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Goff DA, Kullar R, Bauer KA, File TM. Eight Habits of Highly Effective Antimicrobial Stewardship Programs to Meet the Joint Commission Standards for Hospitals. Clin Infect Dis 2017; 64:1134-1139. [PMID: 28203781 DOI: 10.1093/cid/cix065] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 02/13/2017] [Indexed: 01/01/2023] Open
Abstract
In an effort to decrease antimicrobial resistance and inappropriate antibiotic use, The Joint Commission (TJC) recently issued new antimicrobial stewardship standards, consisting of 8 elements of performance, applicable to hospitals effective January 1, 2017. These standards coincide with those recommended by the Infectious Diseases Society of America (IDSA) and the Society of Healthcare Epidemiology (SHEA) guidelines. Little guidance exists on the "how" from these guidance documents. We review the 8 standards and provide real-world experience from established antimicrobial stewardship programs (ASPs) on how institutions can comply with these guidelines to reduce inappropriate antibiotic usage, decrease antimicrobial resistance, and optimize patient outcomes. TJC antimicrobial stewardship standards demonstrate actions being taken at the national level to make quality and patient safety a priority.
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Affiliation(s)
- Debra A Goff
- The Ohio State University Wexner Medical Center, The Ohio State University College of Pharmacy, Columbus, Ohio, USA
| | | | | | - Thomas M File
- Ohio Medical University; and Summa Health, Division of Infectious Disease, Akron, Ohio, USA
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Fernandez TD, Mayorga C, Salas M, Barrionuevo E, Posadas T, Ariza A, Laguna JJ, Moreno E, Torres MJ, Doña I, Montañez MI. Evolution of diagnostic approaches in betalactam hypersensitivity. Expert Rev Clin Pharmacol 2017; 10:671-683. [PMID: 28375040 DOI: 10.1080/17512433.2017.1313110] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Betalactams are the most widely used drugs against infections and the primary cause of antibiotic hypersensitivity reactions. Reaction patterns for different betalactams have been changing in accordance with consumption trends, and vary among countries. As a consequence, in vivo and in vitro tests have had to change with to keep up with new tendencies. Areas covered: This review is focused on advances in betalactam hypersensitivity diagnosis. Changes in in vivo methods have been limited to the inclusion of new haptens. In contrast, major progress has been achieved for in vitro tests since the 1960s, from the first description of immunoassays, the basophil activation test and the lymphocyte transformation test, to the more sophisticated assays developed in last years. Expert commentary: Issues with diagnosis are related to test sensitivity. In vivo tests show higher sensitivity, however they can be risky, especially in severe and life-threatening reactions. Therefore, we believe that in vitro tests should be the preferred method. Current efforts are under way to enhance their sensitivity. Only multidisciplinary approaches involving immunology, proteomics, nanotechnology and chemistry can help us to fully understand conjugate structures and mechanisms involved in hypersensitivity reactions to betalactams, and consequently lead to advances in in vitro methods.
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Affiliation(s)
- Tahia D Fernandez
- a Research Laboratory , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Cristobalina Mayorga
- a Research Laboratory , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain.,b Allergy Unit , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Maria Salas
- b Allergy Unit , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Esther Barrionuevo
- b Allergy Unit , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Teresa Posadas
- b Allergy Unit , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Adriana Ariza
- a Research Laboratory , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Jose J Laguna
- c Allergy Unit , Hospital de la Cruz Roja , Madrid , Spain
| | - Esther Moreno
- d Allergy Service , University Hospital of Salamanca , Salamanca , Spain
| | - Maria J Torres
- b Allergy Unit , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain.,e Laboratory of Nanostructures for Diagnosing and Treatment of Allergic Diseases , Andalusian Center for Nanomedicine and Biotechnology - BIONAND , Málaga , Spain
| | - Inmaculada Doña
- b Allergy Unit , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Maria I Montañez
- a Research Laboratory , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain.,e Laboratory of Nanostructures for Diagnosing and Treatment of Allergic Diseases , Andalusian Center for Nanomedicine and Biotechnology - BIONAND , Málaga , Spain
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153
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Chiriac AM, Rerkpattanapipat T, Bousquet PJ, Molinari N, Demoly P. Optimal step doses for drug provocation tests to prove beta-lactam hypersensitivity. Allergy 2017; 72:552-561. [PMID: 27569064 DOI: 10.1111/all.13037] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Drug provocation tests (DPT) are commonly performed as part of β-lactam (BL) allergy workup, in case of negative skin tests (ST) and in the absence of contraindications. The recommendations of learned societies have created a frame for DPT performance, but protocols vary widely between centres, generating various hypothesis-driven protocols (i.e. empirical dosing, driven by both safety concerns and practical aspects). METHODS The primary objective of this retrospective analysis was to detect eliciting dose thresholds (reactive doses) during BL DPT, using the survival analysis method, in order to suggest optimal step doses. Our secondary objective was to evaluate the safety of our 30-min incremental 1-day protocol. The study included all the patients explored in the Allergy Unit of the University Hospital of Montpellier (France), between September 1996 and July 2015 for a suspicion of drug hypersensitivity reaction to BLs, with negative ST and positive DPT. RESULTS During the study period, 182 positive DPT (accounting for 171 hypersensitive patients) were analysed. We identified eliciting thresholds, and we suggest the following steps for DPT to BLs: 5-15-30-50% of daily therapeutic dose (with additional lower steps for index reactions of anaphylaxis). We confirm the safety of 1-day protocol for immediate and mild nonimmediate reactors, for both children and adults, with a surveillance period of 2 h after the last administered dose, and a prolonged surveillance after discharge of 48 h. CONCLUSION This data-driven approach in designing DPT protocols is a step forward in improving DPT standardization, starting with the most frequently tested drugs, BL antibiotics.
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Affiliation(s)
- A.-M. Chiriac
- Division of Allergy; Department of Pulmonology; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- UPMC Univ Paris 06; UMRS 1136; Equipe - EPAR - IPLESP; Sorbonne Universités; Paris France
| | - T. Rerkpattanapipat
- Allergy, Immunology and Rheumatology Division; Department of Medicine; Faculty of Medicine; Ramathibodi Hospital; Mahidol University; Bangkok Thailand
| | - P.-J. Bousquet
- Division of Allergy; Department of Pulmonology; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
| | - N. Molinari
- Clinical Research Unit; Department of Clinical Information; University Hospital of Montpellier; Montpellier France
- Montpellier University; Montpellier France
- IMAG; UMR 5149; University Hospital of Montpellier; Montpellier France
| | - P. Demoly
- Division of Allergy; Department of Pulmonology; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- UPMC Univ Paris 06; UMRS 1136; Equipe - EPAR - IPLESP; Sorbonne Universités; Paris France
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154
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Torres MJ, Romano A, Celik G, Demoly P, Khan DA, Macy E, Park M, Blumenthal K, Aberer W, Castells M, Barbaud A, Mayorga C, Bonadonna P. Approach to the diagnosis of drug hypersensitivity reactions: similarities and differences between Europe and North America. Clin Transl Allergy 2017; 7:7. [PMID: 28293415 PMCID: PMC5347172 DOI: 10.1186/s13601-017-0144-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 02/22/2017] [Indexed: 12/18/2022] Open
Abstract
Drug hypersensitivity reactions (DHRs) affect an unknown proportion of the general population, and are an important public health problem due to their potential to cause life-threatening anaphylaxis and rare severe cutaneous allergic reactions. DHR evaluations are frequently needed in both ambulatory and hospital settings and have a complex diagnosis that requires a detailed clinical history and other tests that may include in vitro tests and in vivo procedures such as skin tests and drug provocation tests. Although over the years both European and U.S. experts have published statements on general procedures for evaluating DHRs, a substantial discordance in their daily management exists. In this review, we highlight both the differences and the similarities between the European and U.S. perspectives. While a general consensus exists on the importance of skin tests for evaluating DHRs, concordance between Americans and Europeans exists solely regarding their use in immediate reactions and the fact that a confirmation of a presumptive diagnosis by drug provocation tests is often the only reliable way to establish a diagnosis. Finally, great heterogeneity exists in the application of in vitro tests, which require further study to be well validated.
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Affiliation(s)
- M J Torres
- Allergy Unit, National Network ARADyAL, IBIMA-Regional University Hospital of Malaga-UMA (Pavilion C), Plaza del Hospital Civil, 29009 Malaga, Spain.,BIONAND-Andalusian Centre for Nanomedicine and Biotechnology, Malaga, Spain
| | - A Romano
- Allergy Unit, Presidio Columbus, Rome, Italy.,IRCCS Oasi Maria S.S., Troina, Italy
| | - G Celik
- Department of Chest Diseases, Division of Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - P Demoly
- Hôpital Arnaud de Villeneuve, University Hospital of Montpellier and Sorbonne Universités, UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, 75013 Paris, France
| | - D A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - E Macy
- Kaiser Permanente Health Care Program, San Diego, CA USA
| | - M Park
- Mayo Clinic College of Medicine, Division of Allergic Diseases, Mayo Clinic, Rochester, MN 55905 USA
| | - K Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA USA
| | - W Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - M Castells
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MSA USA
| | - A Barbaud
- Sorbonne Universities, UPMC Univ Paris 06, Dermatology and Allergology Department, Tenon Hospital (AP-HP), 4 rue de la chine, 75020 Paris, France
| | - C Mayorga
- Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMA (Pavilion C), Plaza del Hospital Civil, 29009 Malaga, Spain
| | - P Bonadonna
- Allergy Unit, Azienda Ospedaliera Universitaria Intergrata of Verona, Verona, Italy
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155
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156
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Yang MS, Ban GY, Kim MH, Lim KH, Kwon HS, Song WJ, Jung JW, Lee J, Suh DI, Kwon JW, Kim SH, Shin YS, Kang HR, Kim TB, Lee BJ, Lee AY, Park HS, Cho SH. KAAACI Standardization Committee Report on the procedures and applications of the diagnostic tests for drug allergy. ALLERGY ASTHMA & RESPIRATORY DISEASE 2017. [DOI: 10.4168/aard.2017.5.5.239] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Min-Suk Yang
- Department of Internal Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ga-Young Ban
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Min-Hye Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyung-Hwan Lim
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - Hyouk-Soo Kwon
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo-Jung Song
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jeongmin Lee
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jae-Woo Kwon
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yoo Seob Shin
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Hye-Ryun Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Tae-Bum Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung-Jae Lee
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ai-Young Lee
- Department of Dermatology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Hae-Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Abstract
Drug allergy is defined as an adverse drug reaction with an established immunological mechanism. The National Institute for Health and Care Excellence published clinical guidelines on drug allergy in 2014 and quality standards in 2015. The intention of this article is to highlight indications for referral to specialists for management of drug allergy. Accurate diagnosis of drug allergy is critical of course for patient safety, but also for better use of the drugs that we have available and to reduce unnecessary avoidance of drugs. However, there are significant limitations in terms of resource availability and also in terms of testing. There is a careful balance here in that drug allergy is very common and clearly there is neither indication nor sufficient resource in the NHS for all patients with drug allergy to be reviewed by a specialist. It is, therefore, important to highlight to general physicians and physicians of other specialties, those patients who do require referral for specialist review.
