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Vyas L, Raja K, Morrison S, Beggs D, Attalla MS, Patel M, Philips M. Beta-lactam comprehensive allergy management program in a community medical center. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e189. [PMID: 38028889 PMCID: PMC10654959 DOI: 10.1017/ash.2023.461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 12/01/2023]
Abstract
Objective The Beta-lactam Comprehensive Allergy Management Program (CAMP) was implemented to facilitate complete beta-lactam allergy history documentation in the electronic medical record (EMR) and increase beta-lactam utilization. The study objective was to assess the rate of complete allergy histories and days of antimicrobial therapy (DOT) before versus after CAMP implementation. Design Quasi-experimental study with interrupted time-series analysis. Setting Non-teaching, urban, and community medical center within a multi-hospital health system. Patients Adult inpatients with a beta-lactam allergy receiving antimicrobial therapy. Methods The multidisciplinary CAMP team screened, interviewed, and collected allergy history details of adult inpatients with a beta-lactam allergy receiving antimicrobial therapy starting January 4, 2021. Patients were stratified as high, moderate, or low risk of IgE-mediated allergy and referred to an allergist for skin testing or drug challenge. The EMR was updated with interview details and drug challenge or skin test results. The primary endpoint was rate of complete allergy history documentation before (12/1/18-4/1/19) compared to after (1/4/21-5/1/21) program implementation. The secondary endpoint was days of inpatient beta-lactam therapy. Implementation logistics, de-labeling rate, and antimicrobial therapy changes were evaluated. Results The program evaluated 392 individuals, with 184 and 208 patients comprising the pre- and post-intervention groups, respectively. The post-intervention period was associated with an increase of 19.8% in complete allergy histories (0.359 PPc; R 2 0.26; p = 0.002) and 9.34 beta-lactam DOT per 1,000-days-present (1.106 PPc; R 2 0.194; p = 0.009). Conclusion Implementation of a comprehensive beta-lactam allergy management program was associated with higher rates of complete beta-lactam allergy history and beta-lactam use.
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Affiliation(s)
- Lakhini Vyas
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
| | - Karan Raja
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
- Ernest Mario School of Pharmacy, Rutgers University, New Brunswick, NJ, USA
| | - Susan Morrison
- Department of Medicine, Clara Maass Medical Center, Belleville, NJ, USA
| | - Donald Beggs
- Department of Medicine, Clara Maass Medical Center, Belleville, NJ, USA
| | - Mark S. Attalla
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
| | - Mitesh Patel
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
| | - Mona Philips
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
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2
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Harper HM, Sanchez M. Review of Pharmacist Driven Penicillin Allergy Assessments and Skin Testing: A Multi-Center Case-Series. Hosp Pharm 2022; 57:469-473. [PMID: 35898263 PMCID: PMC9310321 DOI: 10.1177/00185787211046862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
Objective: To describe the impact of pharmacy driven penicillin allergy assessments on de-labeling penicillin allergies and antibiotic streamlining opportunities for hospitalized patients. Design: Multi-center, retrospective case-series study. Setting: A health system of 4 non-teaching hospitals. Participants: Patients aged 18 years and older with a physician order for a pharmacist penicillin allergy assessment. Exclusion criteria consisted of patients with anaphylaxis or a type II penicillin allergy, anaphylaxis of any cause within 4 weeks, refusal of penicillin allergy skin test (PAST), antihistamine use within 24 hours, penicillin intolerance, immunosuppression or immunosuppressive medications, or skin conditions that could interfere with PAST. Interventions: The primary endpoint evaluated the number of de-labeled penicillin allergies after pharmacists provided penicillin allergy assessments. Secondary endpoints evaluated the percent of patients with antibiotics deescalated to beta-lactam antibiotics and classification of notable interventions made by pharmacists. Measurements and Main Results: There were 35 patients who met inclusion criteria. Twenty-four patients underwent both penicillin allergy skin testing and oral (PO) amoxicillin challenge. Five patients had allergies de-labeled only after a pharmacist interview. Four patients received only the PO amoxicillin challenge and 2 patients received only PAST. Penicillin allergies were de-labeled from the electronic health record (EHR) in 31 (89%) patients despite all testing negative for a penicillin allergy from PAST or a PO amoxicillin challenge. Four patients had the allergy re-added to the chart on subsequent admissions. No patients experienced a reaction from PAST, PO amoxicillin challenge, or subsequent beta-lactam antibiotics. Twenty-eight (80%) patients had their antibiotic therapy changed as a result of the allergy assessment. Seventeen patients were de-escalated onto beta-lactam antibiotics and aztreonam was stopped in 6 patients. Conclusion: Results from this study suggests that pharmacists expanding their scope of practice with PAST is a safe and effective allergy de-labeling tool. Pharmacist-driven penicillin allergy assessments could provide antibiotic cost savings and avoid aztreonam use. The study supports the need to emphasize education for patients and caretakers regarding allergy testing results to avoid relabeling in future hospital visits.
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Affiliation(s)
- Hanna M. Harper
- Health First Holmes Regional Medical Center, Melbourne, FL, USA
| | - Michael Sanchez
- Health First Holmes Regional Medical Center, Melbourne, FL, USA
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3
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Munasinghe BM, Perera RN, Kumara SKWR. Two lives at stake: Obstetric anaphylactic shock resulting in acute respiratory distress syndrome – A case report. SAGE Open Med Case Rep 2022; 10:2050313X221084843. [PMID: 35320983 PMCID: PMC8935580 DOI: 10.1177/2050313x221084843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/14/2022] [Indexed: 12/23/2022] Open
Abstract
Maternal anaphylaxis is rare albeit life-threatening critical incident dreaded by many due to negative effects on not only the mother but the foetus as well. Antibiotics and anaesthetic agents still contribute to majority of the episodes. Consequences of anaphylaxis such as placental insufficiency and subsequent foetal neurocognitive deficits are devastating outcomes. Acute respiratory distress syndrome following anaphylaxis is even rarer among the normal population. The management of maternal anaphylaxis does not differ from routine recommendations even though close monitoring and preparedness for early delivery should be embedded in the protocols. This is a rare case report of a primi mother who developed anaphylactic shock following intravenous penicillin in the background of negative allergic history, resultant foetal distress requiring emergency lower segment caesarian section and delayed onset acute respiratory distress syndrome which was later attributed to anaphylaxis. Pertinent identification and management which included a multidisciplinary team culminated in favourable outcomes.
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Affiliation(s)
| | - RN Perera
- District General Hospital Mannar, Mannar, Sri Lanka
| | - SKWR Kumara
- District General Hospital Mannar, Mannar, Sri Lanka
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Harada K, Baker MG, Agarwal S. Patient perspectives on penicillin allergy and testing. Allergy Asthma Proc 2022; 43:64-69. [PMID: 34983713 DOI: 10.2500/aap.2022.43.210090] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Most patients who report penicillin allergy are found to tolerate penicillin later in life. Few studies have examined patients' understanding and beliefs about penicillin allergy and testing. Evaluating patients' perspectives may help identify ways to improve patient education and increase testing to de-label those who can tolerate penicillin. Objective: To better understand patient perspectives on penicillin allergy testing and to identify whether patient characteristics and beliefs impact completion of testing. Methods: Patients who were visiting our allergy clinics and had documentation of a penicillin allergy in the electronic medical record (EMR) were approached to complete a survey with regard to their reaction history and knowledge and/or perspectives about penicillin allergy and testing. Eighty-eight patients completed the survey, and their medical records were reviewed to collect results of penicillin testing. Results: Fewer than half of the patients (45.5%) who had EMR-documented penicillin allergy reported awareness that testing for penicillin allergy is available. Awareness of penicillin allergy testing was significantly associated with completion of testing, whereas other patient characteristics, such as education, income, and distance to the hospital, were not. Patients who scheduled a return visit for testing at the time of their initial visit were significantly more likely to follow through with testing. Most patients were interested in penicillin testing. For patients who were not interested, the most frequently cited reason was fear of adverse effects of testing. Conclusion: Among the patients who carried a penicillin allergy label, those who were aware of penicillin allergy testing were more likely to complete testing, and ease of scheduling contributed to higher rates of testing completion. Fear about adverse effects from testing was the most reported barrier. Our findings emphasized the importance of increasing awareness of the availability and safety of penicillin testing through patient education and collaboration with other specialties.
