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Soyer O, Sahiner UM, Sekerel BE. Pro and Contra: Provocation Tests in Drug Hypersensitivity. Int J Mol Sci 2017; 18:ijms18071437. [PMID: 28677662 PMCID: PMC5535928 DOI: 10.3390/ijms18071437] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 06/24/2017] [Accepted: 06/27/2017] [Indexed: 02/06/2023] Open
Abstract
Drug provocation test (DPT) is the controlled administration of a drug to diagnose immune- or non-immune-mediated drug hypersensitivity and the last step for accurate recognition of drug hypersensitivity reactions when the previous diagnostic evaluations are negative or unavailable. A DPT is performed only if other conventional tests fail to yield conclusive results. In each clinical presentation, "to provoke or not to provoke" a patient should be decided after careful assessment of the risk-benefit ratio. Well-defined benefits of DPT include confirmative exclusion of diagnoses of drug hypersensitivity and provision of safe alternatives. However, disadvantages such as safety, difficulty in interpretations of results, lack of objective biomarkers, risks of resensitization, efficiency in daily practice, and lack of standardized protocols, are poorly debated. This review summarizes the current published research concerning DPT, with particular emphasis on the advantages and disadvantages of DPT in an evidence-based manner.
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Affiliation(s)
- Ozge Soyer
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
| | - Umit Murat Sahiner
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
| | - Bulent Enis Sekerel
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
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53
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Macy E, Romano A, Khan D. Practical Management of Antibiotic Hypersensitivity in 2017. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:577-586. [DOI: 10.1016/j.jaip.2017.02.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 02/17/2017] [Accepted: 02/22/2017] [Indexed: 12/19/2022]
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Abstract
Broad-spectrum antibiotics are commonly used by physicians to treat various infections. The source of infection and causative organisms are not always apparent during the initial evaluation of the patient, and antibiotics are often given empirically to patients with suspected sepsis. Fear of attempting cephalosporins and carbapenems in penicillin-allergic septic patients may result in significant decrease in the spectrum of antimicrobial coverage. Empiric antibiotic therapy should sufficiently cover all the suspected pathogens, guided by the bacteriologic susceptibilities of the medical center. It is important to understand the major pharmacokinetic properties of antibacterial agents for proper use and to minimize the development of resistance. In several septic patients, negative cultures do not exclude active infection and positive cultures may not represent the actual infection. This article will review the important differences in the spectrum of commonly used antibiotics for nosocomial bacterial infections with a particular emphasis on culture-negative sepsis and colonization.
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Konvinse KC, Phillips EJ, White KD, Trubiano JA. Old dog begging for new tricks: current practices and future directions in the diagnosis of delayed antimicrobial hypersensitivity. Curr Opin Infect Dis 2016; 29:561-576. [PMID: 27753687 PMCID: PMC5113146 DOI: 10.1097/qco.0000000000000323] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Antimicrobials are a leading cause of severe T cell-mediated adverse drug reactions (ADRs). The purpose of this review is to address the current understanding of antimicrobial cross-reactivity and the ready availability of and evidence for in-vitro, in-vivo, and ex-vivo diagnostics for T cell-mediated ADRs. RECENT FINDINGS Recent literature has evaluated the efficacy of traditional antibiotic allergy management, including patch testing, skin prick testing, intradermal testing, and oral challenge. Although patch and intradermal testing are specific for the diagnosis of immune-mediated ADRs, they suffer from drug-specific limitations in sensitivity. The use of ex-vivo diagnostics, especially enzyme-linked immunospot, has been highlighted as a promising new approach to assigning causality. Knowledge of true rates of antimicrobial cross-reactivity aids empirical antibiotic choice in the setting of previous immune-mediated ADRs. SUMMARY In an era of increasing antimicrobial resistance and use of broad-spectrum antimicrobial therapy, ensuring patients are assigned the correct 'allergy label' is essential. Re-exposure to implicated antimicrobials, especially in the setting of severe adverse cutaneous reaction, is associated with significant morbidity and mortality. The process through which an antibiotic label gets assigned, acted on and maintained is still imprecise. Predicting T cell-mediated ADRs via personalized approaches, including human leukocyte antigen-typing, may pave future pathways to safer antimicrobial prescribing guidelines.
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Affiliation(s)
- Katherine C Konvinse
- aDepartment of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA bInstitute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia cDepartment of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA dDepartment of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA eDepartment of Infectious Diseases, Austin Hospital, Victoria, Australia fDepartment of Infectious Diseases, Alfred Hospital, Victoria, Australia gDepartment of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria, Australia hDepartment of Medicine, University of Melbourne, Victoria, Australia
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Trubiano JA, Worth LJ, Urbancic K, Brown TM, Paterson DL, Lucas M, Phillips E. Return to sender: the need to re-address patient antibiotic allergy labels in Australia and New Zealand. Intern Med J 2016; 46:1311-1317. [PMID: 27527526 PMCID: PMC5096978 DOI: 10.1111/imj.13221] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/04/2016] [Accepted: 08/08/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND/AIM Antibiotic allergies are frequently reported and have significant impacts upon appropriate prescribing and clinical outcomes. We surveyed infectious diseases physicians, allergists, clinical immunologists and hospital pharmacists to evaluate antibiotic allergy knowledge and service delivery in Australia and New Zealand. METHODS An online multi-choice questionnaire was developed and endorsed by representatives of the Australasian Society of Clinical Immunology and Allergy (ASCIA) and the Australasian Society of Infectious Diseases (ASID). The 37-item survey was distributed in April 2015 to members of ASCIA, ASID, the Society of Hospital Pharmacists of Australia and the Royal Australasian College of Physicians. RESULTS Of 277 respondents, 94% currently use or would utilise antibiotic allergy testing (AAT) and reported seeing up to 10 patients/week labelled as antibiotic-allergic. Forty-two per cent were not aware of or did not have AAT available. Most felt that AAT would aid antibiotic selection, antibiotic appropriateness and antimicrobial stewardship (79, 69 and 61% respectively). Patients with the histories of immediate hypersensitivity were more likely to be referred than those with delayed hypersensitivities (76 vs 41%, P = 0.0001). Lack of specialist physicians (20%) and personal experience (17%) were barriers to service delivery. A multidisciplinary approach was a preferred AAT model (53%). Knowledge gaps were identified, with the majority overestimating rates of penicillin/cephalosporin (78%), penicillin/carbapenem (57%) and penicillin/monobactam (39%) cross-reactivity. CONCLUSIONS A high burden of antibiotic allergy labelling and demand for AAT is complicated by a relative lack availability or awareness of AAT services in Australia and New Zealand. Antibiotic allergy education and deployment of AAT, accessible to community and hospital-based clinicians, may improve clinical decisions and reduce antibiotic allergy impacts. A collaborative approach involving infectious diseases physicians, pharmacists and allergists/immunologists is required.