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159
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Moreno E, Laffond E, Muñoz-Bellido F, Gracia MT, Macías E, Moreno A, Dávila I. Performance in real life of the European Network on Drug Allergy algorithm in immediate reactions to beta-lactam antibiotics. Allergy 2016; 71:1787-1790. [PMID: 27543745 DOI: 10.1111/all.13032] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2016] [Indexed: 12/27/2022]
Abstract
European Network on Drug Allergy (ENDA) has proposed an algorithm for diagnosing immediate beta-lactam (BL) allergy. We evaluated its performance in real life. During 1994-2014, 1779 patients with suspected immediate reactions to BL were evaluated following ENDA's short diagnostic algorithm. Five hundred and nine patients (28.6%) were diagnosed of BL hypersensitivity. Of them, 457 (25.7%) were at first evaluation [403 by skin tests (ST), 12 by positive IgE and 42 by controlled provocation tests (CPT)]. At second evaluation (SE), 52 additional patients (10.2% of allergic patients) were diagnosed, [50 (2.8%) by ST and 2 (0.1%) by CPT]. Time between reaction and study was significantly longer in patients diagnosed at SE (median 5 vs 42 months; IQR 34 vs 170; P < 0.0001). Anaphylaxis was significantly associated with a diagnosis at SE. European Network on Drug Allergy/EAACI protocol was appropriate and safe when evaluating BL immediate reactions. Re-evaluation should be performed, particularly when anaphylaxis and long interval to diagnosis are present.
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Affiliation(s)
- E. Moreno
- Allergy Service; University Hospital of Salamanca; Spain
- IBSAL (Instituto Biosanitario de Salamanca); Salamanca Spain
- Department of Biomedical and Diagnostic Sciences; Salamanca Medical School; University of Salamanca; Spain
| | - E. Laffond
- Allergy Service; University Hospital of Salamanca; Spain
- IBSAL (Instituto Biosanitario de Salamanca); Salamanca Spain
- Department of Biomedical and Diagnostic Sciences; Salamanca Medical School; University of Salamanca; Spain
| | - F. Muñoz-Bellido
- Allergy Service; University Hospital of Salamanca; Spain
- IBSAL (Instituto Biosanitario de Salamanca); Salamanca Spain
| | - M. T. Gracia
- Allergy Service; University Hospital of Salamanca; Spain
- IBSAL (Instituto Biosanitario de Salamanca); Salamanca Spain
| | - E. Macías
- Allergy Service; University Hospital of Salamanca; Spain
- IBSAL (Instituto Biosanitario de Salamanca); Salamanca Spain
| | - A. Moreno
- Allergy Service; University Hospital of Salamanca; Spain
| | - I. Dávila
- Allergy Service; University Hospital of Salamanca; Spain
- IBSAL (Instituto Biosanitario de Salamanca); Salamanca Spain
- Department of Biomedical and Diagnostic Sciences; Salamanca Medical School; University of Salamanca; Spain
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160
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Iammatteo M, Ferastraoaru D, Koransky R, Alvarez-Arango S, Thota N, Akenroye A, Jerschow E. Identifying Allergic Drug Reactions Through Placebo-Controlled Graded Challenges. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:711-717.e2. [PMID: 27888028 DOI: 10.1016/j.jaip.2016.09.041] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 09/17/2016] [Accepted: 09/28/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Graded challenges are performed to exclude hypersensitivity reactions in patients with a low likelihood of drug allergy. Literature regarding optimal protocols with a defined number of steps and use of placebo is lacking. OBJECTIVE To identify allergic drug reactions (ADRs) through a 3-step protocol composed of placebo followed by a 2-step graded drug challenge. METHODS We performed a 5-year retrospective chart review of all patients with historical ADRs who underwent single-blind, placebo-controlled graded drug challenges between October 2010 and November 2015 at an outpatient drug allergy clinic. Patients' demographic characteristics and description of historical reaction were obtained. Outcomes of challenges to drug versus placebo were compared by drug class. RESULTS Two hundred twenty-nine patients underwent at least 1 single-blind placebo-controlled graded challenge. The most commonly challenged drug class was beta-lactams (70.8%) followed by nonsteroidal anti-inflammatory drugs (17.5%). The reaction rate to drug and placebo was similar during beta-lactam challenges (9.4% vs 8.2%; P = .9) and during nonsteroidal anti-inflammatory drug challenges (14% vs 7%, P = .5), respectively. Only 10 patients (4.4%) had objective findings during drug challenges. Patients who reacted to placebo before beta-lactam challenges had an increased number of drug allergies (4.3 ± 1.0) compared with nonreactors (2.4 ± 0.1) and to beta-lactam reactors (3.3 ± 0.7) (P = .002). All placebo reactors were female (20 of 183 vs 0 of 46 males; P = .02). CONCLUSIONS Two-step graded challenges are safe in appropriately selected patients with a low risk of reaction. Placebo should be considered to reduce false-positive results, especially in females and in patients with multiple drug allergies.
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Affiliation(s)
- Melissa Iammatteo
- Division of Allergy and Immunology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Denisa Ferastraoaru
- Division of Allergy and Immunology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Rebecca Koransky
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Santiago Alvarez-Arango
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Niharika Thota
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Ayobami Akenroye
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Elina Jerschow
- Division of Allergy and Immunology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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161
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Skin testing and drug challenge outcomes in antibiotic-allergic patients with immediate-type hypersensitivity. Ann Allergy Asthma Immunol 2016; 118:73-79. [PMID: 27864093 DOI: 10.1016/j.anai.2016.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 09/30/2016] [Accepted: 10/01/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND The evaluation of antibiotic immediate-type hypersensitivity is intricate because of nonstandardized skin testing and challenge method variability. OBJECTIVE To determine the safety outcomes and risk factors for antibiotic challenge reactions in patients reporting a history of antibiotic immediate-type hypersensitivity. METHODS A 5-year retrospective review of patients evaluated for immediate-type antibiotic allergy was conducted. Data analyzed included patient demographics, index reaction details, and outcomes of skin testing and challenges, classified as single-step or multistep. RESULTS Antibiotic hypersensitivity history was identified in 211 patients: 78% to penicillins, 10% to fluoroquinolones, 7.6% to cephalosporins, and 3.8% to carbapenems. In total, 179 patients completed the challenges (median age 67 years, range 50-76 years, 56% women), and compared with nonchallenged patients, they reported nonanaphylactic (P < .001) and remote index (P = .003) reactions. Sixteen patients (8.9%) experienced challenge reactions (5 of 28 for single-step challenge, 11 of 151 for multistep challenge), and 11 of these patients had negative skin testing results before the challenge. Challenge-reactive patients were significantly younger (P = .007), more often women (P = .036), and had additional reported antibiotic allergies (P = .005). No correlation was detected between the reported index and observed challenge reaction severities (κ = -0.05, 95% confidence interval -0.34 to 0.24). Anaphylactic rates were similar during single-step and multistep challenges (3.6% vs 3.3%). CONCLUSION In the present population, younger women with multiple reported antibiotic allergies were at greatest risk for challenge reactions. Negative skin testing results did not exclude reactions, and index severity was not predictive of challenge outcome. The multistep and full-dose methods demonstrated a comparable reaction risk for anaphylaxis.
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162
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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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163
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Brockow K, Aberer W, Atanaskovic-Markovic M, Bavbek S, Bircher A, Bilo B, Blanca M, Bonadonna P, Burbach G, Calogiuri G, Caruso C, Celik G, Cernadas J, Chiriac A, Demoly P, Oude Elberink JNG, Fernandez J, Gomes E, Garvey LH, Gooi J, Gotua M, Grosber M, Kauppi P, Kvedariene V, Laguna JJ, Makowska J, Mosbech H, Nakonechna A, Papadopolous NG, Ring J, Romano A, Rockmann H, Sargur R, Sedlackova L, Sigurdardottir S, Schnyder B, Storaas T, Torres M, Zidarn M, Terreehorst I. Drug allergy passport and other documentation for patients with drug hypersensitivity - An ENDA/EAACI Drug Allergy Interest Group Position Paper. Allergy 2016; 71:1533-1539. [PMID: 27145347 DOI: 10.1111/all.12929] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2016] [Indexed: 12/27/2022]
Abstract
The strongest and best-documented risk factor for drug hypersensitivity (DH) is the history of a previous reaction. Accidental exposures to drugs may lead to severe or even fatal reactions in sensitized patients. Preventable prescription errors are common. They are often due to inadequate medical history or poor risk assessment of recurrence of drug reaction. Proper documentation is essential information for the doctor to make sound therapeutic decision. The European Network on Drug Allergy and Drug Allergy Interest Group of the European Academy of Allergy and Clinical Immunology have formed a task force and developed a drug allergy passport as well as general guidelines of drug allergy documentation. A drug allergy passport, a drug allergy alert card, a certificate, and a discharge letter after medical evaluation are adequate means to document DH in a patient. They are to be handed to the patient who is advised to carry the documentation at all times especially when away from home. A drug allergy passport should at least contain information on the culprit drug(s) including international nonproprietary name, clinical manifestations including severity, diagnostic measures, potential cross-reactivity, alternative drugs to prescribe, and where more detailed information can be obtained from the issuer. It should be given to patients only after full allergy workup. In the future, electronic prescription systems with alert functions will become more common and should include the same information as in paper-based documentation.
