1
|
Núñez R, Doña I, Cornejo-García JA. Predictive models and applicability of artificial intelligence-based approaches in drug allergy. Curr Opin Allergy Clin Immunol 2024; 24:189-194. [PMID: 38814733 DOI: 10.1097/aci.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
PURPOSE OF REVIEW Drug allergy is responsible for a huge burden on public healthcare systems, representing in some instances a threat for patient's life. Diagnosis is complex due to the heterogeneity of clinical phenotypes and mechanisms involved, the limitations of in vitro tests, and the associated risk to in vivo tests. Predictive models, including those using recent advances in artificial intelligence, may circumvent these drawbacks, leading to an appropriate classification of patients and improving their management in clinical settings. RECENT FINDINGS Scores and predictive models to assess drug allergy development, including patient risk stratification, are scarce and usually apply logistic regression analysis. Over recent years, different methods encompassed under the general umbrella of artificial intelligence, including machine and deep learning, and artificial neural networks, are emerging as powerful tools to provide reliable and optimal models for clinical diagnosis, prediction, and precision medicine in different types of drug allergy. SUMMARY This review provides general concepts and current evidence supporting the potential utility of predictive models and artificial intelligence branches in drug allergy diagnosis.
Collapse
Affiliation(s)
- Rafael Núñez
- Allergy Research Group, Biomedical Research Institute of Malaga (IBIMA)-BIONAND Platform
| | - Inmaculada Doña
- Allergy Research Group, Biomedical Research Institute of Malaga (IBIMA)-BIONAND Platform
- Allergy Unit, Malaga Regional University Hospital, Malaga
- Inflammatory Diseases Network (RICORS, RD21/0002/0008, Instituto de Salud Carlos III), Málaga, Spain
| | - José Antonio Cornejo-García
- Allergy Research Group, Biomedical Research Institute of Malaga (IBIMA)-BIONAND Platform
- Allergy Unit, Malaga Regional University Hospital, Malaga
- Inflammatory Diseases Network (RICORS, RD21/0002/0008, Instituto de Salud Carlos III), Málaga, Spain
| |
Collapse
|
2
|
Mori F, Saretta F, Riscassi S, Caimmi S, Bottau P, Liotti L, Franceschini F, Bianchi A, Valluzzi RL, Crisafulli G, Caffarelli C. Risk factors for drug hypersensitivity reactions in children. Ital J Pediatr 2024; 50:127. [PMID: 39010141 PMCID: PMC11247891 DOI: 10.1186/s13052-024-01694-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/25/2024] [Indexed: 07/17/2024] Open
Abstract
Drug hypersensitivity reactions are common in children. Risk factors predisposing to IgE-mediated drug allergies and delayed drug reactions are a matter of debate. Gender, age, previous reactions to the same drug or to another drug, reduced drug metabolism, chronic diseases, polypharmacy, drug doses are linked with the onset of hypersensitivity reactions in some children. Novel advances in genetic polymorphisms can rapidly change the approach to the prevention of reactions since gene testing can be a useful screening test for severe cutaneous adverse reactions. Viral infections may act as cofactors in susceptible individuals. Polypharmacy, high doses, repeated doses and parental route of administration are also risk factors. Clinicians should take into account risk factors to allow the risk-benefit balance to be maintained.
Collapse
Affiliation(s)
- Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139, Florence, Italy
| | - Francesca Saretta
- Dipartimento Materno-Infantile, SC Pediatria, Ospedale Latisana-Palmanova, Azienda Sanitaria Universitaria Friuli Centrale, 33100, Udine, Italy
| | - Sara Riscassi
- UOC Di Pediatria, Ospedale Bolzano, Azienda Sanitaria Dell'Alto Adige, Bolzano, 39100, Italy
| | - Silvia Caimmi
- SC Di Pediatria, Fondazione IRCSS Policlinico San Matteo, 27100, Pavia, Italy
| | - Paolo Bottau
- UOC Di Pediatria E Neonatologia, Ospedale Imola (BO), Imola, 40026, Italy
| | - Lucia Liotti
- UOC Pediatria, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", 60100, Ancona, Italy
| | | | - Annamaria Bianchi
- UOC Pediatria, Azienda Ospedaliera San Camillo Forlanini, 00152, Rome, Italy
| | - Rocco Luigi Valluzzi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy
| | - Giuseppe Crisafulli
- Dipartimento Materno-Infantile, UOC Pediatria, University of Messina, Messina, 98122, Italy
| | - Carlo Caffarelli
- Department of Medicine and Surgery, Clinica Pediatrica, Azienda Ospedaliera-Universitaria, University of Parma, 43123, Parma, Italy.
| |
Collapse
|
3
|
Gonzalez-Estrada A, Park MA, Accarino JJO, Banerji A, Carrillo-Martin I, D'Netto ME, Garzon-Siatoya WT, Hardway HD, Joundi H, Kinate S, Plager JH, Rank MA, Rukasin CRF, Samarakoon U, Volcheck GW, Weston AD, Wolfson AR, Blumenthal KG. Predicting Penicillin Allergy: A United States Multicenter Retrospective Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1181-1191.e10. [PMID: 38242531 DOI: 10.1016/j.jaip.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 12/29/2023] [Accepted: 01/07/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND Using the reaction history in logistic regression and machine learning (ML) models to predict penicillin allergy has been reported based on non-US data. OBJECTIVE We developed ML positive penicillin allergy testing prediction models from multisite US data. METHODS Retrospective data from 4 US-based hospitals were grouped into 4 datasets: enriched training (1:3 case-control matched cohort), enriched testing, nonenriched internal testing, and nonenriched external testing. ML algorithms were used for model development. We determined area under the curve (AUC) and applied the Shapley Additive exPlanations (SHAP) framework to interpret risk drivers. RESULTS Of 4777 patients (mean age 60 [standard deviation: 17] years; 68% women, 91% White, and 86% non-Hispanic) evaluated for penicillin allergy labels, 513 (11%) had positive penicillin allergy testing. Model input variables were frequently missing: immediate or delayed onset (71%), signs or symptoms (13%), and treatment (31%). The gradient-boosted model was the strongest model with an AUC of 0.67 (95% confidence interval [CI]: 0.57-0.77), which improved to 0.87 (95% CI: 0.73-1) when only cases with complete data were used. Top SHAP drivers for positive testing were reactions within the last year and reactions requiring medical attention; female sex and reaction of hives/urticaria were also positive drivers. CONCLUSIONS An ML prediction model for positive penicillin allergy skin testing using US-based retrospective data did not achieve performance strong enough for acceptance and adoption. The optimal ML prediction model for positive penicillin allergy testing was driven by time since reaction, seek medical attention, female sex, and hives/urticaria.
Collapse
Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Miguel A Park
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - John J O Accarino
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Michael E D'Netto
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - W Tatiana Garzon-Siatoya
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Heather D Hardway
- Digital Innovation Lab, Department of Health Sciences Research, Mayo Clinic, Jacksonville, Fla
| | - Hajara Joundi
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Susan Kinate
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz
| | - Jessica H Plager
- Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Section of Allergy, Immunology, Division of Pulmonary, Phoenix Children's Hospital, Phoenix, Ariz
| | - Christine R F Rukasin
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Section of Allergy, Immunology, Division of Pulmonary, Phoenix Children's Hospital, Phoenix, Ariz
| | - Upeka Samarakoon
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - Alexander D Weston
- Digital Innovation Lab, Department of Health Sciences Research, Mayo Clinic, Jacksonville, Fla
| | - Anna R Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| |
Collapse
|
4
|
Copaescu AM, Li L, Blumenthal KG, Trubiano JA. How to Define and Manage Low-Risk Drug Allergy Labels. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1095-1106. [PMID: 38724164 DOI: 10.1016/j.jaip.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 06/06/2024]
Abstract
Risk stratification in drug allergy implies that specific risk categories (eg, low, moderate, and high) classify historical drug hypersensitivity reactions. These risk categories can be based on reaction phenotypic characteristics, the timing of the reaction and evaluation, the required reaction management, and individual characteristics. Although a multitude of frameworks have been described in the literature, particularly for penicillin allergy labels, there has yet to be a global consensus, and approaches continue to vary between allergy centers. Immune-mediated drug allergies can sometimes be confirmed using skin testing, but a negative drug challenge is required to demonstrate tolerance and remove the allergy from the electronic health record ("delabel" the allergy). Even for quintessential IgE-mediated drug allergy, penicillin allergy, recent data reveal that a direct oral challenge, without prior skin testing, is an appropriate diagnostic strategy in those who are considered low-risk. Drug allergy pathogenesis and clinical manifestations may vary depending on the culprit drug, and as such, the optimal approach should be based on risk stratification that considers individual patient and reaction characteristics, the likely hypersensitivity reaction phenotype, the drug class, and the patient's clinical needs. This article will describe low-risk drug allergy labels, focusing on β-lactam and sulfonamide antibiotics, nonsteroidal anti-inflammatory drugs, iodinated contrast media, and common chemotherapeutics. This review will also address practical management approaches using currently available risk stratification and clinical decision tools.
Collapse
Affiliation(s)
- Ana Maria Copaescu
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Medicine, Austin Health, the University of Melbourne, Heidelberg, VIC, Australia; Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada; The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada.
| | - Lily Li
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Wash
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, VIC, Australia
| |
Collapse
|
5
|
Sobrino-García M, Muñoz-Bellido FJ, Moreno-Rodilla E, Martín-Muñoz R, García-Iglesias A, Dávila I. Delabeling of allergy to beta-lactam antibiotics in hospitalized patients: a prospective study evaluating cost savings. Int J Clin Pharm 2024:10.1007/s11096-024-01737-7. [PMID: 38642250 DOI: 10.1007/s11096-024-01737-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/04/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Patients with a penicillin allergy label are at risk of an associated increase in adverse antibiotic events and hospitalization costs. AIM We aimed to study the economic savings derived from the correct diagnosis and delabeling inpatients with suspected beta-lactam allergy, considering the acquisition cost of antimicrobials prescribed during a patient's hospital stay. METHOD We prospectively evaluated patients admitted to the University Hospital of Salamanca who had been labeled as allergic to beta-lactams and performed a delabeling study. Subsequently, cost differences between antibiotics administered before and after the allergy study and those derived from those patients who received alternative antibiotics during admission and those who switched to beta-lactams after the allergy study were calculated. RESULTS One hundred seventy-seven inpatients labeled as allergic to beta-lactams underwent a delabeling study; 34 (19.2%) were confirmed to have allergy to beta-lactams. Of the total number of patients, 136 (76.8%) received antibiotics during their hospitalization, involving a mean (SD) cost of €203.07 (318.42) and a median (IQR) cost of €88.97 (48.86-233.56). After delabeling in 85 (62.5%) patients, the antibiotic treatment was changed to beta-lactams. In this group of patients, the mean cost (SD) decreased from €188.91 (351.09) before the change to 91.31 (136.07) afterward, and the median cost (IQR) decreased from €72.92 (45.82-211.99) to €19.24 (11.66-168). The reduction was significant compared to the median cost of patients whose treatment was not changed to beta-lactams (p<0.001). CONCLUSION Delabeling hospitalized patients represents a cost-saving measure for treating patients labeled as allergic to beta-lactams.
Collapse
Affiliation(s)
- Miriam Sobrino-García
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain
| | - Francisco J Muñoz-Bellido
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain.
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain.
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Castilla y León, Spain.
- Red de Enfermedades Inflamatorias - Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain.