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Affiliation(s)
- J A Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.
| | - L J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - K Urbancic
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
- Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia
| | - T M Brown
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - D L Paterson
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - M Lucas
- Department of Clinical Immunology, Pathwest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - E Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
- Department of Medicine, Vanderbilt Medical Center, Nashville, Tennessee, USA
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Trubiano JA, Beekmann SE, Worth LJ, Polgreen PM, Thursky KA, Slavin MA, Grayson ML, Phillips EJ. Improving Antimicrobial Stewardship by Antibiotic Allergy Delabeling: Evaluation of Knowledge, Attitude, and Practices Throughout the Emerging Infections Network. Open Forum Infect Dis 2016; 3:ofw153. [PMID: 27800527 PMCID: PMC5084721 DOI: 10.1093/ofid/ofw153] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 07/12/2016] [Indexed: 12/02/2022] Open
Abstract
Antibiotic allergy testing (AAT) practices of Emerging Infections Network infectious disease physicians were surveyed. Although AAT was perceived to be necessary for removal of inappropriate or unnecessary allergy labels, there was limited access to any form of testing. In this study, we discuss current antibiotic allergy knowledge gaps and the development of AAT practices within antimicrobial stewardship programs, which will potentially improve antimicrobial prescribing.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Susan E Beekmann
- Department of Internal Medicine, Carver College of Medicine , University of Iowa , Iowa City
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Philip M Polgreen
- Department of Internal Medicine, Carver College of Medicine , University of Iowa , Iowa City
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia; Department of Medicine, Vanderbilt Medical Centre, Nashville, Tennessee
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Romano A, Gaeta F, Arribas Poves MF, Valluzzi RL. Cross-Reactivity among Beta-Lactams. Curr Allergy Asthma Rep 2016; 16:24. [PMID: 26898316 DOI: 10.1007/s11882-016-0594-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Penicillins and cephalosporins are the major classes of beta-lactam (BL) antibiotics in use today and one of the most frequent causes of hypersensitivity reactions to drugs. Monobactams, carbapenems, oxacephems, and beta-lactamase inhibitors constitute the four minor classes of BLs. This review takes into account mainly the prospective studies which evaluated cross-reactivity among BLs in subjects with a well-demonstrated hypersensitivity to a certain class of BLs by performing allergy tests with alternative BLs and, in case of negative results, administering them. In subjects with either IgE-mediated or T-cell-mediated hypersensitivity, cross-reactivity among BLs, particularly among penicillins and among cephalosporins, as well as between penicillins and cephalosporins, seems to be mainly related to structural similarities among their side-chain determinants. Specifically, in penicillin-allergic subjects, cross-reactivity between penicillins and cephalosporins may exceed 30% when they are administered cephalosporins with identical side chains to those of responsible penicillins. In these subjects, a few prospective studies have demonstrated a rate of cross-reactivity between penicillins and both carbapenems and aztreonam lower than 1%. With regard to subjects with an IgE-mediated hypersensitivity to cephalosporins, in a single study, about 25% of the 98 subjects with such hypersensitivity had positive results to penicillins, 3% to aztreonam, 2% to imipenem/cilastatin, and 1% to meropenem. The cross-reactivity related to the selective recognition of the BL ring by IgE or T lymphocytes, which entails positive responses to all BLs tested, appears to be exceptional. Some studies concerning cross-reactivity among BLs have found patterns of allergy-test positivity which cannot be explained by either the common BL ring or by similar or identical side chains, thus indicating the possibility of coexisting sensitivities to different BLs because of prior exposures to them.
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Affiliation(s)
- Antonino Romano
- Allergy Unit, Complesso Integrato Columbus, Via G. Moscati, 31, 00168, Rome, Italy. .,IRCCS Oasi Maria S.S., Troina, Italy.
| | - Francesco Gaeta
- Allergy Unit, Complesso Integrato Columbus, Via G. Moscati, 31, 00168, Rome, Italy
| | | | - Rocco Luigi Valluzzi
- Allergy Unit, Complesso Integrato Columbus, Via G. Moscati, 31, 00168, Rome, Italy
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Harandian F, Pham D, Ben-Shoshan M. Positive penicillin allergy testing results: a systematic review and meta-analysis of papers published from 2010 through 2015. Postgrad Med 2016; 128:557-62. [PMID: 27240423 DOI: 10.1080/00325481.2016.1191319] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
β-lactam antibiotics are the most widely used group of antibiotics, given their effectiveness for the most common bacterial pathogens and their relatively low price. Adverse reactions, mainly cutaneous, are often reported to be associated with their use and hence, less effective and usually more costly alternative antibiotics are prescribed. However, it is not clear what is the risk of immediate immune-mediated (i.e. developing within one hour of administration) and potentially life-threatening reactions among those using β-lactam antibiotic. We conducted a systematic review to assess the prevalence of immediate adverse reactions to β-lactam antibiotics, specifically penicillin derivatives, in patients with a reported adverse reaction to β-lactam antibiotics. In addition, we determined the effect of age on the prevalence of immediate reactions. Assessing the true risk of using β-lactam antibiotics in patients with a reported allergy could prevent physicians from unnecessarily discouraging the use of β-lactam antibiotics. We conducted a systematic review and a meta-analysis using the PubMed, OVID, and Embase databases of work published in English and in French in the last 5 years. Studies were only eligible if they established the prevalence of immediate penicillin reactions with skin testing or challenges in case of negative skin tests. The meta-analysis was conducted using Stata version 12.0. The prevalence of immediate reactions to penicillin derivatives in patients reporting a β-lactam hypersensitivity is 1.98% (95%CI; 1.35%, 2.60%) in the pediatric (under 18 years old) group, 7.78% (95%CI; 6.53%, 9.04%) in the adult group, and 2.84% (95%CI; 1.77%, 3.91%) in the combined group, as tested in various studies, using skin tests and oral challenges. The I(2) value ranged between 87.2% and 97.0%. Our results indicate that the prevalence of immediate reactions is higher in adults than in children. However, wide confidence intervals and a large study heterogeneity preclude conclusive estimates.
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Affiliation(s)
| | | | - Moshe Ben-Shoshan
- b Department of Allergy & Immunology , McGill University Health Center, Montreal Children's Hospital , Montreal , Canada
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Tsai CT, Robinson P, Spencer C, Bertozzi CR. Ultrasensitive Antibody Detection by Agglutination-PCR (ADAP). ACS CENTRAL SCIENCE 2016; 2:139-147. [PMID: 27064772 PMCID: PMC4819452 DOI: 10.1021/acscentsci.5b00340] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Indexed: 05/14/2023]
Abstract
Antibodies are widely used biomarkers for the diagnosis of many diseases. Assays based on solid-phase immobilization of antigens comprise the majority of clinical platforms for antibody detection, but can be undermined by antigen denaturation and epitope masking. These technological hurdles are especially troublesome in detecting antibodies that bind nonlinear or conformational epitopes, such as anti-insulin antibodies in type 1 diabetes patients and anti-thyroglobulin antibodies associated with thyroid cancers. Radioimmunoassay remains the gold standard for these challenging antibody biomarkers, but the limited multiplexability and reliance on hazardous radioactive reagents have prevented their use outside specialized testing facilities. Here we present an ultrasensitive solution-phase method for detecting antibodies, termed antibody detection by agglutination-PCR (ADAP). Antibodies bind to and agglutinate synthetic antigen-DNA conjugates, enabling ligation of the DNA strands and subsequent quantification by qPCR. ADAP detects zepto- to attomoles of antibodies in 2 μL of sample with a dynamic range spanning 5-6 orders of magnitude. Using ADAP, we detected anti-thyroglobulin autoantibodies from human patient plasma with a 1000-fold increased sensitivity over an FDA-approved radioimmunoassay. Finally, we demonstrate the multiplexability of ADAP by simultaneously detecting multiple antibodies in one experiment. ADAP's combination of simplicity, sensitivity, broad dynamic range, multiplexability, and use of standard PCR protocols creates new opportunities for the discovery and detection of antibody biomarkers.