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164
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Böhm R, Cascorbi I. Pharmacogenetics and Predictive Testing of Drug Hypersensitivity Reactions. Front Pharmacol 2016; 7:396. [PMID: 27818635 PMCID: PMC5073094 DOI: 10.3389/fphar.2016.00396] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/07/2016] [Indexed: 12/15/2022] Open
Abstract
Adverse drug reactions adverse drug reaction (ADR) occur in approximately 17% of patients. Avoiding ADR is thus mandatory from both an ethical and an economic point of view. Whereas, pharmacogenetics changes of the pharmacokinetics may contribute to the explanation of some type A reactions, strong relationships of genetic markers has also been shown for drug hypersensitivity belonging to type B reactions. We present the classifications of ADR, discuss genetic influences and focus on delayed-onset hypersensitivity reactions, i.e., drug-induced liver injury, drug-induced agranulocytosis, and severe cutaneous ADR. A guidance how to read and interpret the contingency table is provided as well as an algorithm whether and how a test for a pharmacogenetic biomarker should be conducted.
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Affiliation(s)
- Ruwen Böhm
- Institute of Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein Kiel, Germany
| | - Ingolf Cascorbi
- Institute of Experimental and Clinical Pharmacology, University Hospital Schleswig-Holstein Kiel, Germany
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165
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Kowalski ML, Ansotegui I, Aberer W, Al-Ahmad M, Akdis M, Ballmer-Weber BK, Beyer K, Blanca M, Brown S, Bunnag C, Hulett AC, Castells M, Chng HH, De Blay F, Ebisawa M, Fineman S, Golden DBK, Haahtela T, Kaliner M, Katelaris C, Lee BW, Makowska J, Muller U, Mullol J, Oppenheimer J, Park HS, Parkerson J, Passalacqua G, Pawankar R, Renz H, Rueff F, Sanchez-Borges M, Sastre J, Scadding G, Sicherer S, Tantilipikorn P, Tracy J, van Kempen V, Bohle B, Canonica GW, Caraballo L, Gomez M, Ito K, Jensen-Jarolim E, Larche M, Melioli G, Poulsen LK, Valenta R, Zuberbier T. Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement. World Allergy Organ J 2016; 9:33. [PMID: 27777642 PMCID: PMC5062928 DOI: 10.1186/s40413-016-0122-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 08/19/2016] [Indexed: 01/14/2023] Open
Abstract
One of the major concerns in the practice of allergy is related to the safety of procedures for the diagnosis and treatment of allergic disease. Management (diagnosis and treatment) of hypersensitivity disorders involves often intentional exposure to potentially allergenic substances (during skin testing), deliberate induction in the office of allergic symptoms to offending compounds (provocation tests) or intentional application of potentially dangerous substances (allergy vaccine) to sensitized patients. These situations may be associated with a significant risk of unwanted, excessive or even dangerous reactions, which in many instances cannot be completely avoided. However, adverse reactions can be minimized or even avoided if a physician is fully aware of potential risk and is prepared to appropriately handle the situation. Information on the risk of diagnostic and therapeutic procedures in allergic diseases has been accumulated in the medical literature for decades; however, except for allergen specific immunotherapy, it has never been presented in a systematic fashion. Up to now no single document addressed the risk of the most commonly used medical procedures in the allergy office nor attempted to present general requirements necessary to assure the safety of these procedures. Following review of available literature a group of allergy experts within the World Allergy Organization (WAO), representing various continents and areas of allergy expertise, presents this report on risk associated with diagnostic and therapeutic procedures in allergology and proposes a consensus on safety requirements for performing procedures in allergy offices. Optimal safety measures including appropriate location, type and required time of supervision, availability of safety equipment, access to specialized emergency services, etc. for various procedures have been recommended. This document should be useful for allergists with already established practices and experience as well as to other specialists taking care of patients with allergies.
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Affiliation(s)
- Marek L. Kowalski
- Department of Immunology, Rheumatology & Allergy, Medical University of Lodz, 251 Pomorska Str, 92-213 Lodz, Poland
| | - Ignacio Ansotegui
- Department of Allergy and Immunology, Hospital Quiron Bizkaia, Bilbao, Spain
| | - Werner Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Mona Al-Ahmad
- Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Mubeccel Akdis
- Swiss institute of Allergy & Asthma research, Davos, Switzerland
| | - Barbara K. Ballmer-Weber
- Allergy Unit, Dermatology Clinic, University Hospital Zürich, University Zürich, Zürich, Switzerland
| | - Kirsten Beyer
- Kirsten Beyer, Charité Universitätsmedizin Berlin, Klinik für Pädiatrie m.S. Pneumologie und Immunologie, Berlin, Germany
| | - Miguel Blanca
- Hospital Reg. Univ. Carlos Haya, Allergy Serv, Malaga, Spain
| | - Simon Brown
- Royal Perth Hospital, Department of Emergency Medicine, Perth, WA Australia
| | - Chaweewan Bunnag
- Department of Otolaryngology, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Mariana Castells
- Brigham & Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Hiok Hee Chng
- Department of Rheumatology, Allergy & Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Frederic De Blay
- Hôpitaux Universitaires de Strasbourg, Chest Diseases Department, Strasbourg, France
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergology and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa Japan
| | - Stanley Fineman
- Emory University School of Medicine, Atlanta Allergy & Asthma, Atlanta, Georgia
| | | | - Tari Haahtela
- Helsinki University Central Hospital, Helsinki, Finland
| | | | | | - Bee Wah Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joanna Makowska
- CSK, Department of Allergy & Clinical Immunology, Lodz, Poland
| | | | - Joaquim Mullol
- Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic, Clinical & Experimental Respiratory Immunoallergy, IDIBAPS, and CIBERES, Barcelona, Spain
| | - John Oppenheimer
- UMDNJ – Rutgers Medical School, c/o Pulmonary and Allergy Associates, Summit, New Jersey, USA
| | - Hae-Sim Park
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, South Korea
| | | | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital IST, University of Genoa, Genoa, Italy
| | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Harald Renz
- Universitatsklinikum GI & MR GmbH, Institut fur Laboratoriumsmedizin & Path, Standort Marburg, Marburg, Germany
| | - Franziska Rueff
- Klinikum der Ludwig-Maximilians-Universitat, Klinik & Poliklinik fur Dermatologie & Allergologie, Munchen, Germany
| | - Mario Sanchez-Borges
- Allergy and Clinical Immunology Department, Centro Medico-Docente La Trinidadad, Caracas, Venezuela
| | - Joaquin Sastre
- Allergy Department, Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, CIBER de Enfermedades Respiratorias (CIBERES), Institute Carlos III, Madrid, Spain
| | | | - Scott Sicherer
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | | | - Vera van Kempen
- Institute for Prevention and Occupational Medicine, German Social Accident Insurance, Ruhr-University Bochum (IPA), Bochum, Germany
| | - Barbara Bohle
- Division of Experimental Allergology, Department of Pathophysiology, Allergy Research Center of Pathophysiology, Infectiology & Immunology, Medical University of Vienna, Vienna, Austria
| | - G Walter Canonica
- Allergy & Respiratory Disease Clinic, DIMI – Department Int Med, University of Genoa, IRCCS AOU, San Martino – IST, Genoa, Italy
| | - Luis Caraballo
- Immunology Department, Universidad De Cartagena, Cartagena, Colombia
| | | | - Komei Ito
- Department of Allergy, Aichi Children’s Health and Medical Center, Aichi, Japan
| | - Erika Jensen-Jarolim
- Messerli Research Institute, Medical University Vienna, University Vienna, Vienna, Austria
| | - Mark Larche
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
| | | | - Lars K. Poulsen
- Gentofte University Hospital, Lab for Allergology, Allergy Clinic, Hellerup, Denmark
| | | | - Torsten Zuberbier
- Campus Charite Mitte, Klinik fur Dermatologie & Allergologie, Berlin, Germany
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166
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Ariza A, Mayorga C, Salas M, Doña I, Martín-Serrano Á, Pérez-Inestrosa E, Pérez-Sala D, Guzmán AE, Montañez MI, Torres MJ. The influence of the carrier molecule on amoxicillin recognition by specific IgE in patients with immediate hypersensitivity reactions to betalactams. Sci Rep 2016; 6:35113. [PMID: 27731424 PMCID: PMC5059705 DOI: 10.1038/srep35113] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/23/2016] [Indexed: 11/26/2022] Open
Abstract
The optimal recognition of penicillin determinants, including amoxicillin (AX), by specific IgE antibodies is widely believed to require covalent binding to a carrier molecule. The nature of the carrier and its contribution to the antigenic determinant is not well known. Here we aimed to evaluate the specific-IgE recognition of different AX-derived structures. We studied patients with immediate hypersensitivity reactions to AX, classified as selective or cross-reactors to penicillins. Competitive immunoassays were performed using AX itself, amoxicilloic acid, AX bound to butylamine (AXO-BA) or to human serum albumin (AXO-HSA) in the fluid phase, as inhibitors, and amoxicilloyl-poli-L-lysine (AXO-PLL) in the solid-phase. Two distinct patterns of AX recognition by IgE were found: Group A showed a higher recognition of AX itself and AX-modified components of low molecular weights, whilst Group B showed similar recognition of both unconjugated and conjugated AX. Amoxicilloic acid was poorly recognized in both groups, which reinforces the need for AX conjugation to a carrier for optimal recognition. Remarkably, IgE recognition in Group A (selective responders to AX) is influenced by the mode of binding and/or the nature of the carrier; whereas IgE in Group B (cross-responders to penicillins) recognizes AX independently of the nature of the carrier.
