Cephalosporin use in an individual with a history of amoxicillin-associated Stevens Johnson syndrome
Question:
3/5/2024
What is the recommendation for cephalosporin administration in a patient with history of SJS reaction with amoxicillin? Can cephalosporins with dissimilar side chains to amoxicillin be administered? For example, can cefazolin be recommended for future use?
Answer:
This question has been partially addressed by "Ask the Expert" on 10-17-2021, Penicillin and Stevens Johnson syndrome.
PCN and Stevens Johnson syndrome
Question:
10/17/2021
A 38-year-old female presents with a compatible history of Stevens-Johnson syndrome related to sulfa antibiotic at 20 years of age (required ICU admission, but no sequela). At that time, she was told to also avoid penicillins due to increased risk of subsequent SJS because of her prior reaction to the sulfa antibiotic? On my review of the literature, I have not found such an association described. Your insight would be appreciated.
Answer:
People who have survived Stevens-Johnson syndrome must avoid the causative drug or structurally related medicines as Stevens-Johnson syndrome may recur. Cross-reactions can occur between:
Anticonvulsants carbamazepine, phenytoin, lamotrigine and phenobarbital
Beta-lactam antibiotics penicillin, cephalosporin, and carbapenem
Nonsteroidal anti-inflammatory drugs
Sulfonamides sulfamethoxazole, sulfadiazine, sulfapyridine
I also asked Dr Macy for his thoughts:
SJS is commonly misdiagnosed.
https://pubmed.ncbi.nlm.nih.gov/25914229/
SJS is extremely unlikely to be caused by penicillins.
https://pubmed.ncbi.nlm.nih.gov/31821919/
There are rare anecdotal reports of recurrent SJS attributed to unrelated medications.
https://pubmed.ncbi.nlm.nih.gov/27747689/
There is no population-based challenge data that I am aware of showing an clinically-significant increased risk of SJS to a second unrelated medication and up to half of SJS cases have no drug associated. SJS can be induced by an infection that an antibiotic is given for and then misattributed to that antibiotic. This commonly the case when penicillins are implicated as "causing" SJS.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107822/
Andrew Murphy, MD, FAAAAI
Stevens Johnson syndrome is commonly misdiagnosed.
https://pubmed.ncbi.nlm.nih.gov/25914229/
Stevens Johnson syndrome is rarely confirmed to be caused by penicillins or cephalosporins.
https://pubmed.ncbi.nlm.nih.gov/31821919/
https://pubmed.ncbi.nlm.nih.gov/25262461/
The historical concern about cephalosporin use in the setting of a suspected Penicillin "Allergy" was not based on sound science.
https://pubmed.ncbi.nlm.nih.gov/34303019/
Removing all warnings not to use cephalosporins in the setting of penicillin intolerance has been done in a major healthcare organization.
https://pubmed.ncbi.nlm.nih.gov/33914051/
To more directly address the question:
There is no data that has shown a higher risk for Stevens Johnson syndrome after any cephalosporin use in individuals with an episode of a penicillin-associated Stevens Johnson syndrome.
Since Stevens Johnson syndrome is T-cell mediated and it is possible that a T-cell mediated immune response may be directed against specific beta-lactam side-chains, it is currently considered prudent to avoid exposure to another beta-lactam antibiotic that has the same side chain or chain(s) as a beta-lactam implicated as a cause of an episode of Stevens Johnson syndrome.
Eric Macy, MD, MS, FAAAAI