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Affiliation(s)
- Cheng-ting Tsai
- Department
of Chemistry, University of California, Berkeley, California 94720, United States
| | - Peter
V. Robinson
- Department
of Chemistry, University of California, Berkeley, California 94720, United States
| | - Carole
A. Spencer
- USC
Endocrine Laboratories, Department of Medicine, University of Southern California, Los Angeles, California 91105, United States
| | - Carolyn R. Bertozzi
- Department of Chemistry and Howard Hughes Medical Institute, Stanford University, Stanford, California 94305, United States
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Romano A, Gaeta F, Valluzzi RL, Maggioletti M, Caruso C, Quaratino D. Cross-reactivity and tolerability of aztreonam and cephalosporins in subjects with a T cell-mediated hypersensitivity to penicillins. J Allergy Clin Immunol 2016; 138:179-186. [PMID: 27016799 DOI: 10.1016/j.jaci.2016.01.025] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 01/08/2016] [Accepted: 01/12/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND The few studies performed in adults with T cell-mediated hypersensitivity to penicillins have found a rate of cross-reactivity with cephalosporins ranging from 2.8% to 31.2% and an absence of cross-reactivity with aztreonam. OBJECTIVE We sought to evaluate the possibility of using cephalosporins and aztreonam in subjects with documented delayed hypersensitivity to penicillins who especially require them. METHODS We conducted a prospective study of 214 consecutive subjects who had 307 nonimmediate reactions to penicillins (almost exclusively aminopenicillins) and had positive patch test and/or delayed-reading skin test responses to at least 1 penicillin reagent. To assess cross-reactivity with cephalosporins and aztreonam and the tolerability of such alternative β-lactams, all subjects underwent skin tests with cephalexin, cefaclor, cefadroxil, cefuroxime, ceftriaxone, and aztreonam. Subjects with negative responses were challenged with the alternative β-lactams concerned. RESULTS All subjects had negative skin test results to cefuroxime, ceftriaxone, and aztreonam and tolerated challenges. Forty (18.7%) of the 214 subjects had positive skin test responses to at least 1 aminocephalosporin. Of the 174 subjects with negative responses, 170 underwent challenges; 1 reacted to cefaclor. CONCLUSIONS These data demonstrate a rate of cross-reactivity between aminopenicillins and aminocephalosporins (ie, cephalexin, cefaclor, and cefadroxil) of around 20%, as well as the absence of cross-reactivity between penicillins and cefuroxime, ceftriaxone, and aztreonam in all subjects with T cell-mediated hypersensitivity to penicillins, almost exclusively aminopenicillins. Therefore these subjects could be treated with cefuroxime, ceftriaxone, and aztreonam. In those who especially require cephalosporin or aztreonam treatment, however, we recommend pretreatment skin tests because negative responses indicate tolerability.
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Affiliation(s)
- Antonino Romano
- Allergy Unit, Complesso Integrato Columbus, Rome, Italy; IRCCS Oasi Maria S.S., Troina, Italy.
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Abstract
One of the most used cephalosporin in clinical practice is ceftriaxone. Anaphylaxis due to the administration of ceftriaxone is considered a rare event. Here, we report a case of fatal anaphylactic shock after the administration of ceftriaxone in a child who had tolerated the drug in past exposures. The allergic pathogenesis is sustained by the clinical data (short time between the inoculation of the drug and the onset of the symptoms; past exposure to the same molecule and probable sensitization) and the postmortem examination findings (polivisceral congestion and intense eosinophilia found in the histological examination).
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Christiansen IS, Krøigaard M, Mosbech H, Skov PS, Poulsen LK, Garvey LH. Clinical and diagnostic features of perioperative hypersensitivity to cefuroxime. Clin Exp Allergy 2015; 45:807-14. [PMID: 25395022 DOI: 10.1111/cea.12455] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 11/05/2014] [Accepted: 11/07/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The Danish Anaesthesia Allergy Centre (DAAC) investigated 89 adult patients with suspected perioperative cefuroxime-associated hypersensitivity reactions between 2004 and 2013. The goals were to determine whether the time to index reaction after cefuroxime exposure could be used to implicate cefuroxime as the cause of the reactions and explore different test modalities in diagnosing cefuroxime hypersensitivity. METHOD Skin tests, in vitro tests, and titrated provocations were used to determine cefuroxime hypersensitivity. Patients were deemed cefuroxime positive on the basis of at least two positive tests and/or a positive provocation. RESULTS One or more tests were positive for cefuroxime in 24 of 89 (27.0%) patients. One was only specific IgE positive and was deemed cefuroxime negative. Twenty-three (25.8%) were deemed cefuroxime positive. There were four specific IgE-, 4 histamine release test-, 13 skin test-, and 14 provocation positive patients. There were eight (34.8%) patients who were only provocation positive. Data on time to index reaction after cefuroxime exposure were available for 80 patients (22 in the positive group and 58 in the negative group), 22 of 22 (100%) of positive patients reacted in <15 min vs. only 38 of 58 (65.5%) of negative patients. CONCLUSION All patients with confirmed hypersensitivity to cefuroxime reacted within 15 min of administration, but so did 65.5% of Cefuroxime negative patients, making timing of administration an unreliable predictor of causation in the perioperative setting. Provocations were always positive when carried out in skin test positive patients; however, eight patients had positive provocations only, highlighting the need for provocation in skin test negative patients.
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Affiliation(s)
- I S Christiansen
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Copenhagen University Hospital Gentofte, Hellerup, Denmark
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Mirakian R, Leech SC, Krishna MT, Richter AG, Huber PAJ, Farooque S, Khan N, Pirmohamed M, Clark AT, Nasser SM. Management of allergy to penicillins and other beta-lactams. Clin Exp Allergy 2015; 45:300-27. [PMID: 25623506 DOI: 10.1111/cea.12468] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 10/29/2014] [Accepted: 11/07/2014] [Indexed: 12/15/2022]
Abstract
The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and an expert panel have prepared this guidance for the management of immediate and non-immediate allergic reactions to penicillins and other beta-lactams. The guideline is intended for UK specialists in both adult and paediatric allergy and for other clinicians practising allergy in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking, the panel reached consensus. During the development of the guideline, all BSACI members were consulted using a Web-based process and all comments carefully considered. Included in the guideline are epidemiology of allergic reactions to beta-lactams, molecular structure, formulations available in the UK and a description of known beta-lactam antigenic determinants. Sections on the value and limitations of clinical history, skin testing and laboratory investigations for both penicillins and cephalosporins are included. Cross-reactivity between penicillins and cephalosporins is discussed in detail. Recommendations on oral provocation and desensitization procedures have been made. Guidance for beta-lactam allergy in children is given in a separate section. An algorithm to help the clinician in the diagnosis of patients with a history of penicillin allergy has also been included.
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Affiliation(s)
- R Mirakian
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Romano A, Gaeta F, Valluzzi RL, Maggioletti M, Zaffiro A, Caruso C, Quaratino D. IgE-mediated hypersensitivity to cephalosporins: Cross-reactivity and tolerability of alternative cephalosporins. J Allergy Clin Immunol 2015; 136:685-691.e3. [DOI: 10.1016/j.jaci.2015.03.012] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/14/2015] [Accepted: 03/05/2015] [Indexed: 10/23/2022]
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Basile RC, Rivera GG, Del Rio LA, de Bonis TCM, do Amaral GPD, Giangrecco E, Ferraz G, Yoshinari NH, Canola PA, Queiroz Neto A. Anaphylactoid reaction caused by sodium ceftriaxone in two horses experimentally infected by Borrelia burgdorferi. BMC Vet Res 2015; 11:197. [PMID: 26265349 PMCID: PMC4534110 DOI: 10.1186/s12917-015-0478-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 07/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lyme borreliosis is a disease transmitted by ticks to mammals, especially in horses and humans. Caused by a spirochete Borrelia burgdorferi, it can result in lameness, arthritis, carditis, dermatitis and neurological signs. Anaphylactoid reactions are severe responses caused by direct action of substances (drugs, toxins), which can pose risks to life. Still poorly documented in horses, these reactions are caused by the effects of inflammatory mediators such as histamine, kinins and arachidonic acid metabolites. The last two are the most clinically relevant for the species. CASE PRESENTATION The simultaneous occurrence of anaphylactoid reaction in two horses experimentally infected by Borrelia burgdorferi undergoing intravenous treatment with ceftriaxone sodium is reported. It was administered 4.7 × 10(8) spirochetes intradermal and subcutaneous applications in both horses to evaluate clinical aspects of the Lyme disease, 95 days before the application of sodium ceftriaxone. During the administration, one horse (a gelding) showed immediate and severe anaphylactoid symptoms such as urticaria, dyspnea, tachycardia, and eyelid edema, which were controlled by injecting dexamethasone. After 1 day, it expressed signs of abdominal discomfort, caused by severe bloat, which was treated surgically via celiotomy. Subsequently, this gelding had piroplasmosis and severe anemia, requiring treatment with an antimicrobial and blood transfusion. Second horse (a mare) showed signs of hypotension during the application of the antibiotic, which disappeared only when the application was interrupted. Days after the event, the mare developed moderate large colon bloat, which was treated with medication only. Subsequently the mare was evolved into the prodromal phase of laminitis in one of the forelimbs, which was treated for 10 days with non-steroidal anti-inflammatory and rheology modifying drugs and cryotherapy. CONCLUSIONS From the two cases presented here, it does appear that sodium ceftriaxone can induce anaphylactoid reactions in horses infected by Borrelia burgdorferi, which may evolve into colic syndrome, laminitis and the occurrence of opportunistic infections. However, further evidence should be collected in order to draw definite conclusions.
