We report what we believe to be the first two cases of acute
interstitial nephritis associated with
vancomycin and
ceftriaxone therapy in adults. A 40-year-old man with a medical history of
traumatic brain injury and
tonic-clonic seizure disorder was admitted to the hospital with a seizure episode and temperature of 103 degrees F. He was administered
ceftriaxone,
vancomycin, and
acyclovir for suspected bacterial and/or
viral meningitis. On day 4, the patient was noted to have diffuse erythematous plaques on the neck, chest, arms, abdomen, and back, as well as an elevated serum
creatinine level of 3.1 mg/dl (baseline 0.9 mg/dl) and an elevated eosinophil count (6%). Dermatology and renal consultations were obtained, and a diagnosis of suspected acute
interstitial nephritis was made. After a 3-day course of
antibiotic treatment (day 4 of hospitalization), all
antibiotics were discontinued and topical
triamcinolone 0.1%
ointment and
hydrocortisone 2.5% cream were begun for the
rash. The patient was discharged 5 days later with improvement in the
rash, serum
creatinine level (1.0 mg/dl), and eosinophil count (0.9%). A 59-year-old woman with a medical history of
diabetes mellitus was admitted to the hospital with a serum
creatinine level of 3.7 mg/dl, eosinophil count of 8.4%, and fractional excretion of
sodium of 2.94%. The patient had been receiving treatment with
vancomycin and
ceftriaxone for
osteomyelitis for 28 days before this hospital admission. Her baseline serum
creatinine level (before
antibiotic therapy) was 1.0 mg/dl. Renal consultation was obtained, and a diagnosis of probable acute
interstitial nephritis was made.
Ceftriaxone and
vancomycin were discontinued, and her serum
creatinine level gradually decreased to 3.3 mg/dl and then further to 1.5 mg/dl over the next 3 months. Use of the Naranjo
adverse drug reaction probability scale revealed that the adverse reaction was possible in the first case and probable in the second case. Health care professionals need to be cognizant that
drug-induced acute
interstitial nephritis can be associated with concomitant administration of
ceftriaxone and
vancomycin therapy. Early detection of this rare adverse reaction is paramount in order to prevent
acute renal insufficiency.