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Chow TG, Brunner ES, Khan DA. Cephalosporin Allergy: Updates on Diagnostic Testing. Curr Allergy Asthma Rep 2024:10.1007/s11882-024-01171-9. [PMID: 39141068 DOI: 10.1007/s11882-024-01171-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE OF REVIEW Cephalosporins are one of the most prescribed antibiotics worldwide and are implicated in a wide range of hypersensitivity reactions (HSR). This review summarizes recent updates in cephalosporin hypersensitivity with a focus on diagnostic testing. RECENT FINDINGS Reported testing strategies to evaluate different immediate and delayed cephalosporin HSR have included skin testing, in vitro testing, and diagnostic drug challenges. However, the diagnostic performance of in vivo and in vitro tests remains unclear across different hypersensitivity endotypes; adequately powered studies investigating the true positive and negative predictive value of these diagnostic modalities are needed using the reference standard of drug challenges to define cephalosporin hypersensitivity. Refinement of diagnostic testing should be guided by growth in our understanding of cephalosporin antigenic determinants. This growth will be crucial in driving further clarification of cross-reactivity between cephalosporins, and potentially delineating streamlined evaluation processes resulting in reduced unnecessary antibiotic avoidance.
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Affiliation(s)
- Timothy G Chow
- University of Texas Southwestern Medical Center Department of Pediatrics and Internal Medicine, Division of Allergy and Immunology, 5323 Harry Hines Boulevard F04.206, Dallas, TX, 75390-9063, USA.
| | - Elizabeth S Brunner
- University of Texas Southwestern Medical Center Department of Pediatrics and Internal Medicine, Division of Allergy and Immunology, 5323 Harry Hines Boulevard F04.206, Dallas, TX, 75390-9063, USA
| | - David A Khan
- University of Texas Southwestern Medical Center Department of Pediatrics and Internal Medicine, Division of Allergy and Immunology, 5323 Harry Hines Boulevard F04.206, Dallas, TX, 75390-9063, USA
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2
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Belmont AP, Stone CA, Guyer AC, Edelman EJ, Trubiano JA. A call to address penicillin allergy labels in patients with hematopoietic stem cell transplants: How to avoid rash decisions. Transpl Infect Dis 2024:e14350. [PMID: 39101669 DOI: 10.1111/tid.14350] [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: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 08/06/2024]
Abstract
Among patients with hematopoietic stem cell transplants, infections, particularly multidrug-resistant infections, pose a grave threat. In this setting, penicillin allergy labels are both common and harmful. Though the majority of patients who report penicillin allergy can actually tolerate penicillin, penicillin allergy labels are associated with use of alternative antibiotics, which are often more broad spectrum, less effective, and more toxic. In turn, they are associated with more severe infections, multidrug-resistant infections, Clostridium difficile, and increased mortality. Evaluating penicillin allergy labels can immediately expand access to preferred therapeutic options, which are critical to care in patients with recent hematopoietic stem cell transplants. Point-of-care assessment and clinical decision tools now exist to aid the nonallergist in assessment of penicillin allergy. This can aid in expanding use of other beta-lactam antibiotics and assist in risk-stratifying patients to determine a testing strategy. In patients with low-risk reaction histories, direct oral challenges can be employed to efficiently delabel patients across clinical care settings. We advocate for multidisciplinary efforts to evaluate patients with penicillin allergy labels prior to transplantation.
