. The comparative trials supporting rapid amphotericin B infusion have generally used crossover designs, enrolled small numbers of patients, and excluded patients with significant renal or cardiovascular dysfunction. CONCLUSIONS Rapid amphotericin B infusions should be avoided during initiation of therapy when infusion-related reactions tend to be most problematic, and in patients with cardiovascular disease, renal dysfunction, and potassium disorders because of the potential risk for cardiac arrhythmias. The literature currently available is conflicting and insufficient to support the routine use of rapid amphotericin B infusion.
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Affiliation(s)
- M A Gales
- Department of Pharmacy Practice, School of Pharmacy, Southwestern Oklahoma State University, Weatherford, USA
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Thakur CP, Sinha GP, Barat D, Singh RK. Are incremental doses of amphotericin B required for the treatment of visceral leishmaniasis? ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 1994; 88:365-70. [PMID: 7979623 DOI: 10.1080/00034983.1994.11812878] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
One-hundred-and-twenty visceral leishmaniasis patients, all with demonstrable splenic amastigotes after treatment with sodium stibogluconate and pentamidine, were treated with amphotericin B. The patients were allocated into two equal groups matched by age and sex. Patients in one group received amphotericin B in the traditional incremental dose regimen, i.e. 0.05, 0.10, 0.25, 0.50 and 1.0 mg/kg body weight on days 1, 2, 3, 4, and > 4, respectively. Patients in the other group received amphotericin B at a constant 1 mg/kg bodyweight per day from day 1. Each of the 120 patients received a total dose of 20 mg/kg bodyweight. By the end of treatment the incidence of infusion-related toxicities, such as rigor and fever, and of renal toxicities, such as elevated serum creatinine and low serum potassium, was the same in both groups (P > 0.05). The two treatment regimens were also equally effective; every patient was cured and none relapsed within 6 months' follow-up. It is therefore recommended that amphotericin B be given as the full optimal dose (1 mg/kg) from day 1. There seems no advantage in the incremental regimen; not only does it 'waste' 4 days before the optimal dose is reached but it is more expensive and may encourage the development of drug resistance.
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Affiliation(s)
- C P Thakur
- Patna Medical College and Hospital, India
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Cleary JD, Hayman J, Sherwood J, Lasala GP, Piazza-Hepp T. Amphotericin B overdose in pediatric patients with associated cardiac arrest. Ann Pharmacother 1993; 27:715-9. [PMID: 8329789 DOI: 10.1177/106002809302700607] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To report the first five cases of amphotericin B overdose with secondary cardiac complications in a pediatric population. Treatment is also presented. SETTING Hospital. PATIENTS Two infants and three children inpatients receiving amphotericin B. INTERVENTIONS AND RESULTS Cardiac complications were observed in five pediatric patients who received between 4.6 and 40.8 mg/kg/d of amphotericin B. Cardiac arrest occurred in all patients, and four patients died. A detailed description of the cardiac event is provided for one patient who was on a cardiac monitor during the adverse reaction. Hydrocortisone prophylaxis and verapamil therapy were the primary therapies used in patient 1 (the only survivor). Evaluation of the literature provides substantial evidence for the use of hydrocortisone in prevention of cardiac arrhythmias. CONCLUSIONS Amphotericin B overdose can be fatal in children and infants. The presentation in humans appears similar to that in dogs where cardiac arrhythmias occurred at doses of 5-15 mg/kg. Hydrocortisone may decrease the incidence of mortality associated with cardiac arrhythmias in children receiving amphotericin B overdoses. Animal studies are necessary to evaluate this observation and potential disadvantages of hydrocortisone usage.
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Affiliation(s)
- J D Cleary
- School of Pharmacy, University of Mississippi, Jackson 39216
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Bowler WA, Weiss PJ, Hill HE, Hoffmeister KA, Fleck RP, Blacky AR, Oldfield EC. Risk of ventricular dysrhythmias during 1-hour infusions of amphotericin B in patients with preserved renal function. Antimicrob Agents Chemother 1992; 36:2542-3. [PMID: 1489202 PMCID: PMC284371 DOI: 10.1128/aac.36.11.2542] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In order to assess the safety of 1-h infusions of amphotericin B (AMB), we prospectively monitored 213 1-h infusions of AMB (dose range, 0.27 to 0.89 mg/kg of body weight) in 27 patients with creatinine clearances of > 25 ml/min. Holter monitor tracings during 1-h infusions were compared with those during a 4-h baseline period of monitoring. There were no ventricular dysrhythmias during 1-h infusions of AMB that were not present during baseline monitoring. Nausea and/or rigors were noted for 32 (15%) infusions in six (22%) patients. No patient exhibited a temperature rise of > 1 degree C. We conclude that, in doses of up to 0.9 mg/kg, AMB does not appear to induce asymptomatic ventricular dysrhythmias when administered over 1 h to patients with creatinine clearances of > 25 ml/min.
