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Oral Antibiotics and Risk of Serious Cutaneous Adverse Drug Reactions
Erika Y Lee1,2,3, Tara Gomes3,4,5, Aaron M Drucker2,3,6
1Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Importance:
Serious cutaneous adverse drug reactions (cADRs) are potentially life-threatening drug hypersensitivity reactions involving the skin and internal organs. Antibiotics are a recognized cause of these reactions, but no studies have compared relative risks across antibiotic classes.
Objectives:
To explore the risk of serious cADRs associated with commonly prescribed oral antibiotics, and to characterize outcomes of patients hospitalized for them.
Design, Setting, And Participants:
Nested case-control study using population-based linked administrative datasets among adults aged 66 years or older who received at least 1 oral antibiotic between 2002 and 2022 in Ontario, Canada. Cases were those who had an emergency department (ED) visit or hospitalization for serious cADRs within 60 days of the prescription, and each case was matched with up to 4 controls who did not.
Exposure:
Various classes of oral antibiotics.
Main Outcomes And Measures:
Conditional logistic regression estimate of the association between different classes of oral antibiotics and serious cADRs, using macrolides as the reference group.
Results:
During the 20-year study period, we identified 21 758 older adults (median age, 75 years; 64.1% female) who had an ED visit or hospitalization for serious cADRs following antibiotic therapy and 87 025 matched controls who did not. In the primary analysis, sulfonamide antibiotics (adjusted odds ratio [aOR], 2.9; 95% CI, 2.7-3.1) and cephalosporins (aOR, 2.6; 95% CI, 2.5-2.8) were most strongly associated with serious cADRs relative to macrolides. Additional associations were evident with nitrofurantoin (aOR, 2.2; 95% CI, 2.1-2.4), penicillins (aOR, 1.4; 95% CI, 1.3-1.5), and fluoroquinolones (aOR, 1.3; 95% CI, 1.2-1.4). The crude rate of ED visits or hospitalization for cADRs was highest for cephalosporins (4.92 per 1000 prescriptions; 95% CI, 4.86-4.99) and sulfonamide antibiotics (3.22 per 1000 prescriptions; 95% CI, 3.15-3.28). Among the 2852 case patients hospitalized for cADRs, the median length of stay was 6 days (IQR, 3-13 days), 9.6% required transfer to a critical care unit, and 5.3% died in the hospital.
Conclusion And Relevance:
Commonly prescribed oral antibiotics are associated with an increased risk of serious cADRs compared with macrolides, with sulfonamides and cephalosporins carrying the highest risk. Prescribers should preferentially use lower-risk antibiotics when clinically appropriate.
Insights
Sulfonamide and cephalosporin antibiotics pose the highest risk for serious cutaneous adverse drug reactions (cADRs) in older adults compared to macrolides. Prescribers should consider lower-risk antibiotic options when appropriate.
Area of Science:
- Pharmacovigilance
- Drug Safety
- Clinical Pharmacology
Background:
- Serious cutaneous adverse drug reactions (cADRs) are severe hypersensitivity reactions with significant morbidity and mortality.
- Antibiotics are a common cause of cADRs, yet comparative risk data across different antibiotic classes are limited.
Purpose of the Study:
- To compare the risk of serious cADRs associated with various oral antibiotic classes in older adults.
- To describe the clinical outcomes for patients hospitalized due to cADRs.
Main Methods:
- A nested case-control study was conducted using linked administrative datasets in Ontario, Canada (2002-2022).
- Adults aged 66 years and older receiving oral antibiotics were included; cases had ED visits or hospitalizations for cADRs within 60 days of prescription.
- Conditional logistic regression was used to estimate associations, with macrolides as the reference group.
Main Results:
- Sulfonamides (aOR 2.9) and cephalosporins (aOR 2.6) showed the highest association with serious cADRs compared to macrolides.
- Other associated antibiotics included nitrofurantoin (aOR 2.2), penicillins (aOR 1.4), and fluoroquinolones (aOR 1.3).
- Cephalosporins and sulfonamides had the highest crude rates of cADRs per prescription; hospitalized patients faced prolonged stays, critical care transfers, and mortality.
Conclusions:
- Commonly prescribed oral antibiotics, particularly sulfonamides and cephalosporins, increase the risk of serious cADRs in older adults.
- Clinical decisions should favor lower-risk antibiotics when feasible to mitigate cADR risk.
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