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Barker P, Carias DC, Jacobs T, Carpiniello P, Takemoto C, Lieberman J, Adderson E. Promoting penicillin allergy de-labeling for children attending a hematology clinic. Pediatr Blood Cancer 2024; 71:e31034. [PMID: 38679842 DOI: 10.1002/pbc.31034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Up to 10% of children are reported to be allergic to penicillin, but many allergy labels are unverified and may require formal testing. Inaccurate drug allergy labels are associated with a range of adverse clinical outcomes. Patients with hematological disorders may experience frequent and severe infections; those who have been incorrectly labeled penicillin allergic may benefit from allergy de-labeling (ADL) efforts to facilitate access to beta-lactam antibiotics. We developed a multidisciplinary, pharmacist-driven process that enabled non-allergist trained providers to assess and de-label penicillin allergies in a pediatric hematology center. METHODS Volunteers, including physicians, advanced practice providers, nurses, and pharmacists, were trained in skin testing and oral challenge procedures. Patients were identified by review of electronic medical records for penicillin or penicillin-derivative allergy. Patient and family interviews were conducted in cases where a true penicillin allergy was deemed uncertain based on chart review. If allergy could not be de-labeled by chart review or interview alone, patients were offered skin and/or oral challenge testing. RESULTS Fifty-nine patients were initially labeled as penicillin allergic. Allergy labels of 11 (19%) were removed by chart review only, and 15 (25%) after conducting interviews. A total of two (3%) patients were ineligible due to contraindications, and five (9%) declined participation. Twenty-six patients (44%) underwent allergy testing (50% skin testing, 50% oral challenge) of which 23 (88%) were negative. CONCLUSIONS ADL was possible in most patients previously identified as penicillin allergic. Testing was well tolerated with no serious adverse effects.
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Affiliation(s)
- Patricia Barker
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Delia Charest Carias
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Timothy Jacobs
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Philip Carpiniello
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Clifford Takemoto
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Jay Lieberman
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Elisabeth Adderson
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Aytekin Güvenir F, Turgay Yağmur İ, Dibek Mısırlıoğlu E. Alternative Drug Safety in Children with Nonsteroidal Anti-Inflammatory Drug Hypersensitivity. Int Arch Allergy Immunol 2024:1-7. [PMID: 38815557 DOI: 10.1159/000538877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/08/2024] [Indexed: 06/01/2024] Open
Abstract
INTRODUCTION Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used in the pediatric age group as pain relievers, antipyretics and anti-inflammatory drugs. Since NSAIDs are used in many medical conditions, there is a need for alternative NSAIDs to be used safely in people with hypersensitivity reactions. Selective and partially selective COX-2 inhibitors and weak COX-1 inhibitors are generally used as safe alternative drugs. The aim of this study was to evaluate safe NSAIDs determined by oral provocation tests (OPTs) according to phenotypes in children with NSAID hypersensitivity reactions. METHODS The results of the oral provocation test performed with alternative NSAIDs (paracetamol, meloxicam, nimesulide, celecoxib) in patients followed up with the diagnosis of NSAID hypersensitivity reaction in the Pediatric Immunology and Allergy Department between January 2015 and February 2023 were evaluated retrospectively. RESULTS During the study period, 91 patients underwent OPTs with 109 alternative drugs 48 (52.7%) of whom were girls, with a median age of 15 years. 91 patients had a history of reactions to 117 drugs. As an alternative NSAID; OPT was performed with paracetamol in 58 patients, meloxicam in 44 patients, nimesulide in 5 patients, and celecoxib in 2 patients. Since 15 patients used paracetamol safely at home, no tests were performed with paracetamol. Reactions were observed in 3 of the 73 patients (4.1%) who underwent OPT with paracetamol and in 2 of the 44 (4.5%) who underwent OPT with meloxicam. Reactions to nimesulide were also observed in the latter 2 patients (2/5, 40%), but they appeared to tolerate celecoxib. No reaction was observed in the 2 patients who were tested with celecoxib. CONCLUSION Paracetamol, meloxicam, and nimesulide can be used as safe alternative drugs in most children with NSAID hypersensitivity. Selective COX-2 inhibitors should be tried as an alternative in patients who cannot tolerate them.
