January 2000
KNOXVILLE, Tenn. - Pediatric surgeons here reported an increase in cases of infantile hypertrophic pyloric stenosis (IHPS) in infants who were given prophylactic erythromycin following exposure to pertussis in a nearby hospital.
"The findings in this report provide further evidence that erythromycin has a causal role in the etiology of IHPS and raise concerns about the use of erythromycin in neonates," the Centers for Disease Control and Prevention (CDC) said in a recent report. However, the CDC confirmed the importance of preventing pertussis in infants because most pertussis hospitalizations and deaths occur in infants younger than 1 year.
Public health officials should use caution in defining risk groups to minimize unnecessary prophylaxis and parents should be informed about the possible risks for IHPS before giving erythromycin to infants, the CDC said. But erythromycin should still be used in infants at risk for pertussis, until a better alternative can be identified.
In February 1999, pertussis was diagnosed in six neonates born at a hospital in Knoxville and erythromycin prophylaxis was prescribed for about 200 infants because the source of exposure was most likely a health care worker. The incidence of IHPS among the infants peaked during February 1999 with seven cases among 217 infants (rate: 32.3 cases per 1,000 live-born infants), a rate that was nearly seven times higher than the previous year.
A retrospective cohort study of 282 infants born during January-February 1999 at the hospital was conducted to assess a possible association between erythromycin use, gastrointestinal symptoms and IHPS. In the cohort, 157 infants (55.7%) had taken oral erythromycin. The prevalence of erythromycin use was 8.6% among 116 infants born during January 1999 and 88.6% among 166 infants born during February 1999. The erythromycin preparations administered to the infants included ethyl succinate and estolate. No differences were observed in GI symptoms or risk for IHPS in relation to the type of erythromycin preparation.
The infants who were given erythromycin but who did not develop IHPS were aged 1-53 days when they began erythromycin, and the duration of erythromycin exposure ranged from one to 21 days. The seven index IHPS case-patients were aged 2-17 days when they began erythromycin, and the duration of their erythromycin exposure ranged from 10-18 days.
The first case reports of a possible association between IHPS and erythromycin in five neonates were published in 1976, but the association had remained unconfirmed. The only subsequent report of this association was a single case report of IHPS in a breast-fed infant whose mother had taken erythromycin.
The peak in IHPS incidence in this region corresponded with the use of erythromycin. All index IHPS case-patients began having symptoms of either vomiting or excessive irritability while taking erythromycin.
No additional IHPS cases were reported among infants born after February at the hospital. "Although no data exist to confirm a safe and effective alternative to erythromycin for prophylaxis of neonates exposed to pertussis, these findings indicate a need for further examination of recommendations for erythromycin prophylaxis," the CDC said.
The CDC said that cases of pyloric stenosis following use of oral erythromycin should be reported to the Food and Drug Administration (FDA) MedWatch, telephone (800) 332-1088, or on the Web, www.fda.gov/medwatch. Additional information on using erythromycin for treating ophthalmia neonatorum and infant pneumonia caused by Chlamydia trachomatis in newborns is available at www.cdc.gov/nchstp/dstd/eryth.htm or by fax, (800) 332-0178.
For more information:
- CDC. Hypertrophic pyloric stenosis in infants following pertussis prophylaxis with erythromycin - Knoxville, Tennessee, 1999. MMWR 1999;48:1117-21.
- Honein MA, Paulozzi LJ, et al. Infantile hypertrophic pyloric stenosis after pertussis prophylaxis with erythromycin: a case review and cohort study. Lancet. 1999;354:2101-5.
- San Filippo JA. Infantile hypertrophic pyloric stenosis related to ingestion of erythromycin estolate: a report of five cases. J Pediatr Surg. 1976;11:177-80.
- Stang H. Pyloric stenosis associated with erythromycin ingested through breastmilk. Minn Med1986;69:669-70,682.
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