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Molleti RR, Bidell MR, Tatara AW. Fidaxomicin-Associated Hypersensitivity Reactions: Report of a Morbilliform Drug Eruption. J Pharm Pract 2023; 36:993-997. [PMID: 36112954 DOI: 10.1177/08971900221078780] [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] [Indexed: 07/20/2023]
Abstract
PurposeWe report a probable case of morbilliform drug eruption secondary to fidaxomicin in a patient with Clostridioides difficile infection (CDI). Summary: A 62-year-old female presented to our institution's emergency department (ED) with symptoms consistent with Clostridioides difficile infection. The patient was prescribed 2 weeks of oral vancomycin for CDI prior to presentation. Given insufficient response to vancomycin, the patient was started on fidaxomicin with a planned 10-day course. After 2 doses of fidaxomicin, the patient developed a rash on her back that spread within 24 hours. The patient did not experience relief upon administration of a variety of medications for allergic reaction. Improvement was noted upon discontinuation of fidaxomicin. The Food and Drug Administration reports that < 2% of adults treated with fidaxomicin experience a rash as an adverse effect. Conclusion: Fidaxomicin was a probable cause of morbilliform drug eruption in our patient with CDI. The patient improved upon discontinuation of fidaxomicin.
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Affiliation(s)
- Radha R Molleti
- Department of Pharmacy, Memorial Hermann Memorial City Hospital, Houston, Texas, USA
| | - Monique R Bidell
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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2
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Beta-lactam hypersensitivity diagnosis in ambulatory and hospitalized settings require different approaches. Ann Allergy Asthma Immunol 2023; 130:84-92.e1. [PMID: 36122888 DOI: 10.1016/j.anai.2022.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Data on beta-lactam hypersensitivity (BLH) are mainly focused on immediate or mild nonimmediate reactions in the ambulatory setting, but limited in patients with concurrent illness and moderate-to-severe nonimmediate reactions in the hospitalized setting. OBJECTIVE To investigate the entire spectrum of BLH in Thai tertiary hospital. METHODS Clinical characteristics of 357 patients with suspected BLH were evaluated in a 7-year period. Culprit drug identification was performed in 335 patients by combined skin testing, in vitro testing, or drug provocation tests. RESULTS The predominant BLH presentations were non-immunoglobulin (Ig)E-mediated reactions with severe cutaneous adverse reactions of 18.9%, and BLH status was definitively confirmed in 18.1%. The most common verified culprits were cephalosporins (34.8%), particularly in hypersensitivity type IV reactions. Natural penicillins were the main implicated drugs in 48.5% of ambulatory patients. In contrast, cephalosporins and carbapenems were the main implicated drugs in hospitalized patients. Non-IgE-mediated anaphylaxis and serum sickness-like reaction remained diagnostically challenged. New generations of beta-lactams, hospitalized patients, recent allergic history, and underlying malignancies or autoimmune diseases were associated with increased BLH risk. CONCLUSION At present, cephalosporins are the leading causes of BLH, particularly in non-IgE-mediated reactions. More research on the verification of non-IgE hypersensitivity reactions from new generations of beta-lactams should be better emphasized. CLINICAL TRIAL REGISTRATION The registry was approved by the Ethics and Research Committee of the Faculty of Medicine, Chulalongkorn University, and listed on ClinicalTrials.gov (Identifier: NCT01667055; https://www. CLINICALTRIALS gov/ct2/show/NCT01667055).
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Macy E, Trautmann A, Chiriac AM, Demoly P, Phillips EJ. Advances in the Understanding of Drug Hypersensitivity: 2012 Through 2022. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:80-91. [PMID: 36384652 DOI: 10.1016/j.jaip.2022.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/09/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022]
Abstract
Over the last decade there have been key advances in understanding mechanisms, risk, and consequences of both true immunological drug hypersensitivity and unverified drug allergy labels that have changed clinical practice. This has been facilitated by the widespread adoption of electronic health records (EHRs). The vast majority of EHR drug allergy labels are unverified and cause significant morbidity from unnecessary avoidance of optimal drug therapy. There has also been significant movement in our understanding of mechanisms of drug hypersensitivity that, in addition to advancing our understanding of the pathogenesis of immediate and delayed reactions, have guided preventive efforts, diagnostic procedures, and clinical management. More widespread adoption, including scale-up of "allergy" delabeling and appropriate management, specifically for antibiotics, opiates, radiocontrast, chemotherapeutics, biologics, and nonsteroidal anti-inflammatory medications, will be necessary to improve patient outcomes over the next decade. This will require further engagement and collaboration between primary care health care providers, allergists, and other specialists.
