Common Side Effects, Allergies and Reactions to Antibiotics

Please note - many side effects of medications may not be reported. Always consult your doctor or healthcare specialist for medical advice. You may also report side effects to the FDA at http://www.fda.gov/medwatch/ or 1-800-FDA-1088 (1-800-332-1088).

Antibiotics are among the most commonly prescribed medications in the US. An antibiotic side (adverse) effect is an unwanted reaction that occurs in addition to the desirable therapeutic action of the antibiotic. When used appropriately, antibiotics are relatively safe with very few side effects. However, like any drug, antibiotic side effects can occur and may interfere with the patient’s ability to tolerate and finish the course of medication.

Antibiotic reactions can range from mild allergic reactions to severe and debilitating adverse events. Antibiotic side effects are extremely variable from patient to patient and from antibiotic to antibiotic. However, there are some common side effects that may occur within antibiotic drug classes, as described in Table 1.

If a patient is experiencing a bothersome or serious antibiotic side effect, they should contact their health care provider. The outcomes may include staying on the same antibiotic and managing the side effect, adjusting the dose, or switching to a different antibiotic. Usually, antibiotic treatment should not be stopped without a health care provider’s approval. Stopping the antibiotic may allow the infection to worsen and may lead to antibiotic resistance. Even if the infection appears to have cleared up before all of the medication is gone, the full course of antibiotic treatment should always be completed unless told otherwise by a health care provider.

An antibiotic allergy or hypersensitivity reaction can happen with any drug, and allergies are one of the most common antibiotic side effects leading to emergency room admission.1 Health care providers should always be informed of any previous allergic reaction to any medication, including antibiotics. Mild allergic reactions may only result in a skin rash. More severe allergic reactions, called anaphylaxis, can lead to shortness of breath, wheezing, hives, and swelling of the face, lips or tongue. Anaphylaxis is a medical emergency that requires immediate medical attention.

Antibiotics are used to kill bacterial infections; they are not effective against viral infections, such as a cold or the flu, or against fungal infections, like ringworm or vaginal yeast infections. The most common antibiotic classes and drug members are listed in Table 1, along with the most commonly reported antibiotic side effects. This is not a complete list of all available antibiotics or side effects that may occur.

Table 1. Systemic Adverse Effects of Common Antibiotics and Classes

Antibiotic Class Antibiotic Class Members Most Common Side Effects Additional Clinical Comments
Penicillins penicillin, amoxicillin, amoxicillin-clavulanate, ampicillin, piperacillin-tazobactam, nafcillin, oxacillin rash, diarrhea, abdominal pain, nausea/vomiting, drug fever, hypersensitivity (allergic) reactions if bloody stools, anaphylaxis, severe skin reaction, fever occur contact health care provider immediately; ampicillin may cause pseudomembranous colitis
Cephalosporins cephalexin, cefaclor, cefuroxime, ceftibuten, cefdinir, cefixime,  ceftriaxone rash, diarrhea, nausea/vomiting (rare), hypersensitivity (allergic) reactions, serum sickness, vaginal candidiasis cross-hypersensitivity may occur in patients with documented penicillin allergy
Aminoglycosides gentamicin, tobramycin, amikacin renal (kidney) toxicity, ototoxicity (hearing loss), dizziness, nausea/vomiting, nystagmus longer or multiple treatment periods may lead to greater risk for ototoxicity, renal (kidney) toxicity
Carbapenems meropenem, ertapenem, doripenem, imipenem-cilastatin diarrhea, nausea/vomiting, headache, rash, liver toxicity, eosinophilia (elevated white blood cells) Hypersensitivity reactions reported with meropenem, imipenem in patients with penicillin allergy
Antituberculosis
Agents
rifampin, rifabutin, isoniazid, pyrazinamide, ethambutol, dapsone diarrhea, nausea/vomiting, anorexia, hemolytic anemia, liver toxicity, headache, peripheral neuropathy, dizziness, reddish-orange body fluids (rifampin, rifabutin only) sides effects vary among agents, check individually; vitamin B6 (pyridoxine) may be taken to help prevent peripheral neuropathy with isoniazid
Glycopeptides vancomycin, telavancin vancomycin: red man syndrome (flushing, hypotension, itching); phlebitis; telavancin: taste alteration, nausea/vomiting, headache, dizziness IV infusion of vancomycin over 60 minutes may prevent red man syndrome
Macrolides erythromycin, azithromycin, clarithromycin abdominal pain, diarrhea, anorexia, nausea/vomiting, taste alterations (clarithromycin) high rate of gastrointestinal side effects; do not crush, chew, break, open enteric-coated or delayed-release pill
Sulfonamides trimethoprin-sulfamethoxazole, erythromycin-sulfisoxazole, sulfadiazine nausea/vomiting, diarrhea, anorexia, abdominal pain, rash, photosensitivity, headache, dizziness Avoid prolonged sunlight exposure; use sunscreen, wear protective clothing; antibiotic cause of Stevens Johnson Syndrome, Toxic Epidermal Necrolysis
Tetracyclines tetracycline, doxycycline, minocycline nausea/vomiting, diarrhea, anorexia, abdominal pain, tooth discoloration in children < 8 years, liver toxicity Avoid prolonged sunlight exposure; use sunscreen, wear protective clothing
Quinolones ciprofloxacin (Cipro), levofloxacin (Levaquin), moxifloxacin (Avelox), ofloxacin (Floxin) nausea/vomiting, diarrhea, abdominal pain, headache, lethargy, insomnia, photosensitivity (can be severe) Avoid prolonged sunlight exposure; use sunscreen, wear protective clothing;
moxifloxacin associated with higher rates of side effects [shehab]; tendon rupture (rare) more common in age > 60, with corticosteroid use, in kidney, heart, lung translant recipients
Lincosamide clindamycin, lincomycin pseudomembranous colitis (may be severe), diarrhea, nausea/vomiting, rash, hypersensitivity, jaundice (clindamycin) if severe diarrhea during treatment or for up to 8 weeks after treatment consult health care provider immediately, may be pseudomembranous colitis (C. dificile); consider use of less toxic agents
Miscellaneous metronidazole nausea/vomiting, dizziness, headache, vaginal candidiasis, metallic taste avoid alcohol use during treatment and for up to 3 days after, combined use may lead to cramps, nausea/vomiting, flushing, headache; may discolor urine red-brown