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Affiliation(s)
- Kaoru Harada
- From the Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Mary Grace Baker
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shradha Agarwal
- From the Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; and
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5
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Rosti B, Mahler V. Adding a second skin prick test reading and modifying the cut‐off for beta‐lactam–specific
IgE
enhances the sensitivity in the routine diagnostic workup for immediate beta‐lactam hypersensitivity. Contact Dermatitis 2020; 83:361-371. [DOI: 10.1111/cod.13622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Bernadette Rosti
- Allergy‐Clinic of the Department of Dermatology University Hospital of Erlangen Erlangen Germany
- Dental Practice Dr. Ludwig and Colleagues MVZ GmbH Fürth Germany
| | - Vera Mahler
- Allergy‐Clinic of the Department of Dermatology University Hospital of Erlangen Erlangen Germany
- Division of Allergology Paul‐Ehrlich‐Institut Langen Germany
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Alharbi HA. Antibiotic Skin Testing in the Intensive Care Unit: A Systematic Review. Crit Care Nurse 2020; 39:e1-e9. [PMID: 31961941 DOI: 10.4037/ccn2019207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Recent research has shown that a large majority of patients with a history of penicillin allergy are acutely tolerant of penicillins and that there is no clinically significant immunologic cross-reactivity between penicillins and cephalosporins or other β-lactams. The standard test to confirm acute tolerance is challenge with a therapeutic dose. Skin testing is useful only when the culprit antibiotic can haptenate serum proteins and induce an immunoglobulin E-mediated reaction and the clinical history demonstrates such high risk that a direct oral challenge may result in anaphylaxis. OBJECTIVE To review and evaluate the current practice of skin testing for antibiotics (other than penicillin) in critically ill patients by means of a systematic literature review. METHODS This systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Several electronic databases were searched using the following terms: antibiotics, skin test (tests, testing), intensive care, intensive care unit, ICU, critical care, critical care unit. RESULTS Twenty-three articles were identified for inclusion in this review. The results indicate a lack of standardized skin testing for all antibiotics in critical care settings. Oral challenge with nonirritating concentrations of antibiotics can be helpful in determining allergy to these drugs. CONCLUSIONS Critical care providers should evaluate antibiotic allergy using nonirritating concentrations before administering antibiotics to patients. Introduction of a standardized skin test for all antibiotics in intensive care unit patients to help select the most appropriate antibiotic treatment regimen might help save lives and reduce costs.
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Affiliation(s)
- Homood A Alharbi
- Homood A. Alharbi is an assistant professor, College of Nursing, King Saud University, Riyadh, Saudi Arabia
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7
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Mazzoni D, Tee HW, de Menezes SL, Graudins LV, Johnson DF, Newnham ED, Kelley PG, Zubrinich CM, Goh MSY, Trubiano JA, Aung AK. A Survey on Knowledge Gaps in Assessment and Management of Severe Drug Hypersensitivity Reactions: Multicenter Cross-Sectional Study of Australian Health Care Providers. J Clin Pharmacol 2020; 61:25-31. [PMID: 32648298 DOI: 10.1002/jcph.1692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/15/2020] [Indexed: 11/08/2022]
Abstract
Severe drug hypersensitivity reactions (DHRs) are often encountered by health care professionals (HCPs). We evaluated knowledge of doctors and pharmacists in the assessment and management of severe DHRs using a structured questionnaire. A cross-sectional study was conducted in 4 metropolitan hospital networks in Melbourne, Australia. A 13-question, scenario-based multiple-choice questionnaire to assess specific knowledge domains in drug hypersensitivity syndrome recognition, causality attribution, cross-reactivity patterns, appropriate diagnostic tests, and therapy was administered to HCPs of various vocation and specialty groups. Data were analyzed according to profession, self-reported experience, and preparedness in managing severe DHRs. Two hundred thirty-eight participants (45.0% senior doctors, 24.4% junior doctors, and 30.7% pharmacists) across a range of subspecialties achieved an overall median score of 7 (IQR, 5-8)-overall 55.6% correct responses to all questions-with senior doctors outperforming junior doctors and pharmacists (P < .001). The best performance by all participants was in DHR syndrome recognition (60.9%), and the poorest was in diagnostics/therapy (52.0%). HCP group and experience level were significantly associated with better performance in the knowledge domains of cross-reactivity and diagnostics/therapy (P = .003 and < .001, respectively), but not in the domains of syndrome recognition and causality attribution (P > .05). Levels of self-reported preparedness in DHR management were not associated with performance rates in any of the knowledge domains. This study demonstrated significant knowledge gaps in the recognition and management of severe drug hypersensitivity reactions. Targeted multidisciplinary education of staff caring for these patients is needed to improve knowledge gaps.
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Affiliation(s)
- Daniel Mazzoni
- Department of Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Department of General Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Hui Wen Tee
- Department of General Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Sara Lee de Menezes
- Department of General Medicine, Alfred Health, Melbourne, Victoria, Australia
| | | | - Douglas Forsyth Johnson
- Department of General Medicine and Infectious Diseases, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Evan David Newnham
- Department of General Medicine, Eastern Health, Melbourne, Victoria, Australia
| | - Peter Graham Kelley
- Department of Infectious Diseases, Peninsula Health, Melbourne, Victoria, Australia
| | - Celia Mary Zubrinich
- Department of Allergy, Immunology and Respiratory Medicine, Alfred Health, Melbourne, Victoria, Australia
| | | | - Jason Anthony Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Melbourne, Victoria, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, Melbourne, Victoria, Australia
| | - Ar Kar Aung
- Department of General Medicine, Alfred Health, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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8
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Heng YK, Liew YCC, Kong YL, Lim YL. β-Lactam allergy testing and delabeling-Experiences and lessons from Singapore. IMMUNITY INFLAMMATION AND DISEASE 2020; 8:371-379. [PMID: 32506796 PMCID: PMC7416033 DOI: 10.1002/iid3.318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/11/2020] [Accepted: 05/21/2020] [Indexed: 01/08/2023]
Abstract
Background β‐Lactam allergy is over‐reported and this leads to greater healthcare costs. Allergy testing has inherent risks, yet patients who test negative may continue avoiding β‐lactams. Objective To evaluate the safety and diagnostic value of β‐lactams allergy testing locally and usage of antibiotics following negative testing. Methods We performed a retrospective medical record review and follow‐up survey of patients who underwent β‐lactam testing between 2010 and 2016 at the National Skin Centre, Singapore. Results We reviewed the records of 166 patients, with a total of 173 β‐lactam allergy labels. Eighty (46.2%) labels were to penicillin, 75 (43.1%) to amoxicillin/amoxicillin‐clavulanic acid, 11 (6.4%) to cephalexin, and 5 (2.9%) to others. Skin tests were performed in 142 patients and drug provocation tests (DPTs) in 141 patients. Eleven (6.6%) patients defaulted DPTs after skin testing. Out of 166 patients, 22 (13.3%) patients were proven allergic by either skin tests (16) or DPTs (6). Patients who tested positive had nonsevere reactions. Out of 155 patients who were conclusively evaluated, 133 (85.8%) were not allergic. Of these patients, 30 (22.6%) used the tested β‐lactam subsequently, with one reporting a mild reaction. Fifty‐one (38.3%) patients were uncontactable or uncertain if they consumed a β‐lactam since testing negative. Fifty‐two (39.1%) patients had no re‐exposure (35 had no indication, 17 were fearful of reactions). Conclusion Drug allergy testing was safe and removed inappropriate labels. Clinical Implication Allergy testing is efficacious, but fears of subsequent rechallenge should be addressed to maximize the effectiveness of allergy delabeling.
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9
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Voelker D, Pitlick M, Gonzalez-Estrada A, Park M. Minor Determinants of Penicillin and Amoxicillin Are Still Key Components of Penicillin Skin Testing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1980-1986.e7. [PMID: 32006722 DOI: 10.1016/j.jaip.2020.01.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 01/17/2020] [Accepted: 01/17/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND The positive rate and pattern of penicillin skin test (PST) has been reported to be decreasing and changing. Previous studies differ about which penicillin component is the dominant component in positive PST result. OBJECTIVE To characterize past and current PST patterns to determine whether different determinants in PST have changed over time. METHODS A retrospective review of electronic medical records (January 2001-December 2017) was performed for patients who underwent PST. Data were divided into 4 cohorts to see whether trends occurred over time. The cohorts were divided as follows: cohort 1 (2001-2005), cohort 2 (2006-2010), cohort 3 (2011-2015), and cohort 4 (2016-2017). RESULTS A total of 30,883 patients underwent PST with the following breakdowns per cohort: cohort 1, 6,536; cohort 2, 10,372; cohort 3, 10,640; and cohort 4, 3,335. Of these, 329 patients (1.0%) had a positive PST result with a wheal of 3 × 3 mm or greater, with 110 in cohort 1, 130 in cohort 2, 67 in cohort 3, and 22 in cohort 4, whereas 170 patients (0.5%) had a positive PST result with a wheal of 5 × 5 mm or greater, with 54 in cohort 1, 72 in cohort 2, 34 in cohort 3, and 10 in cohort 4. When the positive PST rates of cohort 2 (1.25%), cohort 3 (0.6%), and cohort 4 (0.6%) were compared with those of cohort 1 (1.7%), there was a significant decrease in positive PST rates (P = .0278; P < .0001; P < .0001, respectively). When cohort 1 positive rate to benzylpenicillin polylysine among the positive PST (wheal of 3 × 3 mm or greater) was compared with those of the other cohorts (cohorts 2-4), the percent positive of benzylpenicillin polylysine in PST was 27% compared with 21% (P = .38), 34% (P = .5), and 18% (P = .6), respectively. When the positive PST result was defined as a wheal of 5 × 5 mm or greater, the positive rate for benzylpenicillin polylysine in PST increased over time (cohort 2: 22%, P = .8; cohort 3: 32%, P = .3; cohort 4: 40%, P = .264) compared with cohort 1 (19%). CONCLUSIONS Positive PST rate is decreasing. We demonstrate that despite benzylpenicillin polylysine solely positive rates remaining relatively stable, the minor penicillin determinants and amoxicillin play an important role in PST and their adoption into standard protocol for routine PST should be considered.
