Antibiotic Selection in Patients with G6PD Deficiency
In patients with G6PD deficiency, antibiotic selection should avoid drugs with high oxidative potential such as sulfonamides, nitrofurantoin, and dapsone, which can trigger hemolytic crises. Instead, penicillins, cephalosporins, macrolides, and most tetracyclines are generally safe first-line options. 1, 2
Safe Antibiotic Options for G6PD-Deficient Patients
First-Line Safe Choices:
- Penicillins (amoxicillin, ampicillin, flucloxacillin)
- Cephalosporins (cefazolin, ceftriaxone, cephalexin)
- Macrolides (azithromycin, clarithromycin)
- Tetracyclines (doxycycline) - except in children <8 years
Second-Line Options (Use with Caution):
- Fluoroquinolones - Most are safe, but ciprofloxacin requires monitoring
- Carbapenems (imipenem, meropenem, ertapenem)
Antibiotics to Avoid or Use with Extreme Caution
High Risk (Contraindicated):
- Dapsone - Can cause significant hemolysis in G6PD-deficient individuals 1
- Nitrofurantoin - Associated with hemolytic episodes 3
- Sulfonamides/Cotrimoxazole - Traditional concern, though recent evidence suggests lower risk than previously thought 2, 3
Moderate Risk (Use Only When Benefits Outweigh Risks):
- Chloramphenicol
- Quinolones (particularly ciprofloxacin)
Monitoring Recommendations
When treating infections in G6PD-deficient patients:
Before Treatment:
- Confirm G6PD status with quantitative enzyme activity testing if unknown
- Document G6PD status prominently in medical records
During Treatment:
- Monitor for signs of hemolysis (darkening urine, pallor, fatigue, jaundice)
- Consider serial hemoglobin measurements with high-risk medications
- Ensure adequate hydration
If Hemolysis Occurs:
- Discontinue the offending agent immediately
- Provide supportive care (IV hydration)
- Consider blood transfusion for severe anemia
Special Considerations
Malaria Treatment:
- Avoid primaquine in G6PD-deficient patients 1
- For P. falciparum malaria, artesunate is preferred over quinine, as quinine has higher risk of hemolysis 1, 2
Severe Infections:
- For Rocky Mountain Spotted Fever and other tick-borne diseases, doxycycline remains the drug of choice even in G6PD-deficient patients 1
- For diabetic foot infections requiring broad-spectrum coverage, β-lactam/β-lactamase inhibitor combinations or carbapenems are safer options than fluoroquinolones 1
Recent Evidence:
A 2024 real-world study found that many medications previously thought to be high-risk have been prescribed safely to G6PD-deficient patients, including ciprofloxacin and sulfamethoxazole/cotrimoxazole 3. However, isolated case reports of hemolysis with medications like amoxicillin 4 suggest that individual susceptibility varies, particularly with different G6PD variants.
Risk Stratification by G6PD Variant
- Mediterranean variant (B-): Higher risk of severe hemolysis; requires stricter avoidance of oxidative drugs 2
- African variant (A-): Typically milder deficiency with lower risk of severe hemolysis 2
By understanding the patient's specific G6PD variant and severity of deficiency, antibiotic selection can be further optimized to minimize hemolytic risk while effectively treating infections.