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Affiliation(s)
- Roberta Carvalho Basile
- Faculdade de Ciências Agrárias e Veterinárias, UNESP - Univ Estadual Paulista, Campus Jaboticabal, Departamento de Morfologia e Fisiologia Animal, Laboratório de Farmacologia e Fisiologia do Exercício Equino (LAFEQ), Jaboticabal, SP, 14884-900, Brazil.
| | | | - Lara Antoniassi Del Rio
- Faculdade de Ciências Agrárias e Veterinárias, UNESP - Univ Estadual Paulista, Campus Jaboticabal, Departamento de Morfologia e Fisiologia Animal, Laboratório de Farmacologia e Fisiologia do Exercício Equino (LAFEQ), Jaboticabal, SP, 14884-900, Brazil.
| | - Talissa Camargo Mantovani de Bonis
- Faculdade de Ciências Agrárias e Veterinárias, UNESP - Univ Estadual Paulista, Campus Jaboticabal, Departamento de Morfologia e Fisiologia Animal, Laboratório de Farmacologia e Fisiologia do Exercício Equino (LAFEQ), Jaboticabal, SP, 14884-900, Brazil.
| | - Gabriel Paiva Domingues do Amaral
- Faculdade de Ciências Agrárias e Veterinárias, UNESP - Univ Estadual Paulista, Campus Jaboticabal, Departamento de Morfologia e Fisiologia Animal, Laboratório de Farmacologia e Fisiologia do Exercício Equino (LAFEQ), Jaboticabal, SP, 14884-900, Brazil.
| | - Edson Giangrecco
- Departamento de Clínica e Cirurgia Veterinária, Jaboticabal, Brazil.
| | - Guilherme Ferraz
- Faculdade de Ciências Agrárias e Veterinárias, UNESP - Univ Estadual Paulista, Campus Jaboticabal, Departamento de Morfologia e Fisiologia Animal, Laboratório de Farmacologia e Fisiologia do Exercício Equino (LAFEQ), Jaboticabal, SP, 14884-900, Brazil.
| | - Natalino Hajime Yoshinari
- Faculdade de Medicina da Universidade de São Paulo FMUSP, Departamento de Reumatologia, São Paulo, Brazil.
| | | | - Antonio Queiroz Neto
- Faculdade de Ciências Agrárias e Veterinárias, UNESP - Univ Estadual Paulista, Campus Jaboticabal, Departamento de Morfologia e Fisiologia Animal, Laboratório de Farmacologia e Fisiologia do Exercício Equino (LAFEQ), Jaboticabal, SP, 14884-900, Brazil.
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Abstract
Drug-induced anaphylaxis is a common cause of anaphylaxis and a leading cause of fatal anaphylaxis. Antibiotics, radiocontrast, and nonsteroidal anti-inflammatory drugs are commonly implicated drugs. Vocal cord dysfunction can mimic anaphylaxis and is often overlooked. β-Lactams are a common cause of anaphylaxis; however, skin testing and drug challenge can usually determine tolerability of other classes of β-lactams. Nonionic contrast agents cause anaphylaxis less frequently than ionic contrast, and immunoglobulin E-mediated mechanisms may have a role in some of these reactions. Skin testing with radiocontrast may have a role in evaluating patients with anaphylaxis to nonionic contrast.
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Affiliation(s)
- Merin Kuruvilla
- Atlanta ENT, 5555 Peachtree Dunwoody Rd, Suite 125, Atlanta, GA-30342, USA
| | - David A Khan
- Division of Allergy & Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8859, USA.
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Gaeta F, Valluzzi RL, Alonzi C, Maggioletti M, Caruso C, Romano A. Tolerability of aztreonam and carbapenems in patients with IgE-mediated hypersensitivity to penicillins. J Allergy Clin Immunol 2014; 135:972-976. [PMID: 25457154 DOI: 10.1016/j.jaci.2014.10.011] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 10/01/2014] [Accepted: 10/08/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Studies performed on samples larger than 100 subjects with a documented IgE-mediated hypersensitivity to penicillins have demonstrated a cross-reactivity rate of approximately 1% between penicillins and both imipenem and meropenem, whereas a single study found a cross-reactivity rate of 6.2% with aztreonam in 16 such subjects. OBJECTIVE To assess the cross-reactivity and tolerability of aztreonam and 3 carbapenems (imipenem-cilastatin, meropenem, and ertapenem) in patients with documented IgE-mediated hypersensitivity to penicillins. METHODS A total of 212 consecutive subjects with immediate reactions to penicillins and positive results on skin tests to at least 1 penicillin reagent underwent skin tests with aztreonam and carbapenems; subjects with negative results were challenged with escalating doses of aztreonam and carbapenems. RESULTS All subjects displayed negative skin test results to both aztreonam and carbapenems; 211 accepted challenges and tolerated them. Challenges were not followed by full therapeutic courses. CONCLUSIONS These data indicate the tolerability of both aztreonam and carbapenems in penicillin-allergic subjects. In those who especially require these alternative β-lactams, however, we recommend pretreatment skin tests, both because rare cases of cross-reactivity have been reported and because negative results indicate tolerability.
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Affiliation(s)
| | | | | | | | | | - Antonino Romano
- Allergy Unit, Complesso Integrato Columbus, Rome, Italy; IRCCS Oasi Maria S.S., Troina, Italy.
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Kim MH, Lee JM. Diagnosis and management of immediate hypersensitivity reactions to cephalosporins. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2014; 6:485-95. [PMID: 25374747 PMCID: PMC4214968 DOI: 10.4168/aair.2014.6.6.485] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 06/03/2014] [Indexed: 12/16/2022]
Abstract
Cephalosporins can cause a range of hypersensitivity reactions, including IgE-mediated, immediate reactions. Cephalosporin allergy has been reported with use of a specific cephalosporin, as a cross-reaction between different cephalosporins or as a cross-reaction to other β-lactam antibiotics. Unlike penicillins, the exact allergenic determinants of cephalosporins are less well understood and thus, standardized diagnostic skin testing is not available. Nevertheless, skin testing with diluted solutions of cephalosporins can be valuable in confirming IgE-mediated hypersensitivity reactions. In vitro tests are in development using recent technological advances and can be used as complementary tests. However, they are not commonly used because of their reduced sensitivity and limited availability. In selected cases of inconclusive results in both skin tests and IgE assays, a graded challenge or induction of drug tolerance with the implicated cephalosporin should be performed.
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Affiliation(s)
- Min-Hye Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jong-Myung Lee
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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71
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Abstract
Penicillin is the most frequently reported cause of drug allergy, and cross-reactivity of penicillins with other beta-lactam antibiotics is an area of debate. This review evaluates the available data on immunoglobulin E-mediated penicillin hypersensitivity and cross-reactivity with cephalosporin, carbapenem, and monobactam antibiotics. A MEDLINE search was conducted from 1950 to October 2013, and selected references from review articles were also evaluated. There is a wide variety in reported incidences of cross-reactivity between penicillins and cephalosporins or carbapenems, with early retrospective studies suggesting up to 41.7% and 47.4% cross-reactivity, respectively. Conversely, the use of monobactam antibiotics is frequently employed in the case of a penicillin allergy, as prescribers believe that there is no cross-reactivity between the 2 drug classes. More recent prospective studies suggest that the rates of cross-reactivity with cephalosporins and carbapenems are <5% and <1%, respectively. Similarities in penicillin and cephalosporin side chains may play a role in cross-reactivity between these classes. Cross-reactivity with monobactams is essentially negligible; however, there are some clinical data to support an interaction between ceftazidime and aztreonam, due to the similarity of their side chains. The data reviewed suggest that avoidance of other beta-lactams in patients with type 1 hypersensitivity to penicillins should be reconsidered.