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Affiliation(s)
- Dayne Voelker
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic, Rochester, Minn
| | - Mitchell Pitlick
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic, Rochester, Minn
| | - Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn.
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10
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Cook E, Ramirez M, Turrentine M. Time Has Come for Routine Penicillin Allergy Testing in Obstetrics. AJP Rep 2020; 10:e15-e19. [PMID: 32025345 PMCID: PMC7000251 DOI: 10.1055/s-0039-3401801] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/15/2019] [Indexed: 01/17/2023] Open
Abstract
Objective This study evaluates penicillin allergy during pregnancy to estimate the proportion that could benefit from penicillin allergy testing. Study Design Retrospective cohort study of women with penicillin allergy that delivered from January 1, 2018 to December 31, 2018. Results Among 6,321 deliveries, 446 (7%) were identified with penicillin allergy. Nine percent (41/446) had no documentation of allergy severity. Allergies associated with intolerance, low, moderate, or high risk of anaphylaxis were reported in 6% (25/446), 40% (177/446), 32% (142/446), and 14% (61/446), respectively. Nearly 74% (330/446) received an antibiotic either antepartum, at delivery, or within 6 weeks of postpartum. The majority of women, 81% (360/446) (i.e., undocumented reactions, low, or moderate risk of anaphylaxis) would have been eligible for penicillin allergy testing. Greater appropriate utilization of antibiotics occurred in women with a high 80% (39/49) or moderate risk of anaphylaxis 70% (79/112) versus low risk of anaphylaxis 55% (64/117), history of intolerance 40% (8/20), or undocumented reaction 19% (6/32), p ≤ 0.01. Conclusion Most women who report a penicillin allergy during pregnancy would be candidates for penicillin allergy testing. With the high rate of antibiotic interventions in pregnant women who report a penicillin allergy, consideration should be given for penicillin allergy assessment.
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Affiliation(s)
- Elizabeth Cook
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Mildred Ramirez
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Mark Turrentine
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
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11
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Perioperative Management of the Penicillin-Allergic Patient. J Perianesth Nurs 2019; 34:1284-1288. [PMID: 31611035 DOI: 10.1016/j.jopan.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 08/09/2019] [Indexed: 11/24/2022]
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12
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Kuriakose JP, Vu J, Karmakar M, Nagel J, Uppal S, Hendren S, Englesbe MJ, Ravikumar R, Campbell DA, Krapohl GL. β-Lactam vs Non-β-Lactam Antibiotics and Surgical Site Infection in Colectomy Patients. J Am Coll Surg 2019; 229:487-496.e2. [PMID: 31377412 DOI: 10.1016/j.jamcollsurg.2019.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 07/17/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) represent a significant preventable source of morbidity, mortality, and cost. Prophylactic antibiotics have been shown to decrease SSI rates, and β-lactam antibiotics are recommended by national guidelines. It is currently unclear whether recommended β-lactam and recommended non-β-lactam antibiotic regimens are equivalent with respect to SSI risk reduction in colectomy patients. STUDY DESIGN We conducted a retrospective cohort study of SSI rates between prophylactic intravenously administered recommended β-lactam and non-β-lactam in colectomy patients (25 CPT codes) collected by the Michigan Surgical Quality Collaborative from January 2013 to February 2018. Surgical site infection rates were compared as a dichotomous variable (no SSI vs SSI). Mixed-effects regression was used to compare the association between receiving a β-lactam or non-β-lactam antibiotic and likelihood of having an SSI. RESULTS Of 9,949 patients, 9,411 (94.6%) received β-lactam antibiotics and 538 (5.4%) received non-β-lactam antibiotics. Overall, there were 622 (6.3%) patients with SSIs. Of the patients receiving β-lactam antibiotics, SSIs developed in 571 (6.1%) compared with 51 (9.5%) patients in the non-β-lactam group. After applying mixed-effects logistic regression, prophylactic treatment with a non-β-lactam regimen was associated with significantly higher odds of surgical site infection (odds ratio 1.65; 95% CI 1.20 to 2.26; p < 0.01). CONCLUSIONS Colectomy patients receiving β-lactam antibiotics had a lower likelihood of SSI compared with those receiving non-β-lactam antibiotics, even when antibiotics were compliant with national recommendations. Our findings suggest that surgeons should prescribe β-lactam antibiotics for prophylaxis whenever possible, reserving alternatives for those rare patients with true allergies or clinical indications for non-β-lactam antibiotic prophylaxis.
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Affiliation(s)
- Jonathan P Kuriakose
- Michigan Surgical Quality Collaborative, Ann Arbor, MI; Department of Chemistry, University of Michigan, Ann Arbor, MI
| | - Joceline Vu
- Michigan Surgical Quality Collaborative, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Monita Karmakar
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jerod Nagel
- Department of Pharmacy, University of Michigan, Ann Arbor, MI
| | - Shitanshu Uppal
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | | | - Michael J Englesbe
- Michigan Surgical Quality Collaborative, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Raj Ravikumar
- Department of Allergy and Immunology, University of Michigan, Ann Arbor, MI
| | - Darrell A Campbell
- Michigan Surgical Quality Collaborative, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Greta L Krapohl
- Michigan Surgical Quality Collaborative, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI.
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13
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Torres MJ, Moreno E, Fernandez-Santamaría R, Doña I, Fernandez TD. Diagnostic Approximation to Delabeling Beta-Lactam Allergic Patients. CURRENT TREATMENT OPTIONS IN ALLERGY 2019. [DOI: 10.1007/s40521-019-0202-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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14
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Eser Simsek I, Tuba Cogurlu M, Aydogan M. Suspected Reaction with Cephalosporin May Be a Predictive Factor for β-Lactam Allergy in Children. Int Arch Allergy Immunol 2018; 178:248-254. [PMID: 30517941 DOI: 10.1159/000494506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/12/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Most children diagnosed with β-lactam allergy based only on history are not truly allergic, and mislabeling leads to use of less effective and more costly alternative broader-spectrum antibiotics, significantly increasing drug resistance. OBJECTIVE To determine the frequency and risk factors of confirmed allergy in patients with β-lactam allergy reported by parents or their doctors and evaluate cross-reactivity between β-lactams in children with confirmed allergy. METHOD Sixty-seven children with suspected β-lactam allergy were evaluated via history, sIgE measurements, skin tests, and drug provocation tests over a period of 5 years. RESULTS β-Lactam allergy was confirmed in 10 (14.9%) patients. Six patients had a positive intradermal test result to one or more of the penicillin skin test materials or ceftriaxone, 4 patients with negative skin test results had positive test results with suspected drugs. Age, gender, time interval between evaluation and the initial reaction, personal history of atopy, parental history of drug allergy, reaction type, and multiple drug allergy history were not significantly different between allergic and tolerant patients. For culprit drugs, there was a significant different between the 2 groups; the rate of confirmed diagnosis was significantly higher for cephalosporins such as ceftriaxone, cefuroxime, and cefprozil (p = 0.03). Three patients with allergy to penicillin tolerated cefuroxime; in 4 patients with selective allergy to ceftriaxone tolerated cephalosporins with a dissimilar side chain (cefadroxil, cefuroxime, cefaclor, and cefdinir). CONCLUSION Our study indicates that most patients with a suspected β-lactam allergy tolerated this drug. An appropriate diagnostic allergy workup may prevent the use of less effective and more expensive alternatives.
