Amoxicillin/clavulanic acid/tacrolimus interaction
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Cholestatic liver injury in a child?: case report An 8-year-old boy, who had undergone liver transplantation and was receiving tacrolimus, developed cholestatic liver injury after receiving amoxicillin/clavulanic acid for an upper respiratory tract infection. The boy had undergone liver transplantation at 4 years of age and was receiving tacrolimus [dose, route and duration of treatment not stated] and steroids for immunosuppression. Prior to liver transplantation, he had received amoxicillin/clavulanic acid repeatedly as prophylaxis with no adverse effects. Four years after transplantation, he developed an upper respiratory infection and received amoxicillin/clavulanic acid 25/3.6 mg/kg/day [route not stated] for 2 weeks. Two days after treatment cessation, he developed jaundice. He had elevated transaminase levels, and his total bilirubin on admission was 6.9mg%, with a direct bilirubin of 5.3mg%. Hepatobiliary scintigraphy revealed functional impairment and delayed intestinal bile flow with marker retention 24 hours after administration. A liver biopsy showed signs of drug-induced liver injury. The boy received methylprednisolone and ursodeoxycholic acid. His parameters of cholestasis improved immediately, with complete resolution of cholestasis 12 weeks after illness onset. Over a 7-year follow-up period, he developed two episodes of transaminase elevations without cholestasis. The liver biopsies performed on both occasions were nonspecific and did not show the previously observed abnormalities. Author comment: "Transplant recipients are at higher risk [of hepatotoxicity following amoxicillin/clavulanic acid] due to the frequency of antibacterial interventions and possible interactions with immunosuppressive drugs. . . .Hypothetically, the [boy’s] liver sensitivity could have developed after transplantation, due to interactions with tacrolimus, which is a potent cause of cholestasis, especially after steroid-resistant graft rejections." Studniarz M, et al. Amoxicillin/clavulanic acid-induced cholestatic liver injury after pediatric liver transplantation. Annals of Transplantation 17: 128-131, No. 1, 803072457 Jan 2012 - Poland
0114-9954/10/1407-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved
Reactions 23 Jun 2012 No. 1407
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