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Affiliation(s)
- Eric Macy
- Allergy Department, Kaiser Permanente Southern California, San Diego, Calif.
| | - Axel Trautmann
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - Anca M Chiriac
- Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; Sorbonne Universités, Paris, France; IDESP, UMR UA11, Univ. Montpellier-INSERM, Montpellier, France
| | - Pascal Demoly
- Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; Sorbonne Universités, Paris, France; IDESP, UMR UA11, Univ. Montpellier-INSERM, Montpellier, France
| | - Elizabeth J Phillips
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
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Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J, Khan DA, Golden DBK, Shaker M, Stukus DR, Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333-1393. [PMID: 36122788 DOI: 10.1016/j.jaci.2022.08.028] [Citation(s) in RCA: 141] [Impact Index Per Article: 70.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Aleena Banerji
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Roland Solensky
- Corvallis Clinic, Oregon State University/Oregon Health Science University College of Pharmacy, Corvallis, Ore
| | - Andrew A White
- Department of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St Joe's Hamilton, Hamilton, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew J Greenhawt
- Food Challenge and Research Unit Section of Allergy and Immunology, Children's Hospital Colorado University of Colorado School of Medicine, Aurora, Colo
| | - Caroline C Horner
- Department of Pediatrics, Division of Allergy Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla; James A. Haley Veterans Affairs Hospital, Tampa, Fla
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | - John Oppenheimer
- Division of Allergy, Rutgers New Jersey Medical School, Rutgers, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Copaescu AM, Ben-Shoshan M, Trubiano JA. Tools to improve the diagnosis and management of T-cell mediated adverse drug reactions. Front Med (Lausanne) 2022; 9:923991. [PMID: 36313986 PMCID: PMC9606226 DOI: 10.3389/fmed.2022.923991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/26/2022] [Indexed: 11/25/2022] Open
Abstract
Delayed drug T-cell immune-mediated hypersensitivity reactions have a large clinical heterogeneity varying from mild maculopapular exanthema (MPE) to severe cutaneous adverse reactions (SCARs) such as acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS) and severe skin necrosis and blistering as seen in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Given the knowledge gaps related to the immunopathogenesis of these conditions, the absence of validated diagnostic tools and the significant associated morbidity and mortality, patients with SCARs often have limited drug choices. We performed a comprehensive review aiming to evaluate in vivo diagnostic tools such as delayed intradermal skin and patch testing and ex vivo/in vitro research assays such as the lymphocyte transformation test (LTT) and the enzyme-linked ImmunoSpot (ELISpot) assay. We searched through PubMed using the terms “drug allergy,” “in vivo” and “ex vivo” for original papers in the last 10 years. A detailed meticulous approach adapted to the various clinical phenotypes is recommended for the diagnostic and management of delayed drug hypersensitivity reactions. This review highlights the current diagnostic tools for the delayed drug hypersensitivity phenotypes.
