Oral Antibiotics and Risk of Serious Cutaneous Adverse Drug Reactions

Lee EY, Gomes T, Drucker AM, Daneman N, Asaf A, Wu F, Piguet V, Juurlink DN. JAMA. 2024 Aug 8:e2411437. doi: 10.1001/jama.2024.11437. 

Key Points

Question  Do commonly prescribed oral antibiotics carry differential risks of cutaneous adverse drug reactions (cADRs) leading to an emergency department visit or hospitalization?

Findings  In this population-based, nested case-control study spanning 2 decades, sulfonamide antibiotics and cephalosporins carried the highest risk of serious cADRs relative to macrolides, followed by nitrofurantoin, penicillins, and fluoroquinolones.

Meaning  All commonly prescribed oral antibiotics are associated with an increased risk of serious cADRs compared with macrolides, with sulfonamide antibiotics and cephalosporins carrying the highest risk.

Abstract

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.

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