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Affiliation(s)
- Adrienne T. Terico
- Post-Graduate Year 2 Infectious Diseases Pharmacotherapy Resident, Temple University Hospital, Philadelphia, PA, USA
| | - Jason C. Gallagher
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA, USA
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72
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Romano A, Gaeta F, Valluzzi RL, Zaffiro A, Caruso C, Quaratino D. Natural evolution of skin-test sensitivity in patients with IgE-mediated hypersensitivity to cephalosporins. Allergy 2014; 69:806-9. [PMID: 24673580 DOI: 10.1111/all.12390] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 11/27/2022]
Abstract
There are studies demonstrating that skin-test sensitivity to penicillins can decrease over time and that allergic patients may lose sensitivity if the responsible compounds are avoided. With regard to subjects with IgE-mediated hypersensitivity to cephalosporins, however, such studies are lacking. We evaluated prospectively in a 5-year follow-up 72 cephalosporin-allergic patients. After the first evaluation, patients were classified into two groups according to their patterns of allergologic-test positivity: to both penicillins and cephalosporins (group A), or only to cephalosporins (group B). Skin tests and serum-specific IgE assays were repeated 1 year later and, in case of persistent positivity, 3 and 5 years after the first allergologic examination. Seven (43.7%) of the 16 subjects of group A and 38 (67.8%) of the 56 patients of group B became negative; one was lost to follow-up. Patients of group B became negative sooner and more frequently than group A subjects.
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Affiliation(s)
- A. Romano
- Allergy Unit; Complesso Integrato Columbus; Rome Italy
- IRCCS Oasi Maria S.S.; Troina Italy
| | - F. Gaeta
- Allergy Unit; Complesso Integrato Columbus; Rome Italy
| | | | - A. Zaffiro
- Ambulatorio di Allergologia; IDI-IRCCS; Capranica Italy
| | - C. Caruso
- Allergy Unit; Complesso Integrato Columbus; Rome Italy
| | - D. Quaratino
- Ambulatorio di Allergologia; IDI-IRCCS; Capranica Italy
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73
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Abstract
Although allergy to β-lactam and non-β-lactam antibiotics is commonly claimed, true allergy to these drugs is often absent. Reactions to antibiotics can be classified according to the interval between the last administration of the drug and the onset of symptoms, but except for immediate reactions occurring within an hour of exposure, which are almost always either IgE-mediated or due to direct stimulation of mast cells, reactions occurring later than 1 hour probably have multiple mechanisms, including being IgE-mediated or involving cell-mediated reactions. The latter are likely caused by drug-specific T lymphocytes. The diagnosis of antibiotic allergy can be difficult.
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Affiliation(s)
- Antonino Romano
- Department of Internal Medicine and Geriatrics, UCSC-Allergy Unit, Complesso Integrato Columbus, Via G. Moscati 31, Rome 00168, Italy
| | - Richard Warrington
- Allergy & Clinical Immunology, Health Sciences Centre, Winnipeg, Departments of Medicine and Immunology, University of Manitoba, GC319, 820 Sherbrook Street, Winnipeg, Manitoba R3A 1R9, Canada.
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Arunvikram K, Mohanty I, Sardar KK, Palai S, Sahoo G, Patra RC. Adverse drug reaction and toxicity caused by commonly used antimicrobials in canine practice. Vet World 2014. [DOI: 10.14202/vetworld.2014.299-305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Trubiano J, Phillips E. Antimicrobial stewardship's new weapon? A review of antibiotic allergy and pathways to 'de-labeling'. Curr Opin Infect Dis 2014; 26:526-37. [PMID: 24126717 DOI: 10.1097/qco.0000000000000006] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW The continued emergence of multiresistant pathogens and widespread antimicrobial use has led to a greater emphasis on antimicrobial stewardship programs. Concurrently, an increased awareness of the rising number of antibiotic allergy labels and impact on antimicrobial use has surfaced. The integration of antibiotic allergy de-labeling and antimicrobial stewardship programs may be a pathway worthy of further focus and investigation. RECENT FINDINGS Recent literature has evaluated the efficacy of antibiotic allergy management (historical de-labeling, in-vitro testing, skin prick testing, intradermal testing, and oral challenges) and impact of antibiotic allergy labels on patient outcome. The importance of true and perceived antibiotic allergy cross-reactivity in the setting of β-lactam allergies has been highlighted. The impact of dedicated antibiotic allergy de-labeling clinics, inpatient antibiotic allergy testing, and integrated antimicrobial stewardship programs has been recently appraised. SUMMARY More recent literature supports that appropriate antibiotic allergy in-vitro and in-vivo testing and subsequent antibiotic allergy de-labeling, particularly in regard to β-lactams, can decrease broad-spectrum antibiotic use, costs, patient length of stay, and mortality. Integration of antibiotic allergy management into the decision support systems of inpatient and outpatient antimicrobial stewardship programs represents an important opportunity to further improve measured outcomes from antibiotic utilization.
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Affiliation(s)
- Jason Trubiano
- aDepartment of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, Victoria bThe Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia cDepartments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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76
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Romano A, Caubet JC. Antibiotic allergies in children and adults: from clinical symptoms to skin testing diagnosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:3-12. [PMID: 24565763 DOI: 10.1016/j.jaip.2013.11.006] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 11/20/2013] [Accepted: 11/21/2013] [Indexed: 11/15/2022]
Abstract
Hypersensitivity reactions to β-lactam and non-β-lactam antibiotics are commonly reported. They can be classified as immediate or nonimmediate according to the time interval between the last drug administration and their onset. Immediate reactions occur within 1 hour after the last drug administration and are manifested clinically by urticaria and/or angioedema, rhinitis, bronchospasm, and anaphylactic shock; they may be mediated by specific IgE-antibodies. Nonimmediate reactions occur more than 1 hour after the last drug administration. The most common manifestations are maculopapular exanthems; specific T lymphocytes may be involved in this type of manifestation. The diagnostic evaluation of hypersensitivity reactions to antibiotics is usually complex. The patient's history is fundamental; the allergic examination is based mainly on in vivo tests selected on the basis of the clinical features and the type of reaction, immediate or nonimmediate. Immediate reactions can be assessed by immediate-reading skin tests and, in selected cases, drug provocation tests. Nonimmediate reactions can be assessed by delayed-reading skin tests, patch tests, and drug provocation tests. However, skin tests have been well validated mainly for β-lactams but less for other classes of antibiotics.
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Affiliation(s)
- Antonino Romano
- Allergy Unit, Complesso Integrato Columbus, Rome, Italy; Istituto di Ricovero e Cura a Carattere Scientifico Oasi Maria S.S., Troina, Italy
| | - Jean-Christoph Caubet
- Department of Child and Adolescent, University Hospitals of Geneva and Medical School of The University of Geneva, Geneva, Switzerland.
