Journal of Pharmacy Practice and Community Medicine.2017, 3(4):299-301 • http://dx.doi.org/10.5530/jppcm.2017.4.

75

CASE REPORT OPEN ACCESS

Ceftriaxone-Induced Fatal Anaphylaxis Shock at an Emergency

Department: A Case Report

Ethar Abdelmageed Imam1 and Mohamed Izham Mohamed Ibrahim2

1
Department of Pharmacy, Security Forces Hospital, Makkah, KSA
2
Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, QATAR

Received: 21 July 2017; Abstract

Accepted: 9 September 2017 Anaphylaxis in adults caused by medications such as antibiotics are quite common. To best of
*Correspondence to: our knowledge, the case of anaphylaxis caused by ceftriaxone in our hospital and clinical practice
Mohamed Izham Mohamed Ibrahim, PhD, is rare and especially among Saudi patients. A 31-years old Arab female patient was admitted
Professor of Social and Administrative Pharmacy, to the emergency (ER) department due to influenza symptoms. Patient was suspected having
Clinical Pharmacy and Practice Section, College
of Pharmacy, Qatar University, Al Tarfa St, P.O. pneumonia after examination. History indicated that she did not have penicillin allergy in the
Box 2713, Doha, QATAR. past, no history of any other concomitant medications, and no other comorbidities. Patient was
Email: [email protected] febrile. At ER department, she was given ceftriaxone 1 g intravenous (IV) and within 15 min the
Copyright: © the author(s),publisher and licensee patient started to complain from shortness of breath, bronchospasm and developed irregularity
Indian Academy of Pharmacists. This is an open-
of the vital signs. Patient was suspected experiencing anaphylactic shock. Ceftriaxone was
access article distributed under the terms of the
Creative Commons Attribution Non-Commercial discontinued. Aggressive management started immediately; patient was given oxygen, IM
License, which permits unrestricted non-commercial adrenaline, IV hydrocortisone, IV bolus of normal saline, IV ringer lactate, IV pheniramine, and IV
use, distribution, and reproduction in any medium,
ranitidine. Tepid water sponging was provided to control the fever. After resuscitative treatment,
provided the original work is properly cited.
patient was stabilized and the vital signs were good. The patient then was moved out to the
medical ward. Health care professionals at the Emergency Department should be mindful of
the anaphylaxis possibility with patient receiving antibiotics in the cephalosporin group.
Key words: Anaphylactic Shock, Ceftriaxone, Hypersensitivity, Resuscitative Treatment, Penicillin

INTRODUCTION
Ceftriaxone is a 3rd generation cephalosporin antibiotic, commonly used to treat
infections, both g-positive and -negative bacteria. It can cause a range of hypersensitivity
reactions and should be contraindicated in patients with known hypersensitivity.[1]
Incidence of anaphylaxis caused by ceftriaxone is rare. Anaphylaxis could be caused
by drugs such as antibiotics, opioids, non-steroidal anti-inflammatory drugs (NSAIDs)
and muscle relaxants. Sign and symptoms of anaphylaxis are variable and can range
from mild skin lesion to fatal reaction. It affects different organs and its most severe
form results in anaphylaxis. If patients have previous experience of hypersensitivity
reactions to penicillin and other beta lactam antibacterial agents, they might have
greater risk of hypersensitivity to Ceftriaxone.

Case Presentation

A 31-years old Arab female patient was admitted to the emergency (ER) department
due to influenza symptoms. She weighs 65 kg and 165 cm in height. Based on the

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Journal of Pharmacy Practice and Community Medicine  Vol. 3  ●  Issue 4  ●  Oct-Dec  2017 ● www.jppcm.org 299
 Ceftriaxone-induced fatal anaphylaxis shock