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Affiliation(s)
- Ami P Belmont
- Section of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cosby A Stone
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Autumn C Guyer
- Allergy and Immunology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
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3
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Shah D, Rukasin C, Wang C, Phillips E, Stone C. Unraveling cephalosporin-associated anaphylaxis: A comprehensive analysis using FDA Adverse Event Reporting System data. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1359-1361. [PMID: 38484872 DOI: 10.1016/j.jaip.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Divya Shah
- Department of Internal Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, Ariz.
| | - Christine Rukasin
- Division of Allergy and Immunology, Phoenix Children's Hospital, Phoenix, Ariz; Department of Child Health, University of Arizona College of Medicine, Phoenix, Ariz; Division of Allergic Diseases, Mayo Clinic Arizona, Scottsdale, Ariz
| | - Cong Wang
- Department of Internal Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, Ariz
| | - Elizabeth Phillips
- Department of Medicine, Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Cosby Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
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Mari DC, Banks TA. Removing penicillin allergy label in a hospitalized adolescent with a remote penicillin and recent cephalosporin allergy. Allergy Asthma Proc 2024; 45:207-210. [PMID: 38755784 DOI: 10.2500/aap.2024.45.240002] [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: 05/18/2024]
Abstract
Background: β-Lactam antibiotics are widely used with increased utilization in hospitalized patients. Of this population, as high as 10-20% report an allergy to β-lactam antibiotics but <5% are at risk of developing clinically significant immunoglobulin E- or T-lymphocyte-mediated reactions. Most of the time, these reported allergies are present during an illness with no previous inquiry of their validity, which makes investigation and possible removal of this allergy label a challenge. Methods: We report a 16-year-old boy who presented with 1 week of night sweats, chills, headaches, and fatigue, followed by 1 day of fever and right knee swelling and who was diagnosed with septic bursitis. Due to concern of a penicillin allergy label, the patient was started on a cefepime infusion. Five minutes into the infusion, the patient reported puffy eyes and itchy throat, followed by a witnessed cascading flat nonpruritic erythematous rash from head to shoulders. This rash went away in 3 minutes after stopping the infusion and the patient being given 50 mg of intravenous diphenhydramine and 10 mg of oral dexamethasone. He was subsequently diagnosed with a cefepime allergy. Results: Allergy/immunology was the speciality consulted, and, by using a screening questionnaire, the patient's reported penicillin allergy was determined to be low risk. Subsequent 1-step oral challenge was the key to providing the patient with the necessary antibiotic course to resolve his infection. Conclusion: Multiple reported antibiotic allergies lead to poor antibiotic stewardship that causes impactful health and financial burden on the patient and health-care system. It is thus important to have an evidence-based systematic approach to de-label penicillin antibiotic allergy labels to reduce these potential harms.
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Affiliation(s)
- David C Mari
- From the Allergy and Immunology Department, Lackland Air Force Base, San Antonio, Texas, and
| | - Taylor A Banks
- Division of Pediatric Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
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5
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Dutra KJ, Lazenby GB, Goje O, Soper DE. Cefazolin as the mainstay for antibiotic prophylaxis in patients with a penicillin allergy in obstetrics and gynecology. Am J Obstet Gynecol 2024:S0002-9378(24)00448-4. [PMID: 38527607 DOI: 10.1016/j.ajog.2024.03.019] [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: 11/16/2023] [Revised: 02/20/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024]
Abstract
Cefazolin is the most common antibiotic used for prophylaxis in obstetrics and gynecology. Among those with a penicillin allergy, alternative antibiotics are often chosen for prophylaxis, given fears of cross-reactivity between penicillin and cefazolin. Alternative antibiotics in this setting are associated with adverse sequelae, including surgical site infection, induction of bacterial resistance, higher costs to the healthcare system, and possible Clostridium difficile infection. Given the difference in R1 side chains between penicillin and cefazolin, cefazolin use is safe and should be recommended for patients with a penicillin allergy, including those who experience Immunoglobulin E-mediated reactions such as anaphylaxis. Cefazolin should only be avoided in those who experience a history of a severe, life-threatening delayed hypersensitivity reaction manifested as severe cutaneous adverse reactions (Steven-Johnson Syndrome), hepatitis, nephritis, serum sickness, and hemolytic anemia in response to penicillin administration. In addition, >90% of those with a documented penicillin allergy do not have true allergies on skin testing. Increased referral for penicillin allergy testing should be incorporated into routine obstetric care and preoperative assessment to reduce suboptimal antibiotic prophylaxis use. More education is needed among providers surrounding penicillin allergy assessment and cross-reactivity among penicillins and cephalosporins to optimize antibiotic prophylaxis in obstetrics and gynecology.