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Ariza A, Barrionuevo E, Mayorga C, Montañez M, Perez-Inestrosa E, Ruiz-Sánchez A, Rodríguez-Guéant R, Fernández T, Guéant J, Torres M, Blanca M. IgE to penicillins with different specificities can be identified by a multiepitope macromolecule. J Immunol Methods 2014; 406:43-50. [DOI: 10.1016/j.jim.2014.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 01/16/2014] [Accepted: 03/05/2014] [Indexed: 11/24/2022]
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Richter AG, Nasser SM, Krishna MT. A UK national survey of investigations for beta-lactam hypersensitivity - heterogeneity in practice and a need for national guidelines - on behalf of British Society for Allergy and Clinical Immunology (BSACI). Clin Exp Allergy 2014; 43:941-9. [PMID: 23889247 DOI: 10.1111/cea.12134] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 02/21/2013] [Accepted: 04/04/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND Beta lactams (BL) are the most widely prescribed antibiotics in the UK and the commonest cause of hypersensitivity reactions. There are no UK guidelines for BL testing and the most relevant guidelines were devised by the European Network for Drug Allergy (ENDA) on behalf of the European Academy of Allergy and Clinical Immunology. OBJECTIVE Delivery of allergy services differs across Europe, so this survey was designed to investigate how closely UK practice adhered to these guidelines. METHODS An online survey, using surveymonkey.com software, was sent to all consultants offering an allergy service in the UK and who were members of either BSACI or 'Travellers' (Immunology consultant group). RESULTS The response rate was 48% (n=81/165) and BL allergy testing was undertaken by 78% of respondents. All responders requested SsIgE, although four responders stated they rarely requested. Skin testing was undertaken by 87% of respondents who perform beta lactam testing with 17% undertaking skin prick testing (SPT) only, 77% SPT followed by intra-dermal testing (IDT) if the former were negative or indeterminate and 6% SPT and IDT in all cases. The drugs, doses and protocols for skin testing varied considerably. Drug provocation testing was undertaken by 87% of respondents who undertake beta lactam testing with significant heterogeneity in protocols. Respondents that investigated ≤ 20 patients per year demonstrated lower adherence to ENDA recommendations compared to those who saw > 20. Following positive testing, 79% advised avoidance of all penicillins only and the remainder advised additional drug avoidance. CONCLUSION AND CLINICAL RELEVANCE This survey revealed variation in the investigation and management of BL hypersensitivity in the UK with some centres reporting procedures that could potentially put patients at risk of anaphylaxis if allergy was falsely excluded. This survey highlights an urgent need for evidence based national guidelines and standardisation of practice.
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Affiliation(s)
- A G Richter
- School of Immunity and Infection, University of Birmingham, Birmingham, UK.
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Klimek L, Aderhold C, Sperl A. [Allergies to antibiotic drugs: their importance in otorhinolaryngology]. HNO 2014; 61:409-15. [PMID: 23247751 DOI: 10.1007/s00106-012-2599-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND In 2009, over 40 million prescriptions for antibiotic drugs were counted in outpatient medical care in Germany. This represents a turnover of more than 750 million euros. With over 80 million daily defined doses (DDD), amoxicillin was the most frequently prescribed antibiotic in Germany in 2008. Given the average of 5775 DDD per doctor, otolaryngologists prescribed more antibiotics than specialists in any other field of medicine in 2008; approximately 82% of these were β-lactams and tetracyclines. MATERIAL AND METHODS This article is based on selective literature-based research using the PubMed database. The keywords used in the search were:"allergy","anaphylaxis" and"hypersensitivity", in combination with "penicillin","cephalosporin","carbapenem","cotrimoxazole","macrolide","aztreonam" and"tetracycline". RESULTS Allergic reactions to antibiotics are among the most frequently reported adverse side effects arising from drug treatment. However, non-allergic adverse side effects owing to drug intolerance are also very common and may be clinically indistinguishable from allergic reactions. Owing to a frequent lack of appropriate diagnostic investigation, the decision to withhold effective standard treatments from patients is often based solely upon anamnestic observations. Up to 10% of respondents in an unselected population report an allergy to penicillin. In 80% of these cases, however, no penicillin-specific IgE-antibodies can be detected. CONCLUSION A detailed understanding of the symptoms, diagnostic options and possible cross reactions pertaining to allergic reactions to antibiotics, as well to non-allergic adverse side effects with similar clinical appearance, is very important for otolaryngologists. This profound knowledge ensures that the correct diagnostic steps are taken and that appropriate treatment decisions prevent the unnecessary use of reserve antibiotics.
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Affiliation(s)
- L Klimek
- Zentrum für Rhinologie und Allergologie, HNO-Universitätsklinik Mannheim, An den Quellen 10, 65183, Wiesbaden, Deutschland.
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81
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Romano A, Gaeta F, Valluzzi RL, Alonzi C, Maggioletti M, Zaffiro A, Caruso C, Quaratino D. Absence of cross-reactivity to carbapenems in patients with delayed hypersensitivity to penicillins. Allergy 2013; 68:1618-21. [PMID: 24180646 DOI: 10.1111/all.12299] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2013] [Indexed: 12/01/2022]
Abstract
Studies performed on subjects with IgE-mediated hypersensitivity to penicillins have demonstrated a 1% rate of cross-reactivity between penicillins and both imipenem and meropenem, while a single study found a 5.5% rate of cross-reactivity with imipenem/cilastatin in subjects with T-cell-mediated hypersensitivity to β-lactams, mostly penicillins. We studied 204 consecutive subjects with a well-demonstrated T-cell-mediated hypersensitivity to assess the cross-reactivity with carbapenems and the tolerability of such alternative β-lactams. All 204 subjects underwent skin tests with imipenem/cilastatin and meropenem; 130 of them were skin-tested also with ertapenem. Subjects with negative test results were challenged with these carbapenems. All subjects displayed negative skin tests to carbapenems and tolerated challenges. These data demonstrate the absence of clinically significant T-cell-mediated cross-reactivity between penicillins and carbapenems. Negative delayed-reading skin testing with carbapenems in individuals with documented T-cell-mediated hypersensitivity to penicillins correlates well with subsequent clinical tolerance of therapeutic doses of carbapenems.
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Affiliation(s)
- A. Romano
- Allergy Unit; Complesso Integrato Columbus; Rome Italy
- IRCCS Oasi Maria S.S.; Troina Italy
| | - F. Gaeta
- Allergy Unit; Complesso Integrato Columbus; Rome Italy
| | | | - C. Alonzi
- Allergy Unit; Complesso Integrato Columbus; Rome Italy
| | | | - A. Zaffiro
- Ambulatorio di Allergologia; IDI-IRCCS; Capranica Italy
| | - C. Caruso
- Allergy Unit; Complesso Integrato Columbus; Rome Italy
| | - D. Quaratino
- Ambulatorio di Allergologia; IDI-IRCCS; Capranica Italy
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Yoon SY, Park SY, Kim S, Lee T, Lee YS, Kwon HS, Cho YS, Moon HB, Kim TB. Validation of the cephalosporin intradermal skin test for predicting immediate hypersensitivity: a prospective study with drug challenge. Allergy 2013; 68:938-44. [PMID: 23751142 DOI: 10.1111/all.12182] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cephalosporin is a major offending agent in terms of drug hypersensitivity along with penicillin. Cephalosporin intradermal skin tests (IDTs) have been widely used; however, their validity for predicting immediate hypersensitivity has not been studied. This study aimed to determine the predictive value of cephalosporin intradermal skin testing before administration of the drug. METHODS We prospectively conducted IDTs with four cephalosporins, one each of selected first-, second-, third-, or fourth-generation cephalosporins: ceftezol; cefotetan or cefamandole; ceftriaxone or cefotaxime; and flomoxef, respectively, as well as with penicillin G. After the skin test, whatever the result, one of the tested cephalosporins was administered intravenously and the patient was carefully observed. RESULTS We recruited 1421 patients who required preoperative cephalosporins. Seventy-four patients (74/1421, 5.2%) were positive to at least one cephalosporin. However, none of responders had immediate hypersensitivity reactions after a challenge dose of the same or different cephalosporin, which were positive in the skin test. Four patients who suffered generalized urticaria and itching after challenge gave negative skin tests for the corresponding drug. The IDT for cephalosporin had a sensitivity of 0%, a specificity of 97.5%, a negative predictive value of 99.7%, and a positive predictive value (PPV) of 0%, when challenged with the same drugs that were positive in the skin test. CONCLUSION Routine skin testing with a cephalosporin before its administration is not useful for predicting immediate hypersensitivity because of the extremely low sensitivity and PPV of the skin test (CRIS registration no. KCT0000455).