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Affiliation(s)
- Funda Aytekin Güvenir
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey,
| | - İrem Turgay Yağmur
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Emine Dibek Mısırlıoğlu
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
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Cunha F, Cunha I, Gomes E. Safety of direct oral provocation test to delabel reported mild beta-lactam allergy in infants. Allergol Immunopathol (Madr) 2024; 52:10-15. [PMID: 38459885 DOI: 10.15586/aei.v52i2.887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/30/2023] [Indexed: 03/11/2024]
Abstract
BACKGROUND Around 10% of people report a drug allergy and avoid some medications because of fear of allergic reactions. However, only after a proper diagnostic workup can some of these reactions be confirmed as allergic or nonallergic hypersensitivities. Beta-lactams (BLs) are the most common medication suspected of being involved in drug hypersensivity reactions (DHRs) in children. Recently, direct oral provocation tests (DPT) with BLs gained popularity within pediatric populations as a tool for delabeling children with suspected BL allergies. This study aimed to evaluate the safety of direct provocation tests in infants with mild cutaneous non-immediate reactions to BLs. METHODS The authors retrospectively analyzed the data of 151 infants between 2015 and 2022, referred for evaluating a suspected allergy to BLs that occurred before age 24 months. RESULTS The mean age of the children, including 55% male kids, at the suspected reaction was 15.9 months and the mean age at the time of the DPT was 39.6 months. In most cases, antibiotics were prescribed to treat common upper respiratory infections, such as acute otitis (54.3%) and acute tonsillitis (27.2%). Amoxicillin was considered the culprit drug in 62.9% of the cases, and the combination of amoxicillin-clavulanic acid in the case of 33.8% of children. The most frequent associated cutaneous clinical manifestations were maculopapular exanthema in 74.8% and delayed urticaria/angioedema in 25.2%. Of the 151 infants evaluated, parents of 149 infants agreed for a direct DPT, and only three had a positive test (2%). Symptoms resulting from the DPT were mild and easily treatable. CONCLUSIONS A direct DPT without prior tests is a safe and effective procedure to delabel BL allergy, even in infants. The authors wish to emphasize the importance of properly validating BL allergy suspicions by promoting appropriate diagnostic procedures in infants as, in most cases, DHRs can be excluded and there is no need for further therapeutic restrictions.
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Affiliation(s)
- Francisca Cunha
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal;
| | - Inês Cunha
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Eva Gomes
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
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Serrano-Arias B, Araya-Zúñiga A, Waterhouse-Garbanzo J, Rojas-Barrantes Z, Arguedas-Chacón S, Zavaleta-Monestel E. A Comprehensive Review of Sulfonamide Hypersensitivity: Implications for Clinical Practice. Clin Rev Allergy Immunol 2023; 65:433-442. [PMID: 38175321 DOI: 10.1007/s12016-023-08978-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/05/2024]
Abstract
Sulfonamides, which are drugs commonly prescribed in hospital and outpatient settings, have historically been associated with a high incidence of hypersensitivity reactions. It is believed that there is an increased risk of cross-reactions with other drugs that contain this functional group in their structure. However, it has not been conclusively established that the sulfonamide group is the sole cause of hypersensitivity reactions, as non-antibiotic sulfonamides do not share the same accessory groups with antibiotic sulfonamides. Therefore, cross-reactivity between different types of sulfonamides and sulfonamide-type antibiotics is not clearly demonstrated, and allergic reactions may involve other mechanisms. Misinformation about this topic can lead to inappropriate use of alternative antibiotics with lower efficacy or higher adverse effects, contributing to antibiotic resistance. It is crucial to individualize and monitor patients with a history of allergies to sulfonamide-type antibiotics when introducing a new drug containing sulfa and manage any adverse reactions promptly. Desensitization protocols may be a viable option for patients who specifically benefit from these antibiotics, particularly those who are immunosuppressed. This article provides a descriptive bibliographic review to update information on sulfa allergy, its prevalence, management, and recommendations to prevent such reactions and optimize pharmacotherapy, without underusing these drugs.
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Affiliation(s)
- Bruno Serrano-Arias
- Pharmacy Department, Centro de Investigación y Manejo de Càncer, San José, Costa Rica
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Ramsey A, Rozario C, Stern J. Direct challenges are the gold standard for most antibiotic allergy evaluations. Ann Allergy Asthma Immunol 2023; 131:427-433. [PMID: 37031773 DOI: 10.1016/j.anai.2023.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 04/11/2023]
Abstract
Antibiotic allergies are frequently encountered in clinical practice, and delabeling of these allergies has individual and public health benefits. This review focuses on the evidence supporting graded challenges without preceding skin testing in adult and pediatric patients to the major groups of antibiotics including penicillins, cephalosporins, sulfamethoxazole, fluoroquinolones, tetracyclines, macrolides, metronidazole, carbapenems, and aztreonam. The cost savings, time savings, and evidence for performing graded challenges outside of an allergy/immunology office are also reviewed for graded challenges to penicillins.
