Severe Hemolytic Crisis After Ceftriaxone Administration

Abstract

Ceftriaxone is a commonly administered antibiotic, and hemolytic crisis is a dangerous potential adverse event. We describe 2 children with sickle cell disease who developed severe hemolytic crisis after ceftriaxone administration. Both subsequently demonstrated the presence of anticeftriaxone antibodies that may have been responsible for the massive hemolysis.

Ceftriaxone-induced Hemolytic Anemia

“…Eighteen of these patients, including our patient had previous exposure to ceftriaxone. 4,6,7,[16][17][18][19][20][21][22][23]25,[28][29][30][31] There was no information reported in the remaining 5 patients. 3,5,24,26,27 It is unclear whether the underlying disease processes contribute to the development of anticeftriaxone antibodies and hemolysis, or if repeated exposure to the drug is important, or both.…”

“…13 Hemolysis in pediatric patients with CIHA usually occurs within 30 minutes (range, 5 to 120 min) of ceftriaxone administration. [4][5][6][7][16][17][18][19]21,23,28 The hemolysis is often dramatic and the hemoglobin can acutely drop to 2.5 g/dL (range, 0.4 to 8.4 g/dL) ( Table 1). In adults, the fall in hemoglobin is much less and occurs over a period of hours to days.…”

“…Acute renal failure has been reported in at least 40% of pediatric CIHA patients with an associated mortality rate of 55% (Table 1). The acute drop in hemoglobin along with [4][5][6][7] The rapid progression of hemolysis leading to death in a few hours makes early diagnosis difficult. A high index of DIIHA suspicion is required to promptly diagnose CIHA with serological tests.…”

“…19,26 Plasmapheresis has been attempted as a therapeutic option in few patients with equivocal outcomes. 4,28,29 Immediate discontinuation of ceftriaxone therapy after evidence of hemolysis seems to be beneficial in pediatric CIHA patients. In the review of 23 CIHA pediatric patients, 9 patients including our patient did not receive any further ceftriaxone after hemolysis and 8 (89%) of these patients survived.…”

Variation in Pediatric Emergency Department Care of Sickle Cell Disease and Fever

“…This comprehensive list of parenteral antibiotics was determined taking into consideration the ability of an antibiotic to provide coverage against likely organisms, as well as factors such as the possibility of penicillin allergy and possible previous complications such as cephalosporin-induced hemolysis. 13 Evaluation and management recommendations were considered complete if all of the following were present within the visit: CBC, reticulocyte count, blood culture testing, and administration of parenteral antibiotics. Disposition for each PED visit was categorized as discharged from the ED or admitted (including both inpatient and observation status stays).…”