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Affiliation(s)
- Ana Maria Copaescu
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia,Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre (MUHC), Montreal, QC, Canada,The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), Montreal, QC, Canada,*Correspondence: Ana Maria Copaescu,
| | - Moshe Ben-Shoshan
- The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), Montreal, QC, Canada,Division of Allergy, Immunology and Dermatology, Montreal Children’s Hospital, McGill University Health Centre (MUHC), Montreal, QC, Canada
| | - Jason A. Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia,Department of Oncology, Sir Peter MacCallum Cancer Centre, The University of Melbourne, Parkville, VIC, Australia,Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, VIC, Australia,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Bermingham WH, Bhogal R, Nagarajan S, Mutlu L, El-Shabrawy RM, Madhan R, Maheshwari UM, Murali M, Kudagammana ST, Shrestha R, Sumantri S, Christopher DJ, Mahesh PA, Dedicoat M, Krishna MT. 'Practical management of suspected hypersensitivity reactions to anti-tuberculosis drugs.'. Clin Exp Allergy 2021; 52:375-386. [PMID: 34939251 DOI: 10.1111/cea.14084] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/07/2021] [Accepted: 12/09/2022] [Indexed: 11/28/2022]
Abstract
Tuberculosis (TB) is the commonest cause of death by a single infectious agent globally and ranks amongst the top ten causes of global mortality. The incidence of TB is highest in Low-Middle Income countries (LMICs). Prompt institution of, and compliance with, therapy are cornerstones for a favourable outcome in TB and to mitigate the risk of multiple drug resistant (MDR)-TB, which is challenging to treat. There is some evidence that adverse drug reactions (ADRs) and hypersensitivity reactions (HSRs) to anti-TB drugs occur in over 60% and 3-4% of patients respectively. Both ADRs and HSRs represent significant barriers to treatment adherence and are recognised risk factors for MDR-TB. HSRs to anti-TB drugs are usually cutaneous and benign, occur within few weeks after commencement of therapy and are likely to be T-cell mediated. Severe and systemic T-cell mediated HSRs and IgE mediated anaphylaxis to anti-TB drugs are relatively rare, but important to recognise and treat promptly. T-cell mediated HSRs are more frequent amongst patients with co-existing HIV infection. Some patients develop multiple sensitisation to anti-TB drugs. Whilst skin tests, patch tests and in vitro diagnostics have been used in the investigation of HSRs to anti-TB drugs, their predictive value is not established, they are onerous, require specialist input of an allergist and are resource-dependent. This is compounded by the global, unmet demand for allergy specialists, particularly in low income countries (LICs) / LMICs and now the challenging circumstances of the SARS-CoV-2 pandemic. This narrative review provides a critical analysis of the limited published evidence on this topic and proposes a cautious and pragmatic approach to optimise and standardise the management of HSRs to anti-TB drugs. This includes clinical risk stratification and a dual strategy involving sequential re-challenge and rapid drug desensitisation. Furthermore, a concerted international effort is needed to generate real-time data on ADRs, HSRs, safety and clinical outcomes of these interventions.
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Affiliation(s)
- W H Bermingham
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R Bhogal
- Department of Pharmacy, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Nagarajan
- Department of Allergy and Immunology, Mallige Hospital, Bangalore, India
| | - L Mutlu
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - R Madhan
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS AHER, Mysuru, India
| | - U M Maheshwari
- Department of Respiratory Medicine, St Johns Medical College, Bengaluru, India
| | - M Murali
- Division of Allergy and Clinical Immunology, Department of Medicine, Massachusetts General hospital, Boston, MA, 02114, USA
| | - S T Kudagammana
- Faculty of Medicine, University of Peradeniya, Honorary Consultant Paediatrician, Teaching hospital, Peradeniya, Sri Lanka
| | - R Shrestha
- Departments of Clinical Pharmacology, Dhulikhel Hospital, Kathmandu University Hospital, Nepal
| | - S Sumantri
- Department of Internal Medicine, Universitas Pelita Harapan, Siloam Academic Hospital Lippo Village, Tangerang, Banten, Indonesia
| | - D J Christopher
- Department of Pulmonary Medicine, Christian Medical College, Vellore, India
| | - P A Mahesh
- Department of Respiratory Medicine, JSS Medical College, JSSAHER, Mysuru, India
| | - M Dedicoat
- Department of Infectious Diseases and Tropical Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M T Krishna
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, UK
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Minaldi E, Phillips EJ, Norton A. Immediate and Delayed Hypersensitivity Reactions to Beta-Lactam Antibiotics. Clin Rev Allergy Immunol 2021; 62:449-462. [PMID: 34767158 DOI: 10.1007/s12016-021-08903-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 12/16/2022]
Abstract
Beta-lactam antibiotics are the most commonly reported drug allergy in adults and children. More than 95% of those with reported allergy labels to beta lactams are not confirmed when subjected to allergy testing. Beta lactam antibiotics are associated with a wide spectrum of immediate and delayed drug hypersensitivity reactions. The latency period to symptoms and clinical presentation aids in the causality assessment. Risk stratification based on diagnosis and timing then allows for appropriate management and evaluation. Skin prick testing, intradermal testing and oral challenge are well established for evaluation of immediate reactions. Delayed intradermal testing, patch testing and oral challenge can also be considered for evaluation of mild to moderate delayed reactions. Cross-reactivity between beta-lactams appears to be driven most commonly by a shared R1 side-chain. Standardized algorithms, protocols and pathways are needed for widespread implementation of a pragmatic and effective approach to patients reporting beta lactam allergy.