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Affiliation(s)
- S.-Y. Yoon
- Division of Allergy and Clinical Immunology; Department of Internal Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul; Korea
| | - S. Y. Park
- Division of Allergy and Clinical Immunology; Department of Internal Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul; Korea
| | - S. Kim
- Division of Allergy and Clinical Immunology; Department of Internal Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul; Korea
| | - T. Lee
- Division of Allergy and Clinical Immunology; Department of Internal Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul; Korea
| | - Y. S. Lee
- Division of Allergy and Clinical Immunology; Department of Internal Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul; Korea
| | - H.-S. Kwon
- Division of Allergy and Clinical Immunology; Department of Internal Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul; Korea
| | - Y. S. Cho
- Division of Allergy and Clinical Immunology; Department of Internal Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul; Korea
| | - H.-B. Moon
- Division of Allergy and Clinical Immunology; Department of Internal Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul; Korea
| | - T.-B. Kim
- Division of Allergy and Clinical Immunology; Department of Internal Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul; Korea
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84
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Khan DA. Treating patients with multiple drug allergies. Ann Allergy Asthma Immunol 2013; 110:2-6. [PMID: 23244650 DOI: 10.1016/j.anai.2012.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 11/01/2012] [Accepted: 11/05/2012] [Indexed: 01/15/2023]
Affiliation(s)
- David A Khan
- University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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85
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Chang C, Mahmood MM, Teuber SS, Gershwin ME. Overview of penicillin allergy. Clin Rev Allergy Immunol 2013; 43:84-97. [PMID: 21789743 DOI: 10.1007/s12016-011-8279-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Allergy to penicillin is the most commonly reported antibiotic allergy. However, most patients who report a positive history of a prior reaction to penicillin are not found to be allergic to penicillin upon skin testing. Often, this history is vague or based on a parent's recollection of an event that occurred in the distant past. Avoidance of penicillin based on self-reported allergic history alone often leads to the use of an alternate antibiotic with greater cost or side effect profile. Patients with a negative skin test to both major and minor determinants may generally be given penicillin, with a statistical risk of developing an allergic reaction similar to that observed in the general population. A more cautious approach in these cases where the degree of suspicion is low, an allergic etiology is unproven, or there is a negative skin test, is to do a graded challenge. If the skin test is positive, an alternate antibiotic should be used. If, however, an alternate antibiotic is not available, then desensitization may be performed, but there are limitations to desensitization as well, and tolerance is not permanent. Avoidance of cephalosporins may be recommended in cases of penicillin allergy, but newer generation cephalosporins have demonstrate less cross-reactivity to penicillin than earlier generation ones. Desensitization protocols for cephalosporins are available but not standardized. The mechanisms of antibiotic sensitization are not clearly understood.
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Affiliation(s)
- Christopher Chang
- Division of Allergy, Asthma and Immunology, Nemours/A.I. Dupont Children's Hospital, Thomas Jefferson University, Wilmington, DE, USA
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Abstract
Penicillins and cephalosporins are the most widely used antibiotics for the treatment of common infections, and they are the two main classes of β-lactams. On the basis of the time of appearance of the reaction after drug intake and for diagnostic purposes, hypersensitivity reactions to β-lactams have been classified as immediate or non-immediate. The diagnostic evaluation of allergic reactions to β-lactams has changed over the last decade, for several reasons. In many countries, major and minor determinants for skin testing are not available. In immediate allergic reactions, the sensitivity of skin testing is decreasing. For non-immediate reactions, skin testing appears to be less sensitive than previously reported. The drug provocation test is still necessary for diagnosis. In this education review series, we described three cases of β-lactam allergy: first, a child with an IgE-mediated allergy to benzyl-penicillin; second, a child with a non-allergic hypersensitivity to amoxicillin; and in the third patient, we will discuss about cross-reactivity between penicillins and cephalosporins. These cases are correlated with the practical management of evaluating β-lactam allergy.
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91
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Abstract
Drug allergy encompasses a spectrum of immunologically-mediated hypersensitivity reactions with varying mechanisms and clinical presentations. This type of adverse drug reaction (ADR) not only affects patient quality of life, but may also lead to delayed treatment, unnecessary investigations, and even mortality. Given the myriad of symptoms associated with the condition, diagnosis is often challenging. Therefore, referral to an allergist experienced in the identification, diagnosis and management of drug allergy is recommended if a drug-induced allergic reaction is suspected. Diagnosis relies on a careful history and physical examination. In some instances, skin testing, graded challenges and induction of drug tolerance procedures may be required. The most effective strategy for the management of drug allergy is avoidance or discontinuation of the offending drug. When available, alternative medications with unrelated chemical structures should be substituted. Cross-reactivity among drugs should be taken into consideration when choosing alternative agents. Additional therapy for drug hypersensitivity reactions is largely supportive and may include topical corticosteroids, oral antihistamines and, in severe cases, systemic corticosteroids. In the event of anaphylaxis, the treatment of choice is injectable epinephrine. If a particular drug to which the patient is allergic is indicated and there is no suitable alternative, induction of drug tolerance procedures may be considered to induce temporary tolerance to the drug. This article provides a backgrounder on drug allergy and strategies for the diagnosis and management of some of the most common drug-induced allergic reactions, such allergies to penicillin, sulfonamides, cephalosporins, radiocontrast media, local anesthetics, general anesthetics, acetylsalicylic acid (ASA) and non-steroidal anti-inflammatory drugs.
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92
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Abstract
PURPOSE OF REVIEW Drug provocation test (DPT) is necessary to diagnose most drug hypersensitivity reactions (HSRs) due to decreased sensitivity of skin testing even when combined with in-vitro tests in immunonologic drug HSR and limited availability of these tests in nonimmunologic reaction. We review the principles and controversial issues of DPT, and recent studies using DPT as a diagnostic tool. RECENT FINDINGS DPT is recommended in the diagnosis of HSR to β-lactams, as well as other drug classes [such as acetylsalicylic acid-NSAIDs (ASA-NSAIDs), non-β-lactams antibiotics, heparin, glucocorticoids, and local anesthetic agents]. In view of the decreased sensitivity of skin testing, limited accessibility to new benzylpenicillin polylysine (PPL)/mixture of minor determinant (MDM) test reagents and limited availability of validated sensitive in-vitro tests, individuals who require DPT to β-lactams are increasing. The negative predictive value of allergologic work-up is very high, ranging from 94 to 98% for β-lactams and those reactions after negative tests are mostly nonimmediate and mild. Finally, DPT is recommended to ascertain tolerability of alternative compound when evaluating cross-reactivity among different classes of β-lactams, NSAIDs and glucocorticoids, and possibly iodinated contrast media. SUMMARY DPT is often needed when evaluating patients with suspected drug HSR. More studies regarding standardization of the various protocols are needed in order to increase its acceptance and adoption as a standard practice in the diagnostic algorithm for drug HSR.
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93
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Pipet A, Veyrac G, Wessel F, Jolliet P, Magnan A, Demoly P, Bousquet PJ. A statement on cefazolin immediate hypersensitivity: data from a large database, and focus on the cross-reactivities. Clin Exp Allergy 2011; 41:1602-8. [PMID: 22093010 DOI: 10.1111/j.1365-2222.2011.03846.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 06/23/2011] [Accepted: 07/06/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND More perioperative cefazolin use has resulted in an increased risk of cefazolin-associated reactions. OBJECTIVE The aim of this article is to study immediate reactions to cefazolin and attempt to determine possible allergic cross-reactivity with other ß-lactams using data from the Drug Allergy and Hypersensitivity Database (DAHD). METHODS All 25 cefazolin-associated reactions in the DAHD were reviewed. The cases identified were then investigated according to the European Network for Drug Allergy (ENDA) recommendations by skin testing and challenges. RESULTS A total of 10 individuals with proven IgE-mediated cefazolin hypersensitivity were identified between January 1999 and July 2009. All the index reactions were compatible with an acute IgE-mediated process, six with anaphylaxis, two with systemic allergic reactions without hypotension, and two with urticaria/angioedema. Cefazolin skin tests were positive in seven individuals and cefazolin challenges were positive in three more individuals. In the eight cefazolin allergic patients who had challenges with other ß-lactams, there was no positive reaction noted. CONCLUSION AND CLINICAL RELEVANCE In this cohort of patients with IgE-mediated reactions to cefazolin, a majority tolerated amoxicillin and several patients tolerated other cephalosporins. This implies that the R1 side-chain may play an essential role in IgE-mediated reactions to cefazolin. No clear rule to predict cross-reactivity with other ß-lactams could be determined. More research on IgE-mediated hypersensitivity to cefazolin and other cephalosporins is needed.