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Affiliation(s)
- Karley J Dutra
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC.
| | - Gweneth B Lazenby
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
| | - Oluwatosin Goje
- Department of Subspecialties, Obstetrics and Gynecology Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - David E Soper
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
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6
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Norton AE, Koo G, Stone CA. Building the Evidence Base for Safe Direct Cephalosporin Challenges. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:165-167. [PMID: 38185495 DOI: 10.1016/j.jaip.2023.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 10/30/2023] [Indexed: 01/09/2024]
Affiliation(s)
- Allison E Norton
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Monroe Carell Children's Hospital, Vanderbilt University Medical Center, Nashville, Tenn
| | - Grace Koo
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Monroe Carell Children's Hospital, Vanderbilt University Medical Center, Nashville, Tenn; Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Cosby A Stone
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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7
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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.
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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
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8
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Ramsey A, Rozario C, Stern J. Direct challenges are the gold standard for most antibiotic allergy evaluations. Ann Allergy Asthma Immunol 2023; 131:427-433. [PMID: 37031773 DOI: 10.1016/j.anai.2023.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 04/11/2023]
Abstract
Antibiotic allergies are frequently encountered in clinical practice, and delabeling of these allergies has individual and public health benefits. This review focuses on the evidence supporting graded challenges without preceding skin testing in adult and pediatric patients to the major groups of antibiotics including penicillins, cephalosporins, sulfamethoxazole, fluoroquinolones, tetracyclines, macrolides, metronidazole, carbapenems, and aztreonam. The cost savings, time savings, and evidence for performing graded challenges outside of an allergy/immunology office are also reviewed for graded challenges to penicillins.
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Affiliation(s)
- Allison Ramsey
- Rochester Regional Health, Rochester, New York; Department of Medicine, University of Rochester, Rochester, New York.
| | - Cheryl Rozario
- Department of Medicine, University of Rochester, Rochester, New York
| | - Jessica Stern
- Department of Medicine, University of Rochester, Rochester, New York; Department of Pediatrics, University of Rochester, Rochester, New York
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Kwah J, Banerji A. Delayed Intradermal Skin Testing to Diagnose Culprits Drugs in Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1572-1573. [PMID: 37150547 DOI: 10.1016/j.jaip.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 05/09/2023]
Affiliation(s)
- Jason Kwah
- Department of Internal Medicine, Section of Rheumatology, Allergy, and Immunology, Yale School of Medicine, New Haven, Conn.
| | - Aleena Banerji
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
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10
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Stone CA, Ramsey A. Bringing Data to Bear on the Mushy Middle: Riskier Immediate Reactions to Penicillin. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3249-3251. [PMID: 36496214 DOI: 10.1016/j.jaip.2022.09.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
| | - Allison Ramsey
- Department of Allergy, Immunology, Rheumatology, Rochester Regional Health, Rochester, NY; Department of Medicine, University of Rochester, Rochester, NY
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11
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Advances in immunoglobulin E mediated antibiotic allergy. Curr Opin Pediatr 2022; 34:609-615. [PMID: 36036421 DOI: 10.1097/mop.0000000000001171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to identify recent advances in our understanding and management of immunoglobulin E (IgE)-mediated antibiotic allergy. RECENT FINDINGS Antibiotics remain a leading cause of fatal anaphylaxis reported to the FDA. However, recent advances have defined the features of adult and pediatric patients without true IgE-mediated allergy or any mechanism of anaphylaxis when tested. This has created opportunities to use direct challenges to disprove these allergies at the point-of-care and improves antibiotic stewardship. Additional advances have highlighted cross-reactive structural considerations within classes of drugs, in particular the R1 side-chain of cephalosporins, that appear to drive true immune-mediated cross-reactivity. Further advances in risk-based approaches to skin testing, phenotyping, and re-exposure challenges are needed to standardize antibiotic allergy evaluation. SUMMARY Recent advances in defining true IgE-mediated drug allergy have helped to identify patients unlikely to be skin-test positive. In turn, this has identified patients who can skip skin testing and proceed to direct ingestion challenge using history risk-based approaches. The ability to identify the small number of patients with true IgE-mediated allergy and study their natural history over time, as well as the vast majority without true allergy will facilitate important and novel mechanistic discoveries.