- Servicio de Alergología, Hospital Universitario de Salamanca, Paseo de La Transición Española, 37007, Salamanca, Spain.
| | - Esther Moreno-Rodilla
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Castilla y León, Spain
- Red de Enfermedades Inflamatorias - Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain
| | - Rita Martín-Muñoz
- Hospital Pharmacy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
| | - Aránzazu García-Iglesias
- Admission and Clinical Documentation Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
| | - Ignacio Dávila
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Castilla y León, Spain
- Red de Enfermedades Inflamatorias - Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain
| |
Collapse
|
6
|
Liccioli G, Tomei L, Pessina B, Caubet JC, Barni S, Giovannini M, Sarti L, Mori F. The importance of clinical history in the diagnosis of drug hypersensitivity in children. Pediatr Allergy Immunol 2024; 35:e14091. [PMID: 38444175 DOI: 10.1111/pai.14091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND In case of suspected hypersensitivity reactions (HRs) to drugs, a challenging area for pediatricians is detecting relevant elements in the parent-reported history, in order to reach a definite diagnosis. We analyzed the concordance between the description of the HR and the medical reports documented at the time of the event. Furthermore, we studied any correlation between clinical history variables and the prediction of true allergy. METHODS We retrospectively collected 50 charts of children referred to our Allergy Unit, after a previous access to the Emergency Department. We compared the description of the HR at acute phase to the history told by parents. Type and timing of the HR and culprit drug were classified as "known" or "unknown." The diagnosis was confirmed or excluded at the end of the investigations. Logistic regression analysis was performed to find any significant association. RESULTS The type of the HR was known in 74%, the timing in 28%, and the culprit drug in 98%. We showed that having had a severe HR had an increased odds of remembering the timing; being older >6 years and having had an immediate HR had an increased odds of remembering the type; time to diagnostic was lower in patients whose parents remembered the type of HR. CONCLUSION Our paper underlines the importance of an accurate anamnesis at the time of the event. Providing the physicians with a standardized Case Report Form could be a useful tool to simplify the diagnostic work-up and minimize mistakes due to lack of memory.
Collapse
Affiliation(s)
- Giulia Liccioli
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Leonardo Tomei
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Benedetta Pessina
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Women, Children and Adolescents, University Hospital of Geneva, Geneva, Switzerland
| | - Simona Barni
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| |
Collapse
|
7
|
Chongpison Y, Sriswasdi S, Buranapraditkun S, Thantiworasit P, Rerknimitr P, Mongkolpathumrat P, Chularojanamontri L, Srinoulprasert Y, Rerkpattanapipat T, Chanprapaph K, Disphanurat W, Chakkavittumrong P, Tovanabutra N, Srisuttiyakorn C, Sukasem C, Tuchinda P, Pongcharoen P, Klaewsongkram J. IFN-γ ELISpot-enabled machine learning for culprit drug identification in nonimmediate drug hypersensitivity. J Allergy Clin Immunol 2024; 153:193-202. [PMID: 37678574 DOI: 10.1016/j.jaci.2023.08.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Diagnosing drug-induced allergy, especially nonimmediate phenotypes, is challenging. Incorrect classifications have unwanted consequences. OBJECTIVE We sought to evaluate the diagnostic utility of IFN-γ ELISpot and clinical parameters in predicting drug-induced nonimmediate hypersensitivity using machine learning. METHODS The study recruited 393 patients. A positive patch test or drug provocation test (DPT) was used to define positive drug hypersensitivity. Various clinical factors were considered in developing random forest (RF) and logistic regression (LR) models. Performances were compared against the IFN-γ ELISpot-only model. RESULTS Among the 102 patients who had 164 DPTs, most patients had severe cutaneous adverse reactions (35/102, 34.3%) and maculopapular exanthems (33/102, 32.4%). Common suspected drugs were antituberculosis drugs (46/164, 28.1%) and β-lactams (42/164, 25.6%). Mean (SD) age of patients with DPT was 52.7 (20.8) years. IFN-γ ELISpot, fixed drug eruption, Naranjo categories, and nonsteroidal anti-inflammatory drugs were the most important features in all developed models. The RF and LR models had higher discriminating abilities. An IFN-γ ELISpot cutoff value of 16.0 spot-forming cells/106 PBMCs achieved 94.8% specificity and 57.1% sensitivity. Depending on clinical needs, optimal cutoff values for RF and LR models can be chosen to achieve either high specificity (0.41 for 96.1% specificity and 0.52 for 97.4% specificity, respectively) or high sensitivity (0.26 for 78.6% sensitivity and 0.37 for 71.4% sensitivity, respectively). CONCLUSIONS IFN-γ ELISpot assay was valuable in identifying culprit drugs, whether used individually or incorporated in a prediction model. Performances of RF and LR models were comparable. Additional test datasets with DPT would be helpful to validate the model further.
Collapse
Affiliation(s)
- Yuda Chongpison
- Biostatistics Excellence Centre, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Skin and Allergy Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sira Sriswasdi
- Center of Excellence in Computational Molecular Biology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Center for Artificial Intelligence in Medicine, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Supranee Buranapraditkun
- Skin and Allergy Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pattarawat Thantiworasit
- Skin and Allergy Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pawinee Rerknimitr
- Skin and Allergy Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Division of Dermatology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pungjai Mongkolpathumrat
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Leena Chularojanamontri
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yuttana Srinoulprasert
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ticha Rerkpattanapipat
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kumutnart Chanprapaph
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wareeporn Disphanurat
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Panlop Chakkavittumrong
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Napatra Tovanabutra
- Division of Dermatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chutika Srisuttiyakorn
- Division of Dermatology, Department of Medicine, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Pharmacogenomics and Precision Medicine Clinic, Bumrungrad Genomic Medicine Institute, Bumrungrad International Hospital, Bangkok, Thailand
| | - Papapit Tuchinda
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Padcha Pongcharoen
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Jettanong Klaewsongkram
- Skin and Allergy Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| |
Collapse
|
8
|
Wrenn RH, Trubiano JA. Penicillin Allergy Impact and Management. Infect Dis Clin North Am 2023; 37:793-822. [PMID: 37537003 DOI: 10.1016/j.idc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
There is international evidence that penicillin allergies are associated with inferior prescribing and patient outcomes. A host of tools now exist from assessment (risk assessment tools, clinical decision rules) to delabeling (the removal of a beta-lactam allergy via testing or medical reconciliation) to reduce the impact of these "labels" in the hospital and community setting, as a primary antimicrobial stewardship intervention.
Collapse
Affiliation(s)
- Rebekah H Wrenn
- Duke University Medical Center, Durham, NC, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA.
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Melbourne, Australia; Department of Infectious Diseases, University of Melbourne, at The Peter Doherty Institute for Infection and Immunity, Victoria 3000, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| |
Collapse
|
9
|
Sáenz de Santa María R, Bogas G, Labella M, Ariza A, Salas M, Doña I, Torres MJ. Approach for delabeling beta-lactam allergy in children. FRONTIERS IN ALLERGY 2023; 4:1298335. [PMID: 38033918 PMCID: PMC10684789 DOI: 10.3389/falgy.2023.1298335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023] Open
Abstract
A considerable number of pediatric patients treated with beta-lactam (BL) antibiotics develop delayed onset of skin rashes during the course of treatment. Although the most frequent cause of these symptoms is infectious, many cases are labeled as allergic reactions to these drugs. BL allergy labels could have a negative impact, as they imply avoidance of this group of drugs and the use of second-line antibiotics, leading to a potential increase in adverse effects and the utilization of less effective therapies. This constitutes a major public health concern and economic burden, as the use of broad-spectrum antibiotics can result in multidrug-resistant organisms and prolonged hospital stays. Therefore, it is crucial to delabel patients during childhood to avoid false labeling in adult life. Although the label of BL allergy is among the most frequent causes of allergy referral, its management remains controversial, and new diagnostic perspectives are changing the paradigm of managing BL allergies in children. Traditionally, drug provocation testing (DPT) was exclusively performed in patients who had previously obtained negative results from skin tests (STs). However, the sensitivity of STs is low, and the role of in vitro testing in the pediatric population is not well defined. Recent studies have demonstrated the safety of direct DPT without prior ST or serum tests for pediatric patients who report a low-risk reaction to BLs, which is cost-effective. However, there is still a debate on the optimal allergic workup to be performed in children with a benign immediate reaction and the management of children with severe cutaneous adverse drug reactions. In this review, we will discuss the impact of the label of BL allergy and the role of the different tools currently available to efficiently address BL allergy delabeling in children.
Collapse
Affiliation(s)
- R. Sáenz de Santa María
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - G. Bogas
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. Labella
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - A. Ariza
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. Salas
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - I. Doña
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. J. Torres
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
- Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
- Departamento de Medicina, Universidad de Málaga, Facultad de Medicina, Málaga, Spain
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Lumkul L, Wongyikul P, Kulalert P, Sompornrattanaphan M, Lao-Araya M, Chuamanochan M, Nochaiwong S, Phinyo P. Genetic association of beta-lactams-induced hypersensitivity reactions: A systematic review of genome-wide evidence and meta-analysis of candidate genes. World Allergy Organ J 2023; 16:100816. [PMID: 37780578 PMCID: PMC10541471 DOI: 10.1016/j.waojou.2023.100816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Importance Beta-lactams (BLs) are the most prescribed antibiotics, being the most frequent cause of drug allergy. However, the association between BL allergy and genetic variations is still unclear. Objective This systematic review and meta-analysis aimed to summarize the genetic effects of BL-induced hypersensitivity using existing evidence. Methods We searched PubMed, Medline, Scopus, EMBASE, CINAHL, and Cochrane Library from inception to September 15, 2022 with no language restriction. Genetic association studies investigating genetic variant/polymorphism and risk of drug-induced hypersensitivity reactions among individuals receiving BL-antibiotics were included. We excluded studies of acute interstitial nephritis, drug-induced liver injury, serum sickness, and isolated drug fever. Data were comprehensively synthesized and quality of study were assessed using STrengthening the Reporting of Genetic Association Studies (STREGA). The record screening, extraction and quality assessment were performed by two reviewers and discussions were made to resolve discrepancies. The effects of each variant were pooled and evaluated by modified Venice criteria. Results A total of 9276 records were identified, and 31 studies were eligible for inclusion. Twenty-seven were candidate-gene association studies (5416 cases and 5939 controls), while the others were next-generation sequencing (NGS) or genome-wide association studies (GWASs) (119 838 cases and 1 487 111 controls). Forty-nine polymorphisms were identified and most of them located in allergic reaction pathways. Meta-analyses of 15 candidate variants in a mixture of both immediate and non-immediate reactions revealed weak genetic effects of rs1801275 (8 studies; n = 1,560; odd ratio 0.73; 95%CI: 0.57-0.93) and rs20541 (4 studies; n = 1,482; odd ratio 1.34; 95%CI: 1.07-1.68) in IL4R and IL13, respectively. Results from GWASs and NGS identified, and confirmed associations in HLA regions including HLA-DRA, HLA-B, HLA-DQA, HLA-DRB1, and HLA-DRB3. Conclusion Our study summarized genetic evidence influencing BL-induced hypersensitivity and estimated effects of potential variants. We postulated that the genomic studies provide better insights to the mechanism of reactions and suggest potential effects of HLA Class II variants. However, results were inconsistent and unable to generalize in different settings. Further high-throughput studies with a well-defined function, epigenetic interaction, incorporated with clinical factors, would be beneficial for risk identification in BL-induced hypersensitivity.