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Affiliation(s)
- Ellen Minaldi
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Allison Norton
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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Fernandez J, Jimenez-Rodriguez TW, Blanca-Lopez N. Classifying cephalosporins: from generation to cross-reactivity. Curr Opin Allergy Clin Immunol 2021; 21:346-354. [PMID: 34074874 DOI: 10.1097/aci.0000000000000755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW To review the most recent literature studying the classifications, immunochemistry, and crossreactivity of allergy reactions to cephalosporins. RECENT FINDINGS Over the last five years, research interest has focused on three areas related to cephalosporin allergy: cross-reactivity among cephalosporins and with other beta-lactams; the incidence of adverse reactions in penicillin allergy patients or in reported penicillin allergy labels; and new cephalosporins structures involved in the immunological recognition. SUMMARY Meta-analysis of a substantial number of studies shows that cephalosporins are safer than previously thought. Evidence supports two main conclusions in that regard. First, there is a relatively low percentage of cross-reactivity between cephalosporins and other beta-lactams with penicillins in penicillin allergy patients. Second, there is a very low incidence of allergy reactions in nonselected as well as in selected penicillin allergy patients when cephalosporins are used prior to surgical intervention.On the other hand, few structures have been discovered related to the immune mechanism of cephalosporin allergy reactions, and these are far from being ready to use in clinical practice.
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Affiliation(s)
- Javier Fernandez
- Allergy Section, Alicante General University Hospital, ISABIAL-UMH, Alicante
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9
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Delabeling Delayed Drug Hypersensitivity: How Far Can You Safely Go? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2878-2895.e6. [PMID: 33039012 DOI: 10.1016/j.jaip.2020.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/01/2020] [Accepted: 07/08/2020] [Indexed: 12/17/2022]
Abstract
Delayed immune-mediated adverse drug reactions (IM-ADRs) are defined as reactions occurring more than 6 hours after dosing. They include heterogeneous clinical phenotypes that are typically T-cell-mediated reactions with distinct mechanisms across a wide spectrum of severity from benign exanthems through to life-threatening cutaneous or organ-specific diseases. For mild reactions such as benign exanthem, considerations for delabeling are similar to immediate reactions and may include a graded or single-dose drug challenge with or without preceding skin or patch testing. Evaluation of challenging cases such as the patient who is on multiple drugs at the time a severe delayed IM-ADR occurs should prioritize clinical ascertainment of the most likely phenotype and implicated drug(s). Although not widely available and validated, procedures such as patch testing, delayed intradermal skin testing, and laboratory-based functional drug assays or genetic (human leukocyte antigen) testing may provide valuable information to further help risk stratify patients and identify the likely implicated and/or cross-reactive drug(s). The decision to use a drug challenge as a diagnostic or delabeling tool in a patient with a severe delayed IM-ADR should weigh the risk-benefit ratio, balancing the severity and priority for the treatment of the underlying, and the availability of alternative efficacious and safe treatments.
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10
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Trubiano JA, Soria A, Torres MJ, Trautmann A. Treating Through Drug-Associated Exanthems in Drug Allergy Management: Current Evidence and Clinical Aspects. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2984-2993. [PMID: 33878455 DOI: 10.1016/j.jaip.2021.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/01/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
In the setting of an acute cutaneous adverse drug reaction there is increasing interest in selected phenotypes and hosts to continue drug therapy, especially in settings in which there are limited therapeutic options. This concept of "treating through," defined as the continued use of a drug in the setting of, in particular maculopapular exanthema, potentially avoids unnecessary drug discontinuation. A review of the recent literature, historical viewpoints, and expert opinion are provided within to form recommendations and algorithms for a "treating-through" approach.
