Worldwide Prevalence of Antibiotic-Associated Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis

TAKE-HOME MESSAGE

• This systematic review and meta-analysis of 38 case series, including 2917 patients, found that 28% of the worldwide Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) cases were associated with antibiotics. Unsurprisingly, sulfonamides were the most commonly implicated antibiotic class, with 32% of the antibiotic–associated SJS/TEN cases being associated with this class. The other commonly associated antibiotic classes were penicillins, cephalosporins, fluoroquinolones, and macrolides.
• Physicians should be aware of the antibiotics most commonly associated with SJS/TEN and should thoroughly counsel patients regarding the risks prior to their prescription.

–  Ruth McTighe, MD

Abstract

IMPORTANCE

Antibiotics are an important risk for Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN), which are the most severe types of drug hypersensitivity reaction with a mortality rate up to 50%. To our knowledge, no global systematic review has described antibiotic-associated SJS/TEN.

OBJECTIVE

To evaluate the prevalence of antibiotics associated with SJS/TEN worldwide.

DATA SOURCES

The MEDLINE and Embase databases were searched for experimental and observational studies that described SJS/TEN risks since database inception to February 22, 2022.

STUDY SELECTION

Included studies adequately described SJS/TEN origins and specified the antibiotics associated with SJS/TEN.

DATA EXTRACTION AND SYNTHESIS

Two reviewers (E.Y.L. and C.K.) independently selected the studies, extracted the data, and assessed the risk of bias. A meta-analysis using a random-effects model was performed in the studies that described patient-level associations. Subgroup analyses were performed to explore the heterogeneity. The risk of bias was assessed using the Joanna Briggs Institute checklist, and the certainty of evidence was rated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

MAIN OUTCOMES AND MEASURES

Prevalence of antibiotic-associated SJS/TEN was presented as pooled proportions with 95% CIs.

RESULTS

Among the 64 studies included in the systematic review, there were 38 studies that described patient-level associations; the meta-analysis included these 38 studies with 2917 patients to determine the prevalence of single antibiotics associated with SJS/TEN. The pooled proportion of antibiotics associated with SJS/TEN was 28% (95% CI, 24%-33%), with moderate certainty of evidence. Among antibiotic-associated SJS/TEN, the sulfonamide class was associated with 32% (95% CI, 22%-44%) of cases, followed by penicillins (22%; 95% CI, 17%-28%), cephalosporins (11%; 95% CI, 6%-17%), fluoroquinolones (4%; 95% CI, 1%-7%), and macrolides (2%; 95% CI, 1%-5%). There was a statistically significant heterogeneity in the meta-analysis, which could be partially explained in the subgroup analysis by continents. The overall risk of bias was low using the Joanna Briggs Institute checklist for case series.

CONCLUSION AND RELEVANCE

In this systematic review and meta-analysis of all case series, antibiotics were associated with more than one-quarter of SJS/TEN cases described worldwide, and sulfonamide antibiotics remained the most important association. These findings highlight the importance of antibiotic stewardship, clinician education and awareness, and weighing the risk-benefit assessment of antibiotic choice and duration.

JAMA Dermatology

Worldwide Prevalence of Antibiotic-Associated Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Systematic Review and Meta-analysis

JAMA Dermatol 2023 Feb 15;[EPub Ahead of Print], EY Lee, C Knox, EJ Phillips 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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