Collapse
Affiliation(s)
- Lalita Lumkul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Multidisciplinary Technology for Advanced Medicine (CMUTEAM), Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Pakpoom Wongyikul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Prapasri Kulalert
- Department of Clinical Epidemiology, Faculty of Medicine, Thammasat University, Pathum Thani, 12120, Thailand
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathum Thani, 12120, Thailand
| | - Mongkhon Sompornrattanaphan
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Mongkol Lao-Araya
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Mati Chuamanochan
- Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, 50200, Thailand
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Surapon Nochaiwong
- Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, 50200, Thailand
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Musculoskeletal Science and Translational Research (MSTR), Chiang Mai University, Chiang Mai 50200, Thailand
| |
Collapse
|
12
|
Wijnakker R, van Maaren MS, Bode LGM, Bulatovic M, Hendriks BJC, Loogman MCM, Lutgens SPM, Middel A, Nieuwhof CMG, Roelofsen EE, Schoones JW, Sigaloff KCE, Sprikkelman AB, de Vrankrijker AMM, de Boer MGJ. The Dutch Working Party on Antibiotic Policy (SWAB) guideline for the approach to suspected antibiotic allergy. Clin Microbiol Infect 2023:S1198-743X(23)00178-7. [PMID: 37068548 DOI: 10.1016/j.cmi.2023.04.008] [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: 01/12/2023] [Revised: 03/28/2023] [Accepted: 04/07/2023] [Indexed: 04/19/2023]
Abstract
OBJECTIVES Prudent handling of reported antibiotic allergy is an important aspect of antibiotic stewardship. The Dutch Working Party on Antibiotic Policy (SWAB) constituted a multidisciplinary expert committee to provide evidence-based recommendations for bedside decision making in antibiotic therapy in patients that report an antibiotic allergy. METHODS The guideline committee generated 12 key questions, most of which were population, intervention, comparison and outcome (PICO) questions relevant for both children and adults with suspected antibiotic allergy. For each question a systematic literature search was performed and reviewed for the best available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Quality of evidence was graded from very low to high and recommendations were formulated in structured discussions as strong or weak. RESULTS Sixty recommendations were provided for suspected allergy to beta-lactam antibiotics (BLA) and non-beta-lactam antibiotics (NBLA). Due to the absence of randomized controlled trials in this field, the underlying evidence was predominantly graded as low or very low. Available data supports that a detailed allergy history should always be performed and critically appraised. When cross-allergy between BLA groups is not to be expected due to absence of molecular similarity of the side chains, the patient can be safely exposed to the alternative BLA. An exception to this rule are severe delayed type reactions, in which reexposure to a BLA should only be considered after consultation of a multidisciplinary team. CONCLUSIONS Accumulated scientific data now supports a more liberal approach that better balances benefits of treatment with first choice and usually smaller spectrum antibiotics with appropriate avoidance of antibiotics in case of a truly high risk of a (severe) allergic reaction. In the Netherlands, a formal guideline was developed that provides recommendations for the approach towards suspected allergy to BLA and frequently used NBLA, thereby strongly supporting antimicrobial stewardship.
Collapse
Affiliation(s)
- R Wijnakker
- Department of internal medicine, Tergooi Medical Center, Hilversum & Department of infectious diseases, Leiden University Medical Center, Leiden.
| | - M S van Maaren
- Department of internal medicine, section allergology, Erasmus Medical Center, Rotterdam
| | - L G M Bode
- Department of medical microbiology and infectious diseases, Erasmus Medical Center, Rotterdam
| | - M Bulatovic
- Department of rheumatology and clinical immunology, University Medical Center Utrecht, Utrecht
| | - B J C Hendriks
- Department of clinical pharmacy and toxicology, Leiden University Medical Center, Leiden
| | - M C M Loogman
- General practioner, Dutch college of general practitioners
| | - S P M Lutgens
- Department of medical microbiology, Jeroen Bosch Hospital, 's-Hertogenbosch
| | - A Middel
- Department of internal medicine, University Medical Center Groningen, Groningen
| | - C M G Nieuwhof
- Department of internal medicine and allergology, Maastricht University Medical Center, Maastricht
| | - E E Roelofsen
- Department of clinical pharmacy, Medical Center Haaglanden, The Hague
| | - J W Schoones
- Directorate of Research Policy (formerly: Walaeus Library), Leiden University Medical Center, Leiden
| | - K C E Sigaloff
- Department of infectious diseases, Amsterdam University Medical Center, Amsterdam
| | - A B Sprikkelman
- Department of pediatric pulmonology and allergology, University Medical Center Groningen, Groningen
| | - A M M de Vrankrijker
- Department of pediatric infectious diseases, section infectious diseases, University Medical Center Utrecht, Utrecht
| | - M G J de Boer
- Department of infectious diseases and Department of Clinical Epidemiology, Leiden University Medical Center, Leiden.
| |
Collapse
|
13
|
Srisuwatchari W, Phinyo P, Chiriac AM, Saokaew S, Kulalert P. The Safety of the Direct Drug Provocation Test in Beta-Lactam Hypersensitivity in Children: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:506-518. [PMID: 36528293 DOI: 10.1016/j.jaip.2022.11.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Direct drug provocation test (DPT) without prior skin testing (ST) has been investigated in children suspected of being at risk for beta-lactam (BL) hypersensitivity reaction (HSR). However, no systematic review and meta-analysis has investigated the efficacy and safety of direct DPT for BL-HSR in children. OBJECTIVE To investigate the prevalence of BL-HSR by direct DPT and the safety of direct DPT in children. METHODS We searched MEDLINE, EMBASE, Web of Science, and CINAHL from their inception to July 23, 2022, for studies that performed direct DPT in children with suspected BL-HSR, or for studies that performed DPT in all cases with ST results, but they ignored the ST results. The true prevalence was defined as the proportion of children who experienced an HSR during direct DPT. Safety was determined according to the proportion of children who developed a dangerous reaction following DPT. RESULTS Twenty-eight studies with 8,334 direct challenges were included. Fifteen studies included patients who presented with either immediate or nonimmediate HSR, and the majority of the index reactions were nonsevere. Amoxicillin/amoxicillin-clavulanic acid was the most commonly used during the DPT. The pooled prevalence of confirmed BL-HSR was 5.23% (95% CI 4.17-6.39; I2 = 72%). Immediate and nonimmediate HSR were reported in 0.8% (95% CI 0.43-1.25; I2 = 55.1%) and 3.69% (95% CI 2.66-4.87; I2 = 79.77%), respectively. Severe reactions were found in 3 cases with the frequency of 0.036% (95% CI 0.012-0.112; I2 = 0%). CONCLUSIONS The prevalence of BL-HSR by direct DPT was 5.23%, and the frequency of severe reactions from direct DPT was very low (0.036%). Our findings support direct DPT as a safe and effective delabeling tool in children with suspected nonsevere BL-HSR.
Collapse
Affiliation(s)
- Witchaya Srisuwatchari
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Musculoskeletal Science and Translational Research (MSTR), Chiang Mai University, Chiang Mai, Thailand
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; IDESP, UMR UA11, University of Montpellier, INSERM, Montpellier, France
| | - Surasak Saokaew
- UNIt of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Prapasri Kulalert
- Department of Clinical Epidemiology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand; Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
| |
Collapse
|
14
|
Kühl J, Bergh B, Laudes M, Szymczak S, Heine G. Cofactors of drug hypersensitivity-A monocenter retrospective analysis. FRONTIERS IN ALLERGY 2023; 3:1097977. [PMID: 36686964 PMCID: PMC9854260 DOI: 10.3389/falgy.2022.1097977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/07/2022] [Indexed: 01/07/2023] Open
Abstract
Background Drug hypersensitivity reactions (DHRs) are major medical problems that influence the treatment of patients by both under- and overdiagnosis. Still, little is known about the role of predisposing or protecting cofactors of DHR. Objective This study aims to determine drug-specific cofactors in patients with DHR. Methods Retrospective file chart analysis of inpatients with suspected DHR in our department between 2015 and 2020 was performed. Descriptive statistics and multiple logistic regression were conducted for the estimation and statistical interference. Results DHRs were suspected in 393 patients with 678 culprit drugs. In 183 cases, drug hypersensitivities were confirmed, mostly against nonopioid analgesic drugs and antibiotics. Multiple logistic regression analysis identified a positive association of antibiotic hypersensitivity with obesity [odds ratio (OR) 5.75, average marginal effect (AME) +24.4%] and age and a negative association with arterial hypertension, female sex, elevated immunoglobulin E (IgE), and allergic rhinitis. Hypersensitivity to nonopioid analgesics was associated with atopic dermatitis (OR 10.28, AME +28.5%), elevated IgE, and arterial hypertension. Conclusions Drug-specific cofactors of DHR include obesity for antibiotics and atopic dermatitis for nonopioid analgesics, the knowledge of which may improve the risk calculation for drug provocation tests.
Collapse
Affiliation(s)
- Johanna Kühl
- Allergy Division, Department of Dermatology and Allergy, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Björn Bergh
- Institute of Medical Informatics and Statistics, Kiel University and University Hospital Schleswig-Holstein, Kiel, Germany
| | - Matthias Laudes
- Institute of Diabetes and Clinical Metabolic Research, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Silke Szymczak
- Institute of Medical Biometry and Statistics, University of Lübeck and University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Guido Heine
- Allergy Division, Department of Dermatology and Allergy, University Hospital Schleswig-Holstein, Kiel, Germany,Correspondence: Guido Heine
| |
Collapse
|
15
|
Ben Romdhane H, Ben Fredj N, Ben Fadhel N, Chadli Z, Abderrahmen A, Boughattas NA, Chaabane A, Aouam K. Beta-lactam hypersensitivity in children: Frequency and risk factors. Br J Clin Pharmacol 2023; 89:150-157. [PMID: 33179302 DOI: 10.1111/bcp.14647] [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: 06/03/2020] [Revised: 10/22/2020] [Accepted: 10/30/2020] [Indexed: 12/01/2022] Open
Abstract
AIMS To determine the frequency of an authentic β-lactam (BL) hypersensitivity (HS) amongst a large number of children and to identify clinical risk factors that predict this hypersensitivity. METHODS All children with suspected BL allergy were evaluated by skin tests (ST) with the suspected BL. A 1-day oral provocation test (OPT) was performed in children with negative ST. We defined an authentic BL-HS case if the child exhibited a positive ST or a positive OPT. Risk factors associated with BL-HS were assessed using a univariate analysis. Covariates showing a P-value <.2 were included in the multivariate logistic regression analysis to determine independent predictors. RESULTS A total of 354 patients reporting 368 suspected BL reactions were included. The diagnosis of BL-HS was established in 24 children (6.7%). All these children had a positive ST. OPT was performed in 30 patients and was negative in all of them. In 110 children with a negative ST, BL was tolerated. In the risk factors analysis, 164 children were included. Older age (>5 years) at the reaction (odds ratio = 1.11; 95% confidence interval, 1.01-1.22; P = .02) and BL administered (odds ratio = 7.7; 95% confidence interval, 2.76-21.8; P < .001) were significantly associated with authentic BL-HS. CONCLUSION BL-HS should be evaluated with an appropriate allergy work-up before strict prohibition is made. In addition, age of patient and BL involved can be used as predictive factors of developing BL-HS in this population.
Collapse
Affiliation(s)
- Haifa Ben Romdhane
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Nadia Ben Fredj
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Najah Ben Fadhel
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Zohra Chadli
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Ahlem Abderrahmen
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Naceur A Boughattas
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Amel Chaabane
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Karim Aouam
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| |
Collapse
|
16
|
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: 144] [Impact Index Per Article: 72.0] [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
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Chong CJ, Choo KJL, Ong KY, Tan V, Khoo JBN, Murthee KG, Hanif IM, Naing CS, Lee HY. Improving drug allergy label accuracy by supervised safety- and protocol-driven evaluation. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022. [DOI: 10.47102/annals-acadmedsg.2022118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction: Drug allergies are often self-reported but of unknown accuracy. We carried out a prospective study to examine the utility and safety of formal allergology evaluation, and to identify factors associated with accurate drug allergy labels.
