“Cephalosporins have been reported as rare causes of DILI, but most data come from single case reports,” the researchers said. To study causes of DILI, they analyzed cases from the Drug-Induced Livery Injury Network, an ongoing prospective study at 8 US medical centers. Enrolled patients had strong clinical suspicion for liver injury caused by a drug or an herbal agent. Liver injury was defined based on specific criteria for liver enzymes, alkaline phosphatase (ALP), or total bilirubin levels, or as an international normalized ratio greater than 1.5 that was accompanied by elevated liver enzymes or ALP. Patients were followed for at least 6 months after their baseline visit (Clin Gastroenterol Hepatol. Published January 26, 2015. doi: 10.1016/j.cgh.2015.01.010).
Among the 1,212 cases of DILI in the analysis, one-third were linked to antimicrobial therapies, including 41 (3.3%) in which cephalosporins were implicated, the investigators reported. Nineteen of the cases were tied to a single dose of intravenous cefazolin given before surgery. These patients developed cholestatic or mixed hepatocellular-cholestatic injury 1 to 3 weeks after the cefazolin infusion. They almost always had jaundice and pruritus, and usually also had fever and nausea. Signs and symptoms were self-limiting, resolving within a few days to a few weeks.
“Because of confusion about the specific diagnosis, patients underwent substantial diagnostic testing (including multiple computed tomography scans, magnetic resonance imaging scans, endoscopic retrograde cholangiopancreatography exams, liver biopsies, and others), which often were unnecessary, and in some cases led to severe complications,” the investigators said.
“The study also identified barriers to identifying cefazolin as a cause of DILI,” they said. Patients often did not know they had received the antibiotic, and clinicians, including study investigators, often did not know that cefazolin could cause DILI. In more than half of cases, DILI was linked to cefazolin only after careful medical record reviews. “For these reasons, we speculate that cefazolin is and has been underappreciated as a cause of DILI,” the researchers noted. “The appearance of jaundice and pruritus 1 to 3 weeks after minor surgery should lead to a search of surgical records and medications that might have been given during surgery. These results also imply that the merits of routine use of cefazolin at the time of uncomplicated surgery should be reconsidered carefully.”
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“Two patients died after receiving cephalosporins other than cefazolin, and another patient developed severe liver injury,” the researchers said. “However, in each of the fatal cases, patients had a complicated clinical course, with a severe hypersensitivity reaction on top of an underlying liver disease. Therefore, we urge caution in concluding that non-cefazolin cephalosporin-induced DILI may be severe or fatal,” they said. “Because cephalosporins are used commonly in clinical practice, it is likely that the overall mortality rate associated with cephalosporin use is low, but not nil, and it may be more likely in patients with underlying disorders.”
The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institutes of Health, the National Cancer Institute, and by six Clinical and Translational Science Award grants. The investigators reported having no conflicts of interest.
Pelvic CT may not be needed to diagnose intra-abdominal injury in children
BY JENNIE SMITH
FROM SAEM 2015
| San DIEGO – Children who have suffered blunt trauma are routinely screened in EDs for intra-abdominal injury (IAI) via computed tomography of the abdomen and pelvis. |
Vitals Key clinical point: Abdominal CT scans without a pelvic portion may diagnose intra-abdominal injury in children as well as do full abdominopelvic scans, with less radiation exposure to patients. Major finding: Abdominal CT alone was 85% sensitive (95% CI, 65%-96%) and 99% specific (95% CI, 97%-100%) in identifying IAIs. The four missed injuries were solid organ injuries within the radiographic abdomen. Data source: A retrospective cohort study of 313 patients aged 3 to 17 years presenting to 12 EDs. Disclosures: The study was funded by the Carolinas Trauma Network Research Center of Excellence. None of the investigators disclosed conflicts of interest. |
But concerns about excess exposure to CT radiation, particularly to the gonads, led one group of researchers to question whether it’s necessary to scan the entire abdominopelvic region in all of these patients to identify IAI.
Dr Stacy Reynolds and her colleagues at the Carolinas Medical Center in Charlotte, North Carolina, hypothesized that CT limited to the radiographic abdomen – the region between the dome of the diaphragm to the top of the iliac crest – can capture the vast majority of IAIs in this population.
At the Society for Academic Emergency Medicine annual meeting, Dr Reynolds presented results from a retrospective cohort study enrolling 313 hemodynamically stable pediatric patients (median age 14 years, 64% male) presenting to 12 EDs after blunt trauma. Patients with known pelvic fractures or hip dislocation were excluded, as they would have had a clear indication for a full abdominopelvic CT.