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Affiliation(s)
- Adriana Ariza
- Research Laboratory, IBIMA–Regional University Hospital of Malaga–UMA, Málaga, Spain
| | - Cristobalina Mayorga
- Research Laboratory, IBIMA–Regional University Hospital of Malaga–UMA, Málaga, Spain
- Allergy Unit, IBIMA–Regional University Hospital of Malaga–UMA, Málaga, Spain
- Andalusian Center for Nanomedicine and Biotechnology - BIONAND, Málaga, Spain
| | - María Salas
- Allergy Unit, IBIMA–Regional University Hospital of Malaga–UMA, Málaga, Spain
| | - Inmaculada Doña
- Allergy Unit, IBIMA–Regional University Hospital of Malaga–UMA, Málaga, Spain
| | - Ángela Martín-Serrano
- Research Laboratory, IBIMA–Regional University Hospital of Malaga–UMA, Málaga, Spain
- Andalusian Center for Nanomedicine and Biotechnology - BIONAND, Málaga, Spain
| | - Ezequiel Pérez-Inestrosa
- Andalusian Center for Nanomedicine and Biotechnology - BIONAND, Málaga, Spain
- Department of Organic Chemistry, University of Málaga, IBIMA, Málaga, Spain
| | | | - Antonio E. Guzmán
- Pharmacy Unit, Regional University Hospital of Malaga, Málaga, Spain
| | - María I. Montañez
- Research Laboratory, IBIMA–Regional University Hospital of Malaga–UMA, Málaga, Spain
- Andalusian Center for Nanomedicine and Biotechnology - BIONAND, Málaga, Spain
| | - María J. Torres
- Allergy Unit, IBIMA–Regional University Hospital of Malaga–UMA, Málaga, Spain
- Andalusian Center for Nanomedicine and Biotechnology - BIONAND, Málaga, Spain
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167
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Predictive models in drug allergy: An appropriate patient selection is needed. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:1015. [DOI: 10.1016/j.jaip.2016.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 05/31/2016] [Indexed: 11/20/2022]
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168
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Sáenz de Santa María García M, Morales-Cabeza C, Noguerado-Mellado B, Rojas-Pérez-Ezquerra P, Zubeldia JM. Cutaneous leukocytoclastic vasculitis due to amoxicillin hypersensitivity. Ann Allergy Asthma Immunol 2016; 117:446-447. [PMID: 27590637 DOI: 10.1016/j.anai.2016.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/19/2016] [Accepted: 08/05/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Mercedes Sáenz de Santa María García
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain.
| | - Cristina Morales-Cabeza
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Blanca Noguerado-Mellado
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Patricia Rojas-Pérez-Ezquerra
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Jose M Zubeldia
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain; Biomedical Research Network and Rare Diseases (CIBERER) - U761, Madrid, Spain
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169
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Atanaskovic-Markovic M, Gaeta F, Medjo B, Gavrovic-Jankulovic M, Cirkovic Velickovic T, Tmusic V, Romano A. Non-immediate hypersensitivity reactions to beta-lactam antibiotics in children - our 10-year experience in allergy work-up. Pediatr Allergy Immunol 2016; 27:533-8. [PMID: 26999792 PMCID: PMC7167905 DOI: 10.1111/pai.12565] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2016] [Indexed: 12/02/2022]
Abstract
BACKGROUND Non-immediate reactions to beta-lactam antibiotics (BL) occur more than one hour after drug administration, and the most common manifestations are maculopapular exanthemas and delayed-appearing urticaria and/or angioedema. Infections can lead to skin eruptions and mimic drug hypersensitivity reactions (DHR), if a drug is taken at the same time. The most of children are labeled as 'drug allergic' after considering only the clinical history. OBJECTIVE To diagnose/detect a hypersensitivity or an infection which mimic DHR in children with non-immediate reactions to BL METHODS: A prospective survey was conducted in a group of 1026 children with histories of non-immediate reactions to BL by performing patch tests, skin tests, and in case of negative results, drug provocation tests (DPTs). In 300 children, a study was performed to detect infections by viruses or Mycoplasma pneumoniae. RESULTS Urticaria and maculopapular exanthemas were the most reported non-immediate reactions. Only 76 (7.4%) of 1026 children had confirmed non-immediate hypersensitivity reactions to BL. Fifty-seven children had positive delayed-reading intradermal tests (18 of these with a positive patch test). Nineteen children had positive DPT. Sixty-six of 300 children had positive tests for viruses or Mycoplasma pneumoniae and 2 of them had a positive allergy work-up. CONCLUSIONS A diagnostic work-up should be performed in all children with non-immediate reactions to BL, to remove a false label of hypersensitivity. Even though only 57 (5.5%) of 1026 children displayed positive responses to delayed-reading intradermal tests to BL, such tests appear to be useful in order to reduce the risk for positive DPTs.
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Affiliation(s)
- Marina Atanaskovic-Markovic
- Medical Faculty, University of Belgrade, Belgrade, Serbia.,University Children's Hospital of Belgrade, Belgrade, Serbia
| | | | - Biljana Medjo
- Medical Faculty, University of Belgrade, Belgrade, Serbia.,University Children's Hospital of Belgrade, Belgrade, Serbia
| | | | | | - Vladimir Tmusic
- University Children's Hospital of Belgrade, Belgrade, Serbia
| | - Antonino Romano
- Allergy Unit Complesso Integrato Columbus, Rome, Italy.,IRCCS Oasi Maria S.S., Troina, Italy
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170
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Development of nanostructures in the diagnosis of drug hypersensitivity reactions. Curr Opin Allergy Clin Immunol 2016; 16:300-7. [DOI: 10.1097/aci.0000000000000282] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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171
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Mayorga C, Celik G, Rouzaire P, Whitaker P, Bonadonna P, Rodrigues-Cernadas J, Vultaggio A, Brockow K, Caubet JC, Makowska J, Nakonechna A, Romano A, Montañez MI, Laguna JJ, Zanoni G, Gueant JL, Oude Elberink H, Fernandez J, Viel S, Demoly P, Torres MJ. In vitro tests for drug hypersensitivity reactions: an ENDA/EAACI Drug Allergy Interest Group position paper. Allergy 2016; 71:1103-34. [PMID: 26991315 DOI: 10.1111/all.12886] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2016] [Indexed: 12/15/2022]
Abstract
Drug hypersensitivity reactions (DHRs) are a matter of great concern, both for outpatient and in hospital care. The evaluation of these patients is complex, because in vivo tests have a suboptimal sensitivity and can be time-consuming, expensive and potentially risky, especially drug provocation tests. There are several currently available in vitro methods that can be classified into two main groups: those that help to characterize the active phase of the reaction and those that help to identify the culprit drug. The utility of these in vitro methods depends on the mechanisms involved, meaning that they cannot be used for the evaluation of all types of DHRs. Moreover, their effectiveness has not been defined by a consensus agreement between experts in the field. Thus, the European Network on Drug Allergy and Drug Allergy Interest Group of the European Academy of Allergy and Clinical Immunology has organized a task force to provide data and recommendations regarding the available in vitro methods for DHR diagnosis. We have found that although there are many in vitro tests, few of them can be given a recommendation of grade B or above mainly because there is a lack of well-controlled studies, most information comes from small studies with few subjects and results are not always confirmed in later studies. Therefore, it is necessary to validate the currently available in vitro tests in a large series of well-characterized patients with DHR and to develop new tests for diagnosis.
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Affiliation(s)
- C. Mayorga
- Research Laboratory; IBIMA-Regional University Hospital of Malaga-UMA; Malaga Spain
- Allergy Unit; IBIMA-Regional University Hospital of Malaga-UMA; Malaga Spain
| | - G. Celik
- Division of Immunology and Allergy; Department of Chest Diseases; Ankara University School of Medicine; Ankara Turkey
| | - P. Rouzaire
- Department of Immunology and ERTICa Research Group; University Hospital of Clermont-Ferrand and Auvergne University; Clermont-Ferrand France
| | - P. Whitaker
- Regional Adult Cystic Fibrosis Unit; St James's Hospital; Leeds UK
| | - P. Bonadonna
- Allergy Unit; Azienda Ospedaliera Universitaria Intergata of Verona; Verona Italy
| | - J. Rodrigues-Cernadas
- Immunoallergology Department; Faculty of Medicine; Centro Hospitalar São João; Porto Portugal
| | - A. Vultaggio
- Immunoallergology Unit; Department of Biomedicine; Careggi Hospital; Florence Italy
| | - K. Brockow
- Department of Dermatology and Allergology Biederstein; Technische Universität München; Munich Germany
| | - J. C. Caubet
- Pediatric Allergy Unit; Department of Child and Adolescent; University Hospitals of Geneva; Geneva Switzerland
| | - J. Makowska
- Department of Immunology, Rheumatology and Allergy; Healthy Ageing Research Center; Medical University of Łódź; Łódź Poland
| | - A. Nakonechna
- Allergy and Immunology Clinic; Royal Liverpool and Broadgreen University Hospital; Liverpool UK
| | - A. Romano
- Allergy Unit Complesso Integrato Columbus; Rome and IRCCS Oasi Maria S.S.; Troina Italy
| | - M. I. Montañez
- BIONAND-Andalusian Centre for Nanomedicine and Biotechnology; Malaga Spain
| | - J. J. Laguna
- Allergy Unit; Hospital de la Cruz Roja; Madrid Spain
| | - G. Zanoni
- Section of Immunology; Department of Pathology and Diagnostics; University of Verona; Verona Italy
| | - J. L. Gueant
- Department of Molecular Medicine and Personalized Therapeutics and Inserm UMRS 954N-GERE (Nutrition-Genetics-Environmental Risks); University Hospital of Nancy and University of Lorraine; Nancy France
| | - H. Oude Elberink
- Department of Allergology; GRIAC Research Institute; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - J. Fernandez
- Allergy Section; Alicante University Hospital; UMH; Alicante Spain
| | - S. Viel
- Laboratory of Immunology; Centre Hospitalier Lyon Sud; Hospices Civils de Lyon; Lyon France
| | - P. Demoly
- Hôpital Arnaud de Villeneuve; University Hospital of Montpellier, and Sorbonne Universités; UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR; Paris France
| | - M. J. Torres
- Allergy Unit; IBIMA-Regional University Hospital of Malaga-UMA; Malaga Spain
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172
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Atanaskovic-Markovic M, Caubet JC. Management of drug hypersensitivity in the pediatric population. Expert Rev Clin Pharmacol 2016; 9:1341-1349. [DOI: 10.1080/17512433.2016.1213131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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173
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Kang H, Min TK, Yang HJ, Pyun BY. Cefotaxime-induced drug rash with eosinophilia and systemic symptoms syndrome in a 7-year-old boy. Ann Allergy Asthma Immunol 2016; 117:202-4. [PMID: 27364942 DOI: 10.1016/j.anai.2016.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 06/02/2016] [Accepted: 06/03/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Heejeong Kang
- Department of Pediatrics, Pediatric Allergy and Respiratory Center, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Taek Ki Min
- Department of Pediatrics, Pediatric Allergy and Respiratory Center, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Hyeon-Jong Yang
- Department of Pediatrics, Pediatric Allergy and Respiratory Center, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea.