Method: All patients who underwent drug allergy evaluation in our clinic during the study period were recruited. Baseline demographics, characteristics of index hypersensitivity reaction and outcomes of evaluation were recorded.
Results: A total of 331 patients from March 2019 to June 2021 completed drug allergy evaluation to index drugs of concern. There were 123 (37%) male patients, and the mean age was 49 years (standard deviation 17). There were 170 beta-lactam antibiotics, 53 peri-operative drugs, 43 others, 38 non-steroidal anti-inflammatory drugs, and 27 non-beta-lactam antibiotic evaluations. Index reaction occurred within 5 years in 165 (50%) patients, with latency of less than 4 hours in 125 (38%) patients. The most common index reactions were rash, angioedema and urticaria. There were 57 (17%) evaluations stratified as low risk, 222 (67%) moderate risk, and 52 (16%) high risk based on multidisciplinary consensus. Allergy label was found to be false (negative drug evaluation) in 248 (75%) patients, while 16/237 (7%) skin tests, 44/331 (13%) in-clinic graded challenge, and 23/134 (17%) home prolonged challenges were positive (true drug allergy). The most common evaluation reactions were rash and urticaria. No cases of anaphylaxis were elicited.
Conclusion: Seventy-five percent of drug allergy labels are inaccurate. Risk-stratified, protocolised allergy evaluation is safe. Prolonged drug challenge increases the sensitivity of drug allergy evaluation and should therefore be performed when indicated.
Keywords: Drug allergy, drug hypersensitivity, graded challenge, prolonged drug provocation, skin testing
Collapse
|
18
|
Antibiotic Allergy De-Labeling: A Pathway against Antibiotic Resistance. Antibiotics (Basel) 2022; 11:antibiotics11081055. [PMID: 36009924 PMCID: PMC9404790 DOI: 10.3390/antibiotics11081055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 12/10/2022] Open
Abstract
Antibiotics are one of the most frequently prescribed drugs. Unfortunately, they also are the most common cause for self-reported drug allergy, limiting the use of effective therapies. However, evidence shows that more than 90% of patients labeled as allergic to antibiotics are not allergic. Importantly, the label of antibiotic allergy, whether real or not, constitutes a major public health problem as it directly impacts antimicrobial stewardship: it has been associated with broad-spectrum antibiotic use, often resulting in the emergence of bacterial resistance. Therefore, an accurate diagnosis is crucial for de-labeling patients who claim to be allergic but are not really allergic. This review presents allergy methods for achieving successful antibiotic allergy de-labeling. Patient clinical history is often inaccurately reported, thus not being able to de-label most patients. In vitro testing offers a complementary approach but it shows limitations. Immunoassay for quantifying specific IgE is the most used one, although it gives low sensitivity and is limited to few betalactams. Basophil activation test is not validated and not available in all centers. Therefore, true de-labeling still relies on in vivo tests including drug provocation and/or skin tests, which are not risk-exempt and require specialized healthcare professionals for results interpretation and patient management. Moreover, differences on the pattern of antibiotic consumption cause differences in the diagnostic approach among different countries. A multidisciplinary approach is recommended to reduce the risks associated with the reported penicillin allergy label.
Collapse
|
19
|
De-labeling Beta-lactam in Adult Population. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00316-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
20
|
Alvarez-Cuesta E, Madrigal-Burgaleta R, Broyles AD, Cuesta-Herranz J, Guzman-Melendez MA, Maciag MC, Phillips EJ, Trubiano JA, Wong JT, Ansotegui I. Standards for practical intravenous rapid drug desensitization & delabeling: A WAO committee statement. World Allergy Organ J 2022; 15:100640. [PMID: 35694005 PMCID: PMC9163606 DOI: 10.1016/j.waojou.2022.100640] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/27/2022] [Accepted: 03/03/2022] [Indexed: 12/16/2022] Open
Abstract
Drug hypersensitivity reactions (DHRs) to intravenous drugs can be severe and might leave patients and doctors in a difficult position where an essential treatment or intervention has to be suspended. Even if virtually any intravenous medication can potentially trigger a life-threatening DHR, chemotherapeutics, biologics, and antibiotics are amongst the intravenous drugs most frequently involved in these reactions. Admittedly, suspending such treatments may negatively impact the survival outcomes or the quality of life of affected patients. Delabeling pathways and rapid drug desensitization (RDD) can help reactive patients stay on first-choice therapies instead of turning to less efficacious, less cost-effective, or more toxic alternatives. However, these are high-complexity and high-risk techniques, which usually need expert teams and allergy-specific techniques (skin testing, in vitro testing, drug provocation testing) to ensure safety, an accurate diagnosis, and personalized management. Unfortunately, there are significant inequalities within and among countries in access to allergy departments with the necessary expertise and resources to offer these techniques and tackle these DHRs optimally. The main objective of this consensus document is to create a great benefit for patients worldwide by aiding allergists to expand the scope of their practice and support them with evidence, data, and experience from leading groups from around the globe. This statement of the Drug Hypersensitivity Committee of the World Allergy Organization (WAO) aims to be a comprehensive practical guide on the technical aspects of implementing acute-onset intravenous hypersensitivity delabeling and RDD for a wide range of drugs. Thus, the manuscript does not only focus on clinical pathways. Instead, it also provides guidance on topics usually left unaddressed, namely, internal validation, continuous quality improvement, creating a healthy multidisciplinary environment, and redesigning care (including a specific supplemental section on a real-life example of how to design a dedicated space that can combine basic and complex diagnostic and therapeutic techniques in allergy).
Collapse
Affiliation(s)
| | - Ricardo Madrigal-Burgaleta
- Allergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
- Drug Desensitisation Centre, Catalan Institute of Oncology (ICO), Barcelona, Spain
- Corresponding author. Allergy & Severe Asthma Service, Respiratory Department, 4th Floor, King George V Building, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Ana D. Broyles
- Division of Allergy & Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Javier Cuesta-Herranz
- Department of Allergy and Immunology, FIIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
- RETIC ARADyAL, Instituto de Salud Carlos III, Spain
| | | | - Michelle C. Maciag
- Division of Allergy & Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth J. Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason A. Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Johnson T. Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Steering Committee AuthorsAliF. RunaMBBS, PhD, FRCPaxAngel-PereiraDenisseMDlBanerjiAleenaMDayBerges-GimenoMaria PilarMD, PhDmBernal-RubioLorenaMDmBrockowKnutMDnCardona VillaRicardoMDoCastellsMariana C.MD, PhDpCaubetJean-ChristophMDqChangYoon-SeokMD, PhDrEnsinaLuis FelipeMD, MSc, PhDsChikhladzeMananaPhDtChiriacAnca MirelaMD, PhDuChungWeng-HungMD, PhDvEbisawaMotohiroMD, PhDwFernandesBryanMBBS, MRCPaxGarveyLene HeiseMD, PhDxawGomezMaximilianoMD, PhDyGomez VeraJavierMDzGonzalez DiazSandraMD, PhDaaHongDavid I.MDpIvancevichJuan CarlosMDabKangHye-RyunMD, PhDacKhanDavid A.MDadKuruvillaMerinMDaeLarco SousaJose IgnacioMDafLatour-StaffeldPatriciaMDagLiuAnne Y.MDahMacyEricMDaiMallingHans JorgenMDajMasperoJorgeMDakMaySara M.MDalMayorgaCristobalinaPhDamParkMiguel A.MDanPeterJonathanMBChB, PhDaoPicardMatthieuMD, FRCPCapRodriguez-BouzaTitoMD, PhDaq2RomanoAntoninoMDarSanchez-BorgesMarioMDazbaTannoLuciana KaseMD, PhDuTorresMaria JoseMD, PhDamUreña-TaveraAliciaMDasValluzziRocco L.MDatVolcheckGerald W.MDauYamaguchiMasaoMD, PhDavHospital Universitario de Canarias, Tenerife, SpainAllergy Division, Ramon y Cajal University Hospital, Madrid, SpainDepartment of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, GermanyUniversidad de Antioquia, Medellín, ColombiaDivision of Allergy and Clinical Immunology, Department of Medicine, Brigham & Women's Hospital, Boston, MA, USAPediatric Allergy Unit, Geneva University Hospitals, Geneva, SwitzerlandDivision of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of KoreaDivision of Allergy, Clinical Immunology and Rheumatology, Department of Pediatrics, Federal University of Sao Paulo, BrazilMedical Faculty at Akaki Tsereteli State University, KuTaisi, Tskaltubo, GeorgiaDivision of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, FranceDepartment of Dermatology, Chang Gung Memorial Hospital, Taipei, Linko and Keelung, TaiwanClinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Kanagawa, JapanAllergy Clinic, Copenhagen University Hospital Gentofte, Copenhagen, DenmarkSchool of Health Sciences, Catholic University of Salta, ArgentinaInstitute of Security and Social Services of State Workers, López Mateos Regional Hospital, Mexico City, MexicoRegional Center of Allergy and Clinical Immunology, University Hospital “Dr. José Eleuterio González”, Gonzalitos y Madero s/n Colonia Mitras Centro, Monterrey, MexicoServicio de Alergia e Immunologia, Clinica Santa Isabel, Buenos Aires, ArgentinaInstitute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of KoreaDepartment of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USADivision of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USAAllergy Department, Clinica San Felipe, Lima, PeruCentro Avanzado de Alergia y Asma de Santo Domingo, Santo Domingo, Dominican RepublicStanford University School of Medicine, Palo Alto, CA, USASouthern California Permanente Medical Group, Kaiser Permanente Southern California, San Diego Medical Center, San Diego, CA, USADanish Allergy Centre, University of Copenhagen, Copenhagen, DenmarkAllergy and Respiratory Research Unit, Fundación CIDEA, Buenos Aires, ArgentinaDivision of Pulmonary, Critical Care, Sleep & Allergy, University of Nebraska Medical Center, Omaha, NE, USAAllergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, SpainDivision of Allergic Diseases, Mayo Clinic, Rochester, MN, USADivision of Allergology and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South AfricaDepartment of Medicine, Division of Allergy and Immunology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, CanadaCentro de Patología Alérgica, Hospital Quirón Palmaplanas, Palma, SpainOasi Research Institute – IRCCS, Troina, ItalyClinica Union Medica del Norte, Santiago, Dominican RepublicMultifactorial and Systemic Diseases Research Area, Predictive and Preventive Medicine Research Unit, Division of Allergy, Bambino Gesù Children's Hospital IRCCS, Rome, ItalyDivision of Allergic Diseases, Mayo Clinic, Rochester, MN, USADivision of Respiratory Medicine, Third Department of Medicine, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, JapanDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, DenmarkAllergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UKDivision of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USAAllergy and Clinical Immunology Department, Centro Médico Docente La Trinidad, Caracas, VenezuelaAllergy and Clinical Immunology Department, Clínica El Avila, Caracas, Venezuela
| | | |
Collapse
|
21
|
Khoury P, Srinivasan R, Kakumanu S, Ochoa S, Keswani A, Sparks R, Rider NL. A Framework for Augmented Intelligence in Allergy and Immunology Practice and Research—A Work Group Report of the AAAAI Health Informatics, Technology, and Education Committee. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE 2022; 10:1178-1188. [PMID: 35300959 PMCID: PMC9205719 DOI: 10.1016/j.jaip.2022.01.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 10/18/2022]
Abstract
Artificial and augmented intelligence (AI) and machine learning (ML) methods are expanding into the health care space. Big data are increasingly used in patient care applications, diagnostics, and treatment decisions in allergy and immunology. How these technologies will be evaluated, approved, and assessed for their impact is an important consideration for researchers and practitioners alike. With the potential of ML, deep learning, natural language processing, and other assistive methods to redefine health care usage, a scaffold for the impact of AI technology on research and patient care in allergy and immunology is needed. An American Academy of Asthma Allergy and Immunology Health Information Technology and Education subcommittee workgroup was convened to perform a scoping review of AI within health care as well as the specialty of allergy and immunology to address impacts on allergy and immunology practice and research as well as potential challenges including education, AI governance, ethical and equity considerations, and potential opportunities for the specialty. There are numerous potential clinical applications of AI in allergy and immunology that range from disease diagnosis to multidimensional data reduction in electronic health records or immunologic datasets. For appropriate application and interpretation of AI, specialists should be involved in the design, validation, and implementation of AI in allergy and immunology. Challenges include incorporation of data science and bioinformatics into training of future allergists-immunologists.