In a 2008 study, antibiotic side effects led to greater than 140,000 emergency department admissions per year in the United States. Roughly 50 percent of emergency visits were due to reactions to antibiotics in the penicillin class of drugs, and the other 50 percent were due to a wide variety of antibiotics used to treat many different types of infections. In this study, children less than one year of age were found to have the highest rate of antibiotic side effects. Allergic reactions accounted for the most common type of side effect. It was estimated that over 142,000 emergency department visits per year were due to antibiotic adverse events, and approximately four-fifths of these events were due to allergic reactions. Allergic reactions can typically only be prevented by avoiding the drug, although desensitization may be possible in certain circumstances for patients who have no other antibiotic options. 1

There are also several side effects that are common to most antibiotics, regardless of class or drug. These side effects may include antibiotic-associated diarrhea, yeast infections, serious allergic skin reactions, and complications from intravenous use of antibiotics.

  • Antibiotic-associated diarrhea - Antibiotic-associated diarrhea occurs in patients receiving antibiotics and occurs for no explainable reason. Five to twenty-five percent of patients may develop antibiotic-associated diarrhea. The diarrhea occurs due to eradication of the normal gut flora by the antibiotic and results in an overgrowth of infectious bacteria, such as Clostridium dificile. If the diarrhea is severe, bloody, or is accompanied by stomach cramps of vomiting, a physician should be contacted. The most common antibiotics implicated in antibiotic-associated diarrhea are amoxicillin-clavulanate, ampicillin, and cefixime; however, other antibiotics may lead to this side effect, including cephalosporins, fluoroquinolones, azithromycin, clarithromycin, erythromycin, and tetracycline.2

  • Vaginal yeast infections or oral thrush (candida species): Antibiotics may also change the normal flora balance in the vagina, often leading to an overgrowth of fungal species. Candida albicans is a common fungus normally present in small amounts in the vagina, mouth, gastrointestinal tract, and on the skin and does not normally cause disease or symptoms. However, the fungus may take over when there is limited competition from bacteria due to antibiotic treatment.

  • Stevens Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN): Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but serious allergic reactions to substances, often drugs, that result in serious skin and mucous membrane disorders. Antibiotics such as sulfonamides, penicillins, cephalosporins, and fluoroquinolones may result in SJS and TEN. SJS and TEN can both cause rash, skin peeling, and sores on the mucous membranes and may be life-threatening.3

  • Injection site reactions and phlebitis: A reaction to an antibiotic can occur if the antibiotic is given intravenously in a vein. Injections site reactions and phlebitis (vein inflammation) can occur with intravenously (IV) administered antibiotics. The vein and area with the IV needle may be red, swollen and hot. An infection may or may not be present. Typically, the needle must be removed and reinserted elsewhere to help clear the injection site reaction.

See Also:

References:

1. Shehab N, Patel P, Srinivasan A, et al. Emergency department visits for antibiotic-associated adverse events. Clinical Infectious Diseases 2008;47:735-43.

2. Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med 2002:346:334-9.

3. The Merck Manual for Health Care Professionals. Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN). http://www.merckmanuals.com/professional/dermatologic_disorders/hypersensitivity_and_inflammatory_disorders/stevens-johnson_syndrome_sjs_and_toxic_epidermal_necrolysis_ten.html Accessed online 10/2/2011

Last updated: 2013-06-16 by Leigh Anderson, PharmD.

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