| | - Bok Yang Pyun
- Department of Pediatrics, Pediatric Allergy and Respiratory Center, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
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174
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Barni S, Mori F, Sarti L, Pucci N, Rossi EM, de Martino M, Novembre E. Utility of skin testing in children with a history of non-immediate reactions to amoxicillin. Clin Exp Allergy 2016; 45:1472-4. [PMID: 26178175 DOI: 10.1111/cea.12596] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S Barni
- Allergy Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - F Mori
- Allergy Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - L Sarti
- Allergy Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - N Pucci
- Allergy Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - E M Rossi
- Allergy Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - M de Martino
- Infectious Diseases Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - E Novembre
- Allergy Unit, Anna Meyer Children's University Hospital, Florence, Italy
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175
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Pineda F, Ariza A, Mayorga C, Arribas F, González-Mendiola R, Blanca-López N, Davila G, Cabañes N, Canto G, Laguna JJ, Senent C, Stahl-Skov P, Palacios R, Blanca M, Torres MJ. Role of Histamine Release Test for the Evaluation of Patients with Immediate Hypersensitivity Reactions to Clavulanic Acid. Int Arch Allergy Immunol 2016; 168:233-40. [PMID: 26894754 DOI: 10.1159/000443274] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 12/09/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Immediate hypersensitivity reactions to clavulanic acid (CLV) seem to be on the increase. Diagnosis is mainly based on skin testing and the drug provocation test (DPT), procedures that are not risk free. The aim of this study was to evaluate whether the histamine release test (HRT) could help evaluate patients with selective hypersensitivity to CLV. METHODS Eighteen patients with immediate selective hypersensitivity reactions to CLV (positive skin tests to CLV but negative to the major and minor determinants of benzylpenicillin and amoxicillin; negative DPT to benzylpenicillin and amoxicillin) and 21 controls with tolerance to CLV were included. Direct and passive HRT, using patient whole blood or 'IgE-stripped' donor blood sensitized by patient serum, respectively, were performed by stimulating the blood with CLV, and basophil histamine release was detected by fluorometric determination. RESULTS The clinical symptoms were anaphylaxis (n = 6), urticaria (n = 9) and urticaria-angioedema (n = 3). The median time interval between the reaction and the study was 225 days (interquartile range, IQR: 120-387.5) and between drug intake and the development of symptoms 30 min (IQR: 6.25-30). We obtained similar data for both the direct and passive HRT, with a sensitivity and specificity of 55 and 85%, respectively, a positive predictive value of 76% and a negative predictive value of 69%. CONCLUSIONS The sensitivity of both the direct and passive HRT for diagnosing patients with immediate allergy to CLV is less than 60%. However, the passive HRT has the advantage that it is based on the testing of serum samples that can be handled more easily than fresh blood samples.
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176
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Gomes ER, Brockow K, Kuyucu S, Saretta F, Mori F, Blanca-Lopez N, Ott H, Atanaskovic-Markovic M, Kidon M, Caubet JC, Terreehorst I. Drug hypersensitivity in children: report from the pediatric task force of the EAACI Drug Allergy Interest Group. Allergy 2016; 71:149-61. [PMID: 26416157 DOI: 10.1111/all.12774] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2015] [Indexed: 12/22/2022]
Abstract
When questioned, about 10% of the parents report suspected hypersensitivity to at least one drug in their children. However, only a few of these reactions can be confirmed as allergic after a diagnostic workup. There is still a lack of knowledge on drug hypersensitivity (DH) epidemiology, clinical spectrum, and appropriate diagnostic methods particularly in children. Meanwhile, the tools used for DH management in adults are applied also for children. Whereas this appears generally acceptable, some aspects of DH and management differ with age. Most reactions in children are still attributed to betalactams. Some manifestations, such as nonsteroidal anti-inflammatory drug-associated angioedema and serum sickness-like reactions, are more frequent among young patients as compared to adults. Risk factors such as viral infections are particularly frequent in children, making the diagnosis challenging. The practicability and validity of skin test and other diagnostic procedures need further assessment in children. This study presents an up-to-date review on epidemiology, clinical spectrum, diagnostic tools, and current management of DH in children. A new general algorithm for the study of these reactions in children is proposed. Data are presented focusing on reported differences between pediatric and adult patients, also identifying unmet needs to be addressed in further research.
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Affiliation(s)
- E. R. Gomes
- Allergology Department; Centro Hospitalar do Porto; Porto Portugal
| | - K. Brockow
- Division Environmental Dermatology and Allergology Helmholtz Zentrum München/TUM; Department of Dermatology und AllergologyBiederstein; Technical University Munich; Munich Germany
| | - S. Kuyucu
- Department of Pediatric Allergy and Clinical Immunology; Faculty of Medicine; Mersin University; Mersin Turkey
| | - F. Saretta
- Pediatric Department; Hospital of Palmanova; A.S.S.5 ‘Bassa Friulana’; Palmanova UD Italy
| | - F. Mori
- Allergy Unit; Department of Pediatric; Anna Meyer Children's Hospital; University of Florence; Florence Italy
| | - N. Blanca-Lopez
- Allergy Department; Infanta Leonor University Hospital; Madrid Spain
| | - H. Ott
- Division of Pediatric Dermatology; Children's Hospital Auf der Bult; Hannover Germany
| | - M. Atanaskovic-Markovic
- University Children's Hospital of Belgrade; Medical Faculty University of Belgrade; Belgrade Serbia
| | - M. Kidon
- Allergy and Clinical Immunology Unit and Institute for Pediatric Pulmonology and National CF Center; Safra Children's Hospital; Tel Hashomer Israel
| | - J.-C. Caubet
- Division of Pediatric Allergy; University Hospital of Geneva; Geneva Switzerland
| | - I. Terreehorst
- Department of ENT and Pediatrics; AMC; Amsterdam The Netherlands
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177
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Torres MJ, Montañez MI, Ariza A, Salas M, Fernandez TD, Barbero N, Mayorga C, Blanca M. The role of IgE recognition in allergic reactions to amoxicillin and clavulanic acid. Clin Exp Allergy 2016; 46:264-74. [DOI: 10.1111/cea.12689] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- M. J. Torres
- Allergy Unit; IBIMA-Regional University Hospital of Malaga; Malaga Spain
| | - M. I. Montañez
- Research Laboratory; IBIMA-Regional University Hospital of Malaga; Malaga Spain
- BIONAND-Andalusian Centre for Nanomedicine and Biotechnology; Malaga Spain
| | - A. Ariza
- Research Laboratory; IBIMA-Regional University Hospital of Malaga; Malaga Spain
| | - M. Salas
- Allergy Unit; IBIMA-Regional University Hospital of Malaga; Malaga Spain
| | - T. D. Fernandez
- Research Laboratory; IBIMA-Regional University Hospital of Malaga; Malaga Spain
| | - N. Barbero
- BIONAND-Andalusian Centre for Nanomedicine and Biotechnology; Malaga Spain
- Department of Organic Chemistry; IBIMA; University of Malaga; Malaga Spain
| | - C. Mayorga
- Allergy Unit; IBIMA-Regional University Hospital of Malaga; Malaga Spain
- Research Laboratory; IBIMA-Regional University Hospital of Malaga; Malaga Spain
| | - M. Blanca
- Allergy Unit; IBIMA-Regional University Hospital of Malaga; Malaga Spain
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178
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Anaphylaxis to the amoxicillin skin prick test: utility of the basophil activation test in diagnosis. Ann Allergy Asthma Immunol 2016; 116:259-60. [PMID: 26803535 DOI: 10.1016/j.anai.2015.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/16/2015] [Accepted: 12/17/2015] [Indexed: 11/21/2022]
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179
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Bellón T, Lerma V, González-Valle O, González Herrada C, de Abajo FJ. Vemurafenib-induced toxic epidermal necrolysis: possible cross-reactivity with other sulfonamide compounds. Br J Dermatol 2015; 174:621-4. [PMID: 26412570 DOI: 10.1111/bjd.14201] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2015] [Indexed: 11/27/2022]
Abstract
Vemurafenib is a newly licensed target-directed medication. It has been proven to improve the survival of patients with metastatic melanoma and the BRAF(V600E) mutation; however, adverse cutaneous reactions are frequent. Few cases of life-threatening severe cutaneous adverse reactions (SCARs) induced by vemurafenib have been reported. Dabrafenib, another selective BRAF inhibitor, has been licensed recently as an alternative drug with the same indications. From a molecular point of view, both vemurafenib and dabrafenib contain a sulfonamide group; cross-reactivity to sulfonamide compounds has been reported in allergic patients. We report on a patient with vemurafenib-induced toxic epidermal necrolysis (TEN). In vitro analysis of lymphocyte reactivity to vemurafenib showed positive results, confirming drug causality. In addition, lymphocytes from the patient reacted to dabrafenib and to the antibiotic sulfonamide drug sulfamethoxazole. Moreover, lymphocytes from two patients with cutaneous adverse reactions to sulfamethoxazole also reacted to vemurafenib and dabrafenib in vitro. These data strongly suggest that there might be clinical cross-reactivity between BRAF inhibitors and sulfonamides in some patients. Thus, precautions should be taken to avoid sulfonamide drugs as much as possible in patients showing serious hypersensitivity reactions to vemurafenib and vice versa.
