The Frequency of Drug-Induced Liver Injury Due to Antibiotics Among Hospitalised Patients

Robert A Björnsson; Sigurdur Sölvi Sigurdsson; Dagur Tjörvi Arnarson; Egill Logason; Einar Stefan Björnsson

doi:10.1007/s40264-025-01541-w

The Frequency of Drug-Induced Liver Injury Due to Antibiotics Among Hospitalised Patients

Drug Saf. 2025 Mar 12. doi: 10.1007/s40264-025-01541-w. Online ahead of print.

Authors

Robert A Björnsson¹, Sigurdur Sölvi Sigurdsson¹, Dagur Tjörvi Arnarson¹, Egill Logason¹, Einar Stefan Björnsson^{2

3}

Affiliations

¹ Faculty of Medicine, University of Iceland, Reykjavik, Iceland.
² Faculty of Medicine, University of Iceland, Reykjavik, Iceland. einarsb@landspitali.is.
³ Division of Gastroenterology and Hepatology, Department of Internal Medicine, The National University Hospital of Iceland, Reykjavik, Iceland. einarsb@landspitali.is.

PMID: 40072769
DOI: 10.1007/s40264-025-01541-w

Abstract

Introduction: Most epidemiological studies have found antibiotics to be the most common cause of drug-induced liver injury (DILI). It is unclear what the risk of DILI is associated with different antibiotics.

Objective: The aim of the study was to assess the frequency of DILI due to the most commonly used antibiotics among inpatients, in a population-based setting.

Methods: Patients who were treated with the 14 most-used antibiotics at Landspitali University Hospital Iceland 2012-2023, with concomitant: > 5 × upper limit of normal (ULN) of alanine aminotransferase (ALT) and/or > 2 × ULN of alkaline phosphatase (ALP), were identified. If DILI was a potential cause, the Revised Electronic Causality Assessment Method (RECAM) method was used to determine likelihood of DILI.

Results: Overall 2292 patients fulfilled the inclusion criteria, 52 of whom were found to have DILI, median age 67 (range 21-93) years, 58% females, 17 (33%) with jaundice and three (5.8%) died of liver failure. The most commonly implicated agent was amoxicillin/clavulanate (n = 23) in 1:1327 users (0.075%), ceftriaxone (n = 8) 1:3779 (0.02%), cefazolin (n = 7) 1: 6363 (0.016%), cloxacillin 1:6024 (n = 4) (0.017%), piperacillin/tazobactam (n = 2) 1:1551 (0.097%), vancomycin (n = 2) 1:1966 (0.076%), trimethoprim-sulfamethoxazole (TMP/SMX) (n = 3) 1:1096 (0.091%) and ciprofloxacin (n = 1) 1:10,938 (0.009%). In two cases, more than one antibiotic was considered likely.

Conclusions: Drug-induced liver injury was found to be a rare adverse effect of antibiotics in a population-based setting. Overall, 33% presented with jaundice but three died of liver failure, all due to amoxicillin/clavulanate, which was the most common cause occurring in around 1 in 1300 users. However, TMP/SMX was associated with the highest proportional risk of DILI.