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Affiliation(s)
- Isil Eser Simsek
- Division of Pediatric Allergy and Immunology, Kocaeli University School of Medicine, Kocaeli, Turkey,
| | - Mujde Tuba Cogurlu
- Division of Pediatric Allergy and Immunology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Metin Aydogan
- Division of Pediatric Allergy and Immunology, Kocaeli University School of Medicine, Kocaeli, Turkey
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15
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Sacco KA, Cochran BP, Epps K, Parkulo M, Gonzalez-Estrada A. Inpatient β-lactam test-dose protocol and antimicrobial stewardship in patients with a history of penicillin allergy. Ann Allergy Asthma Immunol 2018; 122:184-188. [PMID: 30465860 DOI: 10.1016/j.anai.2018.11.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 10/17/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Penicillin allergy is the most commonly reported drug allergy in hospitalized patients, resulting in increased second-line antibiotic use, nosocomial infections, and health care use. Given that most patients are not truly allergic, a safe strategy that empowers the admitting physician is needed. OBJECTIVE To assess the effect on antibiotic prescribing practices for hospitalized patients with penicillin allergy using a validated intervention. METHODS An intervention was implemented to educate health care professionals on management of patients with penicillin allergy using a validated risk stratification algorithm to guide testing and antibiotic use. Thirty days of control data using current standard of care was compared with 60 days of postintervention data measuring documentation of penicillin allergy history and antibiotic selection. RESULTS The relative use of cephalosporin and penicillin antibiotics increased by 121.2% (P = .03) and 256% (P = .04), respectively, without an increase in adverse drug reactions. There was a decrease in the use of broad-spectrum antibiotics: vancomycin, 67.2% (P = .04); quinolones, 33.3% (P = .31); carbapenems, 81.9% (P = .08); and aztreonam, 73.8% (P = .18). CONCLUSION The antibiotic choice in patients admitted to the hospital with a reported penicillin allergy can be improved by better evaluation of the allergy history and the use of a risk stratification guideline.
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Affiliation(s)
- Keith A Sacco
- Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Kevin Epps
- Department of Pharmacy, Mayo Clinic, Jacksonville, Florida
| | - Mark Parkulo
- Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Florida.
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16
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Kronman MP, Banerjee R, Duchon J, Gerber JS, Green MD, Hersh AL, Hyun D, Maples H, Nash CB, Parker S, Patel SJ, Saiman L, Tamma PD, Newland JG. Expanding Existing Antimicrobial Stewardship Programs in Pediatrics: What Comes Next. J Pediatric Infect Dis Soc 2018; 7:241-248. [PMID: 29267871 PMCID: PMC7107461 DOI: 10.1093/jpids/pix104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/08/2017] [Indexed: 02/06/2023]
Abstract
The prevalence of pediatric antimicrobial stewardship programs (ASPs) is increasing in acute care facilities across the United States. Over the past several years, the evidence base used to inform effective stewardship practices has expanded, and regulatory interest in stewardship programs has increased. Here, we review approaches for established, hospital-based pediatric ASPs to adapt and report standardized metrics, broaden their reach to specialized populations, expand to undertake novel stewardship initiatives, and implement rapid diagnostics to continue their evolution in improving antimicrobial use and patient outcomes.
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Affiliation(s)
- Matthew P Kronman
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Ritu Banerjee
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - Jennifer Duchon
- Division of Infectious Diseases, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael D Green
- Division of Infectious Diseases, Department of Pediatrics, University of Pittsburgh, Pennsylvania
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | - Holly Maples
- Department of Pharmacy, University of Arkansas, Little Rock, Arkansas
| | - Colleen B Nash
- Division of Infectious Diseases, Department of Pediatrics, University of Chicago, Illinois
| | - Sarah Parker
- Division of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Sameer J Patel
- Division of Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lisa Saiman
- Division of Infectious Diseases, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Pranita D Tamma
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jason G Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University, St. Louis, Missouri
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Abstract
Anaphylaxis is a severe systemic reaction that can be managed appropriately with expedient diagnosis and treatment. Intramuscular epinephrine continues to be the mainstay of treatment of anaphylaxis; however, it is still underused in the community and in the medical setting. Further education and counseling of patients and health care providers is required to prevent and manage anaphylaxis successfully. In-office management of anaphylaxis includes training of staff, preparedness with the necessary supplies and medication, and an effective action plan.
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Affiliation(s)
- Stella E Lee
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Mercy Hospital, 1400 Locust Street, Building B, Suite 11500, Pittsburgh, PA 15219, USA.
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18
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Jimenez-Rodriguez TW, Garcia-Neuer M, Alenazy LA, Castells M. Anaphylaxis in the 21st century: phenotypes, endotypes, and biomarkers. J Asthma Allergy 2018; 11:121-142. [PMID: 29950872 PMCID: PMC6016596 DOI: 10.2147/jaa.s159411] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Anaphylaxis is the most serious of all allergic reactions and can be fatal. The diagnosis is frequently delayed, and misdiagnosis often occurs with asthma or urticaria. Biomarkers such as tryptase are not routinely checked, and appropriate treatment with epinephrine is not administered in a majority of cases, increasing the risk of poor outcomes. The objective of this review is to provide a better understanding of the pathophysiology of anaphylaxis with a description of phenotypes, endotypes, and biomarkers available in both the clinical and research settings. Expanding knowledge with regard to the presentation, causes, and triggers for anaphylaxis among health care providers will improve its diagnosis and management, increase patient safety, and decrease morbidity and mortality.
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Affiliation(s)
- Teodorikez Wilfox Jimenez-Rodriguez
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Allergy Section, Alicante General University Hospital, Alicante, Spain
- PhD Program in Public Health, Medical and Surgical Sciences, Miguel Hernandez University, Alicante, Spain
| | - Marlene Garcia-Neuer
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Leila A Alenazy
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mariana Castells
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Torda A, Chan V. Antibiotic allergy labels-the impact of taking a clinical history. Int J Clin Pract 2018; 72:e13058. [PMID: 29341373 DOI: 10.1111/ijcp.13058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 12/20/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Many patients admitted to hospital have an antibiotic allergy (AAL) documented in their medical record. In many of these, the reaction is not a hypersensitivity reaction or may no longer be relevant. Despite this, the label adversely affects patient care directly in terms of antibiotic selection, and indirectly in terms of patient costs and the development of antimicrobial resistance. AIMS To estimate the prevalence of AALs in a cohort of hospitalised patients, to investigate the feasibility of de-labelling through re-challenge based solely upon clinical grounds. DESIGN This is a cross-sectional study conducted over a 6-month period on adult inpatients. An allergy history was taken from each patient and compared with medical record data regarding allergy. Antibiotic selection data were collected (if relevant). It was then determined whether immediate de-labelling was appropriate, if direct provocation test (DPT) could be relatively safely performed, and if antibiotic selection was appropriate. RESULTS Three thousand eight hundred and fifty five patients were screened, 553 (14.35%) had an AAL, and 352 were interviewed. There were 426 AALs; 276 (64.8%) towards a penicillin. After taking a detailed clinical history of the type of reaction, approximately 20% could be immediately de-labelled and educated (non-allergic, non-severe reactions) and another 38% with either a definite or vague history of mild cutaneous reaction would be suitable for an attempt at clinical de-labelling DPT. CONCLUSIONS These simple measures to 'de-label' patients appropriately, would increase the quality of care of this group known to have higher costs, infection with more resistant bacteria and worse health outcomes that 'non-labelled' patients.
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Affiliation(s)
- Adrienne Torda
- Prince of Wales Clinical School, University of New South Wales, Randwick, NSW, Australia
- Prince of Wales Hospital, Randwick, NSW, Australia
| | - Victor Chan
- Prince of Wales Clinical School, University of New South Wales, Randwick, NSW, Australia
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20
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Blumenthal KG, Shenoy ES, Wolfson AR, Berkowitz DN, Carballo VA, Balekian DS, Marquis KA, Elshaboury R, Gandhi RG, Meka P, Kubiak DW, Catella J, Lambl BB, Hsu JT, Freeley MM, Gruszecki A, Wickner PG. Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:616-625.e7. [PMID: 28483315 DOI: 10.1016/j.jaip.2017.02.019] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/17/2017] [Accepted: 02/22/2017] [Indexed: 12/19/2022]
Abstract
Addressing inaccurate penicillin allergies is encouraged as part of antibiotic stewardship in the inpatient setting. However, implementing interventions targeted at the 10% to 15% of inpatients reporting a previous penicillin allergy can pose substantial logistic challenges. We implemented a computerized guideline for patients with reported beta-lactam allergy at 5 hospitals within a single health care system in the Boston area. In this article, we describe our implementation roadmap, including both successes achieved and challenges faced. We explain key implementation steps, including assembling a team, stakeholder engagement, developing or selecting an approach, spreading the change, establishing measures, and measuring impact. The objective was to detail the lessons learned while empowering others to be part of this important, multidisciplinary work to improve the care of patients with reported beta-lactam allergies.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and the Massachusetts General Professional Organization, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Erica S Shenoy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Infection Control Unit, Massachusetts General Hospital, Boston, Mass; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | | | | | - Diana S Balekian
- Allergy Unit, Department of Medicine, North Shore Medical Center, Salem, Mass; Asthma and Allergy Affiliates, Salem, Mass
| | - Kathleen A Marquis
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Ramy Elshaboury
- Department of Pharmacy, Massachusetts General Hospital, Boston, Mass
| | - Ronak G Gandhi
- Department of Pharmacy, Massachusetts General Hospital, Boston, Mass
| | - Praveen Meka
- Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Faulkner Hospital, Boston, Mass
| | - David W Kubiak
- Harvard Medical School, Boston, Mass; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Department of Pharmacy, Brigham and Women's Hospital, Boston, Mass
| | | | - Barbara B Lambl
- Division of Infectious Diseases, Department of Medicine, North Shore Medical Center, Salem, Mass
| | - Joyce T Hsu
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | | | - Alana Gruszecki
- Pharmacy Department, Brigham and Women's Faulkner Hospital, Boston, Mass
| | - Paige G Wickner
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
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21
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Pongdee T, Li JT. Evaluation and Management of Penicillin Allergy. Mayo Clin Proc 2018; 93:101-107. [PMID: 29304914 DOI: 10.1016/j.mayocp.2017.09.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 11/23/2022]
Abstract
Penicillin allergy is the most commonly reported drug allergy in the United States. Although penicillin allergy is widely reported, 80% to 90% of individuals with self-reported penicillin allergy are actually able to tolerate penicillins after undergoing evaluation for penicillin allergy. Because most patients with self-reported penicillin allergy will have subsequent negative allergy testing results and tolerate penicillins, they may be unnecessarily exposed to broader-spectrum antibiotics. Use of such antibiotics leads to increased risks of developing antibiotic-resistant microorganisms and incur higher health care utilization costs. In this article, we provide an overview of penicillin allergy and its clinical manifestations as well as an approach for the evaluation and management of penicillin allergy.
