Management of Ertapenem-Induced Skin Rash
If ertapenem causes a skin rash, discontinue the drug immediately and assess the severity of the reaction; for mild, non-severe rashes, symptomatic treatment with topical corticosteroids and emollients is appropriate, while severe cutaneous reactions require immediate cessation and alternative antibiotic selection. 1
Initial Assessment and Drug Discontinuation
The FDA label for ertapenem reports skin-related adverse events including rash (2.5%), pruritus (2.0%), erythema, dermatitis, desquamation, and urticaria as documented adverse reactions 1. When a rash develops:
- Stop ertapenem immediately if the rash is severe, progressive, or accompanied by systemic symptoms (fever, mucosal involvement, blistering), as these may indicate serious cutaneous adverse reactions 2
- Document the timing, morphology, and distribution of the rash to characterize whether this represents an immediate-type (occurring within hours) or delayed-type reaction (occurring days later) 2
- Assess for signs of anaphylaxis or severe cutaneous adverse reactions (SCAR) including Stevens-Johnson syndrome or toxic epidermal necrolysis, which require emergency management 2
Symptomatic Management
For mild to moderate rashes without systemic involvement:
- Apply topical corticosteroids such as hydrocortisone 1% or moderate-potency agents like clobetasone butyrate 0.05% to affected areas to reduce inflammation and erythema 3
- Use emollients and moisturizers multiple times daily to maintain skin barrier function and prevent dryness 3
- Avoid alcohol-containing lotions; instead use oil-in-water creams or ointments 3
- For pruritus, prescribe oral antihistamines such as cetirizine, loratadine, or fexofenadine 3
- Topical polidocanol-containing lotions can provide additional relief for itching 3
- Avoid hot showers and excessive soap use, as these can worsen skin dryness 3
Alternative Antibiotic Selection
When selecting an alternative antibiotic after ertapenem-induced rash:
- Carbapenems share limited cross-reactivity with other beta-lactams; if the reaction was non-severe and delayed-type, other beta-lactams (penicillins or cephalosporins) can generally be used safely 2
- For immediate-type reactions to ertapenem, cephalosporins can be administered in a monitored clinical setting with appropriate precautions 2
- Aztreonam and other carbapenems (imipenem, meropenem) appear safe in patients with non-severe delayed-type carbapenem reactions, though data are limited 2
- Consider non-beta-lactam alternatives such as fluoroquinolones or aminoglycosides depending on the infection type and susceptibility patterns 2
Important Caveats
Do not re-challenge with ertapenem if the initial reaction was severe (grade 3 or higher), involved mucosal surfaces, or suggested a severe cutaneous adverse reaction 2, 1. The clinical trials safety profile showed ertapenem was discontinued in 4.7% of patients due to adverse experiences, with skin reactions being among the documented causes 1.
For future antibiotic selection, document this reaction clearly in the medical record and communicate it to other healthcare providers, pharmacies, and the patient to prevent inadvertent re-exposure 2.