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Martino JG, Cang W, Jaskowiak J, Tavakoli A, Clapp C, Marro H, Kim A. Implementation of a multidisciplinary inpatient drug desensitization program. Am J Health Syst Pharm 2023; 80:1670-1676. [PMID: 37605927 DOI: 10.1093/ajhp/zxad189] [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: 08/18/2023] [Indexed: 08/23/2023] Open
Abstract
PURPOSE The purpose of this project was to analyze the process of adult inpatient drug desensitization and to create a multidisciplinary standardized procedure with the aim of improving patient safety, efficiency, length of stay, and patient satisfaction. SUMMARY A team consisting of physicians, pharmacists, nurses, critical care specialists, and operational capacity managers was created. The electronic health system was queried to evaluate the frequency of desensitizations, level of care, implicated medications, and length of stay. An electronic desensitization request form was created along with a desensitization team and email listserver for notification of key stakeholders. CONCLUSION A standardized, safe, and efficient process for inpatient drug desensitization requires advance planning and participation from all disciplines involved. Operational and logistical aspects of desensitization are crucial components of rapid drug desensitization. A structured, multidisciplinary approach to inpatient desensitization is feasible.
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Affiliation(s)
- Janine G Martino
- Department of Pharmacy, Jacobs Medical Center, UC San Diego Health, La Jolla, CA, USA
| | - William Cang
- Department of Pharmacy, Jacobs Medical Center, UC San Diego Health, La Jolla, CA, USA
| | - Jaclyn Jaskowiak
- Department of Pharmacy, Jacobs Medical Center, UC San Diego Health, La Jolla, CA, USA
| | - Aran Tavakoli
- Department of Nursing Education, Development and Research, UC San Diego Health, San Diego, CA, USA
| | - Christopher Clapp
- Department of Nursing Education, Development and Research, UC San Diego Health, San Diego, CA, USA
| | - Hannah Marro
- Department of Nursing, Medical and Surgical ICU, UC San Diego Health, La Jolla, CA, USA
| | - Alexander Kim
- Department of Patient Flow/ Capacity Management, UC San Diego Health, La Jolla, CA, USA
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2
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Huynh V, Janssen C, Beaumier L. [ARN COVID-19 COMIRNATY Vaccine desensitization in a case of PEG Severe Immediate Hypersensitivity]. REVUE FRANCAISE D'ALLERGOLOGIE (2009) 2022; 62:431-434. [PMID: 34484471 PMCID: PMC8400452 DOI: 10.1016/j.reval.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/22/2021] [Indexed: 01/26/2023]
Abstract
Vaccination is the most efficient way to fight the Covid epidemic. However, suspicion of severe hypersensitivity to PEG (PolyEthylen Glycol) usually constitutes a vaccine contraindication. We report the case of a patient with a proven allergy to PEG and skin sensitization to the COMIRNATY vaccine (PEG in its composition). He was able to benefit from the vaccine under the 5-step desensitization protocol. Conclusions: Specific allergological management should be offered to patients suspected of severe hypersensitivity to PEG and other vaccine excipients. We propose a solution for Comirnaty administration for patients with a proven severe allergy to PEG.
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Affiliation(s)
- V.A. Huynh
- Service d’allergologie, Centre Hospitalier Annecy-Genevois, 1, avenue de l’Hôpital, 74370 Epagny Metz-Tessy, France,Auteur correspondant
| | - C. Janssen
- Service Infectiologie, Centre Hospitalier Annecy-Genevois, 1, avenue de l’Hôpital, 74370 Epagny Metz-Tessy, France
| | - L. Beaumier
- Pharmacie, Centre Hospitalier Annecy-Genevois, 1, avenue de l’Hôpital, 74370 Epagny Metz-Tessy, France
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3
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Asfotase Alfa hypersensitivity: an outpatient 8-steps desensitization protocol. Immunol Res 2021; 69:609-611. [PMID: 34528188 DOI: 10.1007/s12026-021-09232-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/28/2021] [Indexed: 10/20/2022]
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4
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Pandya A, Gregory ER, Cherian S, Parashar S, Gierer S. Implementation of EMR-based standardized antibiotic desensitization protocols and its impact on providers. Allergy Asthma Proc 2021; 42:160-166. [PMID: 33685562 DOI: 10.2500/aap.2021.42.200115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: As desensitization protocols become more readily available and published, more institutions are implementing them and searching for ways to streamline the process. There have been no published studies to date on the effect that electronic medical record systems (EMR) have on the safety and efficiency of β-lactam antibiotic desensitization. Objective: The purpose of this study was to evaluate the changes in workflow, efficiency, and medical errors after implementation of β-lactam antibiotic desensitization. Methods: A collaborative effort between the Allergy/Immunology Division and the Pharmacy Department led to the creation and implementation of antibiotic desensitization order sets. Pre- and postimplementation of β-lactam antibiotic surveys were sent to pharmacists and allergy/immunology fellows and attendings at a single-center tertiary care center. Results: There were only 26 valid respondents (12.3%) to both the pre- and postimplementation surveys. The percentage of respondents who thought that the time needed to prepare desensitization materials was < 4 hours increased from 23% to 77% (p < 0.001). The percentage of respondents who thought that the time needed to input electronic desensitization orders was < 1 hour increased from 19% to 54% (p = 0.002). The percentage of respondents who identified zero errors increased from 42% to 92% (p = 0.001). The perception of the overall desensitization process efficiency significantly increased (p < 0.001). Conclusion: Creation of standardized electronic β-lactam antibiotic desensitization order sets significantly decreased the time taken to order and prepare materials and increased overall efficiency.