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Affiliation(s)
- A Pipet
- INSERM U 915, L'institut du thorax, Nantes, France.
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94
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Abstract
Once administered, a drug can activate the immune system by various mechanisms and lead to a large range of clinical manifestations closely related to the type of immune reaction elicited. Administration of the drug can classically result in an immunoglobulin E (IgE)-type sensitization, but can also result in more complex activation of the immune system potentially resulting in severe syndromes, such as the drug-induced hypersensitivity syndrome (DIHS). Although there has been a major increase in our knowledge over the last years, the exact mechanisms of drug allergy are not well understood for most clinical manifestations. A complex interaction between individual characteristics, environmental factors, and the drug itself is usually responsible for adverse reactions to drugs. In this educational review series, we described three cases of drug allergy: first, a child with a typical IgE-mediated drug allergy, second, a child with a non-immediate reaction to penicillin, and in the third patient, we will discuss the drug-induced hypersensitivity syndrome, which is rare but potentially fatal. These cases are correlated to the immune mechanism potentially involved.
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Affiliation(s)
- Jean-Christoph Caubet
- Department of Child and Adolescent, University Hospitals of Geneva and Medical School of the University of Geneva, Geneva, Switzerland
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95
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Montañez MI, Torres MJ, Perez-Inestrosa E, Blanca M. Clarification concerning amoxicillin skin testing. J Allergy Clin Immunol 2011; 128:685; author reply 686. [PMID: 21665258 DOI: 10.1016/j.jaci.2011.04.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 04/22/2011] [Indexed: 11/29/2022]
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97
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Ponvert C, Perrin Y, Bados-Albiero A, Le Bourgeois M, Karila C, Delacourt C, Scheinmann P, De Blic J. Allergy to betalactam antibiotics in children: results of a 20-year study based on clinical history, skin and challenge tests. Pediatr Allergy Immunol 2011; 22:411-8. [PMID: 21535179 DOI: 10.1111/j.1399-3038.2011.01169.x] [Citation(s) in RCA: 162] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Studies based on skin and challenge tests have shown that 12-60% of children with suspected betalactam hypersensitivity were allergic to betalactams. Responses in skin and challenge tests were studied in 1865 children with suspected betalactam allergy (i) to confirm or rule out the suspected diagnosis; (ii) to evaluate diagnostic value of immediate and non-immediate responses in skin and challenge tests; (iii) to determine frequency of betalactam allergy in those children, and (iv) to determine potential risk factors for betalactam allergy. The work-up was completed in 1431 children, of whom 227 (15.9%) were diagnosed allergic to betalactams. Betalactam hypersensitivity was diagnosed in 50 of the 162 (30.9%) children reporting immediate reactions and in 177 of the 1087 (16.7%) children reporting non-immediate reactions (p<0.001). The likelihood of betalactam hypersensitivity was also significantly higher in children reporting anaphylaxis, serum sickness-like reactions, and (potentially) severe skin reactions such as acute generalized exanthematic pustulosis, Stevens-Johnson syndrome, and drug reaction with systemic symptoms than in other children (p<0.001). Skin tests diagnosed 86% of immediate and 31.6% of non-immediate sensitizations. Cross-reactivity and/or cosensitization among betalactams was diagnosed in 76% and 14.7% of the children with immediate and non-immediate hypersensitivity, respectively. The number of children diagnosed allergic to betalactams decreased with time between the reaction and the work-up, probably because the majority of children with severe and worrying reactions were referred for allergological work-up more promptly than the other children. Sex, age, and atopy were not risk factors for betalactam hypersensitivity. In conclusion, we confirm in numerous children that (i) only a few children with suspected betalactam hypersensitivity are allergic to betalactams; (ii) the likelihood of betalactam allergy increases with earliness and/or severity of the reactions; (iii) although non-immediate-reading skin tests (intradermal and patch tests) may diagnose non-immediate sensitizations in children with non-immediate reactions to betalactams (maculopapular rashes and potentially severe skin reactions especially), the diagnostic value of non-immediate-reading skin tests is far lower than the diagnostic value of immediate-reading skin tests, most non-immediate sensitizations to betalactams being diagnosed by means of challenge tests; (iv) cross-reactivity and/or cosensitizations among betalactams are much more frequent in children reporting immediate and/or anaphylactic reactions than in the other children; (v) age, sex and personal atopy are not significant risk factors for betalactam hypersensitivity; and (vi) the number of children with diagnosed allergy to betalactams (of the immediate-type hypersensitivity especially) decreases with time between the reaction and allergological work-up. Finally, based on our experience, we also propose a practical diagnostic approach in children with suspected betalactam hypersensitivity.
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Affiliation(s)
- C Ponvert
- Department of Paediatrics, Pulmonology, Allergy and Dermatology Service, Paris Descartes University, Necker-Enfants Malades Hospital, 149 rue de Sèvres, Paris, France.
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98
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Scheetz MH, Bolon MK, Esterly JS, Reddy P, Postelnick M, Lee TA. Life-Years Gained with Meropenem over Ciprofloxacin in Penicillin-Allergic Patients with Gram-Negative Bacilli Sepsis: Results of a Probabilistic Model. Pharmacotherapy 2011; 31:469-79. [DOI: 10.1592/phco.31.5.469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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99
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Diagnostic des réactions d’hypersensibilité allergique et non allergique aux médicaments courants de l’enfant : arbre décisionnel. Arch Pediatr 2011; 18:486-92. [DOI: 10.1016/j.arcped.2011.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 01/10/2011] [Accepted: 01/10/2011] [Indexed: 11/18/2022]
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100
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Diagnosis and management of drug hypersensitivity reactions. J Allergy Clin Immunol 2011; 127:S67-73. [PMID: 21354502 DOI: 10.1016/j.jaci.2010.11.047] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 11/12/2010] [Indexed: 11/24/2022]
Abstract
The present article addresses the advances in the diagnosis and management of drug hypersensitivity reactions that were discussed in the 4th Drug Hypersensitivity Meeting held in Rome in April 2010. Such reactions can be classified as immediate or nonimmediate according to the time interval between the last drug administration and onset. Immediate reactions occur within 1 hour, and nonimmediate reactions occur after more than 1 hour. Clinical and immunologic studies suggest that type-I (IgE-mediated) and type-IV (T cell-mediated) pathogenic mechanisms are involved in most immediate and nonimmediate reactions, respectively. In diagnosis prick, patch, and intradermal tests are the most readily available tools. Determination of specific IgE levels is still the most common in vitro method for diagnosing immediate reactions. New diagnostic tools, such as the basophil activation test, the lymphocyte activation test, and enzyme-linked immunospot assays for analysis of the frequency of antigen-specific, cytokine-producing cells, have been developed for evaluating either immediate or nonimmediate reactions. The sensitivity of allergologic tests is not 100%; therefore in selected cases provocation tests are necessary. In the diagnosis of nonallergic hypersensitivity reactions to nonsteroidal anti-inflammatory drugs, the provocation test with the suspected drug still represents the "gold standard." However, there was no consensus regarding the use of this test in subjects with histories of hypersensitivity reactions to 1 (single reactors) or more (multiple reactors) nonsteroidal anti-inflammatory drugs. With regard to management, desensitization allows patients to be treated with irreplaceable chemotherapy agents, such as taxanes, platinum salts, and mAbs, to which they have presented hypersensitivity reactions. Desensitization also permits the use of aspirin in aspirin-sensitive patients undergoing revascularization and in subjects with aspirin-exacerbated respiratory disease.
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