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12
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Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J, Khan DA, Golden DBK, Shaker M, Stukus DR, Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333-1393. [PMID: 36122788 DOI: 10.1016/j.jaci.2022.08.028] [Citation(s) in RCA: 164] [Impact Index Per Article: 82.0] [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
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Mabilat C, Gros MF, Van Belkum A, Trubiano JA, Blumenthal KG, Romano A, Timbrook TT. Improving antimicrobial stewardship with penicillin allergy testing: a review of current practices and unmet needs. JAC Antimicrob Resist 2022; 4:dlac116. [PMID: 36415507 PMCID: PMC9675589 DOI: 10.1093/jacamr/dlac116] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Penicillin allergy, the most frequently reported drug allergy, has been associated with suboptimal antibiotic therapy, increased antimicrobial resistance, increased rates of Clostridioides difficile colonization and infection, as well as extended hospital length of stay and increased cost. Although up to 10% of all patients may report penicillin allergy, most penicillin allergies are not confirmed. As such, most patients with a penicillin allergy can still safely use penicillin and related drugs following a more precise assessment. Herein, we review the current practices and unmet needs in penicillin allergy testing. The diagnostic algorithm is mostly based on a clinical history assessment followed by in vivo testing, i.e. skin test and/or drug challenge. As these tests are labour and resource intensive, there is increased interest in point-of-care penicillin allergy de-labelling solutions incorporated into Antimicrobial Stewardship Programmes including digital assessment tools. These can be locally parameterized on the basis of characteristics of target populations, incidence of specific allergies and local antibiotic usage to perform clinical risk stratification. Safely ruling out any residual risk remains essential and in vivo drug challenge and/or skin testing should be systematically encouraged. Gradual understanding and convergence of the risk stratification of the clinical presentation of penicillin allergy is enabling a wider implementation of this essential aspect of antimicrobial stewardship through digitalized decision tools and in vivo testing. More research is needed to deliver point of care in vitro diagnostic tools to democratize this de-labelling practice, which would be highly beneficial to patient care. This progress, together with better education of patients and clinicians about the availability, efficacy and safety of penicillin allergy testing, will increase the dissemination of penicillin allergy assessment as an important component of Antimicrobial Stewardship Programmes.
