Letter: Cephalothin-induced granulocytopenia

Agranulocytosis during antibiotic therapy: drug sensitivity or sepsis?

Forty-three patients reviewed from the literature and five cases of agranulocytosis during antibiotic therapy studied by the author are presented. Time required to develop agranulocytosis with antibiotics was < 19 days in comparison to > 40 days required with nonantibiotic drugs. In all, agranulocytosis occurred concomitantly with drug treatment and became normal as treatment was discontinued. Retrospective rechallenge studies suggest that agranulocytosis may be dose related. In all cases PMNs were almost completely deleted and marrows were devoid of granulocyte precursors. In contrast, leukopenia secondary to overwhelming sepsis displayed persisting granulocytes in peripheral blood and marrow. While leukagglutinins were not found in nine cited cases, four serums were toxic to test PMNs as measured by suppression of postphagocytosis respiratory burst. Clindamycin directly suppressed development of CFU-G in one sensitive patient but not in 16 normal controls. The hazard of antibiotics in suppressing granulocytopoiesis is emphasized by these observations.

Cephalosporin-induced immune cytopenia in the dog: demonstration of erythrocyte-, neutrophil-, and platelet-associated IgG following treatment with cefazedone

Cephalosporin treatment in man has been associated with a low incidence of hemolytic anemia, thrombocytopenia, and neutropenia; some cases have been shown to be immune-mediated. This triad of blood dyscrasias was also demonstrated in our laboratory in a series of toxicity studies in dogs of two cephalosporin compounds, cefonicid and cefazedone; these studies provided evidence for drug-associated immune hemolytic anemia, based on conventional laboratory tests. To further investigate possible immune mechanisms of the cephalosporin-induced cytopenias, we measured erythrocyte-associated, platelet-associated (PAIgG), and serum antineutrophil IgG over the course of cephalosporin treatment, using highly sensitive 125I-staphylococcal protein A (SPA) assays, as well as the direct antiglobulin test; we compared these findings with the hematologic changes. Intravenous treatment with high doses of cefazedone (540 mg/kg/day, increased to a maximum of 840 mg/kg/day for 4 months or until hematologic effects were evident) resulted in a high incidence of anemia (7/14), thrombocytopenia (11/14), and neutropenia (7/14). Of the affected dogs examined, 6/7 with anemia, 9/9 with thrombocytopenia, and 7/7 with neutropenia showed increased levels of the respective cell-associated antibody, compared with untreated controls. Unaffected dosed animals generally did not show these changes. In 3/3 dogs examined following remission of thrombocytopenia, PAIgG returned to levels comparable with controls; as one of these dogs suffered a relapse, increased PAIgG was again observed. Animals sacrificed during cytopenic episodes showed cytologic and histologic evidence of increased hemophagocytosis. We conclude that antibody-mediated blood cell destruction contributes to all three cephalosporin-induced cytopenias in the dog.

Cephalosporin-induced changes in the ultrastructure of canine bone marrow

Fourteen healthy dogs were given 540 to 840 mg/kg of cefazedone (Refosporen) intravenously for up to 4 months or until peripheral blood cell count were depressed. Within 6 to 10 weeks treated dogs developed pancytopenia (5/14), thrombocytopenia (11/14), moderate to severe neutropenia (8/14), and/or normocytic anemia with erythroblastemia (8/14). Ultrastructural changes in bone marrow of severely cytopenic dogs included mitochondrial damage in hematopoietic and nonhematopoietic cells, thickening of endosteal bone lining layers, increased adventitial coverage of vascular sinuses, and an increased number of active macrophages. Swollen, ruptured mitochondria were in erythroid, granulocytic, and megakaryocytic cells, and, to a lesser extent, in macrophages, reticular endothelial, and bone lining cells. Maturation arrest was evident in both erythroid and granulocytic cell lines. There was also evidence of ineffective erythropoiesis and granulopoiesis. None of these changes were observed in bone marrow of controls, treated dogs that did not develop cytopenia, or dogs allowed to recover after cessation of dosing.

The hematopathology of cefonicid- and cefazedone-induced blood dyscrasias in the dog

Cephalosporin treatment in man has been associated with blood dyscrasias that include a time- and dose-related anemia, neutropenia, and thrombocytopenia, the hematopathology of which remains poorly characterized. A similar hematologic syndrome can be produced in dogs following daily intravenous injections of 540-840 mg/kg cefazedone or 400-500 mg/kg cefonicid for 1-3 months. Using this animal model, histologic and cytologic changes in blood, bone marrow, spleen, and liver were studied over the course of the cephalosporin-induced cytopenias. Peripheral blood cytologic observations included an absence, generally, of erythroid regenerative changes, increased numbers of macroplatelets, spherocytosis, erythroblastemia, and toxic neutrophil morphology. Interim and postmortem cytologic and histologic observations of bone marrow included hypoplastic and toxic changes, primarily in cytopenic dogs receiving high doses of cefonicid, and regenerative changes in hematopoietic tissue of affected cefazedone-treated animals. The latter included variable erythroid hyperplasia, increased megakaryocytes, and decreased marrow fat and was accompanied by evidence of extra-medullary hematopoiesis and increased hemosiderin and hemophagocytosis in liver and splenic tissue. The incidence and severity of these changes were dose-dependent, corresponded with the cytopenias observed peripherally, and, like the cytopenias, were fully reversible. These observations suggest that the hematologic syndrome associated with cephalosporin treatment in the dog has multiple toxicologic mechanisms, which include peripheral cytotoxic effects and bone marrow damage with depressed or ineffective hematopoiesis.