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Affiliation(s)
- T Bellón
- Institute for Health Research, University Hospital La Paz-IdiPAZ, P° Castellana 261, 28046, Madrid, Spain
| | - V Lerma
- Clinical Pharmacology Unit, Principe de Asturias University Hospital, Madrid, Spain
| | - O González-Valle
- Department of Dermatology, University Hospital of Getafe, Madrid, Spain
| | | | - F J de Abajo
- Clinical Pharmacology Unit, Principe de Asturias University Hospital, Madrid, Spain.,Department of Biomedical Sciences (Pharmacology), University of Alcalá, Madrid, Spain
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180
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Rosenfield L, Kalicinsky C, Warrington R. A retrospective comparison of false negative skin test rates in penicillin allergy, using pencilloyl-poly-lysine and minor determinants or Penicillin G, followed by open challenge. Allergy Asthma Clin Immunol 2015; 11:34. [PMID: 26594228 PMCID: PMC4654886 DOI: 10.1186/s13223-015-0098-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/07/2015] [Indexed: 12/04/2022] Open
Abstract
Background A history of penicillin allergy in patients is common, but only 10–15 % are truly allergic. While the gold standard for diagnosing penicillin allergy is challenge, it is not recommended that this be done without first carrying out diagnostic skin testing. This is carried out with the major determinant benzylpenicilloyl (PPL) and the minor determinant mixture (MDM), consisting of penilloate, penicilloate and Penicillin G. However, since availability of the MDM is limited, Penicillin G alone has been used. Methods A retrospective chart review was carried out on patients tested for penicillin allergy in the Clinical Immunology and Allergy Clinic at the Health Sciences Centre, Winnipeg, Canada between 2005 and 2013. A total of 521 patients charts were reviewed, of whom 240 had skin testing, ImmunoCap® for IgE to Penicillin G and V and had oral challenges with penicillin, amoxicillin or cloxacillin. Results 17/240 (7.5 %) were skin test positive, 8 to PPL, 4 to MDM and 5 to Penicillin G. One was also positive on ImmunoCap® testing. Three patients had negative skin tests but weakly positive ImmunoCap®. 222 patients with negative skin tests and serological tests were challenged. Of these, 12 patients reacted to challenge. Three of the challenges were equivocal. Of the nine patients with definite positive challenges, three were tested with Penicillin G and six with MDM. Therefore the false negative rates for testing were 2.3 % with PPL and Penicillin G and 6.97 % for PPL and MDM. The difference was not significant (p = 0.0856). Conclusions In this group of patients with a history of penicillin allergy tested with the major determinant of benzyl penicillin and either MDM or Penicillin G, there was no difference in the rate of false negative testing, based on oral penicillin challenges. Therefore, Penicillin G can be safely used as an alternative to MDM in diagnosing penicillin allergy.
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Affiliation(s)
- Lana Rosenfield
- Section of Clinical Immunology and Allergy, Department of Internal Medicine, Health Sciences Centre and University of Manitoba, Winnipeg, MB Canada
| | - Chrystyna Kalicinsky
- Section of Clinical Immunology and Allergy, Department of Internal Medicine, Health Sciences Centre and University of Manitoba, Winnipeg, MB Canada
| | - Richard Warrington
- Section of Clinical Immunology and Allergy, Department of Internal Medicine, Health Sciences Centre and University of Manitoba, Winnipeg, MB Canada
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181
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Ledford DK. Cephalosporin Side Chain Cross-reactivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:1006-7. [DOI: 10.1016/j.jaip.2015.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 06/17/2015] [Accepted: 08/10/2015] [Indexed: 11/16/2022]
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182
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Capanoglu M, Vezir E, Misirlioglu ED, Guvenir H, Buyuktiryaki B, Toyran M, Kocabas CN. Additional provocation testing in patients with negative provocation test results with β-lactam antibiotics. Ann Allergy Asthma Immunol 2015; 116:82-3. [PMID: 26522258 DOI: 10.1016/j.anai.2015.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 10/07/2015] [Accepted: 10/08/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Murat Capanoglu
- Department of Pediatric Allergy and İmmunology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
| | - Emine Vezir
- Department of Pediatric Allergy and İmmunology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
| | - Emine Dibek Misirlioglu
- Department of Pediatric Allergy and İmmunology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
| | - Hakan Guvenir
- Department of Pediatric Allergy and İmmunology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
| | - Betul Buyuktiryaki
- Department of Pediatric Allergy and İmmunology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
| | - Muge Toyran
- Department of Pediatric Allergy and İmmunology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
| | - Can N Kocabas
- Department of Pediatric Allergy, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey.
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183
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Stone SF, Phillips EJ, Wiese MD, Heddle RJ, Brown SGA. Immediate-type hypersensitivity drug reactions. Br J Clin Pharmacol 2015; 78:1-13. [PMID: 24286446 DOI: 10.1111/bcp.12297] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 11/18/2013] [Indexed: 11/27/2022] Open
Abstract
Hypersensitivity reactions including anaphylaxis have been reported for nearly all classes of therapeutic reagents and these reactions can occur within minutes to hours of exposure. These reactions are unpredictable, not directly related to dose or the pharmacological action of the drug and have a relatively high mortality risk. This review will focus on the clinical presentation, immune mechanisms, diagnosis and prevention of the most serious form of immediate onset drug hypersensitivity reaction, anaphylaxis. The incidence of drug-induced anaphylaxis deaths appears to be increasing and our understanding of the multiple and complex reasons for the unpredictable nature of anaphylaxis to drugs is also expanding. This review highlights the importance of enhancing our understanding of the biology of the patient (i.e. immune response, genetics) as well as the pharmacology and chemistry of the drug when investigating, diagnosing and treating drug hypersensitivity. Misdiagnosis of drug hypersensitivity leads to substantial patient risk and cost. Although oral provocation is often considered the gold standard of diagnosis, it can pose a potential risk to the patient. There is an urgent need to improve and standardize diagnostic testing and desensitization protocols as other diagnostic tests currently available for assessment of immediate drug allergy are not highly predictive.
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Affiliation(s)
- Shelley F Stone
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research and the University of Western Australia, Perth, Western Australia; Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia
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184
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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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185
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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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186
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Perkins JR, Barrionuevo E, Ranea JA, Blanca M, Cornejo-Garcia JA. Systems biology approaches to enhance our understanding of drug hypersensitivity reactions. Clin Exp Allergy 2015; 44:1461-72. [PMID: 25040150 DOI: 10.1111/cea.12371] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hypersensitivity drug reactions (HDRs) encompass a wide spectrum of unpredictable clinical entities. They represent an important health problem, affecting people of all ages, and lead to a large strain on the public health system. Here, we summarize experiments that use high-throughput genomics technologies to investigate HDRs. We also introduce the field of systems biology as a relatively recent discipline concerned with the integration and analysis of high-throughput data sets such as DNA microarrays and next-generation sequencing data. We describe previous studies that have applied systems biology techniques to related fields such as allergy and asthma. Finally, we present a number of potential applications of systems biology to the study of HDRs, in order to make the reader aware of the types of analyses that can be performed and the insights that can be gained through their application.
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Affiliation(s)
- J R Perkins
- Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMA, Spain
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187
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Trautmann A, Seitz CS, Stoevesandt J, Kerstan A. Aminopenicillin-associated exanthem: lymphocyte transformation testing revisited. Clin Exp Allergy 2015; 44:1531-8. [PMID: 25323308 DOI: 10.1111/cea.12437] [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: 07/16/2014] [Revised: 09/19/2014] [Accepted: 10/13/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The lymphocyte transformation test (LTT) has been promoted as in-vitro test for diagnosis of drug hypersensitivity. For determination of statistical LTT sensitivity, series of patients with clinically uniform reactions followed by complete drug hypersensitivity work-up are mandatory. Assessment of LTT specificity requires control patients who tolerated exposure to the drug studied. OBJECTIVE To prospectively determine the diagnostic value of the LTT in a clinically and diagnostically well-defined series of patients. METHODS Patients with exanthematous skin eruptions after ampicillin (AMP) intake were included in this study. After exclusion or confirmation of delayed-onset allergic AMP hypersensitivity by skin and provocation testing, two independent LTTs were performed: one standard LTT and a modified LTT with additional anti-CD3/anti-CD28 monoclonal antibody stimulation. RESULTS By testing, delayed-onset allergic AMP hypersensitivity was diagnosed in 11 patients and definitely ruled out in 26. The standard LTT reached a diagnostic sensitivity of 54.5% while the modified LTT yielded 72.7%. However, the methodical test modification resulted in a decline of specificity from 92.3% (standard LTT) to 76.9%. CONCLUSIONS AND CLINICAL RELEVANCE In cases of AMP-associated exanthems, the diagnostic value of the LTT compared with routine allergy testing is limited. When evaluating such exanthems, provocation testing remains the gold standard. Delayed reading of intradermal skin tests remains most useful to avoid positive provocation reactions.
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Affiliation(s)
- A Trautmann
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany
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188
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Bonadonna P, Pagani M, Aberer W, Bilò MB, Brockow K, Oude Elberink H, Garvey L, Mosbech H, Romano A, Zanotti R, Torres MJ. Drug hypersensitivity in clonal mast cell disorders: ENDA/EAACI position paper. Allergy 2015; 70:755-63. [PMID: 25824492 DOI: 10.1111/all.12617] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2015] [Indexed: 01/08/2023]
Abstract
Mastocytosis is a clonal disorder characterized by the proliferation and accumulation of mast cells (MC) in different tissues, with a preferential localization in skin and bone marrow (BM). The excess of MC in mastocytosis as well as the increased releasability of MC may lead to a higher frequency and severity of immediate hypersensitivity reactions. Mastocytosis in adults is associated with a history of anaphylaxis in 22-49%. Fatal anaphylaxis has been described particularly following hymenoptera stings, but also occasionally after the intake of drugs such as nonsteroidal anti-inflammatory drugs, opioids and drugs in the perioperative setting. However, data on the frequency of drug hypersensitivity in mastocytosis and vice versa are scarce and evidence for an association appears to be limited. Nevertheless, clonal MC disorders should be ruled out in cases of severe anaphylaxis: basal serum tryptase determination, physical examination for cutaneous mastocytosis lesions, and clinical characteristics of anaphylactic reaction might be useful for differential diagnosis. In this position paper, the ENDA group performed a literature search on immediate drug hypersensitivity reactions in clonal MC disorders using MEDLINE, EMBASE, and Cochrane Library, reviewed and evaluated the literature in five languages using the GRADE system for quality of evidence and strength of recommendation.
