Acute Liver Failure Induced by Anti-infectious Drugs: Causes and Management

Abstract

Worldwide, antimicrobial agents are the most common cause of idiosyncratic drug-induced liver injury (DILI) and drug-induced acute liver failure (ALF). The causes vary geographically; antituberculosis medications, sulfonamides, penicillin group of drugs, and macrolides are the top four implicated antibacterial agents, followed by antifungal and antiviral drugs. Women are at a higher risk for drug-induced ALF. Some drugs have distinct clinical, biochemical, and histological signatures. ALF caused by drugs generally has a subacute presentation that permits time for adequate work up, evaluation, and transfer to a tertiary facility for intensive monitoring and/or liver transplantation. Spontaneous survival is less common in patients with idiosyncratic drug-induced ALF, particularly in higher stages of encephalopathy, and liver transplantation may be the only means for survival. Liver explant biopsies have generally demonstrated submassive to massive necroses. There is no specific antidote in almost all of the cases. Immediate cessation of the offending medication at or before the onset of jaundice may limit the progression of liver injury in some cases; N-acetyl cysteine (NAC) may be helpful in patients with early stages of encephalopathy. Steroids may be given in patients with immunoallergic manifestations. This review summarizes the current knowledge about the presentation and management of ALF from antimicrobial agents.