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Affiliation(s)
- Thanai Pongdee
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
| | - James T Li
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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22
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Faitelson Y, Boaz M, Dalal I. Asthma, Family History of Drug Allergy, and Age Predict Amoxicillin Allergy in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:1363-1367. [PMID: 29226807 DOI: 10.1016/j.jaip.2017.11.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 11/01/2017] [Accepted: 11/15/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Suspected adverse reactions to amoxicillin are common, but there are no known factors that can predict amoxicillin allergy in children. In addition, methods used for the diagnosis of amoxicillin allergy are not standardized and their role in diagnosis is not clear. OBJECTIVE To identify predictive factors and to assess the role of skin test in the diagnosis of amoxicillin allergy in children. METHODS Children with a history of immediate (excluding anaphylaxis) or nonimmediate reactions to amoxicillin were tested by skin prick test, followed by oral graded challenge with amoxicillin. Clinical characteristics of the reaction before and after the challenge were recorded, and data of personal and relatives' drug allergies and atopy were collected for statistical analysis. RESULTS Skin prick tests followed by an oral graded challenge with amoxicillin were performed on 133 children. The skin test result was not of clinical value because it was negative in all children. Three children (2%) had an immediate reaction and 7 children (5%) had a nonimmediate reaction. Asthma (odds ratio [OR], 0.12; 95% CI, 0.017-0.869; P = .03), family history of drug allergy (OR, 0.12; 95% CI, 0.026-0.613; P = .01), older age at reaction (OR, 0.837; 95% CI, 0.699-1; P = .05), and angioedema (OR, 0.22; 95% CI, 0.043-1.12; marginally significant at P = .069) were associated with reduced chance to pass the oral challenge. CONCLUSIONS Skin prick test did not contribute to the diagnosis of amoxicillin allergy. The presence of asthma, family history of drug allergy, and older age at reaction can be used as predictive factors for true amoxicillin allergy in children.
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Affiliation(s)
- Yoram Faitelson
- Allergy and Immunology Unit, Edit Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Mona Boaz
- Department of Nutrition Sciences, Ariel University, Ariel, Israel; Department of Epidemiology & Research Unit, Edit Wolfson Medical Center, Holon, Israel
| | - Ilan Dalal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Pediatrics, Edit Wolfson Medical Center, Holon, Israel
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23
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Soria A, Autegarden E, Amsler E, Gaouar H, Vial A, Francès C, Autegarden JE. A clinical decision-making algorithm for penicillin allergy. Ann Med 2017; 49:710-717. [PMID: 28844171 DOI: 10.1080/07853890.2017.1370125] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND About 10% of subjects report suspected penicillin allergy, but 85-90% of these patients are not truly allergic and could safely receive beta-lactam antibiotics Objective: To design and validate a clinical decision-making algorithm, based on anamnesis (chronology, severity, and duration of the suspected allergic reactions) and reaching a 100% sensitivity and negative predictive value, to assess allergy risk related to a penicillin prescription in general practise. STUDY DESIGN AND METHODS All patients were included prospectively and explorated based on ENDA/EAACI recommendations. Results of penicillin allergy work-up (gold standard) were compared with results of the algorithm. RESULTS Allergological work-up diagnosed penicillin hypersensitivity in 41/259 patients (15.8%) [95% CI: 11.5-20.3]. Three of these patients were diagnosed as having immediate-type hypersensitivity to penicillin, but had been misdiagnosed as low risk patients using the clinical algorithm. Thus, the sensitivity and negative predictive value of the algorithm were 92.7% [95% CI: 80.1-98.5] and 96.3% [95% CI: 89.6-99.2], respectively, and the probability that a patient with true penicillin allergy had been misclassified was 3.7% [95% CI: 0.8-10.4]. CONCLUSIONS Although the risk of misclassification is low, we cannot recommend the use of this algorithm in general practice. However, the algorithm can be useful in emergency situations in hospital settings. Key messages True penicillin allergy is considerably lower than alleged penicillin allergy (15.8%; 41 of the 259 patients with suspected penicillin allergy). A clinical algorithm based on the patient's clinical history of the supposed allergic event to penicillin misclassified 3/41 (3.7%) truly allergic patients.
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Affiliation(s)
- Angèle Soria
- a Department of Dermatology and Allergology , Tenon Hospital, APHP , Paris , France.,b Immunology and Infectious diseases Center - Paris (Cimi-Paris) , Sorbonne University , Paris , France.,c INSERM U1135, Cimi-Paris , Paris , France
| | - Elodie Autegarden
- a Department of Dermatology and Allergology , Tenon Hospital, APHP , Paris , France
| | - Emmanuelle Amsler
- a Department of Dermatology and Allergology , Tenon Hospital, APHP , Paris , France
| | - Hafida Gaouar
- a Department of Dermatology and Allergology , Tenon Hospital, APHP , Paris , France
| | - Amandine Vial
- a Department of Dermatology and Allergology , Tenon Hospital, APHP , Paris , France
| | - Camille Francès
- a Department of Dermatology and Allergology , Tenon Hospital, APHP , Paris , France
| | - Jean-Eric Autegarden
- a Department of Dermatology and Allergology , Tenon Hospital, APHP , Paris , France
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Are Cephalosporins Safe for Use in Penicillin Allergy without Prior Allergy Evaluation? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:82-89. [PMID: 28958745 DOI: 10.1016/j.jaip.2017.07.033] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 12/28/2022]
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25
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Castells M. Diagnosis and management of anaphylaxis in precision medicine. J Allergy Clin Immunol 2017; 140:321-333. [PMID: 28780940 DOI: 10.1016/j.jaci.2017.06.012] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 12/18/2022]
Abstract
Anaphylaxis is the most severe and frightening of the allergic reactions, placing patients at high risk and demanding prompt recognition and immediate management by health care providers. Yet because its symptoms imitate those of other diseases, such as asthma and urticaria, current data suggest that its diagnosis is often missed, with underuse of tryptase measurement; its treatment is delayed, with little use of epinephrine; and its underlying cause or causes are poorly investigated. Deaths from anaphylaxis are difficult to investigate because of miscoding. Surprisingly, patients treated with new and powerful chemotherapy agents and humanized mAbs present with nonclassical symptoms of anaphylaxis, and patients may present with unrecognized clonal mast cell disorders with KIT mutations may present as Hymenoptera-induced or idiopathic anaphylaxis. The goal of this review is to recognize the presentations of anaphylaxis with the description of its current phenotypes, to provide new insight and understanding of its mechanisms and causes through its endotypes, and to address its biomarkers for broad clinical use. Ultimately, the aim is to empower allergists and heath care providers with new tools that can help alleviate patients' symptoms, preventing and protecting them against anaphylaxis.