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Affiliation(s)
- P. Bonadonna
- Allergy Unit; Azienda Ospedaliera Universitaria Intergrata of Verona; Verona Italy
| | - M. Pagani
- Medicine Ward; Pieve di Coriano Hospital Azienda Ospedaliera Carlo Poma Mantova; Mantova Italy
| | - W. Aberer
- Department of Dermatology and Venerology; Medizinische Universitat Graz; Graz Austria
| | - M. B. Bilò
- Allergy Unit; Department of Internal Medicine; Ospedali Riuniti di Ancona; Ancona Italy
| | - K. Brockow
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Munich Germany
| | - H. Oude Elberink
- Department of Allergology; GRIAC Research Institute; University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - L. Garvey
- Allergy Clinic; Copenhagen University Hospital; Gentofte Denmark
| | - H. Mosbech
- Allergy Clinic; Copenhagen University Hospital; Gentofte Denmark
| | - A. Romano
- Allergy Unit Complesso Integrato Columbus; Rome and IRCCS Oasi Maria S.S.; Troina Italy
| | - R. Zanotti
- Department of Medicine; Hematology Section; Azienda Ospedaliera Universitaria Intergrata of Verona; Verona Italy
| | - M. J. Torres
- Allergy Unit; Regional University Hospital-IBIMA; UMA; Málaga Spain
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189
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Alvarez-Cuesta E, Madrigal-Burgaleta R, Angel-Pereira D, Ureña-Tavera A, Zamora-Verduga M, Lopez-Gonzalez P, Berges-Gimeno MP. Delving into cornerstones of hypersensitivity to antineoplastic and biological agents: value of diagnostic tools prior to desensitization. Allergy 2015; 70:784-94. [PMID: 25832325 DOI: 10.1111/all.12620] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evidence regarding drug provocation test (DPT) with antineoplastic and biological agents is scarce. Our aim was to assess the usefulness of including DPT as a paramount gold standard diagnostic tool (prior to desensitization). METHODS Prospective, observational, longitudinal study with patients who, during a 3-year period, were referred to the Desensitization Program at Ramon y Cajal University Hospital. Patients underwent a structured diagnostic protocol by means of anamnesis, skin tests (ST), risk assessment, and DPT. Oxaliplatin-specific IgE was determined in oxaliplatin-reactive patients (who underwent DPT regardless of oxaliplatin-specific IgE results). Univariate analysis and multivariate analysis were used to identify predictors of the final diagnosis among several variables. RESULTS A total of 186 patients were assessed. A total of 104 (56%) patients underwent DPT. Sixty-four percent of all DPTs were negative (i.e., hypersensitivity was excluded). Sensitivity for oxaliplatin-specific IgE (0.35 UI/l cutoff point) was 34%, specificity 90.3%, negative predictive value 45.9%, positive predictive value 85%, negative likelihood ratio 0.7, and positive likelihood ratio 3.5. CONCLUSIONS These are the first reported data based on more than 100 DPTs with antineoplastic and biological agents (paclitaxel, oxaliplatin, rituximab, infliximab, irinotecan, and other drugs). Implementation of DPT in diagnostic protocols helps exclude hypersensitivity (in 36% of all referred patients), and avoids unnecessary desensitizations in nonhypersensitive patients (30-56% of patients, depending on culprit-drug). Drug provocation test is vital to validate diagnostic tools; consequently, quality data are shown on oxaliplatin-specific IgE and oxaliplatin-ST in the largest series of oxaliplatin-reactive patients reported to date (74 oxaliplatin-reactive patients). Identifying phenotypes and predictors of a diagnosis of hypersensitivity may be helpful for tailored plans.
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Affiliation(s)
| | | | - D. Angel-Pereira
- Allergy Division; Ramon y Cajal University Hospital; Madrid Spain
| | - A. Ureña-Tavera
- Allergy Division; Ramon y Cajal University Hospital; Madrid Spain
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190
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Trubiano JA, Leung VK, Chu MY, Worth LJ, Slavin MA, Thursky KA. The impact of antimicrobial allergy labels on antimicrobial usage in cancer patients. Antimicrob Resist Infect Control 2015; 4:23. [PMID: 26034582 PMCID: PMC4450507 DOI: 10.1186/s13756-015-0063-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 05/19/2015] [Indexed: 11/16/2022] Open
Abstract
Background Antibiotic allergy labels are associated with sub-optimal prescribing patterns and poorer clinical outcomes in non-cancer populations, but the effect of labelling on antimicrobial usage in patients with cancer is unknown. Findings A retrospective review of hospitalized patients admitted to the Peter MacCallum Cancer Centre (2010-2012) identified 23 % of cancer patients (n = 198) with an antimicrobial allergy label (AA). Comparison of those with an antimicrobial allergy label to those without demonstrated increased antibiotic use per admission (3 vs. 2, p = 0.01), increased fluoroquinolone use (11 % vs. 6 %, p < 0.05), increased antibiotic course duration (15 vs. 13 days, p = 0.09), higher readmission rates (53 % vs. 28 %, p < 0.001) and poorer concordance with prescribing guidelines (47 % vs. 91 %, p < 0.001). Patients in the AA group on multivariate analysis had a higher number of antibiotics employed, longer duration of antibiotic therapy and higher rate of readmission. Conclusions Antimicrobial usage, including the use of restricted antibiotics, is higher in patients with cancer. Antibiotic de-labelling strategies in cancer patients must be evaluated to aid antimicrobial stewardship initiatives.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC Australia ; Department of Infectious Diseases, Austin Health, East Melbourne, VIC Australia
| | - Vivian K Leung
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC Australia
| | - Man Y Chu
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC Australia
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC Australia ; Victorian Infectious Diseases Service, Peter Doherty Institute, Melbourne, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC Australia ; Victorian Infectious Diseases Service, Peter Doherty Institute, Melbourne, Australia
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191
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Fox SJ, Park MA. Penicillin skin testing is a safe and effective tool for evaluating penicillin allergy in the pediatric population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 2:439-44. [PMID: 25017533 DOI: 10.1016/j.jaip.2014.04.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 03/30/2014] [Accepted: 04/30/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Penicillin skin testing has been validated in the evaluation of adult patients with penicillin allergy. However, the commercially available benzylpenicilloyl polylysine (Pre-Pen) is not indicated in the pediatric population. Moreover, the safety and validity of penicillin skin testing in the pediatric population has not been well studied. OBJECTIVE We describe the safety and validity of penicillin skin testing in the evaluation of children with a history of penicillin allergy. METHODS Children (<18 years) with a history of penicillin allergy were evaluated with penicillin skin tests and were reviewed for basic demographics, penicillin skin test results, adverse drug reaction to penicillin after penicillin skin test, and adverse reaction to penicillin skin test. By using the χ(2) test, we compared the differences in the proportion of children and adults with a positive penicillin skin test. P value (<.05) was considered statistically significant. The institutional review board approved the study, and all the subjects signed written informed consents. RESULTS A total of 778 children underwent penicillin skin testing; 703 of 778 patients had a negative penicillin skin test (90.4%), 66 had a positive test (8.5%), and 9 had an equivocal test (1.1%). Children were more likely to have a positive penicillin skin test (P < .0001) compared with adults (64 of 1759 [3.6%]); 369 of 703 patients with negative penicillin skin test (52%) were challenged with penicillin, and 14 of 369 patients (3.8%) had an adverse drug reaction. No adverse reactions to penicillin skin testing were observed. CONCLUSION Penicillin skin testing was safe and effective in the evaluation of children with a history of penicillin allergy.
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Affiliation(s)
| | - Miguel A Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn.
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Agache I, Bilò M, Braunstahl GJ, Delgado L, Demoly P, Eigenmann P, Gevaert P, Gomes E, Hellings P, Horak F, Muraro A, Werfel T, Jutel M. In vivo diagnosis of allergic diseases--allergen provocation tests. Allergy 2015; 70:355-65. [PMID: 25640808 DOI: 10.1111/all.12586] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2015] [Indexed: 12/31/2022]
Abstract
The allergen challenge test has been the mainstay of diagnosis of allergic diseases for a long time since it offers a direct proof of the clinical relevance of a particular allergen for the allergic disease symptoms and severity. Standardisation and availability for daily practice (including safety issues) are still to be refined but most of the challenge tests have safely crossed the border from research tools to diagnostic tests available for daily practice for a well trained clinical staff.
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Affiliation(s)
- I. Agache
- Transylvania University Brasov; Brasov Romania
| | - M. Bilò
- Internal Medicine; Allergy Unit; Ancona Italy
| | | | - L. Delgado
- Faculty of Medicine; Allergy Division; Porto University; Porto Portugal
| | - P. Demoly
- Allergy; University Hospital of Montpellier; Montpellier France
| | - P. Eigenmann
- Paediatrics; University Hospital Geneva; Geneva Switzerland
| | - P. Gevaert
- Otorhinolaryngology; Ghent University; Ghent Belgium
| | - E. Gomes
- Servico de Imunoalergologia; Hospital Maria Pia; Porto Portugal
| | - P. Hellings
- Department of Orothinolaryngology; University Hospitals Leuven; Leuven Belgium
| | - F. Horak
- Department of Allergy Research; Allergy Center Wien West; Vienna Austria
| | - A. Muraro
- Department of Pediatrics; Referral Centre for Food Allergy; Padua General University Hospital; Padua Italy
| | - T. Werfel
- Dermatology and Allergy; Hannover Medical School; Hannover Austria
| | - M. Jutel
- Department of Clinical Immunology; Wroclaw Medical University; Wroclaw Poland
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Recognition of multiepitope dendrimeric antigens by human immunoglobulin E. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2015; 11:579-88. [DOI: 10.1016/j.nano.2015.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 12/22/2014] [Accepted: 01/14/2015] [Indexed: 12/14/2022]
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194
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Arikoglu T, Aslan G, Batmaz SB, Eskandari G, Helvaci I, Kuyucu S. Diagnostic evaluation and risk factors for drug allergies in children: from clinical history to skin and challenge tests. Int J Clin Pharm 2015; 37:583-91. [PMID: 25822038 DOI: 10.1007/s11096-015-0100-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 03/10/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Parent or self-reported drug allergy claims frequently overestimate the real incidence of hypersensitivity reactions. A detailed and algorithmic diagnostic evaluation of drug reactions may allow a proper diagnosis. OBJECTIVE The aim of this study was to determine the confirmation rates and risk factors for confirmed allergic drug reactions in children. SETTING Mersin University Hospital in Turkey. METHOD The study consisted of children between ages of 8 months and 18 years with the history of suspected drug allergy as reported by the clinician or the patients. Parents were interviewed by a clinician to complete questionnaires that included questions about demographic data and characteristics of index drug reaction. Immediate reactions (IRs) were assessed with immediate-reading skin prick (SPT) and intradermal tests (IDT). Nonimmediate reactions (NIRs) were assessed with SPT, both early and delayed reading of IDT and patch tests. In case of negative skin tests, drug provocation tests were performed. The possible risk factors for confirmed drug allergy in univariate analysis (p < 0.1) were entered into the multivariate logistic regression analysis to determine independent predictors. MAIN OUTCOME MEASURE (1) Confirmation rates of drug allergy (2) Risk factors related to confirmed drug allergy in children. RESULTS We evaluated a total of 180 suspected drug allergy reactions in 97 children, mainly to antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs) and anticonvulsants. Among all suspected allergic drug reactions, 97 (53.9 %) were immediate type and 83 (46.1 %) were non-immediate type. The average time interval between the reaction and allergologic work-up was 5 months. Drug allergy confirmation rates were 30.1 % for beta-lactams, 27.2 % for non-betalactams, 21.1 % for NSAIDs and 30 % for anticonvulsants. Eight of 54 confirmed NIRs showed positivity on immediate skin tests. Regulatory T cells, TGF-β and IL-10 levels were not different between groups with and without confirmed drug allergy. A strong family and personal history of drug allergy were found to be significantly related to the confirmed allergic drug reactions. CONCLUSION Parent or self-reported drug allergy should be evaluated with a standardized diagnostic work-up before strict prohibitions are made. In addition, family and personal histories of drug allergy were significant risk factors related to allergic drug reactions in children.