Collapse
|
22
|
Schrüfer P, Stoevesandt J, Trautmann A. Outcome of a de-labelling algorithm compared with results of penicillin (β-lactam) allergy testing. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:26. [PMID: 35317861 PMCID: PMC8941741 DOI: 10.1186/s13223-022-00659-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
Background Penicillin allergy labels frequently impede guideline-directed treatment with a penicillin or other β-lactam antibiotics. Despite presumed allergy, targeted questioning may indicate a low probability of sensitization and permit reasonably safe administration of the antibiotic in question. In this study, we evaluated a standardized algorithm aiming to differentiate non-allergic patients from those with true allergic β-lactam hypersensitivity. Methods We retrospectively applied a de-labelling algorithm in 800 consecutive patients with suspected β-lactam hypersensitivity. All had undergone complete allergy work-up permitting to definitely exclude or diagnose β-lactam allergy between 2009 and 2019. Results In 595 (74.4%) out of 800 cases evaluated, β-lactam allergy could be excluded by negative challenge testing. IgE-mediated anaphylaxis was diagnosed in 70 (8.7%) patients, delayed-type hypersensitivity in 135 (16.9%). In 62 (88.6%) anaphylaxis cases, the algorithm correctly advised to use an alternative antibiotic. Accuracy was higher in patients with moderate to severe anaphylaxis (97.7%) compared to those with a history of mild reactions (73.1%). The algorithm correctly identified 122 (90.4%) patients with proven delayed-type hypersensitivity. It permitted de-labelling in 330 (55.5%) out of 595 patients with diagnostic exclusion of penicillin hypersensitivity, but failed to identify the remaining 265 (44.5%) as low-risk cases. Conclusions The algorithm detected 89.8% of cases with penicillin (β-lactam) allergy, sensitivity was optimal for moderate to severe anaphylaxis. Study data justify the implementation of a standardized de-labelling algorithm under close supervision in order to permit guideline-directed treatment and reduce the use of broad-spectrum antibiotics as part of an antibiotic stewardship program. Supplementary Information The online version contains supplementary material available at 10.1186/s13223-022-00659-1.
Collapse
Affiliation(s)
- Philipp Schrüfer
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, 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.
| |
Collapse
|
23
|
Courtemanche J, Baril L, Clément A, Bédard MA, Plourde M, Émond M. Is it possible to identify patients at low risk of having a true penicillin allergy? CAN J EMERG MED 2022; 24:366-368. [PMID: 35301689 DOI: 10.1007/s43678-022-00286-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 02/24/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Jacob Courtemanche
- Département de Médecine Familiale et de Médecine d'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada.
| | - Laurence Baril
- Département de Médecine Familiale et de Médecine d'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Audrey Clément
- Département de Médecine Familiale et de Médecine d'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Marc-Antoine Bédard
- Département de Médecine, Service d'immunologie-allergie, CHU de Québec - Université Laval, Québec, QC, Canada
| | - Miville Plourde
- Département de Médecine d'urgence, CHU de Québec - Université Laval, Québec, QC, Canada
| | - Marcel Émond
- Département de Médecine d'urgence, CHU de Québec - Université Laval, Québec, QC, Canada
| |
Collapse
|
24
|
|
25
|
Arıkoğlu T, Kuyucu S, Caubet JC. New diagnostıc perspectives in the management of pediatrıc beta-lactam allergy. Pediatr Allergy Immunol 2022; 33:e13745. [PMID: 35338725 DOI: 10.1111/pai.13745] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 12/15/2022]
Abstract
Since overdiagnosis of beta-lactam (BL) allergy is common in the pediatric population, delabeling is a critical part of antimicrobial stewardship. Undesirable consequences of inaccurate BL allergy labeling can be handled by incorporating traditional delabeling or newer risk-based strategies into antibiotic stewardship programs. Conventional assessment of BL allergy relies upon a stepwise algorithm including a clinical history with skin testing followed by drug provocation tests (DPTs). However, a growing number of studies highlighted the suboptimal diagnostic value of skin testing in children. Recently, there has been a paradigm shift in the practice of BL allergy assessment due to recent challenging data which emphasize the safety and accuracy of direct DPTs in children with a suspicion of non-immediate mild cutaneous reactions such as maculopapular eruption, delayed urticaria, and possibly also for benign immediate reactions such as urticaria/angioedema. Identifying low-risk BL allergy patients, in whom skin tests can be skipped and proceeding directly to DPTs could be safe, has become a hot topic in recent years. New risk stratification and predictive modeling studies that have the potential to better predict BL allergy risk status have recently been introduced into the field of drug allergy, particularly in adults. However, in contrast to adults, risk assessment studies in children are rare, and optimal risk definitions are controversial. In the coming years, promising potential methods to elucidate the predictors of BL allergy in children will require multidimensional approaches that may include predictive analytics, artificial intelligence techniques, and point-of-care clinical decision tools.
Collapse
Affiliation(s)
- Tuğba Arıkoğlu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
| |
Collapse
|
26
|
Gaberino CL, Chiu AM, Mahatme SS. The effects of beta-lactam allergy relabeling on antibiotic prescribing practices. Ann Allergy Asthma Immunol 2021; 128:307-313. [PMID: 34890777 DOI: 10.1016/j.anai.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/05/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Beta-lactam antibiotic allergy labels are highly prevalent but rarely indicate an allergic intolerance. These patient-reported allergies lead to broad-spectrum antibiotic use, conferred resistance, increased expense, and adverse effects. OBJECTIVE To implement and assess the impact of a history-based clinical guideline that directs antibiotic management and beta-lactam allergy relabeling for patients reporting beta-lactam allergies. METHODS Patients with beta-lactam allergy labels were identified by our trained multidisciplinary team in diverse clinical settings. This quality improvement project was conducted to evaluate the safety and impact of the guideline on antibiotic use by comparing prescribing practices before and after guideline implementation. RESULTS A total of 79 patients with beta-lactam allergies were identified (penicillins-90%, cephalosporins-10%). After guideline implementation, outcomes of allergy relabeling included the following: (1) complete removal, indicating an unlikely true allergy (27%); (2) updated to detail successfully tolerated beta-lactam courses (48%); or (3) no change made to current label (25%). Beta-lactam antibiotic courses before and after guideline implementation compared with total antibiotic courses: allergy removed (44% vs 70%; P < .001), allergy updated (32% vs 68%; P < .001), and no change (27% vs 41%; P = .08). Compared with before guideline implementation, beta-lactam antibiotics were 3 times more likely to be prescribed after allergy assessment (odds ratio, 3.22; 95% confidence interval, 2.4-4.3; P < .05). CONCLUSION The implementation of the beta-lactam allergy clinical guideline resulted in most patients' allergy labels being removed or advantageously updated. These allergy label changes correlated with a substantial increase in the percentage of beta-lactam antibiotics prescribed. After guideline implementation, beta-lactam antibiotics had a 3-fold increased odds of being prescribed independent of allergy label outcome.
Collapse
Affiliation(s)
- Courtney L Gaberino
- Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Asriani M Chiu
- Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; Division of Asthma, Allergy, and Clinical Immunology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sheran S Mahatme
- Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| |
Collapse
|
27
|
Syrowatka A, Song W, Amato MG, Foer D, Edrees H, Co Z, Kuznetsova M, Dulgarian S, Seger DL, Simona A, Bain PA, Purcell Jackson G, Rhee K, Bates DW. Key use cases for artificial intelligence to reduce the frequency of adverse drug events: a scoping review. Lancet Digit Health 2021; 4:e137-e148. [PMID: 34836823 DOI: 10.1016/s2589-7500(21)00229-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 08/13/2021] [Accepted: 09/10/2021] [Indexed: 12/31/2022]
Abstract
Adverse drug events (ADEs) represent one of the most prevalent types of health-care-related harm, and there is substantial room for improvement in the way that they are currently predicted and detected. We conducted a scoping review to identify key use cases in which artificial intelligence (AI) could be leveraged to reduce the frequency of ADEs. We focused on modern machine learning techniques and natural language processing. 78 articles were included in the scoping review. Studies were heterogeneous and applied various AI techniques covering a wide range of medications and ADEs. We identified several key use cases in which AI could contribute to reducing the frequency and consequences of ADEs, through prediction to prevent ADEs and early detection to mitigate the effects. Most studies (73 [94%] of 78) assessed technical algorithm performance, and few studies evaluated the use of AI in clinical settings. Most articles (58 [74%] of 78) were published within the past 5 years, highlighting an emerging area of study. Availability of new types of data, such as genetic information, and access to unstructured clinical notes might further advance the field.
Collapse
Affiliation(s)
- Ania Syrowatka
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Wenyu Song
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mary G Amato
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
| | - Dinah Foer
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Heba Edrees
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
| | - Zoe Co
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Sevan Dulgarian
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Diane L Seger
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Aurélien Simona
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Paul A Bain
- Countway Library of Medicine, Harvard Medical School, Boston, MA, USA
| | - Gretchen Purcell Jackson
- IBM Watson Health, Cambridge, MA, USA; Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kyu Rhee
- IBM Watson Health, Cambridge, MA, USA; CVS Health, Wellesley Hills, MA, USA
| | - David W Bates
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Harvard T H Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
28
|
Demirhan A, Yildirim DD, Arikoglu T, Ozhan AK, Tokmeci N, Yuksek BC, Kuyucu S. A combined risk modeling strategy for clinical prediction of beta-lactam allergies in children. Allergy Asthma Proc 2021; 42:e159-e166. [PMID: 34871164 DOI: 10.2500/aap.2021.42.210068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Drug provocation test (DPT) without skin tests is increasingly recommended in the evaluation of children with low-risk beta-lactam (BL) allergies. However, risk definitions are unclear. Objective: The aim of this study was to compose a clinical predictive model that could identify the children at low risk who could safely undergo direct DPT. Methods: The clinical data of 204 children who underwent a full diagnostic algorithm for suspected BL allergy were analyzed. Clinical data were used to construct mathematical predictive model for confirmed BL allergies. A prospective new sample was used for external validation of the final model. Results: The presentations during the index reaction were anaphylaxis in 5.9% and cutaneous reactions in the majority. BL allergy was confirmed in 15.7% of suspected cases. A backward multiple logistic regression model showed that a family history of drug allergy (adjusted odds ratio [aOR], 5.52), anaphylaxis (aOR, 5.14), any atopic disease other than asthma (aOR, 4.38), and a reaction interval of 0-6 hours during the index reaction (aOR, 5.32) were significantly associated with a confirmed BL allergy. A mathematical combined model based on these factors showed a sensitivity of 77.8% and a negative predictive value (NPV) of 94.3%. The validation study replicated sensitivity and NPV values of the main cohort. Conclusion: The risk definition in BL allergies should depend on population-specific predictive models, including a combination of significant risk factors rather than empiric risk approaches. This may help to accurately determinate children at low risk who may safely proceed to direct DPT.