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Affiliation(s)
- Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia.
| | - Angèle Soria
- Sorbonne Universités, Paris, France; Service de Dermatologie et d'Allergologie, Hôpital Tenon, Paris HUEP, APHP, Paris, France; Centre d'Immunologie et des Maladies Infectieuses - Paris (Cimi-Paris), INSERM U1135, Paris, France
| | - Maria J Torres
- Allergy Unit, IBIMA-Regional University Hospital of Malaga UMA, Malaga, Spain; Andalusian Center for Nanomedicine and Biotechnology - BIONAND, Malaga, Spain
| | - Axel Trautmann
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany
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11
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Schrüfer P, Brockow K, Stoevesandt J, Trautmann A. Predominant patterns of β-lactam hypersensitivity in a single German Allergy Center: exanthem induced by aminopenicillins, anaphylaxis by cephalosporins. Allergy Asthma Clin Immunol 2020; 16:102. [PMID: 33292467 PMCID: PMC7672956 DOI: 10.1186/s13223-020-00488-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/10/2020] [Indexed: 11/23/2022] Open
Abstract
Background Penicillins and other β-lactam antibiotics are the most common elicitors of allergic drug reaction. However, data on the pattern of clinical reaction types elicited by specific β-lactams are scarce and inconsistent. We aimed to determine patterns of β-latam allergy, i.e. the association of a clinical reaction type with a specific β-lactam antibiotic. Methods We retrospectively evaluated data from 800 consecutive patients with suspected β-lactam hypersensitivity over a period of 11 years in a single German Allergy Center. Results β-lactam hypersensitivity was definitely excluded in 595 patients, immediate-type (presumably IgE-mediated) hypersensitivity was diagnosed in 70 and delayed-type hypersensitivity in 135 cases. Most (59 out of 70, 84.3%) immediate-type anaphylactic reactions were induced by a limited number of cephalosporins. Delayed reactions were regularly caused by an aminopenicillin (127 out of 135, 94.1%) and usually manifested as a measles-like exanthem (117 out of 135, 86.7%). Intradermal testing proved to be the most useful method for diagnosing β-lactam allergy, but prick testing was already positive in 24 out of 70 patients with immediate-type hypersensitivity (34.3%). Patch testing in addition to intradermal testing did not provide additional information for the diagnosis of delayed-type hypersensitivity. Almost all β-lactam allergic patients tolerated at least one, usually several alternative substances out of the β-lactam group. Conclusions We identified two patterns of β-lactam hypersensitivity: aminopenicillin-induced exanthem and anaphylaxis triggered by certain cephalosporins. Intradermal skin testing was the most useful method to detect both IgE-mediated and delayed-type β-lactam hypersensitivity.
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Affiliation(s)
- Philipp Schrüfer
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Knut Brockow
- Department of Dermatology and Allergy, Technical University of Munich, 80802, Munich, Germany
| | - Johanna Stoevesandt
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Axel Trautmann
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany.
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12
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Gelincik A, Brockow K, Çelik GE, Doña I, Mayorga C, Romano A, Soyer Ö, Atanaskovic‐Markovic M, Barbaud A, Torres MJ. Diagnosis and management of the drug hypersensitivity reactions in Coronavirus disease 19: An EAACI Position Paper. Allergy 2020; 75:2775-2793. [PMID: 32511784 PMCID: PMC7300843 DOI: 10.1111/all.14439] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 02/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19), a respiratory tract infection caused by a novel human coronavirus, the severe acute respiratory syndrome coronavirus 2, leads to a wide spectrum of clinical manifestations ranging from asymptomatic cases to patients with mild and severe symptoms, with or without pneumonia. Given the huge influence caused by the overwhelming COVID-19 pandemic affecting over three million people worldwide, a wide spectrum of drugs is considered for the treatment in the concept of repurposing and off-label use. There is no knowledge about the diagnosis and clinical management of the drug hypersensitivity reactions that can potentially occur during the disease. This review brings together all the published information about the diagnosis and management of drug hypersensitivity reactions due to current and candidate off-label drugs and highlights relevant recommendations. Furthermore, it gathers all the dermatologic manifestations reported during the disease for guiding the clinicians to establish a better differential diagnosis of drug hypersensitivity reactions in the course of the disease.
