Fatal amphotericin B overdose due to administration of nonlipid formulation instead of lipid formulation.
The toxicity of amphotericin B deoxycholate has led to increased preference for lipid formulations with more favorable safety profiles. However, the primary use of lipid formulations is cost prohibitive, and many hospital formularies list both lipid and nonlipid formulations. A dispensing and administration error that caused amphotericin B deoxycholate to be given instead of liposomal amphotericin B related in a fatality. Measures to prevent confusion and aid in understanding the differences between lipid and nonlipid formulations of amphotericin B should be implemented.
Mohr
John F
JF
Division of Infectious Diseases and Center for the Study of Emerging and Re-emerging Pathogens, University of Texas Health Science Center-Houston, TX 77030, USA. john.mohr@uth.tmc.edu
Hall
Andrea C
AC
Ericsson
Charles D
CD
Ostrosky-Zeichner
Luis
L
D000328:Adult; D000666:Amphotericin B / Q000008:administration & dosage / Q000506:poisoning* / Q000627:therapeutic use; D000935:Antifungal Agents / Q000008:administration & dosage / Q000506:poisoning*; D002626:Chemistry, Pharmaceutical; D003840:Deoxycholic Acid / Q000008:administration & dosage / Q000506:poisoning*; D004338:Drug Combinations; D062787:Drug Overdose; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D008081:Liposomes; D008508:Medication Errors; D016919:Meningitis, Cryptococcal / Q000188:drug therapy
D000935:Antifungal Agents; D004338:Drug Combinations; D008081:Liposomes; D003840:Deoxycholic Acid; D000666:Amphotericin B; C059765:amphotericin B, deoxycholate drug combination