Collapse
Affiliation(s)
- Ali Demirhan
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Didem D. Yildirim
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Tugba Arikoglu
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Aylin K. Ozhan
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Nazan Tokmeci
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Burcu C. Yuksek
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Semanur Kuyucu
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| |
Collapse
|
29
|
Arikoglu T, Kont AO, Demirhan A, Yuksek BC, Tokmeci N, Kuyucu S. Risk stratification in beta-lactam allergy. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00295-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
30
|
Abstract
PURPOSE OF REVIEW Understand how the clinical history has been used to risk stratify patients reporting a beta-lactam allergy, both in clinical care pathways and predictive models. RECENT FINDINGS Drug allergy clinical care pathways have emerged as a safe and effective method of stratifying patients with a reported beta-lactam allergy into risk categories, with 'low-risk' patients able to proceed straight to direct challenges or test doses. These methods have streamlined antibiotic stewardship policies and penicillin allergy de-labeling. However, how to define 'low-risk' has been subject to much debate. New research has developed predictive models that utilize the clinical history to assess a patient's true risk of beta-lactam allergy. SUMMARY The clinical history has long been an essential part of drug allergy evaluation and has proven invaluable within the past decade in the development of drug allergy clinical pathways. Evidence-based predictive models that use the clinical history to assess a patient's true risk of beta-lactam allergy offer tremendous promise, but differ in crucial areas such as the populations they study, the predictor variables they use, and the ultimate accuracy they attain. These models highlight key aspects of the drug allergy history and pave the way for future large-scale research.
Collapse
Affiliation(s)
| | - Allen Judd
- Division of Rheumatology, Allergy and Immunology, Department of Medicine
| | - Kimberly Blumenthal
- Medical Practice Evaluation Center
- The Mongan Institute, Massachusetts General Hospital
- Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
31
|
Piotin A, Godet J, Trubiano JA, Grandbastien M, Guénard-Bilbault L, de Blay F, Metz-Favre C. Predictive factors of amoxicillin immediate hypersensitivity and validation of PEN-FAST clinical decision rule. Ann Allergy Asthma Immunol 2021; 128:27-32. [PMID: 34271183 DOI: 10.1016/j.anai.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/12/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The challenge of delabeling amoxicillin allergy is an important issue for patients and clinicians, especially when anaphylaxis is reported. A recent study has proposed a clinical decision rule, PEN-FAST, to identify low-risk penicillin allergies. OBJECTIVE To validate the PEN-FAST clinical decision rule in a population with high risk of suspected immediate amoxicillin allergy and to identify clinical predictive factors of amoxicillin immediate hypersensitivity. METHODS We retrospectively analyzed medical records of patients with a suspected immediate amoxicillin allergy who carried out an allergologic evaluation by a specialist in the Allergy Unit of Strasbourg University Hospital from 2015 to 2020. RESULTS A total of 142 adult patients (88 women [62.0%]; median age, 52 [interquartile range, 40.3-62.0] years) were analyzed. Most of them reported anaphylaxis (68.8%). Internal validation of PEN-FAST score revealed a good discrimination with area under the curve of 0.86 (95% confidence interval, 0.79-0.92). A cutoff of less than 3 points for PEN-FAST was used to classify 29 from 142 patients at low risk of allergy, of whom only 2 (6.9%) received positive results of allergy testing. The negative predictive value for successful delabeling was 0.93 (95% confidence interval, 0.77-0.99). Predictive clinical features for immediate amoxicillin hypersensitivity were time since reaction (P < .001), time elapsed between drug intake and first symptom (P < .001), severity grade reaction (P < .001), and treatment or hospitalization required (P < .001). CONCLUSION PEN-FAST has been validated to identify low-risk penicillin allergies in our European cohort of patients mainly reporting anaphylaxis. This is the first reported external validation of a penicillin allergy clinical decision rule internationally.
Collapse
Affiliation(s)
- Anays Piotin
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France.
| | - Julien Godet
- Public Health Department, Strasbourg University Hospital, Strasbourg, France
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Australia; Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Manon Grandbastien
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France
| | | | - Frédéric de Blay
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France; EA 3070 Federation of Translational Medicine, FHU Homicare, University of Strasbourg, Strasbourg, France
| | - Carine Metz-Favre
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France
| |
Collapse
|
32
|
Sabato V, Gaeta F, Valluzzi RL, Van Gasse A, Ebo DG, Romano A. Urticaria: The 1-1-1 Criterion for Optimized Risk Atratification in β-Lactam Allergy Delabeling. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3697-3704. [PMID: 34146749 DOI: 10.1016/j.jaip.2021.05.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/13/2021] [Accepted: 05/31/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND A spurious label of β-lactam allergy compromises antibiotic stewardship. Delabeling protocols based on direct challenges (ie, not preceded by allergy tests) can be applied in low-risk patients. OBJECTIVE This study aims at determining the significance of the characteristics of urticaria in the risk stratification for delabeling. METHODS The characteristics of urticarial eruptions that had occurred during therapeutic courses with a β-lactam, namely the time interval between the exposure and onset, the dose (first or subsequent) after which urticaria appeared, and the duration of the eruption, were correlated to the results of a systematic allergy workup (skin tests, specific IgE measurements, and challenges). Data from 410 patients enrolled in 3 allergy centers (Rome and Troina, Italy, and Antwerp, Belgium) were analyzed. A multivariable logistic regression was performed, which included appearance within 1 hour after the first dose and regression within 1 day: a model that can be summarized as the "1-1-1" urticaria criterion. RESULTS An urticarial eruption that had appeared within 1 hour after the first dose and had regressed within 1 day was more frequently reported in the group with a positive allergy workup, with odds ratios of 17 (95% confidence interval [CI]: 9-31), 11 (95% CI: 6-20), and 48 (95% CI: 14-157), respectively (P < .005). The 1-1-1 criterion displayed a sensitivity and specificity of 85%, and a negative predictive value and a positive predictive value of 80% and 90%, respectively. CONCLUSION Patients with urticaria meeting the 1-1-1 criterion should be considered at high risk and referred for an allergy workup with skin testing and specific IgE measurement before challenging.
Collapse
Affiliation(s)
- Vito Sabato
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; Allergology Unit, AZ Jan Palfijn, Ghent, Belgium; Infla-Med Centre of Excellence, University of Antwerp, Antwerpen, Belgium
| | - Francesco Gaeta
- Allergy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rocco Luigi Valluzzi
- Multifactorial and Systemic Diseases Research Area, Predictive and Preventive Medicine Research Unit, Division of Allergy, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Athina Van Gasse
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Didier Gaston Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; Allergology Unit, AZ Jan Palfijn, Ghent, Belgium; Infla-Med Centre of Excellence, University of Antwerp, Antwerpen, Belgium.
| | | |
Collapse
|
33
|
Al-Ahmad M, Edin J, Musa F, Rodriguez-Bouza T. Drug Allergy Profile From a National Drug Allergy Registry. Front Pharmacol 2021; 11:555666. [PMID: 33542684 PMCID: PMC7851708 DOI: 10.3389/fphar.2020.555666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 11/09/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Drug hypersensitivity reactions (DHRs) are among the most frequent reasons for consultation in allergy departments and are becoming more common due to increasing prevalence and case complexity. Objective: To describe the most common drugs associated with clinical reactions, diagnostic methods used, and outcomes of allergic evaluations of a national drug allergy registry over a 12-year period were used. Methods: An observational, prospective, patient’s data registry-based study was conducted to analyze all referrals to the drug allergy outpatient clinics at Al-Rashed Allergy Center, Kuwait, between 2007 and 2019. Demographics, description of DHRs, and results of allergy tests to potential causative medications were reviewed. Diagnostic methods were focused mainly on skin tests (STs) and drug provocation test (DPT), when indicated. Results: We evaluated 1,553 patients with reported DHRs. The mean age of the population was 41.52 ± 16.93 years, and the study population consisted of 63.7% female patients. Hypersensitivity was finally confirmed in 645 (41.5%) of patients, probable in 199 (12.8%), and not confirmed/nonallergic in 709 (45.6%) patients. Anti-inflammatory drugs and analgesics contributed to 39.22% of all confirmed drug allergies, followed by antibiotics 38.1% (β-lactam antibiotics (BLs) constituted 73.98% of all antibiotics and 28.21% of all drugs), anesthetics 1.8%, and radio-contrast media 0.31%. The majority of reactions were non-immediate 51.44%. The most commonly presenting symptoms among confirmed patients were urticaria 57.80%, angioedema 42.50%, respiratory symptoms 47.60%, and erythema 33.60%. Symptoms of anaphylaxis/anaphylactic shock were reported by 284 patients (44.00%) among confirmed cases. The most common method of diagnosis was a positive clinical history (54.4% in BLs and 90.45% in nonsteroidal anti-inflammatory drugs (NSAIDs). Among confirmed allergy to BLs, a positive ST was obtained in 31.9% of patients and positive DPT in 13.7%. Conclusion: NSAIDs and antibiotics, mainly BLs, are the most commonly implicated in confirmed allergy. In both confirmed and not confirmed/nonallergic cases, BLs are the most frequently involved DHRs which are mainly immediate, and the most commonly presenting symptoms were urticaria, angioedema, and respiratory symptoms. Diagnosis was confirmed mainly by a positive clinical history and when indicated, by positive STs or a DPT.
Collapse
Affiliation(s)
- Mona Al-Ahmad
- Al Rashed Allergy Centre, Ministry of Health, Kuwait.,Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait
| | - Jusufovic Edin
- Medical Faculty, University of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Fardous Musa
- Al Rashed Allergy Centre, Ministry of Health, Kuwait
| | | |
Collapse
|
34
|
Rosti B, Mahler V. Adding a second skin prick test reading and modifying the cut‐off for beta‐lactam–specific
IgE
enhances the sensitivity in the routine diagnostic workup for immediate beta‐lactam hypersensitivity. Contact Dermatitis 2020; 83:361-371. [DOI: 10.1111/cod.13622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Bernadette Rosti
- Allergy‐Clinic of the Department of Dermatology University Hospital of Erlangen Erlangen Germany
- Dental Practice Dr. Ludwig and Colleagues MVZ GmbH Fürth Germany
| | - Vera Mahler
- Allergy‐Clinic of the Department of Dermatology University Hospital of Erlangen Erlangen Germany
- Division of Allergology Paul‐Ehrlich‐Institut Langen Germany
| |
Collapse
|
35
|
Blumenthal KG, Harkness T, Phillips EJ, Ramsey A, Banerji A, Samarakoon U, Stone C, Fu X, Khan DA, Otani I, Camargo CA, Zhang Y, Donelan K, Blumenthal KG, Banerji A, Harkness T, Mancini CM, Samarakoon U, Ahola CM, Judd AD, Arman W, Phillips E, Stone C, Williams K, Osea RE, Ramsey A, Mustafa SS, Blue H, Otani I, Guyer A, Khan D. Patient Characteristics and Concerns about Drug Allergy: A Report from the United States Drug Allergy Registry. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2958-2967. [DOI: 10.1016/j.jaip.2020.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/29/2020] [Accepted: 08/19/2020] [Indexed: 12/11/2022]
|
36
|
Moreno EM, Moreno V, Laffond E, Gracia-Bara MT, Muñoz-Bellido FJ, Macías EM, Curto B, Campanon MV, de Arriba S, Martin C, Davila I. Usefulness of an Artificial Neural Network in the Prediction of β-Lactam Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2974-2982.e1. [PMID: 32702519 DOI: 10.1016/j.jaip.2020.07.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 07/01/2020] [Accepted: 07/06/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND An accurate diagnosis of β-lactam (BL) allergy improves the use of antibiotics, increases patients' safety, and reduces costs to health systems. Nevertheless, it requires skin and drug provocation tests, which are time-consuming and put the patient at risk. Furthermore, allergy testing is not available in circumstances such as the urgent need for antibiotic therapy. OBJECTIVE To evaluate the usefulness of an artificial neural network (ANN) in the prediction of hypersensitivity to BLs, and compare it with logistic regression (LR) analysis. METHODS In a single-center study, 656 patients evaluated for BL allergy between 1994 and 2000 were retrospectively analyzed, and the data were used to construct an ANN. The ANN predictive capabilities were compared with LR and then prospectively evaluated in 615 patients who underwent BL evaluation between 2011 and 2017. RESULTS A total of 1271 patients were evaluated. All patients had a definite diagnosis as allergic or nonallergic to BL. The prospective sample showed a lower percentage of patients with allergy than the retrospective sample (20.7% vs 25.8%; P = .018). In the retrospective and prospective series, the ANN reached a sensitivity of 89.5% and 81.1%, a specificity of 86.1% and 97.9%, a positive predictive value of 82.1% and 91.1%, and a negative predictive value of 92.1% and 95.2%, respectively. The ANN's performance was far superior to that of the LR, whose best performance reached a sensitivity of 31.9% and a specificity of 98.8%. CONCLUSIONS This ANN demonstrated a superior performance than the LR in predicting BL hypersensitivity without misdiagnosing severe allergic reactions. The ANN could be a helpful tool to classify the reaction risk, particularly in the identification of low-risk patients, in which an open challenge could be done to delabel patients.
