The Frequency of Drug-Induced Liver Injury Due to Antibiotics Among Hospitalised Patients

Robert A Björnsson, Sigurdur Sölvi Sigurdsson, Dagur Tjörvi Arnarson, Egill Logason and Einar Stefan Björnsson ()
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Robert A Björnsson: University of Iceland
Sigurdur Sölvi Sigurdsson: University of Iceland
Dagur Tjörvi Arnarson: University of Iceland
Egill Logason: University of Iceland
Einar Stefan Björnsson: University of Iceland

Drug Safety, 2025, vol. 48, issue 7, No 7, 795-804

Abstract: Abstract Introduction Most epidemiological studies have found antibiotics to be the most common cause of drug-induced liver injury (DILI). It is unclear what the risk of DILI is associated with different antibiotics. Objective The aim of the study was to assess the frequency of DILI due to the most commonly used antibiotics among inpatients, in a population-based setting. Methods Patients who were treated with the 14 most-used antibiotics at Landspitali University Hospital Iceland 2012–2023, with concomitant: > 5 × upper limit of normal (ULN) of alanine aminotransferase (ALT) and/or > 2 × ULN of alkaline phosphatase (ALP), were identified. If DILI was a potential cause, the Revised Electronic Causality Assessment Method (RECAM) method was used to determine likelihood of DILI. Results Overall 2292 patients fulfilled the inclusion criteria, 52 of whom were found to have DILI, median age 67 (range 21–93) years, 58% females, 17 (33%) with jaundice and three (5.8%) died of liver failure. The most commonly implicated agent was amoxicillin/clavulanate (n = 23) in 1:1327 users (0.075%), ceftriaxone (n = 8) 1:3779 (0.02%), cefazolin (n = 7) 1: 6363 (0.016%), cloxacillin 1:6024 (n = 4) (0.017%), piperacillin/tazobactam (n = 2) 1:1551 (0.097%), vancomycin (n = 2) 1:1966 (0.076%), trimethoprim-sulfamethoxazole (TMP/SMX) (n = 3) 1:1096 (0.091%) and ciprofloxacin (n = 1) 1:10,938 (0.009%). In two cases, more than one antibiotic was considered likely. Conclusions Drug-induced liver injury was found to be a rare adverse effect of antibiotics in a population-based setting. Overall, 33% presented with jaundice but three died of liver failure, all due to amoxicillin/clavulanate, which was the most common cause occurring in around 1 in 1300 users. However, TMP/SMX was associated with the highest proportional risk of DILI.

Date: 2025
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DOI: 10.1007/s40264-025-01541-w

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