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Affiliation(s)
- Aslı Gelincik
- Department of Internal Medicine Division of Immunology and Allergic Diseases Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein Faculty of Medicine Technical University of Munich Munich Germany
| | - Gülfem E. Çelik
- Department of Chest Diseases Division of Immunology and Allergy Ankara University School of Medicine Ankara Turkey
| | - Inmaculada Doña
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Cristobalina Mayorga
- Research Laboratory IBIMA‐Regional University Hospital of Malaga‐UMA‐ARADyAL Malaga Spain
| | - Antonino Romano
- IRCCS Oasi Maria S.S. Troina Italy
- Fondazione Mediterranea G.B. Morgagni Catania Italy
| | - Özge Soyer
- Pediatric Allergy Department Hacettepe University School of Medicine Ankara Turkey
| | | | - Annick Barbaud
- Department of Dermatology and Allergology, Tenon Hospital (AP‐HP) Sorbonne Universities, Pierre et Marie Curie University Paris France
- Institut Pierre Louis d’Epidémiologie et de Santé Publique AP‐HP Sorbonne Université Paris France
| | - Maria Jose Torres
- Allergy Unit Regional University Hospital of Malaga‐IBIMA‐UMA‐BIONAND‐ARADyAL Malaga Spain
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Romano A, Atanaskovic‐Markovic M, Barbaud A, Bircher AJ, Brockow K, Caubet J, Celik G, Cernadas J, Chiriac A, Demoly P, Garvey LH, Mayorga C, Nakonechna A, Whitaker P, Torres MJ. Towards a more precise diagnosis of hypersensitivity to beta-lactams - an EAACI position paper. Allergy 2020; 75:1300-1315. [PMID: 31749148 DOI: 10.1111/all.14122] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/08/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023]
Abstract
A recent survey of the European Academy of Allergy and Clinical Immunology (EAACI) Drug Allergy Interest Group (DAIG) on how European allergy specialists deal with beta-lactam (BL) hypersensitivity demonstrated a significant heterogeneity in current practice, suggesting the need to review and update existing EAACI guidelines in order to make the diagnostic procedures as safe and accurate, but also as cost-effective, as possible. For this purpose, a bibliographic search on large studies regarding BL hypersensitivity diagnosis was performed by an EAACI task force, which reviewed and evaluated the literature data using the GRADE system for quality of evidence and strength of recommendation. The updated guidelines provide a risk stratification in BL hypersensitivity according to index reaction(s), as well as an algorithmic approach, based on cross-reactivity studies, in patients with a suspicion of BL hypersensitivity and an immediate need for antibiotic therapy, when referral to an allergist is not feasible. Furthermore, the update addresses availability and concentrations of skin test (ST) reagents, ST and drug provocation test (DPT) protocols, and diagnostic algorithms and administration of alternative BL in allergic subjects. Specifically, distinct diagnostic algorithms are suggested depending on risk stratification of the patient into high and low risk based on the morphology and chronology of the reaction, immediate (ie, occurring within 1-6 hours after the last administered dose) or nonimmediate (ie, occurring more than 1 hour after the initial drug administration), and the reaction severity. Regarding the allergy workup, the main novelty of this document is the fact that in some low-risk nonimmediate reactions ST are not mandatory, especially in children. For DPT, further studies are necessary to provide data supporting the standardization of protocols, especially of those regarding nonimmediate reactions, for which there is currently no consensus.
