Piperacillin-lnduced Acute Interstitial Nephritis

Piperacillin-lnduced Acute Interstitial Nephritis J. Soto J.M. Bosch M.J.A. Alsar Ortiz M.J. Moreno J.D. Gonzalez J.M. Diaz Clinical Pharmacology Unit, Hospital Santa Cruz, Liencres-Cantabria; Hematology Service, Hospital Insular, Las Palmas de Gran Canaria, Spain Maria J. Alsar Ortiz, /Floranes, 48-1°D, E-39010 Santander, Cantabria (Spain) Dear Sir, Acute interstitial nephritis (AIN) has been well documented during therapy with antimicrobial agents of the penicillin class, including penicillin G [1], ampicillin [2], oxacil-lin [3], methicillin [4], nafcillin [5], carbenicil-lin [6] and mezlocillin [7]. Piperacillin is a semisynthetic penicillin with activity against Pseudomonas aerugi-nosa, other gram-negative bacteria and some gram-positive bacteria, which has been available commercially in a great number of countries for long time. Despite a worldwide clinical experience, however, AIN associated with piperacillin has been reported just once [8]. Here we describe a patient with probably clinical AIN in association with piperacillin therapy. A 59-year-old man was admitted to our hospital for acute nonlymphoblastic leukemia (M2 of the FAB classification). His induction treatment was done with Adriamycin (30 mg/m2 i.v. for 3 days) and cytarabine (1 g/l2 h/m2 for 3 days plus 100 mg/m2 for 7 days). Allopurinol (200 mg/day) was added to the treatment. He had no history of drug reaction or allergies. Two months later, the patient presented fever and pulmonary infiltrates in a chest X-ray, which were treated with antibiotics (vancomycin: 500 mg/6 h, amikacin: 500 mg/ 12 h, imipenem: 500 mg/6 h) and amphotericin B (30 mg/day). Ten days later the infiltrates and fever persisted unchanged. As we suspected tuberculous infection, antibiotics and amphotericin B were discontinued, and rifampicin (600 mg/day), isoniazid (300 mg/day), ethambutol (1,200 mg/day) and py-razinamide (1750 mg/day) were instituted, with good response, and the fever and the infiltrates disappeared. At this time his blood urea nitrogen (BUN) and serum creatinine levels were 56 mg/dl (19.9 mmol/l) and 2.3 mg/dl (203.3 μmol/l), respectively, the rest of laboratory data being normal [except an uric acid level of 13.4 mg/dl (0.79 mmol/l)]. The hemogram showed a normal number of leukocytes, neu-trophils and red blood cells. The platelet count was 30,000/μl, and urinalysis was normal without hematuria and eosinophils. Two weeks later, the patient developed fever again, since Acinetobacteranitratusgτew from blood cultures. The patient was given intravenous piperacillin (4 g every 6 h), because the germ was sensible to this antibiotic. The rest of the medication was not changed.