Bacitracin Disease Interactions

Clostridioides difficile-associated diarrhea (CDAD), formerly pseudomembranous colitis, has been reported with almost all antibacterial drugs and may range from mild diarrhea to fatal colitis. The most common culprits include clindamycin and lincomycin. Antibacterial therapy alters the normal flora of the colon, leading to overgrowth of C difficile, whose toxins A and B contribute to CDAD development. Morbidity and mortality are increased with hypertoxin-producing strains of C difficile; these infections can be resistant to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea after antibacterial use. Since CDAD has been reported to occur more than 2 months after antibacterial use, careful medical history is necessary. Therapy with broad-spectrum antibacterials and other agents with significant antibacterial activity should be administered cautiously in patients with history of gastrointestinal disease, particularly colitis; pseudomembranous colitis (generally characterized by severe, persistent diarrhea and severe abdominal cramps, and sometimes associated with the passage of blood and mucus), if it occurs, may be more severe in these patients and may be associated with flares in underlying disease activity. Antibacterial drugs not directed against C difficile may need to be stopped if CDAD is suspected or confirmed. Appropriate fluid and electrolyte management, protein supplementation, antibacterial treatment of C difficile, and surgical evaluation should be started as clinically indicated.

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Adequate hydration is crucial to minimize the risk of nephrotoxicity associated with the systemic use of bacitracin. Dehydration should preferably be corrected prior to initiation of therapy. In patients who may be at risk for dehydration, such as those with severe and/or prolonged diarrhea or vomiting, fluid status should be monitored closely. If signs of renal irritation develop during therapy, hydration should be increased as indicated, accompanied by a reduction in dosage if necessary. Therapy should be withdrawn if urinary output decreases progressively or azotemia increases.

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The systemic use of bacitracin is contraindicated in patients with elevated BUN or nonprotein nitrogen or other evidence of renal impairment. Bacitracin is highly nephrotoxic and may cause glomerular and tubular necrosis, manifested initially by albuminuria, hematuria, cylindruria, and rising blood concentrations of the drug, then eventually by oliguria, azotemia, and renal failure. Bacitracin-induced nephrotoxicity is related to the total daily dosage and the duration of administration. To minimize the risk of toxicity, patients should be adequately hydrated, urine should be alkalinized to pH 6 or greater, the usual dosage should not be exceeded, and use with other nephrotoxic agents should be avoided. Renal function should be closely monitored, and therapy withdrawn promptly if toxicity develops.

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