Collapse
Affiliation(s)
- Esther M Moreno
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain; Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Department of Biomedical and Diagnostic Sciences, Salamanca Medical School, University of Salamanca, Salamanca, Spain; RETIC de Asma, Reacciones adversas y Alérgicas (ARADYAL), Madrid, Spain
| | - Vidal Moreno
- Department of Computer Science and Automation, University of Salamanca, Salamanca, Spain.
| | - Elena Laffond
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain; Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Department of Biomedical and Diagnostic Sciences, Salamanca Medical School, University of Salamanca, Salamanca, Spain
| | - M Teresa Gracia-Bara
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain; Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Francisco J Muñoz-Bellido
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain; Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Department of Biomedical and Diagnostic Sciences, Salamanca Medical School, University of Salamanca, Salamanca, Spain
| | - Eva M Macías
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain; Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Department of Biomedical and Diagnostic Sciences, Salamanca Medical School, University of Salamanca, Salamanca, Spain
| | - Belen Curto
- Department of Computer Science and Automation, University of Salamanca, Salamanca, Spain
| | - M Valle Campanon
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain
| | - Sonia de Arriba
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain; Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Department of Biomedical and Diagnostic Sciences, Salamanca Medical School, University of Salamanca, Salamanca, Spain
| | - Cristina Martin
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain
| | - Ignacio Davila
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain; Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Department of Biomedical and Diagnostic Sciences, Salamanca Medical School, University of Salamanca, Salamanca, Spain; RETIC de Asma, Reacciones adversas y Alérgicas (ARADYAL), Madrid, Spain
| |
Collapse
|
37
|
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: 163] [Impact Index Per Article: 40.8] [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.
Collapse
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
| |
Collapse
|
38
|
Trubiano JA, Vogrin S, Chua KYL, Bourke J, Yun J, Douglas A, Stone CA, Yu R, Groenendijk L, Holmes NE, Phillips EJ. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med 2020; 180:745-752. [PMID: 32176248 PMCID: PMC7076536 DOI: 10.1001/jamainternmed.2020.0403] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Penicillin allergy is a significant public health issue for patients, antimicrobial stewardship programs, and health services. Validated clinical decision rules are urgently needed to identify low-risk penicillin allergies that potentially do not require penicillin skin testing by a specialist. OBJECTIVE To develop and validate a penicillin allergy clinical decision rule that enables point-of-care risk assessment of patient-reported penicillin allergies. DESIGN, SETTING, AND PARTICIPANTS In this diagnostic study, a multicenter prospective antibiotic allergy-tested cohort of 622 patients from 2 tertiary care sites in Melbourne, Australia (Austin Health and Peter MacCallum Cancer Centre) was used for derivation and internal validation of a penicillin allergy decision rule. Backward stepwise logistic regression was used to derive the model, including clinical variables predictive of a positive penicillin allergy test result. Internal validation of the final model used bootstrapped samples and the model scoring derived from the coefficients. External validation was performed in retrospective penicillin allergy-tested cohorts consisting of 945 patients from Sydney and Perth, Australia, and Nashville, Tennessee. Patients who reported a penicillin allergy underwent penicillin allergy testing using skin prick, intradermal, or patch testing and/or oral challenge (direct or after skin testing). Data were collected from June 26, 2008, to June 3, 2019, and analyzed from January 9 to 12, 2019. MAIN OUTCOMES AND MEASURES The primary outcome for the model was any positive result of penicillin allergy testing performed during outpatient or inpatient assessment. RESULTS From an internal derivation and validation cohort of 622 patients (367 female [59.0%]; median age, 60 [interquartile range{IQR}, 48-71] years) and an external validation cohort of 945 patients (662 female [70.1%]; median age, 55 [IQR, 38-68] years), the 4 features associated with a positive penicillin allergy test result on multivariable analysis were summarized in the mnemonic PEN-FAST: penicillin allergy, five or fewer years ago, anaphylaxis/angioedema, severe cutaneous adverse reaction (SCAR), and treatment required for allergy episode. The major criteria included an allergy event occurring 5 or fewer years ago (2 points) and anaphylaxis/angioedema or SCAR (2 points); the minor criterion (1 point), treatment required for an allergy episode. Internal validation showed minimal mean optimism of 0.003 with internally validated area under the curve of 0.805. A cutoff of less than 3 points for PEN-FAST was chosen to classify a low risk of penicillin allergy, for which only 17 of 460 patients (3.7%) had positive results of allergy testing, with a negative predictive value of 96.3% (95% CI, 94.1%-97.8%). External validation resulted in similar findings. CONCLUSIONS AND RELEVANCE In this study, PEN-FAST was found to be a simple rule that accurately identified low-risk penicillin allergies that do not require formal allergy testing. The results suggest that a PEN-FAST score of less than 3, associated with a high negative predictive value, could be used by clinicians and antimicrobial stewardship programs to identify low-risk penicillin allergies at the point of care.
Collapse
Affiliation(s)
- Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia.,Peter MacCallum Cancer Centre, Department of Infectious Diseases and The National Centre for Infections in Cancer, Parkville, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Australia
| | - Kyra Y L Chua
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Australia
| | - Jack Bourke
- Department of Allergy and Immunology, Fiona Stanley Hospital, Murdoch, Australia
| | - James Yun
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Abby Douglas
- Peter MacCallum Cancer Centre, Department of Infectious Diseases and The National Centre for Infections in Cancer, Parkville, Australia
| | - Cosby A Stone
- Department of Infectious Diseases, Vanderbilt University Medical Centre, Nashville, Tennessee
| | - Roger Yu
- Department of Infectious Diseases, Vanderbilt University Medical Centre, Nashville, Tennessee
| | | | - Natasha E Holmes
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Australia
| | - Elizabeth J Phillips
- Department of Infectious Diseases, Vanderbilt University Medical Centre, Nashville, Tennessee.,Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| |
Collapse
|
39
|
Mayorga C, Fernandez TD, Montañez MI, Moreno E, Torres MJ. Recent developments and highlights in drug hypersensitivity. Allergy 2019; 74:2368-2381. [PMID: 31557314 DOI: 10.1111/all.14061] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 12/12/2022]
Abstract
Drug hypersensitivity reactions (DHRs) are nowadays the third cause of allergy after rhinitis and asthma with a significant increase in prevalence in both adults and paediatric population with new drugs included as culprit. For this, DHRs represent not only a health problem but also a significant financial burden for affected individuals and health systems. Mislabelling DHRs is showing to be a relevant problem for both, false label of drug allergic and false label of nonallergic. All this reinforces the need to improve accurate diagnostic approaches that allow an appropriate management. Moreover, there is a need for training both, nonallergist stakeholders and patients to improve the reaction identification and therefore decrease the mislabelling. The use of allergy cards has shown to be relevant to avoid the induction of DHRs due to the prescription of wrong medication. Recent developments over the last 2 years and highlights about risk factors, diagnostic approaches, mechanisms involved as well as prevention actions, and management have been reviewed. In these papers, it has been outlined the need for correct diagnosis and de-labelling of patients previously false-reported as allergic, which will improve the management and treatment of patients with DHRs.
Collapse
Affiliation(s)
- Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
| | - Tahia D. Fernandez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Maria Isabel Montañez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
| | - Esther Moreno
- Allergy Unit Hospital Universitario de Salamanca‐ARADyAL IBSAL Salamanca Spain
| | - María José Torres
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
- Universidad de Málaga Málaga Spain
| |
Collapse
|
40
|
Regateiro F, Rezende I, Pinto N, Abreu C, Carreiro-Martins P, Gomes E. Short and extended provocation tests have similar negative predictive value in non-immediate hypersensitivity to beta-lactams in children. Allergol Immunopathol (Madr) 2019; 47:477-483. [PMID: 30910271 DOI: 10.1016/j.aller.2019.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Drug provocation tests (DPTs) are the gold-standard method to diagnose non-immediate hypersensitivity reactions (NIHSR) to beta-lactam antibiotics (BL) in children. Our aim was to compare the negative predictive value (NPV) of one-day (short) DPT versus 3-7 days (extended) DPT for the diagnosis of NIHSR to BL in paediatric age. A secondary aim was to compare confidence on drug re-exposure after short and extended negative DPTs. METHODS The occurrence of HSR on drug re-exposure and drug refusal after negative diagnostic DPTs were evaluated in children/adolescents with a history of NIHSR to BL using a questionnaire performed six months to ten years after DPT. Patients were divided into two groups according to the protocol performed: short DPT vs. extended DPT. RESULTS We enrolled 212 children and adolescents (86 females, 126 males, mean age at DPT 5.52 years, p25=3 years, p75=7.25 years): 69 tested with short DPT, and 143 with extended DPT. The NPV of both types of DPT together was 95.2%. The NPV of short DPT was 97.5% and the NPV of extended DPT was 93.8% (p=0.419). After negative DPT, beta-lactams were refused by carers in 14.75% of the children requiring subsequent treatment, 6.98% in the short DPT group and 18.99% in the extended DPT group (p=0.074). CONCLUSIONS In our paediatric sample, prolonging drug administration did not increase the NPV of diagnostic DPT for NIHSR to BL or reduce drug refusal. Altogether, the data here reported suggest that, however intuitive, prolonging DPT is not beneficial in the parameters analysed.