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Affiliation(s)
- Mariana Castells
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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26
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Sacco KA, Bates A, Brigham TJ, Imam JS, Burton MC. Clinical outcomes following inpatient penicillin allergy testing: A systematic review and meta-analysis. Allergy 2017; 72:1288-1296. [PMID: 28370003 DOI: 10.1111/all.13168] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND A documented penicillin allergy is associated with increased morbidity including length of hospital stay and an increased incidence of resistant infections attributed to use of broader-spectrum antibiotics. The aim of the systematic review was to identify whether inpatient penicillin allergy testing affected clinical outcomes during hospitalization. METHODS We performed an electronic search of Ovid MEDLINE/PubMed, Embase, Web of Science, Scopus, and the Cochrane Library over the past 20 years. Inpatients having a documented penicillin allergy that underwent penicillin allergy testing were included. RESULTS Twenty-four studies met eligibility criteria. Study sample size was between 24 and 252 patients in exclusively inpatient cohorts. Penicillin skin testing (PST) with or without oral amoxicillin challenge was the main intervention described (18 studies). The population-weighted mean for a negative PST was 95.1% [CI 93.8-96.1]. Inpatient penicillin allergy testing led to a change in antibiotic selection that was greater in the intensive care unit (77.97% [CI 72.0-83.1] vs 54.73% [CI 51.2-58.2], P<.01). An increased prescription of penicillin (range 9.9%-49%) and cephalosporin (range 10.7%-48%) antibiotics was reported. Vancomycin and fluoroquinolone use was decreased. Inpatient penicillin allergy testing was associated with decreased healthcare cost in four studies. CONCLUSIONS Inpatient penicillin allergy testing is safe and effective in ruling out penicillin allergy. The rate of negative tests is comparable to outpatient and perioperative data. Patients with a documented penicillin allergy who require penicillin should be tested during hospitalization given its benefit for individual patient outcomes and antibiotic stewardship.
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Affiliation(s)
- K. A. Sacco
- Department of Internal Medicine; Mayo Clinic; Jacksonville FL USA
| | - A. Bates
- Department of Internal Medicine; Mayo Clinic; Jacksonville FL USA
| | - T. J. Brigham
- Winn-Dixie Foundation Medical Library; Mayo Clinic; Jacksonville FL USA
| | - J. S. Imam
- Department of Internal Medicine; Mayo Clinic; Jacksonville FL USA
| | - M. C. Burton
- Department of Internal Medicine; Mayo Clinic; Jacksonville FL USA
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27
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Muraro A, Lemanske RF, Castells M, Torres MJ, Khan D, Simon HU, Bindslev-Jensen C, Burks W, Poulsen LK, Sampson HA, Worm M, Nadeau KC. Precision medicine in allergic disease-food allergy, drug allergy, and anaphylaxis-PRACTALL document of the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma and Immunology. Allergy 2017; 72:1006-1021. [PMID: 28122115 DOI: 10.1111/all.13132] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2017] [Indexed: 12/30/2022]
Abstract
This consensus document summarizes the current knowledge on the potential for precision medicine in food allergy, drug allergy, and anaphylaxis under the auspices of the PRACTALL collaboration platform. PRACTALL is a joint effort of the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma and Immunology, which aims to synchronize the European and American approaches to allergy care. Precision medicine is an emerging approach for disease treatment based on disease endotypes, which are phenotypic subclasses associated with specific mechanisms underlying the disease. Although significant progress has been made in defining endotypes for asthma, definitions of endotypes for food and drug allergy or for anaphylaxis lag behind. Progress has been made in discovery of biomarkers to guide a precision medicine approach to treatment of food and drug allergy, but further validation and quantification of these biomarkers are needed to allow their translation into practice in the clinical management of allergic disease.
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Affiliation(s)
- A. Muraro
- Food Allergy Referral Centre Veneto Region; Department of Women and Child Health; Padua General University Hospital; Padua Italy
| | - R. F. Lemanske
- Department of Pediatrics; University of Wisconsin School of Medicine and Public Health; Madison WI USA
| | - M. Castells
- Drug Hypersensitivity and Desensitization Center; Brigham & Women's Hospital; Harvard Medical School; Boston MA USA
| | - M. J. Torres
- Allergy Unit; Regional University Hospital of Malaga-IBIMA; UMA; Malaga Spain
| | - D. Khan
- Division of Allergy & Immunology; Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - H.-U. Simon
- Institute of Pharmacology; University of Bern; Bern Switzerland
| | - C. Bindslev-Jensen
- Department of Dermatology and Allergy Centre; Odense Research Center for Anaphylaxis (ORCA); Odense University Hospital; Odense Denmark
| | - W. Burks
- Department of Pediatrics; University of North Carolina; Chapel Hill NC USA
| | - L. K. Poulsen
- Allergy Clinic; Copenhagen University Hospital at Gentofte Hospital; Copenhagen Denmark
| | - H. A. Sampson
- Icahn School of Medicine at Mount Sinai; New York NY USA
| | - M. Worm
- Klinik für Dermatologie; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - K. C. Nadeau
- Department of Medicine; Stanford University School of Medicine; Stanford CA USA
- Sean N. Parker Center for Allergy and Asthma Research; Stanford University School of Medicine; Stanford CA USA
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de Las Vecillas Sánchez L, Alenazy LA, Garcia-Neuer M, Castells MC. Drug Hypersensitivity and Desensitizations: Mechanisms and New Approaches. Int J Mol Sci 2017; 18:E1316. [PMID: 28632196 PMCID: PMC5486137 DOI: 10.3390/ijms18061316] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/13/2017] [Accepted: 06/14/2017] [Indexed: 12/13/2022] Open
Abstract
Drug hypersensitivity reactions (HSRs) are increasing in the 21st Century with the ever expanding availability of new therapeutic agents. Patients with cancer, chronic inflammatory diseases, cystic fibrosis, or diabetes can become allergic to their first line therapy after repeated exposures or through cross reactivity with environmental allergens. Avoidance of the offending allergenic drug may impact disease management, quality of life, and life expectancy. Precision medicine provides new tools for the understanding and management of hypersensitivity reactions (HSRs), as well as a personalized treatment approach for IgE (Immunoglobuline E) and non-IgE mediated HSRs with drug desensitization (DS). DS induces a temporary hyporesponsive state by incremental escalation of sub-optimal doses of the offending drug. In vitro models have shown evidence that IgE desensitization is an antigen-specific process which blocks calcium flux, impacts antigen/IgE/FcεRI complex internalization and prevents the acute and late phase reactions as well as mast cell mediator release. Through a "bench to bedside" approach, in vitro desensitization models help elucidate the molecular pathways involved in DS, providing new insights to improved desensitization protocols for all patients. The aim of this review is to summarize up to date information on the drug HSRs, the IgE mediated mechanisms of desensitization, and their clinical applications.
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Affiliation(s)
- Leticia de Las Vecillas Sánchez
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
- Department of Allergy, Marqués de Valdecilla University Hospital-IDIVAL, 39011 Santander, Spain.
| | - Leila A Alenazy
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
- Department of Medicine, College of Medicine, King Saud University, Riyadh 12372, Saudi Arabia.
- Master of Medical Sciences in Immunology Program, Harvard Medical School, Boston, MA 02115, USA.
| | - Marlene Garcia-Neuer
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Mariana C Castells
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Cildag S, Senturk T, Sargin G. The effects of distraction on symptoms during drug provocation test. Med Pharm Rep 2017; 90:18-21. [PMID: 28246492 PMCID: PMC5305082 DOI: 10.15386/cjmed-688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/27/2016] [Accepted: 06/29/2016] [Indexed: 11/27/2022] Open
Abstract
Background Some patients may have psychosomatic complaints due to their previous experiences during the drug hypersensitivity reaction. Worry about being hurt due to an administered drug is termed nocebo effect, which is the opposite of the placebo effect. In our study, we investigated the effect of distraction on symptoms during drug provocation test. Methods Our study included 112 patients who underwent DPTs for alternative purposes in our clinic. Previous hypersensitivity reactions of all the patients had objective signs. Patients were divided into two groups for the DPT. Sixty-three patients were kept busy during the test, performing tasks such as filling questionnaires, arranging files in alphabetical and numerical order, and doing archiving (Group 1). Forty-nine patients did not perform any tasks during the test (Group 2). Reactions that occurred during the test were recorded. Results During the DPT, 5 patients in Group 1 (5/63, 7.9%) and 17 patients in Group 2 (17/49, 34.7%), i.e. a total of 22 patients (22/112, 19.6%), had a reaction. There was a statistically significant difference between Group 1 and Group 2 according to the frequency of the reaction development. Conclusions Patient psychosomatic complaints during DPTs are proportional to their association with previous allergic reactions. In order to prevent such reactions, it may be beneficial to keep the patients busy with an activity in order to distract them during the test.
