Fatal anaphylactic shock following cefoperazone-sulbactam re-exposure: a short report on systemic gaps in adverse drug reaction management.

Abstract

This report presents a case of fatal anaphylactic shock following re-exposure to cefoperazone-sulbactam, highlighting systemic gaps in adverse drug reaction (ADR) management. The patient initially tolerated the drug without immediate adverse effects but developed severe hypersensitivity reactions upon subsequent exposures, ultimately leading to death. Analysis revealed that the healthcare team underestimated the risk of delayed IgE-mediated sensitization, and critical allergy information was not documented in the emergency department (ED). Additionally, the electronic health record (EHR) system lacked real-time allergy alerts. Fragmented communication during care transitions and technological deficiencies further exacerbated the risks.