Drug eruptions in children with ENT infections

Macrolide Allergic Reactions

Macrolides are antimicrobial agents that can be used to treat a variety of infections. Allergic reactions to macrolides occur infrequently but can include minor to severe cutaneous reactions as well as systemic life-threatening reactions such as anaphylaxis. Most reports of allergic reactions occurred in patients without prior exposure to a macrolide. Cross-reactivity among macrolides may occur due to the similarities in their chemical structures; however, some published literature indicates that some patients can tolerate a different macrolide. Most published reports detailed an allergic reaction to erythromycin. Desensitization protocols to clarithromycin and azithromycin have been described in the literature. The purpose of this article is to summarize macrolide-associated allergic reactions reported in published literature. An extensive literature search was conducted to identify publications linking macrolides to hypersensitivity reactions.

Management of allergy to penicillins and other beta-lactams

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.

Cutaneous drug reactions in children: a multicentric study

Introduction

According to studies conducted in outpatients, it is estimated that 2.5% of children who are treated with a drug will experience a cutaneous adverse drug reaction (CADR).

Aim

To analyze the CADR reports involving pediatric patients recorded by three different university hospitals for describing common, serious, and interesting cutaneous drug eruption patterns.

Material and methods

For this purpose, the patients’ data from three different universities were reviewed retrospectively. Diagnosis was based on history, clinical findings and laboratory test results. The CADRs were classified into seven categories; urticaria, angioedema, maculopapular eruption, fixed drug eruption, erythema multiforme, acute generalized exanthematous pustulosis, drug rash with eosinophilia and systemic symptoms syndrome.

Results

A total of 122 patients who had CADRs were enrolled in the study. The most frequently detected cutaneous drug reactions were urticaria + angioedema. Most of patients had no previous experience with the same drug and the most common causative agent of CADRs was antimicrobials.

Conclusions

Since CADRs are relatively rare, the current multicentric study can provide meaningful information about the cutaneous eruption patterns of commonly used drugs.

Suspicion of macrolide allergy after treatment of infectious diseases including Helicobacter pylori: results of allergological testing

BACKGROUND

Macrolides are useful in a wide range of bacterial infections including upper and lower respiratory tract, skin, and sexually transmitted diseases and are used in Helicobacter pylori eradication regimen. Skin symptoms occurring during drug therapy are mostly attributed to the antibiotic, causing considerable limitations of future therapeutic options. The aim of this retrospective analysis was to demonstrate results of diagnostic testing in cases of clinically suspected immediate and delayed macrolide hypersensitivity.

METHODS

A total of 125 patients with a history of immediate or delayed hypersensitivity symptoms in temporal relation to treatment with a macrolide antibiotic were studied using standardised skin tests followed by oral challenges. Selected patients with severe symptoms were further evaluated with in vitro tests.

RESULTS

Macrolide hypersensitivity was excluded in 109 patients (87.2%) by tolerated oral challenge tests. During 113 challenges in four patients an exanthema was provoked by the suspected macrolide. Only one patient developed a positive late skin test reaction. Out of the 28 Helicobacter pylori-treated patients, one patient with clarithromycin allergy was identified, whereas in eight cases amoxicillin allergy caused the exanthema. Laboratory tests using the suspected macrolides were constantly negative.

CONCLUSIONS

History alone leads to an over-estimation of macrolide hypersensitivity. Moreover, skin and in vitro tests seem to be not very useful in identifying hypersensitive patients. Challenge tests appear to be necessary for definitely confirming or ruling out macrolide allergy.

Skin testing and drug provocation in the diagnosis of nonimmediate reactions to aminopenicillins in children

BACKGROUND

Nonimmediate allergic reactions (NIR) to aminopenicillin include several entities, the most common of which are urticaria-like and maculopapular exanthemas.

AIMS OF THE STUDY

To evaluate a group of children who developed one or more episodes of skin reactions suggestive of NIR after aminopenicillin administration.

METHODS

The inclusion criteria required negative immediate skin tests and absence of specific IgE antibodies to different penicillins. Intradermal and patch tests were carried out with delayed readings and, if negative, a drug-provocation test including a full therapeutic course of the drug was given. Two different groups were compared: A) children with positive skin testing or a positive drug-provocation test and B) children with negative skin testing and good tolerance after a drug-provocation test.

RESULTS

Group A was composed of 20 patients. Positive intradermal/patch tests were found in one patient and in the remaining 19, a positive response to a drug-provocation test confirmed the diagnosis. Group B (the control group) consisted of 19 patients with similar symptoms after aminopenicillin intake but good tolerance. No differences in age, dose or number of previous treatments were observed between the groups. The clinical entities were also similar in both groups.

CONCLUSIONS

Reproducible nonimmediate skin reactions to aminopenicillins may occur in children in spite of negative skin testing. The value of this diagnostic procedure seems to be limited in this type of reaction, with drug-provocation tests (DPT) being a reasonable and safe alternative if the diagnosis has to be confirmed.