The hematologic effects of cefonicid and cefazedone in the dog: a potential model of cephalosporin hematotoxicity in man

Cephalosporin antibiotics cause a variety of hematologic disturbances in man, the pathogeneses and hematopathology of which remain poorly characterized. There is a need for a well-defined animal model in which these blood dyscrasias can be studied. In four subacute toxicity studies, the intravenous administration of cefonicid or cefazedone to beagle dogs caused a dose-dependent incidence of anemia, neutropenia, and thrombocytopenia after 1-3 months of treatment. A nonregenerative anemia was the most compromising of the cytopenias and occurred in approximately 50% of dogs receiving 400-500 mg/kg cefonicid or 540-840 mg/kg cefazedone. All three cytopenias were completely reversible following cessation of treatment; the time required for recovery of the erythron (approximately 1 month) was considerably longer than that of the granulocytes and platelets (hours to a few days). Upon rechallenge with either cephalosporin, the hematologic syndrome was reproduced in most dogs tested; cefonicid (but not cefazedone)-treated dogs showed a substantially reduced induction period (15 +/- 5 days) compared to that of the first exposure to the drug (61 +/- 24 days). This observation, along with the rapid rate of decline in red cell mass parameters of affected dogs, suggests that a hemolytic component complicated the red cell production problem and that multiple toxicologic mechanisms contributed to the cytopenia. We conclude that the administration of high doses of cefonicid or cefazedone to dogs can induce hematotoxicity similar to the cephalosporin-induced blood dyscrasias described in man and thus provides a useful model for studying the mechanisms of these disorders.

Bone and joint infections caused by gram-positive bacteria: treatment with cefotaxime

Cefotaxime treatment was evaluated in 41 patients with serious bone and joint infections. Septic arthritis and bursitis (8), acute and chronic osteomyelitis (33) were treated with 3 to 12 g of cefotaxime per day for three to 52 days. The diagnosis of osteomyelitis or septic arthritis was made on the basis of clinical and roentgenographic evidence of infection. The diagnosis of a joint infection was confirmed by a positive culture of a joint aspirate sample. The diagnosis of a bone infection was confirmed by either a positive culture of a bone biopsy or of blood in combination with a positive bone scan or roentgenogram. Staphylococcus aureus was the most frequently isolated pathogen. Overall, 36 of 41 patients, who met all criteria for evaluation, had satisfactory responses to cefotaxime. The drug was well tolerated by all patients. However, six patients had a direct Coomb's test, two patients were noted to be neutropenic and two patients developed a macular rash. It is concluded that cefotaxime is a useful and safe antibiotic for the treatment of osteomyelitis and septic arthritis.

Cephalosporin-induced immune neutropenia

Neutropenia is an occasional complication of treatment with cephalosporin antibiotics. This report describes two patients who had neutropenia while receiving high doses of cephalosporins. The neutrophil counts returned to normal after stopping the drug, and cephalosporin-dependent neutrophil antibodies were demonstrated in both cases, using the granulocyte immunofluorescence test. In one patient, the immune neutropenia appeared to be due to a drug adsorption mechanism similar to penicillin-induced haemolytic anaemia, while an immune complex mechanism may have been involved in the second patient.

Cefmenoxime: clinical evaluation

Cefmenoxime was evaluated in an open trial consisting of 41 patients. Forty infections in 36 patients could be evaluated. Thirteen patients had pyelonephritis due to Escherichia coli (two bacteremic), Pseudomonas aeruginosa, Klebsiella pneumoniae, or Streptococcus faecalis; all improved and 12 of 13 were clinically cured, but one relapse (S. faecalis) occurred at two weeks. Six patients with cystitis due to E. coli, Citrobacter freundii, Serratia marcescens, P. aeruginosa, or S. faecalis all improved, but relapse or reinfection, or both, occurred in five due to P. aeruginosa, S. faecalis, C. fruendii, or E. coli. Neurogenic bladder or other complications were present in five of 13 patients with pyelonephritis and five of six with cystitis. Ten patients with pneumonia and one with tracheobronchitis due to Hemophilus influenzae, S. pneumoniae, S. agalactiae, or Neisseria meningitidis all improved and seven had resolution without relapse, but P. aeruginosa emerged in two patients, one of whom died. Eight soft tissue infections due to Staphylococcus aureus, Peptococcus prevotti, Streptococcus species, or infections of mixed origin resolved in six. Sterility of blood cultures was obtained in one patient with endocarditis due to S. anginosus, but other therapy was substituted. Clinical resolution of the toxic shock syndrome and subsequent negative endocervical cultures for S. aureus occurred in one. Granulocytopenia of unverified cause in four (with less than 1,500 mm3) and two (with less than 2,000 mm3) was reversible. Headache during treatment occurred in six patients and a possible disulfiram-like effect in three. Elevations of serum glutamic oxalacetic transaminase and alkaline phosphatase occurred in five, Coombs' positivity in two, and diarrhea in three. Clinical efficacy of cefmenoxime was significant. Possible side effects require further study.