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Affiliation(s)
- Allison Ramsey
- Rochester Regional Health, Rochester, New York; Department of Medicine, University of Rochester, Rochester, New York.
| | - Cheryl Rozario
- Department of Medicine, University of Rochester, Rochester, New York
| | - Jessica Stern
- Department of Medicine, University of Rochester, Rochester, New York; Department of Pediatrics, University of Rochester, Rochester, New York
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Karavaizoglu C, Suleyman A, Yavuz Alıc R, Dolu KO, Yucel E, Demirkale ZH, Cimen SS, Ozdemir C, Tamay ZU. Drug Allergy in Children: Adverse Reactions after Skin Testing. Int Arch Allergy Immunol 2023; 185:56-62. [PMID: 37729879 DOI: 10.1159/000533641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 08/07/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION Skin tests are one of the most widely used diagnostic tools for suspected drug allergies in children. Studies on systemic reactions occurring during skin testing with allergens have mostly been conducted in pediatric and adult patient groups together. However, data on adverse reactions including allergic reactions after drug skin tests in children are scarce. It is aimed to determine the adverse reactions after skin test in children with suspected drug allergy. METHODS Patients who underwent a drug skin test due to the suspicion of drug allergy between May 2017 and June 2020 were evaluated, retrospectively. Data about adverse reactions seen after skin testing at the testing area in the clinic were analyzed. RESULTS The study included 1,073 children (585 [54.5%] boys and 488 [45.5%] girls) with a median age of 7.5 years. A total of 12 (1.1%) reactions were detected after skin testing, and 4 (0.4%) of them were allergic reactions. Of the allergic reactions, three were anaphylaxis and one was urticaria. Two of the reactions (1 anaphylaxis and 1 urticaria) were detected after the skin prick test and the remaining 2 were detected after intradermal test. Three of the nonallergic reactions were considered as vasovagal reactions and seven were considered as nonspecific and anxiety-related reactions. CONCLUSION Although drug skin tests were generally well-tolerated and adverse reactions were rare, severe allergic reactions including anaphylaxis may ensue. Skin tests should be necessarily performed in clinical settings in experienced centers.
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Affiliation(s)
- Cagla Karavaizoglu
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey,
| | - Ayse Suleyman
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Roza Yavuz Alıc
- Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Kazım Okan Dolu
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Esra Yucel
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Zeynep Hızlı Demirkale
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sevgi Sipahi Cimen
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Cevdet Ozdemir
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
- Institute of Child Health, Department of Pediatric Basic Sciences, Istanbul University, Istanbul, Turkey
| | - Zeynep Ulker Tamay
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Capanoglu M, Erkocoglu M, Kaya A, Misirlioglu ED, Ginis T, Toyran M, Civelek E, Kocabas CN. Confirmation of Drug Allergy in a General Pediatrics Outpatient Clinic. Ann Allergy Asthma Immunol 2022; 129:784-789. [PMID: 36126914 DOI: 10.1016/j.anai.2022.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/09/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The studies including diagnostic workup on true drug allergy in children are limited. OBJECTIVE This study aimed to evaluate the frequency of confirmed drug allergies in children with a history of suspected drug allergies who had applied to the general paediatric outpatient clinics of our hospital due to various health problems. METHODS The history of drug allergy was questioned in children who applied to the general pediatric outpatient clinics of our hospital. Allergy tests were performed to confirm drug allergy in children whose history was compatible with drug allergy. RESULTS In this study, the parents of 5,553 children aged between 4 months and 17.9 years were asked, "Has your child ever developed an allergy after drug use?". Seven percent of parents (n=389/5,553) thought that their child had a drug allergy. When these patients were evaluated by a paediatric allergist, it was suspected that 21.1% (n=82/389) had a drug allergy. When diagnostic tests were performed for drug allergies, drug allergy was confirmed in only 4.2% (n=3/72). As a result, the frequency of drug allergies according to the history was 1.47% (n=82/5,553) in the population we studied, while the frequency of confirmed drug allergies was found to be 0.05% (n=3/5,553). CONCLUSION The patient and/or parent statements alone are not sufficient for the diagnosis of drug allergies in children. In order to confirm or rule out drug allergies, drug allergy tests must be performed and so unnecessary drug restrictions can be avoided.
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Affiliation(s)
- Murat Capanoglu
- MD, Department of Pediatric Allergy and Immunology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey.
| | - Mustafa Erkocoglu
- MD, Assoc. Prof. Department of Pediatric Allergy and Immunology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey.
| | - Aysenur Kaya
- MD, Prof. Department of Pediatric Allergy and Immunology, Istinye University Faculty of Medicine, Istanbul, Turkey.
| | - Emine Dibek Misirlioglu
- MD, Prof. Department of Pediatric Allergy and Immunology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey.
| | - Tayfur Ginis
- MD, Department of Pediatric Allergy and Immunology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey.
| | - Muge Toyran
- MD, Prof. Department of Pediatric Allergy and Immunology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey.
| | - Ersoy Civelek
- MD, Prof. Department of Pediatric Allergy and Immunology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey.
| | - Can Naci Kocabas
- MD, Prof. Department of Pediatric Allergy and Immunology, Muğla Sitki Kocman University Faculty of Medicine, Mugla, Turkey.
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