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Affiliation(s)
- Tugba Arikoglu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Çiftlikköy, Yenişehir, 33343, Mersin, Turkey,
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196
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Mori F, Cianferoni A, Barni S, Pucci N, Rossi ME, Novembre E. Amoxicillin allergy in children: five-day drug provocation test in the diagnosis of nonimmediate reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:375-80.e1. [PMID: 25609343 DOI: 10.1016/j.jaip.2014.11.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 10/30/2014] [Accepted: 11/03/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND The drug provocation test (DPT) is the gold standard to rule out drug hypersensitivity. There are standardized DPT protocols to diagnose immediate reactions to drugs, but not for nonimmediate reactions. OBJECTIVE The aim of this study was to show the sensitivity and specificity of an allergy work-up that included a 5-day DPT in children with histories of nonimmediate reactions to amoxicillin through focusing on a pediatric population with histories of immediate and nonimmediate reactions to amoxicillin. METHODS Two hundred consecutive patients with histories of amoxicillin reactions referred to the Allergy Unit of Anna Meyer Children's Hospital for suspected drug allergy from 2008 to 2011 underwent in vivo tests with the culprit drug according to European Academy of Allergy and Clinical Immunology guidelines. Moreover, most of those children, regardless of the skin tests results, were challenged with amoxicillin for a total of 5 days. RESULTS In 4 years, 200 patients were evaluated for a history of drug hypersensitivity to amoxicillin. The majority of patients (76%) had a history of mild nonimmediate reactions. All 200 patients underwent skin tests, and 9 of 200 tested positive. A total of 177 DPTs were performed with amoxicillin for 5 days in each child. Diagnosis of amoxicillin allergy was confirmed by a DPT in 17 patients (9.6%); 14/17 had history of nonimmediate reactions; 4/14 (26.6%) reacted on day 5. CONCLUSION According to our results, a long-term DPT protocol increases the sensitivity of the allergy work-up, and it should be recommended for patients with a history of amoxicillin nonimmediate reaction.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy.
| | | | - Simona Barni
- Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
| | - Neri Pucci
- Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
| | - Maria Elisabetta Rossi
- Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
| | - Elio Novembre
- Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
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Bourke J, Pavlos R, James I, Phillips E. Improving the Effectiveness of Penicillin Allergy De-labeling. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:365-34.e1. [PMID: 25609352 DOI: 10.1016/j.jaip.2014.11.002] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Revised: 11/03/2014] [Accepted: 11/04/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Approximately 10-20% of hospitalized patients are labeled as penicillin allergic, and this is associated with significant health and economic costs. OBJECTIVES We looked at the effectiveness of penicillin allergy de-labeling in clinical practice with the aim of deriving risk stratification models to guide testing strategies. METHODS Consecutive patients aged 15 years or more, referred to a Western Australian public hospital drug allergy service between 2008 and 2013 for beta-lactam allergy, were included. Follow-up surveys were conducted. Results of skin prick testing and intradermal testing (SPT/IDT) and oral challenge (OC), and follow-up of post testing antibiotic usage were the main outcomes. RESULTS SPT/IDT was performed in 401 consecutive patients with immediate (IMM) (≤ 1 hour) (n = 151) and nonimmediate (NIM) (>1 hour) (n = 250) reactions. Of 341 patients, 42 (12.3%) were SPT/IDT+ to ≥ 1 penicillin reagents, including 35/114 (30.4%) in the IMM group and 7/227 (3.1%) in the NIM group (P < .0001). Of 355 SPT/IDT patients, 3 (0.8%), all in the IMM group, had nonserious positive OC reactions to single dose penicillin VK (SPT/IDT negative predictive value [NPV] 99.2%). Selective or unrestricted beta-lactam was recommended in almost 90% overall, including 238/250 (95.2%) in the NIM group and 126/151 (83.4%) in the IMM group (P = .0001). Of 182 patients, 137 (75.3%) were following the allergy label modifications (ALM) at the time of follow-up. CONCLUSIONS Penicillin SPT/IDT/OC safely de-labels penicillin-allergic patients and identifies selective beta-lactam allergies; however, incomplete adherence to ALM recommendations impairs effectiveness. Infrequent SPT/IDT+ and absent OC reactions in patients with NIM reactions suggest OC alone to be a safe and cost-effective de-labeling strategy that could improve the coverage of penicillin allergy de-labeling in lower risk populations.
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Affiliation(s)
- Jack Bourke
- Department of Clinical Immunology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Rebecca Pavlos
- Institute for Immunology & Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
| | - Ian James
- Institute for Immunology & Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
| | - Elizabeth Phillips
- Department of Clinical Immunology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia; Institute for Immunology & Infectious Diseases, Murdoch University, Perth, Western Australia, Australia; Vanderbilt University School of Medicine, Nashville, Tenn.
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Abstract
PURPOSE Cefaclor is widely prescribed for various infectious diseases. As its consumption increases, the number of hypersensitivity reactions to cefaclor has increased. This study aimed to evaluate the immunologic findings of immediate hypersensitivity to cefaclor. MATERIALS AND METHODS We enrolled 47 patients with immediate hypersensitivity to cefaclor from Ajou University Hospital and Asan Medical Center. Serum specific IgE, IgG1, and IgG4 antibodies to cefaclor-human serum albumin (HSA) conjugate were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS The most common phenotype was anaphylaxis (Group I, 78.7%), followed by urticaria (Group II, 21.3%). The detection of specific IgE, IgG1, and IgG4 to cefaclor-HSA conjugate by ELISA tended to be higher in Group I (40.5%, 41.7%, 21.6%) than in Group II (20.0%, 20.0%, 0%) with no statistical significance. Significant associations were found between specific IgE and IgG1 or IgG4 (p<0.001, p=0.019). ELISA inhibition tests showed significant inhibitions by both free cefaclor and cefaclor-HSA conjugate. For basophil activation tests in patients having no specific IgE antibody, the CD63 expression level on basophils increased with incubations of free cefaclor. CONCLUSION The most common manifestation of immediate hypersensitivity to cefaclor was anaphylaxis, most of which was mediated by IgE; however, a non-IgE mediated direct basophil activation mechanism was suggested in a subset of anaphylaxis patients.
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Affiliation(s)
- Hye-Soo Yoo
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Seung-Hyun Kim
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Hyouk-Soo Kwon
- Division of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Bum Kim
- Division of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Hee Nam
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Young-Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Hae-Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.
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Safety and Outcomes of Test Doses for the Evaluation of Adverse Drug Reactions: A 5-Year Retrospective Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:768-74. [DOI: 10.1016/j.jaip.2014.08.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 08/04/2014] [Accepted: 08/05/2014] [Indexed: 11/22/2022]
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Hjortlund J, Mortz CG, Stage TB, Skov PS, Dahl R, Bindslev-Jensen C. Positive serum specific IgE has a short half-life in patients with penicillin allergy and reversal does not always indicate tolerance. Clin Transl Allergy 2014; 4:34. [PMID: 25905005 PMCID: PMC4405882 DOI: 10.1186/2045-7022-4-34] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 09/18/2014] [Indexed: 12/02/2022] Open
Abstract
Background The positive and negative predictive values of specific IgE to penicillins are not well established for penicillin hypersensitivity. One reason may be that serum IgE levels to penicillin diminish over time. The objective in this study was to investigate variations in serum half-life (T½) for specific IgE to penicillins (s-IgE) and to evaluate the outcome of penicillin challenges in patients with previous but not present specific IgE to penicillins. Methods Two subgroups were investigated. All included patients had a history of penicillin allergy with reported symptoms such as urticaria/angioedema or unclassified cutaneous rash. T½ of specific IgE to penicillins was calculated based on sera from 29 patients with repeated measurements of s-IgE. Twenty-two patients with a previous positive s-IgE was followed and challenged with penicillin when IgE had become negative. Results The T½ for s-IgE varied between the 26 patients with decreasing s-IgE from 1.6 months to 76.4 months and 52% had a T½ of less than a year. The three patients with stable and increasing IgE-values showed T½ approaching infinity A total of 29 challenges with β-lactams were performed. Four different patterns were seen when evaluating the clinical reaction to challenge (positive/negative) and post-challenge boost of s-IgE (yes/no). Eight (36.4%) had negative challenge and negative post-challenge s-IgE, eight (36.4%) negative challenge, but positive post-challenge s-IgE levels. 3 (13.6%) had positive challenge and positive post-challenge s-IgE whereas 3 (13.6%) were challenge positive, but had negative post-challenge s-IgE. Conclusion Specific IgE to penicillins declines over time stressing the importance of a close time relation between diagnostic work-up and clinical reaction. Reversal of previously positive s-IgE may still be associated with positive penicillin challenges and/or re-boostering of s-IgE to positivity.
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Affiliation(s)
- Janni Hjortlund
- Department of Dermatology and Allergy Centre, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark
| | - Charlotte Gotthard Mortz
- Department of Dermatology and Allergy Centre, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark
| | | | - Per Stahl Skov
- Department of Dermatology and Allergy Centre, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark
| | - Ronald Dahl
- Department of Dermatology and Allergy Centre, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark
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