Agranulocytosis associated with semisynthetic penicillins and cephalosporins. Report of 7 cases

Within one year we observed in the same intensive care unit seven severely polytraumatized patients with agranulocytosis (AG) associated with treatment by semisynthetic penicillins or cephalosporins combined with aminoglycosides. Antibiotics were given because of severe bacterial respiratory or generalised infections. Five patients died, four of them without haematological remission. Bone marrow aspirates showed hypoplasia of granulopoiesis due to a lack of mature cells. Leukocyte and granulocyte counts in the blood declined continuously over a period of 8 to 11 days. In average, minimal granulocyte counts occurred after 21 days of hospitalisation and 14 days of antibiotic drug exposure. Beside the incriminated antibiotics all patients were treated sporadically with other agents of which may cause AG. Granulocyte kinetics and serial bone marrow examinations of one patient suggest a phenothiazine type of AG, which is caused by a toxic damage of granulopoiesis. Declining absolute granulocyte counts in the blood together with persisting high temperatures during antibiotic treatment should give rise to the suspicion of a beginning AG.

Hemolytic anemia and pancytopenia induced by cefoxitin

A 77-year-old man received cefoxitin for the treatment of peritonitis. He developed hemolytic anemia and became clinically jaundiced. The patient was switched from cefoxitin to doxycycline. His total bilirubin decreased and his hematocrit increased. Several weeks later he developed septicemia. For an infiltration in the left lower lobe, he was treated with cefoxitin and gentamicin. The patient proceeded to develop a mild granulocytopenia and thrombocytopenia. Anemia was not seen because the patient was transfused several times. Bone marrow aspiration showed a mildly hypocellular marrow with a depression of all cell series, suggesting drug-induced bone marrow toxicity. Nine days after discontinuing cefoxitin, his blood elements had gone back to normal. This is the fourth case on file at Merck Sharp & Dohme of hemolytic anemia induced by cefoxitin. There have been several reports of hemolytic anemia or pancytopenia caused by cephalothin, but few, if any, citing the other cephalosporins, particularly cefoxitin. Clinicians should be made aware of the possibility of hematologic toxicities occurring with cefoxitin therapy. Patients should have their erythrocytes, leukocytes, and platelets monitored while on this drug.

Neutropenia associated with cefotaxime

Neutropenia is rarely associated with cephalosporins. We report a case of neutropenia associated with cefotaxime. A seven-year-old boy was admitted to the Chidoribashi Hospital with suspected septicemia. Cefotaxime 2 g/d was started. On day 18, neutropenia associated with cefotaxime was suspected. On day 22, the patient was transferred to Fukuoka Children's Hospital because of continuing neutropenia and eosinophilia. In Fukuoka Children's Hospital, bone marrow puncture revealed severe bone marrow depression. After one month, the patient was discharged. When we considered case reports of granulocytopenia, leukopenia, and agranulocytosis associated with cephalosporins, we found two types of leukopenia. One is the granulocytopenic type and the other is the neutropenic type. In diagnosing leukopenia due to cephalosporins, an increased percentage of eosinophils in white-blood-cell analysis is significant.

Drug-induced immunological neutropenia

Antineutrophil antibody capable of opsonising normal neutrophils was detected in the sera of 16 neutropenic patients receiving various drugs. A single drug was involved in 10 cases, multiple medication in 6. 4 patients received semisynthetic penicillins, 8 some form of antimicrobial, and 2 antithyroid agents. Neutrophil counts rose, and antineutrophil antibody activity declined or disappeared, after drug therapy was stopped. Opsonisation related to the semisynthetic penicillins was independent of complement but dependent on drug concentration. Complement-dependent opsonic activity was demonstrated in 2 patients (1 receiving methimazole and 1 receiving multiple medication) and in the patient receiving methimazole this activity was shown to reside in the IgM serum-fraction. In another patient receiving multiple drugs, a complement-independent IgG antibody was demonstrated.

Cephalothin induced neutropenia during the treatment of bacterial endocarditis

The occurrence of cephalothin induced neutropenia in 3 patients with infective endocarditis is described. In each patient, withdrawal of cephalothin was followed by rapid haematological recovery. It is apparent that granulocytopenia may frequently occur in patients receiving prolonged, high dose, intravenous cephalothin for the treatment of bacterial endocarditis.