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Affiliation(s)
- W A Bowler
- Department of Internal Medicine (Infectious Disease Division and Cardiology Division), Naval Hospital, San Diego, California 92134-5000
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Oldfield EC, Garst PD, Hostettler C, White M, Samuelson D. Randomized, double-blind trial of 1- versus 4-hour amphotericin B infusion durations. Antimicrob Agents Chemother 1990; 34:1402-6. [PMID: 2201256 PMCID: PMC175990 DOI: 10.1128/aac.34.7.1402] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
We conducted a randomized, double-blind trial of 1- versus 4-h infusions of amphotericin B to determine whether there was any difference in infusion-related toxicity. A total of 128 maintenance infusions in 12 patients were studied; 62 were randomized to 1-h infusions (group A) and 66 were randomized to 4-h infusions (group B). We found no significant differences between patients in groups A and B in mean temperature, pulse, or systolic or diastolic blood pressure measured during the infusions. At a significant level of 0.05, the power to detect a mean difference in temperature of 2 degrees C, a pulse difference of 20 beats per min, a decrease in diastolic blood pressure of 10 mm Hg, or a decrease in systolic blood pressure of 20 mm Hg was 0.95. Rigors and chills were noted in 15 of 62 (24.1%) infusions in group A patients and 12 of 66 (18.1%) infusions in group B patients (P = 0.40). Meperidine was required because of severe persistent rigors in 6 of 62 (9.6%) infusions in group A patients and 6 of 66 (8.9%) infusions in group B patients (P = 0.91). An increase in temperature was noted in five (8%) of the group A infusions and seven (10.6%) of the group B infusions (P = 0.63). The mean time to onset of rigors, an increase in temperature, and an increase in pulse occurred significantly earlier in group A than in group B patients (P = 0.02 for all comparisons). We conclude that there is no difference in the incidence or severity of the infusion-related toxicity of amphotericin B with a 1-h infusion rate compared with a 4-h infusion rate. However, the onset of infusion-related toxicity occurs significantly earlier with a 1-h infusion.
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Affiliation(s)
- E C Oldfield
- Department of Internal Medicine, Naval Hospital, San Diego, California 92134-5000
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Hart LL, Middleton RK, McQueen KD, Borchardt-Phelps PK. Amphotericin B dilution. DICP : THE ANNALS OF PHARMACOTHERAPY 1990; 24:597-8. [PMID: 2193457 DOI: 10.1177/106002809002400609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- L L Hart
- Department of Pharmaceutical Services, University of Minnesota Hospital and Clinic, Minneapolis 55455
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Cleary JD, Weisdorf D, Fletcher CV. Effect of infusion rate on amphotericin B-associated febrile reactions. DRUG INTELLIGENCE & CLINICAL PHARMACY 1988; 22:769-72. [PMID: 3068038 DOI: 10.1177/106002808802201005] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Our objective was to prospectively study febrile and chill reactions associated with two amphotericin B (AB) infusion rates, slow (2-hour) versus rapid (45 minute). Seventeen consenting bone marrow transplant recipients in whom AB was to be initiated for documented or suspected fungal infections were recruited. After standardized premedication, patients received eight daily AB infusions (0.5 mg/kg/d, concentration 0.25 mg/ml). Rate was assigned using a randomized, crossover pair design. Axillary temperature, chills, and meperidine dose required to resolve chills were monitored for each infusion. For the first pair of infusions, fever (defined as a rise of 1 degree C) occurred frequently, in 12 of 17 (70.5 percent) and 13 of 17 patients (76.4 percent), with a mean rise of 1.7 degrees C (range 1.1-3.7) and 1.7 degrees C (1.1-3.5) degrees for the 45-minute and 2-hour infusions, respectively (p greater than 0.10). Chills were observed in 15 of 17 (88.2 percent) and 14 of 17 (82.3 percent) recipients of the 45-minute and 2-hour infusions, respectively. The time of onset (p greater than 0.10) and the duration of chills (p = 0.08) were similar for both infusion rates. Meperidine requirements for rapid and slow infusions were similar as well (p = 0.12). These data suggest that for patients free of preexisting renal and cardiac disease, rapid AB infusions are well tolerated and produce adverse reactions (fever and chills) similar in nature and severity to slower infusions.
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Affiliation(s)
- J D Cleary
- Department of Clinical Pharmacy, University of Mississippi, Jackson 39216
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