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Cholangiopathy after short-term administration of piperacillin and imipenem/cilastatin
C Quattropani1, M Schneider, A Helbling
1Departments of Clinical Pharmacology,Visceral and Transplantation Surgery,Clinical Immunology and Pathology, University of Berne, Switzerland.
Abstract:
We describe a patient who suffered from intestinal perforation after abdominal trauma. Perioperatively, he was treated with a single dose of piperacillin and 9 doses of imipenem/cilastatin over 3 days. The patient was discharged 5 days after surgery in good clinical condition and with normal liver values except for a marginal elevation of alanine aminotransferase. Two weeks after discharge, he developed fatigue, fever and pruritus, necessitating rehospitalization. He was jaundiced and had elevated alkaline phosphatase and transaminases. After exclusion of an intra-abdominal fluid collection, a vascular problem, and infectious or autoimmune liver disease, a liver biopsy was performed. The biopsy revealed centrizonal bilirubinostasis, a portal infiltrate rich in eosinophils and cholangitis. Lymphocyte transformation tests for piperacillin and imipenem/cilastatin were positive, suggesting an immunological mechanism for the observed hepatopathy. Cholestasis gradually decreased but was detectable for several weeks. The patient had a full clinical and biochemical recovery after 3 months. We conclude that short-term therapy with piperacillin, imipenem/cilastatin or the combination of these drugs can lead to the same type of hepatopathy as described for amoxycillin/clavulanic acid or antistaphylococcal penicillins. Liver biopsy and positive lymphocyte transformation are compatible with an immunological mechanism.
Insights
Antibiotic-induced liver injury can occur with short-term use of piperacillin and imipenem/cilastatin. This case highlights potential immunological mechanisms and the need for careful monitoring of liver function during antibiotic therapy.
Area of Science:
- Hepatology
- Pharmacology
- Immunology
Background:
- Abdominal trauma and intestinal perforation necessitate perioperative antibiotic treatment.
- Piperacillin and imipenem/cilastatin are commonly used antibiotics for intra-abdominal infections.
Observation:
- A patient developed jaundice, fatigue, and pruritus two weeks post-discharge after a 3-day course of piperacillin and imipenem/cilastatin.
- Liver biopsy revealed centrizonal bilirubinostasis, eosinophilic portal infiltrate, and cholangitis.
Findings:
- Lymphocyte transformation tests were positive for both piperacillin and imipenem/cilastatin, indicating an immune-mediated drug reaction.
- The patient experienced cholestasis and elevated liver enzymes, consistent with drug-induced liver injury (DILI).
Implications:
- Short-term antibiotic therapy with piperacillin/imipenem-cilastatin can cause hepatotoxicity, similar to other beta-lactam antibiotics.
- Positive lymphocyte transformation tests and liver biopsy findings support an immunological mechanism for this DILI.
- Prompt diagnosis and cessation of the offending agent are crucial for full clinical and biochemical recovery from antibiotic-induced liver injury.