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Affiliation(s)
- Aarti Pandya
- From the Section of Allergy, Asthma and Immunology, Children's Mercy Hospital, Kansas City, Missouri
| | - Eric R. Gregory
- Department of Pharmacy Services, The University of Kansas Health System, Kansas City, Kansas; and
| | - Sheeba Cherian
- Division of Allergy, Clinical Immunology and Rheumatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Sonya Parashar
- Division of Allergy, Clinical Immunology and Rheumatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Selina Gierer
- Division of Allergy, Clinical Immunology and Rheumatology, University of Kansas Medical Center, Kansas City, Kansas
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Vultaggio A, Matucci A, Nencini F, Bormioli S, Vivarelli E, Maggi E. Mechanisms of Drug Desensitization: Not Only Mast Cells. Front Pharmacol 2020; 11:590991. [PMID: 33424601 PMCID: PMC7793680 DOI: 10.3389/fphar.2020.590991] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/25/2020] [Indexed: 12/30/2022] Open
Abstract
Drug desensitization (DD) allows transient clinical tolerance to the drug in reactive patients and it is frequently and successfully used in the management of both IgE and non IgE-mediated hypersensitivity reactions (HRs). The underlying mechanisms behind this process is not well understood. The desensitization procedure is associated with the inhibition of mast cells degranulation and cytokine production, that, is attributable, at least partially, to the abrogation of Ca2+ mobilization; in vitro findings and in vivo mouse models of rapid desensitization show that the organization and spatial distribution of actin is critical for Ca2+ mobilization. Some clinical observations may suggest the induction of a longer memory of tolerance by DD and they raise the suspicion that other cells and mechanisms are involved in DD. Some data are emerging about the modifications of immune responses during DD in patients with previous immediate HRs. In particular, an increase of regulatory cytokines, mainly represented by IL-10, has been shown, and more importantly, the appearance of IL-35 producing T regulatory cells has been described during DD. The release of controlled cellular mediators by mast cells over time and the development of the antigen-specific regulation of adaptive response allow to safely and successfully reach the target dose of a first line drug during DD.
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Affiliation(s)
| | - Andrea Matucci
- Immunoallergology Unit, Careggi University Hospital, Florence, Italy
| | - Francesca Nencini
- Immunoallergology Unit, Careggi University Hospital, Florence, Italy
| | - Susanna Bormioli
- Immunology and Cellular Therapy, Careggi University Hospital, Florence, Italy
| | | | - Enrico Maggi
- Translational Immunology Unit, Immunology Area, Pediatric Hospital Bambino Gesù, IRCCS, Rome, Italy
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Controversies in Allergy: Chemotherapy Reactions, Desensitize, or Delabel? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2907-2915.e1. [PMID: 32805455 DOI: 10.1016/j.jaip.2020.08.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/27/2020] [Accepted: 08/03/2020] [Indexed: 12/14/2022]
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Stone CA, Trubiano J, Coleman DT, Rukasin CRF, Phillips EJ. The challenge of de-labeling penicillin allergy. Allergy 2020; 75:273-288. [PMID: 31049971 DOI: 10.1111/all.13848] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 03/28/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Even though 8%-25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de-labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. METHODS We performed an evidence-based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de-labeling. Over the period 1928-2018 in Pubmed and Medline, search terms used included "penicillin allergy" or "penicillin hypersensitivity" alone or in combination with "adverse events," "testing," "evaluation," "effects," "label," "de-labeling," "prick or epicutaneous," and "intradermal" skin testing, "oral challenge or provocation," "cross-reactivity," and "antimicrobial stewardship". RESULTS Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. CONCLUSIONS Operationalizing penicillin allergy de-labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de-labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.