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Affiliation(s)
- Songul Cildag
- Adnan Menderes University Hospital, Department of Immunology - Allergy, Aydin, Turkey
| | - Taskin Senturk
- Adnan Menderes University Hospital, Department of Immunology - Allergy, Aydin, Turkey
| | - Gokhan Sargin
- Adnan Menderes University Hospital, Department of Immunology - Allergy, Aydin, Turkey
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Narayanan PP, Jeffres MN. Feasibility, Benefits, and Limitations of a Penicillin Allergy Skin Testing Service. Ann Pharmacother 2017; 51:504-510. [PMID: 28152605 DOI: 10.1177/1060028017690854] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To critically examine the feasibility, benefits, and limitations of an inpatient penicillin skin testing service and how pharmacists can be utilized. DATA SOURCES A PubMed search was performed from July 2016 through September 2016 using the following search terms: penicillin skin testing, penicillin allergy, β-lactam allergy. Additional references were identified from a review of literature citations. STUDY SELECTION AND DATA EXTRACTION All English-language studies assessing the use of penicillin skin testing as well as management and clinical outcomes of patients with a β-lactam allergy were evaluated. DATA SYNTHESIS The prevalence of people self-identifying as penicillin allergic ranges from 10% to 20% in the United States. Being improperly labeled as penicillin allergic is associated with higher health care costs, worse clinical outcomes, and an increased prevalence of multidrug-resistant infections. Penicillin skin testing can be a tool used to clarify penicillin allergies and has been demonstrated to be a successful addition to antimicrobial stewardship programs in multiple health care settings. Prior to implementing a penicillin skin testing service, institutions will need to perform a feasibility analysis of who will supply labor and accept the financial burden as well as identify if the positive benefits of a penicillin skin testing service overcome the limitations of this diagnostic test. CONCLUSION We conclude that institutions with high percentages of patients receiving non-β-lactams because of penicillin allergy labels would likely benefit the most from a penicillin skin testing service.
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Affiliation(s)
| | - Meghan N Jeffres
- 2 University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Evaluation of a Computerized Decision Support Intervention to Decrease Use of Anti-Pseudomonal Carbapenems in Penicillin Allergic Patients. Antibiotics (Basel) 2016; 5:antibiotics5010007. [PMID: 27025522 PMCID: PMC4810409 DOI: 10.3390/antibiotics5010007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/31/2015] [Accepted: 01/08/2016] [Indexed: 12/01/2022] Open
Abstract
Allergies to β-lactam antibiotics are commonly documented in hospitalized patients; however, true allergy is uncommon. Cross-reactivity rates for advanced generation cephalosporins and carbapenems are low; particularly for patients without a history of symptoms consistent with type 1 hypersensitivity. We observed that providers preferentially prescribed antipseudomonal carbapenems (APC) over advanced generation cephalosporins for patients with β-lactam allergy history, including those with low risk for antimicrobial-resistant infections. Information was inserted into the computerized decision support system (CDSS) to aid clinicians in assessing β-lactam cross-reactivity risk and selecting appropriate therapy. A retrospective evaluation was conducted in a small hospital to assess the impact of the CDSS changes in APC prescribing. Inpatients (n = 68) who received at least one APC dose during hospitalization over a 13 month pre-intervention period were compared to inpatients who received an APC during the 15 month post-intervention period (n = 59) for documented APC indications and β-lactam allergy history. APC initiations were measured and corrected per 1000 patient-days; interrupted time-series analysis was performed to assess changes in use before and after implementation. Aggregate monthly APC initiations decreased from 7.01 to 6.14 per 1000 patient-days after the implementation (p = 0.03). Post-intervention APC initiations for patients with low-risk β-lactam histories decreased from 92% to 83% (p = 0.17). No adverse events were observed in patients with low-risk β-lactam histories. The intervention was associated with a reduction in APC initiations.
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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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Blumenthal KG, Parker RA, Shenoy ES, Walensky RP. Improving Clinical Outcomes in Patients With Methicillin-Sensitive Staphylococcus aureus Bacteremia and Reported Penicillin Allergy. Clin Infect Dis 2015; 61:741-9. [PMID: 25991471 DOI: 10.1093/cid/civ394] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/09/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia is a morbid infection. First-line MSSA therapies (nafcillin, oxacillin, cefazolin) are generally avoided in the 10% of patients reporting penicillin (PCN) allergy, but most of these patients are not truly allergic. We used a decision tree with sensitivity analyses to determine the optimal evaluation and treatment for patients with MSSA bacteremia and reported PCN allergy. METHODS Our model simulates 3 strategies: (1) no allergy evaluation, give vancomycin (Vanc); (2) allergy history-guided treatment: if history excludes anaphylactic features, give cefazolin (Hx-Cefaz); and (3) complete allergy evaluation with history-appropriate PCN skin testing: if skin test negative, give cefazolin (ST-Cefaz). Model outcomes included 12-week MSSA cure, recurrence, and death; allergic reactions including major, minor, and potentially iatrogenic; and adverse drug reactions. RESULTS Vanc results in the fewest patients achieving MSSA cure and the highest rate of recurrence (67.3%/14.8% vs 83.4%/9.3% for Hx-Cefaz and 84.5%/8.9% for ST-Cefaz) as well as the greatest frequency of allergic reactions (3.0% vs 2.4% for Hx-Cefaz and 1.7% for ST-Cefaz) and highest rates of adverse drug reactions (5.2% vs 4.6% for Hx-Cefaz and 4.7% for ST-Cefaz). Even in a "best case for Vanc" scenario, Vanc yields the poorest outcomes. ST-Cefaz is preferred to Hx-Cefaz although sensitive to input variations. CONCLUSIONS Patients with MSSA bacteremia and a reported PCN allergy should have the allergy addressed for optimal treatment. Full allergy evaluation with skin testing seems to be preferred, although more data are needed.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine Medical Practice Evaluation Center, Massachusetts General Hospital Harvard Medical School
| | - Robert A Parker
- Medical Practice Evaluation Center, Massachusetts General Hospital Harvard Medical School Biostatistics Center, Department of Medicine, Massachusetts General Hospital, Boston
| | - Erica S Shenoy
- Medical Practice Evaluation Center, Massachusetts General Hospital Harvard Medical School Infection Control Unit Division of Infectious Disease, Department of Medicine
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital Harvard Medical School Division of Infectious Disease, Department of Medicine
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Wolanin SA, Demain JG, Meier EA. Successful desensitization of a patient with aplastic anemia to antithymocyte globulin. ALLERGY & RHINOLOGY (PROVIDENCE, R.I.) 2015; 6:64-7. [PMID: 25730287 PMCID: PMC4388879 DOI: 10.2500/ar.2015.6.0110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Antithymocyte globulin (ATG) is a polyclonal gamma immunoglobulin derived from either rabbit or equine serum that serves as therapy for aplastic anemia; however, ATG causes serum sickness in up to 70% and anaphylaxis in up to 5% of recipients. Intradermal (ID) skin testing has been the primary technique used to evaluate for a preexisting Gell and Coombs type I hypersensitivity reaction to ATG. There are no data reporting the predictive value of delayed reactions to ID testing on the risk of serum sickness. This study was designed to establish the importance of epicutaneous and ID skin testing before the administration of ATG through a case report and literature discussion. We report a patient with severe aplastic anemia that was successfully desensitized to ATG after a negative epicutaneous skin test and positive ID skin test. The patient had neither systemic nor localized reactions during the desensitization. Desensitization to ATG in patients with positive epicutaneous skin testing has been shown to be associated with serious and potentially life-threatening complications and should only be considered when the benefits outweigh the risks. Epicutaneous skin testing should be considered in conjunction with ID skin testing when screening for potential sensitivity to ATG. Because of the serious risk of anaphylaxis, desensitization should be performed in an intensive care unit setting in conjunction with a physician familiar with drug desensitization and the management of anaphylaxis.
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Affiliation(s)
| | - Jeffrey G. Demain
- Department of Pediatrics, University of Washington, Seattle, Washington, and
| | - Eric A. Meier
- Allergy Asthma and Immunology Center of Alaska, Anchorage, Alaska
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Kula B, Djordjevic G, Robinson JL. A systematic review: can one prescribe carbapenems to patients with IgE-mediated allergy to penicillins or cephalosporins? Clin Infect Dis 2014; 59:1113-22. [PMID: 25048853 DOI: 10.1093/cid/ciu587] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cross-reactivity between penicillins or cephalosporins and carbapenems is anticipated as all have a beta lactam ring. However, the true incidence of immunoglobulin (Ig)E-mediated cross-reactivity is not known. METHODS A systematic review was conducted to collect and combine all published data on children and adults reported to have a clinical history of IgE-mediated hypersensitivity to a penicillin and/or cephalosporin who were subsequently given a carbapenem. Reactions were classified as proven, suspected, or possible IgE-mediated and non-IgE-mediated. RESULTS Ten studies and 12 case reports describing 854 participants fit the study criteria. For patients with previous proven, suspected, or possible IgE-mediated penicillin reactions (N = 838), the incidence of any type of suspected hypersensitivity reaction to a carbapenem was 36/838 (4.3%; 95% confidence interval [CI], 3.1%-5.9%) and the incidence of proven (1/838), suspected (0/838), or possible (19/838) IgE-mediated reactions was 20/838 (2.4%; 95% CI, 1.6%-3.7%). Of the subset of patients with positive penicillin skin tests (n = 295), only 1 had a hypersensitivity reaction (0.3%; 95% CI, .06%-1.9%), and this was a possible IgE-mediated reaction. For patients with previous proven, suspected, or possible IgE-mediated cephalosporin reactions (N = 12), the incidence of any type of hypersensitivity reaction to a carbapenem was 3/12 (25%); this included 2 non-IgE-mediated reactions and 1 possible IgE-mediated reaction. CONCLUSIONS The cross-reactivity between penicillins and carbapenems for IgE-mediated reactions is very low, but caution is still advised. Cross-reactivity rates may be higher between cephalosporins and carbapenems; however, minimal data are available.
