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Antimicrobial-associated acute hepatitis
Susan C Nicholson1, C Douglas Webb, Robert C Moellering
1Infectious Diseases, Bristol-Myers Squibb, Plainsboro, New Jersey 08536, USA. Susan.Nicholson@BMS.com
Abstract:
Recently, the case history of a 44-year-old woman who experienced acute hepatitis subsequent to therapy for chronic sinusitis was reviewed. The patient sequentially was administered clarithromycin, levofloxacin, amoxicillin-clavulanate, and gatifloxacin. Her adverse events were attributed definitively to gatifloxacin, a surprising conclusion because many other possible causes of hepatitis existed in this case. Not ruled out as potential causes of the clinical and laboratory adverse events were hepatitis other than hepatitis A or B. Other antimicrobials administered were dismissed. In particular, extended treatment with amoxicillin-clavulanate has been clearly linked to hepatotoxic effects that may occur long after therapy begins. Thus, while we agree that physicians must be aware of the potential for antimicrobial hepatotoxicity, we believe that this case study is not a solidly documented case of hepatitis attributable to gatifloxacin and overlooks other possible causes of acute hepatitis of which prescribers should be aware.
Insights
This case review questions attributing acute hepatitis solely to gatifloxacin, highlighting other potential causes like amoxicillin-clavulanate. Physicians should consider broader differential diagnoses for drug-induced liver injury.
Area of Science:
- Pharmacology
- Hepatology
- Infectious Diseases
Background:
- Antimicrobial agents are frequently prescribed for common infections.
- Drug-induced liver injury (DILI) is a significant concern in clinical practice.
- Distinguishing the causative agent in polypharmacy cases can be challenging.
Observation:
- A patient with chronic sinusitis developed acute hepatitis after receiving multiple antibiotics, including clarithromycin, levofloxacin, amoxicillin-clavulanate, and gatifloxacin.
- The adverse event was attributed to gatifloxacin, despite the presence of other potential etiologies.
- Hepatitis unrelated to Hepatitis A or B was not excluded.
Findings:
- The case study's definitive attribution of hepatitis to gatifloxacin is questioned due to concurrent antibiotic use and other potential causes.
- Extended amoxicillin-clavulanate therapy is a known risk factor for hepatotoxicity, which may manifest late.
- The study suggests gatifloxacin may not be the sole or primary cause of the observed hepatitis.
Implications:
- Clinicians should maintain a high index of suspicion for various causes of acute hepatitis when patients are on multiple medications.
- A thorough differential diagnosis, considering all administered antimicrobials and other potential hepatotoxins, is crucial.
- This case underscores the importance of robust evidence for attributing DILI to a specific drug, especially in complex therapeutic regimens.