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Affiliation(s)
| | - Marie-Françoise Gros
- bioMérieux, Medical Affairs, 100 Rue Louis Pasteur, F-69280 Marcy l'Etoile, France
| | - Alex Van Belkum
- Current address:BaseClear, Sylviusweg 74, 2333 BE Leiden, The Netherlands
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, 145 Studley Road, Heidelberg, Victoria, 3084Australia
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | | | - Tristan T Timbrook
- bioMérieux, BioFire Diagnostics, Global Medical Affairs, 515 Colorow Drive, Salt Lake City, UT 84108, USA
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14
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Koo G, Yu R, Phillips EJ, Stone CA. Retrospective stratification of cephalosporin allergy label risk using validated penicillin allergy frameworks. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2472-2475.e1. [PMID: 35690369 DOI: 10.1016/j.jaip.2022.05.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/09/2022] [Accepted: 05/30/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Grace Koo
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Roger Yu
- University of Chicago Pritzker School of Medicine, Chicago, Ill
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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15
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Changes in Sensitization Patterns in the Last 25 Years in 619 Patients with Confirmed Diagnoses of Immediate Hypersensitivity Reactions to Beta-Lactams. Biomedicines 2022; 10:biomedicines10071535. [PMID: 35884838 PMCID: PMC9312895 DOI: 10.3390/biomedicines10071535] [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: 04/30/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 11/22/2022] Open
Abstract
Beta-lactam (BL) drugs are the antibiotics most prescribed worldwide due to their broad spectrum of action. They are also the most frequently implied in hypersensitivity reactions with a known specific immunological mechanism. Since the commercialization of benzylpenicillin, allergic reactions have been described; over the years, other new BL drugs provided alternative treatments to penicillin, and amoxicillin is now the most prescribed BL in Europe. Diagnosis of BL allergy is mainly based on skin tests and drug provocation tests, defining different sensitization patterns or phenotypes. In this study, we evaluated 619 patients with a confirmed diagnosis of BL-immediate allergy during the last 25 years, using the same diagnostic procedures with minor adaptations to the successive guidelines. The initial eliciting drug was benzylpenicillin, which changed to amoxicillin with or without clavulanic acid and cephalosporins in recent years. In skin tests, we found a decrease in sensitivity to major and minor penicillin determinants and an increase in sensitivity to amoxicillin and others; this might reflect that the changes in prescription could have influenced the sensitization patterns, thus increasing the incidence of specific reactions to side-chain selective reactions.
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16
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Koo G, Stollings JL, Lindsell C, Dear ML, Kripalani S, Nelson GE, McCoy AB, Rice TW, Phillips EJ, Stone CA. Low-risk penicillin allergy delabeling through a direct oral challenge in immunocompromised and/or multiple drug allergy labeled patients in a critical care setting. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1660-1663.e2. [PMID: 35131513 DOI: 10.1016/j.jaip.2022.01.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Grace Koo
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tenn
| | - Christopher Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn; Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tenn
| | - Mary Lynn Dear
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tenn
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tenn
| | - George E Nelson
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Allison B McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tenn
| | - Todd W Rice
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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17
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SÜLEYMAN A, YÜCEL E, TAMAY Z, GÜLER N. Safety of Cefazolin in Prophylaxis in Β-Lactam Allergic Children. BEZMIALEM SCIENCE 2022. [DOI: 10.14235/bas.galenos.2021.6570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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18
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Ramsey A. Cephalexin, Cefaclor, and Ampicillin: Points in the Picture of β-Lactam Cross-Reactivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:556-557. [PMID: 35144774 DOI: 10.1016/j.jaip.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 12/02/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Allison Ramsey
- Department of Allergy/Immunology/Rheumatology, Rochester Regional Health, Rochester, NY.
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19
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Sarfani S, Stone C, Murphy GA, Richardson DR. Understanding Penicillin Allergy, Cross-reactivity, and Antibiotic Selection in the Preoperative Setting. J Am Acad Orthop Surg 2022; 30:e1-e5. [PMID: 34669610 PMCID: PMC8928301 DOI: 10.5435/jaaos-d-21-00422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/08/2021] [Indexed: 02/01/2023] Open
Abstract
Penicillin allergies are reported by 8% to 15% of the US population, but up to 95% of these allergies do not correspond to a true allergy when tested. Recent studies have demonstrated that having a penicillin allergy label (PAL) results in a 50% increased odds of surgical site infection among patients reporting a penicillin allergy entirely attributable to the use of a beta-lactam alternative antibiotic (primarily clindamycin or vancomycin). This study provides a review of the prevalence of PAL, the cross-reactivity with cefazolin, immunogenic components of cefazolin and penicillin, and current guidelines for preoperative antibiotic selection in patients with PALs. On understanding these principles, a new set of guidelines and a risk stratification tool are proposed for assessing allergies and determining appropriate antibiotic choice, dosage, and timing in the orthopaedic preoperative setting.