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Affiliation(s)
- Cosby A. Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
| | - Jason Trubiano
- Department of Infectious Diseases Austin Health Heidelberg Victoria Australia
- Department of Infectious Diseases Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Medicine (Austin Health) University of Melbourne Parkville Victoria Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Parkville Victoria Australia
| | - David T. Coleman
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
| | - Christine R. F. Rukasin
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
| | - Elizabeth J. Phillips
- Division of Infectious Diseases, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
- Department of Pharmacology Vanderbilt University School of Medicine Nashville Tennessee
- Department of Pathology, Microbiology and Immunology Vanderbilt University Medical Center Nashville Tennessee
- Institute for Immunology & Infectious Diseases Murdoch University Murdoch Western Australia Australia
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Anaphylaxis in the Workplace. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0155-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Alvarez-Perea A, Tanno LK, Baeza ML. How to manage anaphylaxis in primary care. Clin Transl Allergy 2017; 7:45. [PMID: 29238519 PMCID: PMC5724339 DOI: 10.1186/s13601-017-0182-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 11/16/2017] [Indexed: 12/13/2022] Open
Abstract
Anaphylaxis is defined as a severe life-threatening generalized or systemic hypersensitivity reaction characterized by rapidly developing airway and/or circulation problems. It presents with very different combinations of symptoms and apparently mild signs and can progress to fatal anaphylactic shock unpredictably. The difficulty in recognizing anaphylaxis is due, in part, to the variability of diagnostic criteria, which in turn leads to a delay in administration of appropriate treatment, thus increasing the risk of death. The use of validated clinical criteria can facilitate the diagnosis of anaphylaxis. Intramuscular epinephrine (adrenaline) is the medication of choice for the emergency treatment of anaphylaxis. Administration of corticosteroids and H1-antihistamines should not delay the administration of epinephrine, and the management of a patient with anaphylaxis should not end with the acute episode. Long-term management of anaphylaxis should include avoidance of triggers, following confirmation by an allergology study. Etiologic factors suspected in the emergency department often differ from the real causes of anaphylaxis. Evaluation of patients with a history of anaphylaxis should also include an assessment of personal data, such as age and comorbidities, which may increase the risk of severe reactions. Special attention should also be paid to co-factors, as these may easily confound the cause of the anaphylaxis. Patients experiencing anaphylaxis should administer epinephrine as soon as possible. Education (including the use of Internet and social media), written personalized emergency action plans, and self-injectable epinephrine have proven useful for the treatment of further anaphylaxis episodes.
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Affiliation(s)
- Alberto Alvarez-Perea
- Allergy Service, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo, 46, 28007 Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Luciana Kase Tanno
- Hospital Sírio Libanês, São Paulo, Brazil
- Division of Allergy, Department of Pulmonology, University Hospital of Montpellier, Montpellier, France
- Pierre and Marie Curie Institute of Epidemiology and Public Health, Sorbonne Universités, Paris, France
| | - María L. Baeza
- Allergy Service, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo, 46, 28007 Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Biomedical Research Network on Rare Diseases (CIBERER)-U761, Madrid, Spain
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Staso P, Leonov A. Drug desensitization in 17-year-old male with Mast Cell Activation Syndrome, pneumonia, and antibiotic hypersensitivities. AME Case Rep 2017; 1:7. [PMID: 30263994 DOI: 10.21037/acr.2017.11.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 11/16/2017] [Indexed: 11/06/2022]
Abstract
Rapid desensitization (RD) is utilized in order to provide necessary medications to patients with drug hypersensitivity. RD is performed in a closely monitored setting to protect patients from severe anaphylactic or anaphylactoid reactions. A recently classified syndrome, mast cell activation syndrome (MCAS), has been defined by episodic symptoms caused by mast cell mediators and is associated with specific laboratory markers. Patient with MCAS and history of systemic reactions to ceftriaxone and azithromycin presented with pneumonia requiring treatment with ceftriaxone and azithromycin, both provided via desensitization protocols. Desensitization for drug hypersensitivities in the setting of MCAS presents several controversial issues as mechanism of hypersensitivity may not be related to IgE-mediated but rather non-specific mast-cell degranulation. The controversies of diagnosis and management of antibiotic hypersensitivity in patients with MCAS discussed. Our case demonstrates that desensitization protocols can be used in MCAS patients with noted hypersensitivities. The intricacies of desensitization in the setting of MCAS are not fully understood and will require further research and characterization.
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Affiliation(s)
- Patrick Staso
- Department of Medicine and Pediatrics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Andrey Leonov
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
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11
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McNulty CMG, Park MA. Delayed Cutaneous Hypersensitivity Reactions to Antibiotics: Management with Desensitization. Immunol Allergy Clin North Am 2017; 37:751-760. [PMID: 28965638 DOI: 10.1016/j.iac.2017.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Successful desensitization to mild to moderate delayed cutaneous adverse reaction to antibiotics has been described in a limited number of antibiotics and found to be safe. However, there are ample opportunities to standardize protocols for delayed cutaneous adverse reactions to antibiotics.
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Affiliation(s)
- Caitlin M G McNulty
- Division of Allergic Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Miguel A Park
- Division of Allergic Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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First case of allergy to nivolumab. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1140-1141. [DOI: 10.1016/j.jaip.2017.01.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 12/23/2016] [Accepted: 01/20/2017] [Indexed: 02/06/2023]
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13
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The use of standardized drug desensitization protocols at a pediatric institution. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:834-836.e5. [PMID: 28034551 DOI: 10.1016/j.jaip.2016.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 11/05/2016] [Accepted: 11/15/2016] [Indexed: 02/02/2023]
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