What is the management for anaphylaxis due to intravenous (i.v.) Ceftriaxone?

Management of Anaphylaxis Due to IV Ceftriaxone

Immediate administration of intramuscular epinephrine into the anterolateral thigh is the first-line treatment for anaphylaxis due to IV ceftriaxone, with no absolute contraindications to its use. 1

Immediate Management Protocol

1. First-line treatment: Epinephrine

   • Administer epinephrine 0.01 mg/kg (maximum 0.5 mg in adults, 0.3 mg in children) intramuscularly into the anterolateral thigh (vastus lateralis) 2, 1
   • Use 1:1000 (1 mg/mL) concentration for intramuscular injection
   • May repeat every 5 minutes as necessary if symptoms persist 2
   • Note: Intramuscular injection into the thigh produces higher and more rapid peak plasma levels compared to arm injections 2

2. Airway and Circulation Management

   • Place patient in recumbent position with elevated lower extremities 2
   • Establish and maintain airway (endotracheal intubation if necessary) 2
   • Administer oxygen at 6-8 L/min 2
   • Establish venous access 2

3. Fluid Resuscitation

   • Administer normal saline for fluid replacement 2
   • Adults may require 1-2 L of normal saline (5-10 mL/kg in first 5 minutes) 2
   • Children can receive up to 30 mL/kg in the first hour 2
   • Consider colloid-containing solutions if hypotension persists 2

Management of Refractory Symptoms

1. For persistent hypotension despite IM epinephrine:

   • Consider epinephrine infusion 2, 1
   • Preparation: Add 1 mg (1 mL) of 1:1000 epinephrine to 250 mL D5W (concentration: 4.0 μg/mL)
   • Infuse at 1-4 μg/min (15-60 drops/min), increasing to maximum of 10 μg/min if needed 2
   • Alternative: 1:100,000 solution (1 mg in 100 mL saline) at 30-100 mL/h (5-15 μg/min) 2

2. For bronchospasm:

   • Administer nebulized albuterol 2.5-5 mg in 3 mL saline 1

3. Adjunctive therapies (after epinephrine administration):

   • Hydrocortisone 200 mg IV (adults) 1
   • Antihistamines: Diphenhydramine 1-2 mg/kg IV/IM (maximum 50 mg) 1
   • Consider ranitidine 1 mg/kg IV if available 1

Post-Acute Management

1. Monitoring:

   • Monitor patient for at least 4-6 hours after initial symptoms resolve 1
   • Watch for biphasic reactions, particularly in severe cases or those requiring multiple epinephrine doses 1

2. Prevention of recurrent anaphylaxis:

   • Continue hydrocortisone 200 mg/24h IV for severe cases 1
   • Double the usual hydrocortisone dose for 48 hours after severe anaphylaxis 1
   • Document ceftriaxone allergy prominently in medical records 3

Important Considerations for Ceftriaxone-Induced Anaphylaxis

• Ceftriaxone can cause severe and occasionally fatal hypersensitivity reactions including anaphylaxis 3

• Anaphylaxis can occur with the first dose of ceftriaxone, even without prior exposure 4, 5

• Risk factors for ceftriaxone-induced adverse events include:

  • Previous history of allergic reactions to cephalosporins or penicillins 3, 6
  • Rapid intravenous injection 6
  • Unlabeled use of the drug 6

• Fatal outcomes have been reported with ceftriaxone-induced anaphylaxis 4, 7

• Ceftriaxone was responsible for the highest number of deaths in the Iranian pharmacovigilance database (49 cases) 6

Follow-up Recommendations

• Arrange consultation with an allergist-immunologist 1
• Provide patient with an epinephrine autoinjector and proper training before discharge 1
• Develop a personalized anaphylaxis emergency action plan 1
• Advise patient to wear medical identification jewelry indicating ceftriaxone allergy 8
• Recommend avoidance of all cephalosporins and careful consideration before using other beta-lactam antibiotics 3, 6