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Affiliation(s)
- Shumaila Sarfani
- University of Tennessee- Campbell Clinic Orthopaedics Memphis, TN
| | - Cosby Stone
- Vanderbilt University Medical Center, Nashville, TN, Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine
| | - G. Andrew Murphy
- University of Tennessee- Campbell Clinic Orthopaedics Memphis, TN
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20
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Minaldi E, Phillips EJ, Norton A. Immediate and Delayed Hypersensitivity Reactions to Beta-Lactam Antibiotics. Clin Rev Allergy Immunol 2021; 62:449-462. [PMID: 34767158 DOI: 10.1007/s12016-021-08903-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 12/16/2022]
Abstract
Beta-lactam antibiotics are the most commonly reported drug allergy in adults and children. More than 95% of those with reported allergy labels to beta lactams are not confirmed when subjected to allergy testing. Beta lactam antibiotics are associated with a wide spectrum of immediate and delayed drug hypersensitivity reactions. The latency period to symptoms and clinical presentation aids in the causality assessment. Risk stratification based on diagnosis and timing then allows for appropriate management and evaluation. Skin prick testing, intradermal testing and oral challenge are well established for evaluation of immediate reactions. Delayed intradermal testing, patch testing and oral challenge can also be considered for evaluation of mild to moderate delayed reactions. Cross-reactivity between beta-lactams appears to be driven most commonly by a shared R1 side-chain. Standardized algorithms, protocols and pathways are needed for widespread implementation of a pragmatic and effective approach to patients reporting beta lactam allergy.
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Affiliation(s)
- Ellen Minaldi
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Allison Norton
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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21
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Macy E, Crawford WW, Nguyen MT, Adams JL, McGlynn EA, McCormick TA. Population-Based Incidence of New Ampicillin, Cephalexin, Cefaclor, and Sulfonamide Antibiotic "Allergies" in Exposed Individuals with and without Preexisting Ampicillin, Cephalexin, or Cefaclor "Allergies". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:550-555. [PMID: 34757066 DOI: 10.1016/j.jaip.2021.10.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/01/2021] [Accepted: 10/15/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is a theoretical concern, unconfirmed by population-based challenge data, that clinically significant, immunologically mediated hypersensitivity occurs among β-lactams sharing side chains. OBJECTIVE To determine the population-based allergy incidence associated with the use of β-lactams sharing exact R1 side chains (ampicillin, cephalexin, and cefaclor [ACC]), with or without a current ACC allergy or a sulfonamide antibiotic allergy for comparison. METHODS All courses of ACC and trimethoprim-sulfamethoxazole used by any Kaiser Permanente California members in 2017 and 2018, with follow-up through January 2019, were identified along with their preexisting antibiotic allergy status and all new antibiotic-specific allergies reported within 30 days of course initiation. RESULTS A total of 1,167,713 courses of ACC were administered to individuals. No sulfonamide antibiotic or ACC allergy and 4771 new ACC allergies (0.41%) were reported. Moreover, 130,032 courses of ACC were administered to individuals with a sulfonamide antibiotic allergy; no ACC allergy and 904 new ACC allergies (0.70%) were reported. There were 5,958 courses of ACC administered to individuals with an ACC allergy; 2,341 who also had sulfonamide antibiotic allergy, as well as 52 new ACC allergies (0.87%) were reported. CONCLUSIONS The incidence of new ACC allergy reports is minimally and no-specifically increased when a preexisting ACC or sulfonamide antibiotic allergy exists greater than the baseline incidence in the population. This argues against clinically significant, immunologically mediated cross-reactivity among β-lactams sharing exact side chains in individuals with preexisting but unconfirmed β-lactam allergy. Any previously reported, even unrelated antibiotic allergy appears to be a risk factor for reporting a new antibiotic allergy.