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Affiliation(s)
- Antonino Romano
- Casa di Cura Quisisana Rome & Fondazione Mediterranea G.B. Catania Italy
| | | | - Annick Barbaud
- Departement of Dermatology and Allergology Institut Pierre Louis d'Epidemiologie et de Sante Publique INSERM Tenon Hospital Sorbonne Université Paris France
| | | | - Knut Brockow
- Department of Dermatology and Allergy Biederstein Technische Universität München Munich Germany
| | | | - Gulfem Celik
- Department of Immunology and Allergy Ankara University School of Medicine Ankara Turkey
| | - Josefina Cernadas
- Department of Allergy and Immunology Centro Hospitalar Universitário de S João Porto Portugal
| | - Anca‐Mirela Chiriac
- Division of Allergy Department of Pulmonology Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- UMRS 1136 Equipe ‐ EPAR ‐ IPLESP UPMC Univ Sorbonne Universités Paris France
| | - Pascal Demoly
- Division of Allergy Department of Pulmonology Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- UMRS 1136 Equipe ‐ EPAR ‐ IPLESP UPMC Univ Sorbonne Universités Paris France
| | - Lene H. Garvey
- Allergy Clinic Department of Dermatology and Allergy Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga-IBIMA Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga-UMA-ARADyAL Malaga Spain
| | - Alla Nakonechna
- Clinical Immunology and Allergy Unit Sheffield Teaching Hospital Sheffield UK
- University of Liverpool Liverpool UK
| | - Paul Whitaker
- Regional Adult Cystic Fibrosis Unit St James's Hospital Leeds UK
| | - María José Torres
- Allergy Unit Hospital Regional Universitario de Málaga-UMA-ARADyAL Malaga Spain
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Phillips EJ, Bigliardi P, Bircher AJ, Broyles A, Chang YS, Chung WH, Lehloenya R, Mockenhaupt M, Peter J, Pirmohamed M, Roujeau JC, Shear NH, Tanno LK, Trubiano J, Valluzzi R, Barbaud A. Controversies in drug allergy: Testing for delayed reactions. J Allergy Clin Immunol 2018; 143:66-73. [PMID: 30573342 DOI: 10.1016/j.jaci.2018.10.030] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/27/2018] [Accepted: 10/30/2018] [Indexed: 01/11/2023]
Abstract
Controversies exist with regard to in vivo approaches to delayed immunologically mediated adverse drug reactions, such as exanthem (maculopapular eruption), drug reaction with eosinophilia and systemic symptoms, acute generalized exanthematous pustulosis, Stevens-Johnson syndrome/toxic epidermal necrolysis, and fixed drug eruptions. In particular, widespread differences exist between regions and practice on the availability and use of intradermal and patch testing, the standard drug concentrations used, the use of additional drugs in intradermal and patch testing to help determine cross-reactivity, the timing of testing in relation to the occurrence of the adverse drug reaction, the use of testing in specific phenotypes, and the use of oral challenge in conjunction with delayed intradermal and patch testing to ascertain drug tolerance. It was noted that there have been advances in the science of delayed T cell-mediated reactions that have shed light on immunopathogenesis and provided a mechanism of preprescription screening in the case of HLA-B*57:01 and abacavir hypersensitivity and HLA-B*15:02 and carbamazepine Stevens-Johnson syndrome/toxic epidermal necrolysis in Southeast Asian subjects. Future directions should include the collaboration of large international networks to develop and standardize in vivo diagnostic approaches, such as skin testing and patch testing, combined with ex vivo and in vitro laboratory approaches.
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Affiliation(s)
- Elizabeth J Phillips
- Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch, Australia.