Collapse
|
41
|
Ramsey A, Sheikh A. Innovations in Health Care Delivery: Drug Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2143-2150. [DOI: 10.1016/j.jaip.2019.04.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/18/2019] [Accepted: 04/23/2019] [Indexed: 01/03/2023]
|
42
|
Risk Stratification and Prediction in Beta-Lactam Allergic Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2182-2184. [DOI: 10.1016/j.jaip.2019.05.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/10/2019] [Indexed: 11/23/2022]
|
43
|
|
44
|
Christodoulou E, Ma J, Collins GS, Steyerberg EW, Verbakel JY, Van Calster B. A systematic review shows no performance benefit of machine learning over logistic regression for clinical prediction models. J Clin Epidemiol 2019; 110:12-22. [PMID: 30763612 DOI: 10.1016/j.jclinepi.2019.02.004] [Citation(s) in RCA: 793] [Impact Index Per Article: 158.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/18/2019] [Accepted: 02/05/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The objective of this study was to compare performance of logistic regression (LR) with machine learning (ML) for clinical prediction modeling in the literature. STUDY DESIGN AND SETTING We conducted a Medline literature search (1/2016 to 8/2017) and extracted comparisons between LR and ML models for binary outcomes. RESULTS We included 71 of 927 studies. The median sample size was 1,250 (range 72-3,994,872), with 19 predictors considered (range 5-563) and eight events per predictor (range 0.3-6,697). The most common ML methods were classification trees, random forests, artificial neural networks, and support vector machines. In 48 (68%) studies, we observed potential bias in the validation procedures. Sixty-four (90%) studies used the area under the receiver operating characteristic curve (AUC) to assess discrimination. Calibration was not addressed in 56 (79%) studies. We identified 282 comparisons between an LR and ML model (AUC range, 0.52-0.99). For 145 comparisons at low risk of bias, the difference in logit(AUC) between LR and ML was 0.00 (95% confidence interval, -0.18 to 0.18). For 137 comparisons at high risk of bias, logit(AUC) was 0.34 (0.20-0.47) higher for ML. CONCLUSION We found no evidence of superior performance of ML over LR. Improvements in methodology and reporting are needed for studies that compare modeling algorithms.
Collapse
Affiliation(s)
- Evangelia Christodoulou
- Department of Development & Regeneration, KU Leuven, Herestraat 49 box 805, Leuven, 3000 Belgium
| | - Jie Ma
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef 2, Leiden, 2333 ZA The Netherlands
| | - Jan Y Verbakel
- Department of Development & Regeneration, KU Leuven, Herestraat 49 box 805, Leuven, 3000 Belgium; Department of Public Health & Primary Care, KU Leuven, Kapucijnenvoer 33J box 7001, Leuven, 3000 Belgium; Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG UK
| | - Ben Van Calster
- Department of Development & Regeneration, KU Leuven, Herestraat 49 box 805, Leuven, 3000 Belgium; Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef 2, Leiden, 2333 ZA The Netherlands.
| |
Collapse
|
45
|
Outcomes from an inpatient beta-lactam allergy guideline across a large US health system. Infect Control Hosp Epidemiol 2019; 40:528-535. [PMID: 30915929 PMCID: PMC6536839 DOI: 10.1017/ice.2019.50] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: To assess the safety of, and subsequent allergy documentation associated with, an antimicrobial stewardship intervention consisting of test-dose challenge procedures prompted by an electronic guideline for hospitalized patients with reported β-lactam allergies. Design: Retrospective cohort study. Setting: Large healthcare system consisting of 2 academic and 3 community acute-care hospitals between April 2016 and December 2017. Methods: We evaluated β-lactam antibiotic test-dose outcomes, including adverse drug reactions (ADRs), hypersensitivity reactions (HSRs), and electronic health record (EHR) allergy record updates. HSR predictors were examined using a multivariable logistic regression model. Modification of the EHR allergy record after test doses considered relevant allergy entries added, deleted, and/or specified. Results: We identified 1,046 test-doses: 809 (77%) to cephalosporins, 148 (14%) to penicillins, and 89 (9%) to carbapenems. Overall, 78 patients (7.5%; 95% confidence interval [CI], 5.9%–9.2%) had signs or symptoms of an ADR, and 40 (3.8%; 95% CI, 2.8%–5.2%) had confirmed HSRs. Most HSRs occurred at the second (ie, full-dose) step (68%) and required no treatment beyond drug discontinuation (58%); 3 HSR patients were treated with intramuscular epinephrine. Reported cephalosporin allergy history was associated with an increased odds of HSR (odds ratio [OR], 2.96; 95% CI, 1.34–6.58). Allergies were updated for 474 patients (45%), with records specified (82%), deleted (16%), and added (8%). Conclusion: This antimicrobial stewardship intervention using β-lactam test-dose procedures was safe. Overall, 3.8% of patients with β-lactam allergy histories had an HSR; cephalosporin allergy histories conferred a 3-fold increased risk. Encouraging EHR documentation might improve this safe, effective, and practical acute-care antibiotic stewardship tool.
Collapse
|
46
|
Siew LQC, Li PH, Watts TJ, Thomas I, Ue KL, Caballero MR, Rutkowski K, Till SJ, Pillai P, Haque R. Identifying Low-Risk Beta-Lactam Allergy Patients in a UK Tertiary Centre. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2173-2181.e1. [PMID: 30922992 DOI: 10.1016/j.jaip.2019.03.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 02/19/2019] [Accepted: 03/12/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND There are marked geographical as well as temporal differences in patient sensitization profiles to β-lactams (BL). OBJECTIVE To determine the utility of skin test reagents and identify a cohort of patients where skin testing can be safely omitted in a cohort of patients referred to a UK tertiary referral center. METHODS A retrospective study of the clinical characteristics of 1092 patients referred for BL allergy testing was analyzed using multivariate regression analysis. The effectiveness of skin test reagents was also evaluated. RESULTS Multivariate logistic regression identified that a history of anaphylaxis (odds ratio [OR] 10.98, P = .001) and the patients' recall of the index drug (apart from ampicillin and meropenem, OR 3.51-12.43, P < .05) were independent predictors of type I BL allergic status and a time of less than 1 year elapsed since index reaction significantly increasing the odds of a patient with a history of anaphylaxis, having a type I BL allergy (OR 38.66, P = .003). An absence of anaphylactic severity, unknown name of the index drug and a reaction occurring more than 1 year before testing, has a negative predictive value (NPV) of 98.4%, which was similar to the NPV of skin testing of 98.9% for type I BL allergy. The NPV of skin testing with benzylpenicillin + amoxicillin ± index BL was similar with (98.9%) or without (98.1%) the use of benzylpenicillin polylysine and minor determinant for type I BL allergy. CONCLUSION We identified a "low risk" cohort of patients where the history is of similar reliability to skin testing in predicting nonallergic status for BL allergy.
Collapse
Affiliation(s)
- Leonard Quok Chean Siew
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK; Peter Gorer Department of Immunobiology, Guy's Hospital, King's College London, London, UK.
| | - Philip Hei Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Timothy J Watts
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK
| | - Iason Thomas
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK; Peter Gorer Department of Immunobiology, Guy's Hospital, King's College London, London, UK
| | - Kok Loong Ue
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK; Peter Gorer Department of Immunobiology, Guy's Hospital, King's College London, London, UK
| | - M Rosario Caballero
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK
| | - Krzysztof Rutkowski
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK
| | - Stephen J Till
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK; Peter Gorer Department of Immunobiology, Guy's Hospital, King's College London, London, UK
| | - Prathap Pillai
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK; Peter Gorer Department of Immunobiology, Guy's Hospital, King's College London, London, UK
| | - Rubaiyat Haque
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK; Peter Gorer Department of Immunobiology, Guy's Hospital, King's College London, London, UK
| |
Collapse
|
47
|
Savic LC, Khan DA, Kopac P, Clarke RC, Cooke PJ, Dewachter P, Ebo DG, Garcez T, Garvey LH, Guttormsen AB, Hopkins PM, Hepner DL, Kolawole H, Krøigaard M, Laguna JJ, Marshall SD, Mertes PM, Platt PR, Rose MA, Sabato V, Sadleir PHM, Savic S, Takazawa T, Voltolini S, Volcheck GW. Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations. Br J Anaesth 2019; 123:e82-e94. [PMID: 30916014 DOI: 10.1016/j.bja.2019.01.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/21/2018] [Accepted: 01/09/2019] [Indexed: 11/30/2022] Open
Abstract
Unsubstantiated penicillin-allergy labels are common in surgical patients, and can lead to significant harm through avoidance of best first-line prophylaxis of surgical site infections and increased infection with resistant bacterial strains. Up to 98% of penicillin-allergy labels are incorrect when tested. Because of the scarcity of trained allergists in all healthcare systems, only a minority of surgical patients have the opportunity to undergo testing and de-labelling before surgery. Testing pathways can be modified and shortened in selected patients. A variety of healthcare professionals can, with appropriate training and in collaboration with allergists, provide testing for selected patients. We review how patients might be assessed, the appropriate testing strategies that can be used, and the minimum standards of safe testing.
Collapse
Affiliation(s)
- L C Savic
- Anaesthetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - D A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - P Kopac
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - R C Clarke
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Nedlands, Western Australia, Australia
| | - P J Cooke
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - P Dewachter
- Service d'Anesthésie-Réanimation, Groupe Hospitalier de Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris 13, Sorbonne-Paris-Cité, Paris, France
| | - D G Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - T Garcez
- Department of Immunology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - L H Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - A B Guttormsen
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - P M Hopkins
- Anaesthetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - D L Hepner
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA, USA
| | - H Kolawole
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia; Department of Anaesthesia, Peninsula Health, Melbourne, Australia
| | - M Krøigaard
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital, Gentofte, Denmark
| | - J J Laguna
- Allergy Unit, Allergo-Anaesthesia Unit, Hospital Central de la Cruz Roja, Faculty of Medicine, Alfonso X El Sabio University, ARADyAL, Madrid, Spain
| | - S D Marshall
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia; Department of Anaesthesia, Peninsula Health, Melbourne, Australia
| | - P M Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France
| | - P R Platt
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Nedlands, Western Australia, Australia
| | - M A Rose
- Department of Anaesthesia, Royal North Shore Hospital, and University of Sydney, Sydney, NSW, Australia
| | - V Sabato
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - P H M Sadleir
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Nedlands, Western Australia, Australia; Department of Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - S Savic
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - T Takazawa
- Intensive Care Unit, Gunma University Hospital, Maebashi, Gunma, Japan
| | - S Voltolini
- Allergy Unit, Policlinic Hospital San Martino, Genoa, Italy
| | - G W Volcheck
- Division of Allergic Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| |
Collapse
|
48
|
Nohra D, Schrijvers R, Touati N, Nahas O, Ben Fadhel N, Ferrando L, Demoly P, Chiriac AM. Risk factors for positive paracetamol drug provocation testing and procedure optimization. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2045-2048.e2. [PMID: 30708142 DOI: 10.1016/j.jaip.2019.01.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/31/2018] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Dunya Nohra
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France; Equipe EPAR - IPLESP, UMR 1136 INSERM - Sorbonne Université, Paris, France
| | - Rik Schrijvers
- KU Leuven Department of Microbiology and Clinical Immunology, Laboratory of Clinical Immunology, Leuven, Belgium
| | - Nidhal Touati
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France
| | - Olga Nahas
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France
| | - Najah Ben Fadhel
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France; Department of Clinical Pharmacology, University Hospital of Fattouma Bourguiba, Monastir, Tunisia
| | - Laetitia Ferrando
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France
| | - Pascal Demoly
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France; Equipe EPAR - IPLESP, UMR 1136 INSERM - Sorbonne Université, Paris, France
| | - Anca-Mirela Chiriac
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France; Equipe EPAR - IPLESP, UMR 1136 INSERM - Sorbonne Université, Paris, France.
| |
Collapse
|
49
|
Torres MJ, Moreno E, Fernandez-Santamaría R, Doña I, Fernandez TD. Diagnostic Approximation to Delabeling Beta-Lactam Allergic Patients. CURRENT TREATMENT OPTIONS IN ALLERGY 2019. [DOI: 10.1007/s40521-019-0202-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
50
|
Ellis AG, Bloomberg GR. Oral challenge outcomes in children with adverse aminopenicillin reactivity. Ann Allergy Asthma Immunol 2019; 122:422-424. [PMID: 30641194 DOI: 10.1016/j.anai.2019.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/20/2018] [Accepted: 01/04/2019] [Indexed: 01/27/2023]
Affiliation(s)
- Alysa G Ellis
- Washington University School of Medicine, St Louis, Missouri.
| | | |
Collapse
|