Necrotizing Esophagitis and Bleeding Associated With Cefazolin

To report the case of a patient who presented with rare necrotizing esophagitis related to cefazolin-associated coagulopathy. A review of the literature is also provided.

A 53-year-old male patient was admitted for management of septicemia and femur osteomyelitis. Long-term cefazolin treatment was initiated after cultures and sensitivity revealed methicillin-sensitive Staphylococcus aureus. The patient was given intravenous cefazolin 2 g every 24 hours. On day 15 of cefazolin treatment, the patient presented to the emergency department complaining of black coffee ground emesis. On upper-gastrointestinal endoscopy, the patient was determined to have necrotizing esophagitis. He was found to have an international normalized ratio (INR) of 8.11 and prothrombin time (PT) of 89.2 s. Intravenous vitamin K, fresh frozen plasma, and packed red blood cells were administered. The INR was rechecked 4 hours later and found to have decreased to 1.55 with a PT of 17 s. The patient did not have medical conditions or take medications that could have caused bleeding.

Based on the Naranjo algorithm, it was determined that cefazolin had a "probable" relationship. Increased bleeding risk has been associated with other cephalosporins, although much less commonly with cefazolin. Possible mechanisms and implications are discussed.

High-risk patients being treated with cefazolin therapy should be monitored for potentially severe adverse events, including bleeding and necrotizing esophagitis.