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Affiliation(s)
- Brittany Kula
- Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Canada
| | - Gordana Djordjevic
- Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Canada
| | - Joan L Robinson
- Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Canada
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Picard M, Paradis L, Bégin P, Paradis J, Des Roches A. Skin testing only with penicillin G in children with a history of penicillin allergy. Ann Allergy Asthma Immunol 2014; 113:75-81. [PMID: 24856884 DOI: 10.1016/j.anai.2014.04.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 04/15/2014] [Accepted: 04/25/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND The absence of commercially available penicilloyl-polylysine (PPL) for most of the last decade severely hampered the practice of penicillin allergy evaluation because skin testing without PPL is reported to have a poor negative predictive value (NPV). OBJECTIVE To determine the safety and NPV of skin testing without PPL using only penicillin G followed by a 3-dose graded challenge to the incriminated penicillin in children with a history of penicillin allergy. METHODS Patients evaluated for a history of penicillin allergy at the CHU Sainte-Justine Allergy Clinic between December 2006 and December 2009 were skin tested only with penicillin G and underwent a 3-dose graded challenge to the culprit penicillin if the skin test result was negative. RESULTS Among 563 patients skin tested to penicillin G, 185 (33%) had a positive skin test result. These patients had a shorter interval between the initial reaction and skin testing compared with patients with a negative skin test result (P = .03). A total of 375 of 378 patients (99%) with a negative skin test result were challenged and 18 (4.8%) reacted, translating into a NPV of 95.2% (95% confidence interval [CI], 92.5%-97.1%). Three of 17 patients with a history of anaphylaxis and a negative skin test result reacted to challenge (NPV, 82.4%; 95% CI, 59.0-93.8%). All challenge reactions were mild and resolved promptly with treatment. CONCLUSION Among children with a history of penicillin allergy, skin testing only with penicillin G followed by a 3-dose graded challenge to the incriminated penicillin is safe and yields a good NPV. This approach could be useful when PPL is unavailable.
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Affiliation(s)
- Matthieu Picard
- Division of Allergy, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Louis Paradis
- Division of Allergy, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Philippe Bégin
- Division of Allergy, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Jean Paradis
- Division of Allergy, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Anne Des Roches
- Division of Allergy, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada.
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Arunvikram K, Mohanty I, Sardar KK, Palai S, Sahoo G, Patra RC. Adverse drug reaction and toxicity caused by commonly used antimicrobials in canine practice. Vet World 2014. [DOI: 10.14202/vetworld.2014.299-305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Sartori-Valinotti JC, Kloesel B, Park MA. 76-year-old woman with pruritus [corrected] and lip swelling. Mayo Clin Proc 2013; 88:e79-84. [PMID: 23910421 DOI: 10.1016/j.mayocp.2012.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 11/15/2012] [Accepted: 11/19/2012] [Indexed: 11/15/2022]
Affiliation(s)
- Julio C Sartori-Valinotti
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
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Unger NR, Gauthier TP, Cheung LW. Penicillin Skin Testing: Potential Implications for Antimicrobial Stewardship. Pharmacotherapy 2013; 33:856-67. [DOI: 10.1002/phar.1288] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Nathan R. Unger
- Department of Pharmacy Practice; Nova Southeastern University College of Pharmacy; Palm Beach Gardens Florida
| | - Timothy P. Gauthier
- Department of Pharmacy Practice; Nova Southeastern University College of Pharmacy; Fort Lauderdale Florida
| | - Linda W. Cheung
- Pharmacy Service, James A. Haley Veterans' Hospital; Tampa Florida
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Erkoçoğlu M, Kaya A, Civelek E, Ozcan C, Cakır B, Akan A, Toyran M, Ginis T, Kocabas CN. Prevalence of confirmed immediate type drug hypersensitivity reactions among school children. Pediatr Allergy Immunol 2013; 24:160-7. [PMID: 23373964 DOI: 10.1111/pai.12047] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite drug-related hypersensitivity reactions are an important health problem, epidemiologic data on drug allergy and hypersensitivity are limited, and studies including diagnostic work-up are scarce. The aim of this study was to determine the actual frequency of immediate type drug hypersensitivity using diagnostic tests in school children with parent-reported drug allergies. METHODS This study involved three phases. The first phase is a survey of children with a mean age of 12.9 yrs attending grades 6-8 of primary schools with a questionnaire asking drug-related symptoms within 2 h of ingestion. The total population of sixth to eight grade school children was 210,000, and a sample size of 9096 was deemed to be representative of Ankara [(p) = 1.0%, α < 0.05, β = 0.8, (d) = 0.2.] During the second phase, a detailed clinical history was obtained by phone from the parents of children who had positive parent-reported drug allergy. The final stage of the study consisted of a detailed diagnostic work-up of children with a clinical history consistent with immediate type drug hypersensitivity reaction. RESULTS Overall, 11,233 questionnaires were distributed, 10,096 of which were retrieved after completion by parents. The rate of parent-reported immediate type drug hypersensitivity was 7.87% (792 children). However, phone survey revealed a clinical history suggestive of drug allergy in only 117 children (1.16%). After further diagnostic work-up, the true frequency of immediate type drug hypersensitivity was 0.11%. CONCLUSION Our results suggest that a positive clinical history is not enough to make a diagnosis of drug allergy, which highlights the significance of undertaking further diagnostic evaluation.
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Affiliation(s)
- Mustafa Erkoçoğlu
- Department of Pediatric Allergy and Immunology, Ankara Children's Hematology Oncology Education and Research Hospital, Ankara, Turkey
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Kao L, Rajan J, Roy L, Kavosh E, Khan DA. Adverse reactions during drug challenges: a single US institution's experience. Ann Allergy Asthma Immunol 2012; 110:86-91.e1. [PMID: 23352526 DOI: 10.1016/j.anai.2012.11.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 11/02/2012] [Accepted: 11/12/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Drug challenge is a useful tool when diagnostic testing lacks predictive value for a questionable history of drug allergy. Placebo-controlled drug challenge studies demonstrate that a significant number of patients report purely subjective symptoms to placebo. OBJECTIVE To evaluate the safety and rate of adverse effects when performing drug challenges and to identify predictive factors for occurrences of subjective symptoms during drug challenges. METHODS We performed a 6-year, retrospective medical record review of patients who underwent drug challenges by members of the Allergy and Immunology Division after consultation deemed drug challenges to be appropriate. Statistical analysis was performed to compare the proportion of patients with subjective symptoms based on certain factors, including sex, age, number of listed drug allergies, interval from historical drug reaction to the drug challenge, and types of historical reaction. RESULTS A total of 114 patients underwent 123 drug challenges. Only 1 patient was deemed to have a true positive drug challenge result. Twenty patients reported subjective symptoms during graded challenge, all of which were not deemed a positive challenge. There was a significantly higher proportion of patients who reported subjective symptoms in females, those with a higher number of listed drug allergies, and those whose historical reactions were primarily subjective in nature. CONCLUSION Drug challenges are safe procedures in appropriately selected patients. A number of patients report subjective symptoms during drug challenges. Identifying patients at high risk for subjective symptoms may assist in determining whether placebo-controlled drug challenges should be performed.
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Affiliation(s)
- Leon Kao
- Division of Allergy and Immunology at the University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
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SAMBRANO BRITTANY, GORDON RACHEL, MAYS RANA, LAPOLLA WHITNEY, SCHEINFELD NOAH. Intravenous antibiotics used in dermatology. Dermatol Ther 2012; 25:70-81. [DOI: 10.1111/j.1529-8019.2012.01533.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Lin RY. Probability and pragmatism in penicillin allergy evaluations. Ann Allergy Asthma Immunol 2011; 107:546-7. [PMID: 22123390 DOI: 10.1016/j.anai.2011.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 09/08/2011] [Accepted: 09/14/2011] [Indexed: 10/17/2022]
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Moreno E, Dávila I, Laffond E, Gracia T, Múñoz F, Lorente F. Immediate allergic reactions to β-lactams: diagnostic accuracy of skin tests. Ann Allergy Asthma Immunol 2011; 107:89-90. [PMID: 21704894 DOI: 10.1016/j.anai.2011.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 03/31/2011] [Accepted: 05/02/2011] [Indexed: 11/19/2022]
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