Flucloxacillin

Abstract

Drug-induced liver injury: case report A 91-year-old woman developed drug-induced liver injury (DILI) while receiving flucloxacillin for bilateral lower leg cellulitis. The woman, who had diabetes mellitus type 2, heart failure, chronic kidney disease, atrial fibrillation, Alzheimer’s dementia and hypertension presented with worsening of jaundice with associated pruritus, confusion and dark urine. Six weeks prior to the onset of jaundice, she was started on oral flucloxacillin 500mg four times a day for a week for bilateral lower leg cellulitis and, treatment was continued further for 5 days. She had also taken paracetamol/codeine [cocodamol] 3 weeks prior to the presentation for pain in the lumbar region due to a fall. At presentation, an examination revealed jaundice with excoriation marks on her arms and back, and confusion. Cardiovascular, abdominal, respiratory and vital signs examinations were found to be normal. Blood analysis revealed altered liver function test values with amylase 12 U/L, gamma-glutamyl transferase 831 IU/L, bilirubin 240 μmol/L, alkaline phosphatase 1083 IU/L and alanine transferase 116 IU/L. Her abdominal CT scan revealed a normal appearance of the pancreas with no intra or extra-hepatic duct dilatation and thin walled gallbladder with subtle pericholecystic fluid. Hepatitis serology revealed previous exposure to cytomegalovirus and Ebstein-Barr virus but no ongoing infection. An autoimmune antibodies analysis was also negative. Subsequently, flucloxacillin-induced liver injury was confirmed. The woman’s levels of ALP, bilirubin, ALT, liver synthetic function were monitored and managed. Multidisciplinary approach was considered to improve nutrition and functional ability. Naltrexone was more effective in alleviating the pruritis as compare to colestyramine therapy. Her Liver function test values settled gradually and, pruritis improved significantly over the next 4 weeks.