| | - Paul Bigliardi
- Department of Dermatology, Dermato-Allergy Division, University of Minnesota, Minneapolis, Minn
| | - Andreas J Bircher
- Department of Dermatology, Allergy Unit, University Hospital, University of Basel, Basel, Switzerland
| | - Ana Broyles
- Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Yoon-Seok Chang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei, Linkou and Keelung, Taiwan
| | - Rannakoe Lehloenya
- Division of Dermatology and Combined Drug Allergy Clinic, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Maja Mockenhaupt
- Department of Dermatology, Dokumentationszentrum schwerer Hautreaktionen (dZh), Medical Center and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Jonny Peter
- Division of Dermatology and Combined Drug Allergy Clinic, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Munir Pirmohamed
- Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | | | - Neil H Shear
- Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Luciana Kase Tanno
- University Hospital of Montpellier, Montpellier, and Sorbonne Université, INSERM, Paris, France; Hospital Sírio Libanês, São Paulo, Brazil
| | - Jason Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, University of Melbourne, Heidelberg, Australia; National Centre for Infections in Cancer, Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Rocco Valluzzi
- Allergy Department, Pediatric Hospital Bambino Gesù, Rome, Vatican City, Italy
| | - Annick Barbaud
- Dermatology and Allergy Department, Tenon Hospital, Medecine Sorbonne University, Paris, France; Assistance publique-hopitaux de Paris, Paris, France
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Torres MJ, Adkinson NF, Caubet JC, Khan DA, Kidon MI, Mendelson L, Gomes ER, Rerkpattanapipat T, Zhang S, Macy E. Controversies in Drug Allergy: Beta-Lactam Hypersensitivity Testing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:40-45. [PMID: 30245291 DOI: 10.1016/j.jaip.2018.07.051] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 07/20/2018] [Indexed: 12/13/2022]
Abstract
All beta-lactam use is associated with a certain rate of adverse reactions. Many of these adverse reactions result in an allergy to the beta-lactam being entered into the patient's medical record. Unfortunately, only a small minority of these recorded allergies are clinically significant immunologically mediated drug hypersensitivity. An unconfirmed allergy to beta-lactams is a significant public health risk, because patients so labeled typically do not receive narrow-spectrum penicillins and cephalosporins when clinically indicated. The alternative antibiotics they receive result in poorer clinical outcomes, increased incidence of serious antibiotic-resistant infections, prolonged hospitalizations, and greater health care utilization. There is a wide variation in beta-lactam allergy incidence and prevalence around the world, based in part on the specific beta-lactams used and overused. There is a wide variation in specific protocols used to confirm current tolerance of beta-lactams and remove these inaccurate allergy reports. Harmonizing testing protocols, when possible, may lead to more widespread use of narrow-spectrum beta-lactams, when clinically indicated, and improve patient safety worldwide. Further research is needed to better understand the regional differences in reporting beta-lactam allergy as this relates to regional differences in beta-lactam use and overuse, the frequency of clinically significant immunologically mediated beta-lactam hypersensitivity, and the optimal testing strategies to confirm current tolerance, based on presenting clinical symptoms.
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Affiliation(s)
- Maria J Torres
- Allergy Unit, IBIMA-Regional University Hospital of Malaga UMA, Malaga, Spain; Andalusian Center for Nanomedicine and Biotechnology - BIONAND, Malaga, Spain
| | - N Franklin Adkinson
- Allergy & Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Child and Adolescent Department, Geneva University Hospitals, Geneva, Switzerland
| | - David A Khan
- Division of Allergy & Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mona I Kidon
- Clinical Immunology, Angioedema and Allergy Unit, Chaim Sheba Medical Center, Pediatric Allergy Clinic, Safra Children's Hospital, Tel Hashomer, Ramat Gan, Israel; Faculty of Pediatric Medicine, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Louis Mendelson
- New England Food Allergy Treatment Center, West Hartford, Conn
| | - Eva Rebelo Gomes
- Allergy and Clinical Immunology Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Ticha Rerkpattanapipat
- Allergy, Immunology and Rheumatology Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Shuchen Zhang
- Department of Allergy, Tongji Hospitals, Tongji Medical College of Huangzhong University of Science and Technology, Wuhan, China
| | - Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, Kaiser Permanente San Diego Medical Center, San Diego, Calif.
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Schatz M, Sicherer SH, Zeiger RS. The Journal of Allergy and Clinical Immunology: In Practice 2017 Year in Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:328-352. [PMID: 29397373 DOI: 10.1016/j.jaip.2017.12.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/19/2017] [Indexed: 12/29/2022]
Abstract
An impressive number of clinically impactful studies and reviews were published in The Journal of Allergy and Clinical Immunology: In Practice in 2017. As a service to our readers, the editors provide this Year in Review article to highlight and contextualize the advances published over the past year. We include information from articles on asthma, allergic rhinitis, rhinosinusitis, immunotherapy, atopic dermatitis, contact dermatitis, food allergy, anaphylaxis, drug hypersensitivity, urticarial/angioedema, eosinophilic disorders, and immunodeficiency. Within each topic, epidemiologic findings are presented, relevant aspects of prevention are described, and diagnostic and therapeutic advances are enumerated. Treatments discussed include behavioral therapy, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We hope this review will help readers consolidate and use this extensive and practical knowledge for the benefit of patients.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif.
| | - Scott H Sicherer
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif
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