examination, patient was suspected having pneumonia. following IM administration with mean maximum plasma
She has history of celiac disease. History taking showed concentrations occurring between 2 and 3 h post-dose.
that she does not have penicillin allergy in the past, no Multiple IV or IM doses ranging from 0.5 to 2 g at 12-
history of any other concomitant medications, and no to 24-h intervals resulted in 15% to 36% accumulation
other comorbidities. Upon admission, patient was febrile of Ceftriaxone above single dose values.[3] Ceftriaxone is
with 38 degree Celsius. At ER department she was given reversibly bound to human plasma proteins and crosses
ceftriaxone 1 g intravenous (IV) and within 15 min the the blood placenta barrier.
patient started to complain from shortness of breath
and bronchospasm started with severe drop in the blood Ceftriaxone induced anaphylaxis is a rare case but the
pressure (BP); the vital signs i.e. BP was 65/52 mmHg, incidence of hypersensitivity skin reactions was reported
normal blood oxygen saturation levels (SpO2) was 87%, between 1 to 3%.[4] Cephalosporin reactions can be divided
and respiratory rate (RR) was 31/min. No sensitivity test into in two categories: (1) immediate which develop within
was taken prior to the administration of the medicine. 1 h after drug administration, and (2) nonimmediate which
Anaphylactic reaction was suspected. develop after 1 h of drug administration.[5] Anaphylaxis
can happen in patients with immunoglobulin E-mediated
Action: Ceftriaxone was stopped immediately. Aggressive allergy.[6,7] Anaphylaxis is an acute life threatening reaction.
management started immediately with resuscitative Antibiotic skin testing is not normally done in a patients
treatment. Patient was put on high flow oxygen via face without a history of allergy including food allergy. Patients
mask and was administered the following: injection (Inj.) planned to take antibiotic therapy especially intravenous
adrenaline 500 micrograms intramuscular (IM) (0.5 mL), route or intramuscular should apply the penicillin skin
Inj. hydrocortisone slow IV 200 mg, ringer lactate IV, Inj. test. If patient sensitive to penicillin thus, there is cross
pheniramine 1mg/kg slow IV and Inj ranitidine 1mg/kg sensitivity with cephalosporin to develop allergy. Fast
IV along with two boluses of normal saline. She was given recognition and appropriate aggressive treatment using the
tepid water sponging to control the fever. Airway, Breathing, Circulation, Disability, and Exposure
(ABCDE) approach are important for the successful
Evaluation: On the same day, after 6 hrs of resuscitative management of anaphylaxis. [8] Patients must constantly
treatment, patient had pulse rate of 82/min; BP 100/71 be observed and followed up. Healthcare professionals
mmHg and RR 21/min. Patients laboratory investigations are encouraged to refer to international guidelines e.g.
showed raised monocyte count: UK guidelines for emergency treatment of anaphylactic
reactions for emergency treatment of anaphylaxis [8] and
Monocyte % = 13.70 % (normal range: 0.00 - 12.00) other useful websites e.g. www.resus.org.uk, www.bsaci.org.
www.eaaci.net, www.cochrane.org. www.bestbets.org.
Monocytes = 1.16 10e3/uL (normal range: 0.00 - 0.90). Patient need to know the allergen responsible, know how
to avoid situations and be able to recognize the early
Other laboratory values: symptoms of anaphylaxis.

Vitamin D (25-OH) = 6.9 ng/mL (normal range: >30.0 - CONCLUSION

70.0), it shows severe drop in the level.
An antibiotic medication allergy is a harmful reaction to
Creatine kinase MB isoenzyme-CK-MB = 0.3 U/L (normal an antibiotic. All antibiotics can produce allergy varying
range: 3.6 - 4.9) between patients. Each antibiotic can be tested for allergy.
Usually patients stating an allergy to any medication or
Patient was closely monitored, then discharged to the
food or suffering from asthma or disease exacerbated
medical ward with no further issues.
by allergies. Skin test should be carried out. Healthcare
providers should be careful in using cephalosporin and
DISCUSSION penicillin group antibiotics. Patient education is important.
ADR cases should be reported to the hospital and national
Cephalosporins are among the most commonly-used pharmacovigilance center.
antibiotics in the treatment of routine infections and
their use is increasing over time. [2] Ceftriaxone is a Acknowledgement: None
broad-spectrum cephalosporin antibiotic for IV or IM
administration. Ceftriaxone was completely absorbed Competing interests: None declared
300 Journal of Pharmacy Practice and Community Medicine  Vol. 3  ●  Issue 4  ●  Oct-Dec  2017 ● www.jppcm.org
 Ceftriaxone-induced fatal anaphylaxis shock

Funding: None Antimicrobial Chemotherapy. 2006;58(2):401-7.

3. Drugs.com. Ceftriaxone. Available from: https://www.drugs.com/pro/
ceftriaxone.html.
Abbreviation: None
4. Saritas A, Erbas M, Gonen I, Candar M, Ozturk O, Kandis H, et al. Asystole
after the first dose of ceftriaxone. Am J Emergency Med. 2012;30(7):1321-e3-4.

REFERENCES 5. Romano A, Demoly P. Recent advances in the diagnosis of drug allergy.

Current Opinion Allergy Clinical Immunol. 2007;7(4):299-303.
1. Up-to-date. Cephalosporin allergy: clinical manifestation and diagnosis. 6. Norrby SR. Side effects of cephalosporins. Drugs. 1987;34(2):105-20.
Available from: https://www.uptodate.com/contents/cephalosporin-allergy- 7. Guéant JL, Guéant-Rodriguez RM, Viola M, et al. IgE-mediated
clinical-manifestations-and-diagnosis. hypersensitivity to cephalosporins. Current Pharm Des. 2006;12(26):3335-45.
2. Ferech M, Coenen S, Malhotra-Kumar S, et al. European Surveillance of 8. UK Resuscitation Council (UK). Emergency treatment of anaphylactic
Antimicrobial Consumption (ESAC): outpatient antibiotic use in Europe. J reactions: Guidelines for healthcare providers. 2016.(assessed 2,2017)

Cite this article as: Imam EA and Ibrahim MIM. Ceftriaxone-Induced Fatal Anaphylaxis Shock at an Emergency Department:
A Case Report. J Pharm Pract Community Med. 2017;3(4):299-301.

Journal of Pharmacy Practice and Community Medicine  Vol. 3  ●  Issue 4  ●  Oct-Dec  2017 ● www.jppcm.org 301