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Affiliation(s)
- Eric Macy
- Department of Allergy and Clinical Immunology, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, Calif.
| | - William W Crawford
- Department of Allergy and Clinical Immunology, Southern California Permanente Medical Group, South Bay Medical Center, Los Angeles, Calif
| | - Myngoc T Nguyen
- Department of Allergy and Clinical Immunology, Permanente Medical Group, Oakland Medical Center, Oakland, Calif
| | - John L Adams
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif; Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif
| | - Elizabeth A McGlynn
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif; Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif; Kaiser Permanente Research, Pasadena, Calif
| | - Thomas A McCormick
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif
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22
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Fernandez J, Jimenez-Rodriguez TW, Blanca-Lopez N. Classifying cephalosporins: from generation to cross-reactivity. Curr Opin Allergy Clin Immunol 2021; 21:346-354. [PMID: 34074874 DOI: 10.1097/aci.0000000000000755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW To review the most recent literature studying the classifications, immunochemistry, and crossreactivity of allergy reactions to cephalosporins. RECENT FINDINGS Over the last five years, research interest has focused on three areas related to cephalosporin allergy: cross-reactivity among cephalosporins and with other beta-lactams; the incidence of adverse reactions in penicillin allergy patients or in reported penicillin allergy labels; and new cephalosporins structures involved in the immunological recognition. SUMMARY Meta-analysis of a substantial number of studies shows that cephalosporins are safer than previously thought. Evidence supports two main conclusions in that regard. First, there is a relatively low percentage of cross-reactivity between cephalosporins and other beta-lactams with penicillins in penicillin allergy patients. Second, there is a very low incidence of allergy reactions in nonselected as well as in selected penicillin allergy patients when cephalosporins are used prior to surgical intervention.On the other hand, few structures have been discovered related to the immune mechanism of cephalosporin allergy reactions, and these are far from being ready to use in clinical practice.
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Affiliation(s)
- Javier Fernandez
- Allergy Section, Alicante General University Hospital, ISABIAL-UMH, Alicante
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23
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Caballero ML, Krantz MS, Quirce S, Phillips EJ, Stone CA. Hidden Dangers: Recognizing Excipients as Potential Causes of Drug and Vaccine Hypersensitivity Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:2968-2982. [PMID: 33737254 PMCID: PMC8355062 DOI: 10.1016/j.jaip.2021.03.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 12/18/2022]
Abstract
Excipients are necessary as a support to the active ingredients in drugs, vaccines, and other products, and they contribute to their stability, preservation, pharmacokinetics, bioavailability, appearance, and acceptability. For both drugs and vaccines, these are rare reactions; however, for vaccines, they are the primary cause of immediate hypersensitivity. Suspicion for these "hidden dangers" should be high, in particular, when anaphylaxis has occurred in association with multiple chemically distinct drugs. Common excipients implicated include gelatin, carboxymethylcellulose, polyethylene glycols, and products related to polyethylene glycols in immediate hypersensitivity reactions and propylene glycol in delayed hypersensitivity reactions. Complete evaluation of a suspected excipient reaction requires detailed information from the product monograph and package insert to identify all ingredients that are present and to understand the function and structure for these chemicals. This knowledge helps develop a management plan that may include allergy testing to identify the implicated component and to give patients detailed information for future avoidance of relevant foods, drugs, and vaccines. Excipient reactions should be particularly considered for specific classes of drugs where they have been commonly found to be the culprit (eg, corticosteroids, injectable hormones, immunotherapies, monoclonal antibodies, and vaccines). We provide a review of the evidence-based literature outlining epidemiology and mechanisms of excipient reactions and provide strategies for heightened recognition and allergy testing.
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Affiliation(s)
| | - Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, IdiPAZ, Madrid, Spain; Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Elizabeth J Phillips
- Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt School of Medicine, Nashville, Tenn; Institute of Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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24
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Ballas ZK. The 2021 AAAAI Foundation Faculty Development awardees. J Allergy Clin Immunol 2021; 147:1629-1633. [PMID: 33773974 DOI: 10.1016/j.jaci.2021.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Zuhair K Ballas
- Division of Immunology, University of Iowa, and Iowa City VA Health Care System, Iowa City, Iowa.
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