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Shi W, Liu N, Huang JX, Xiao H, Meng J, Li PH. Penicillin Allergy in China: Consequences of Inappropriate Skin Testing Practices and Policies. Clin Exp Allergy 2024. [PMID: 39053914 DOI: 10.1111/cea.14546] [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: 04/23/2024] [Revised: 06/23/2024] [Accepted: 07/09/2024] [Indexed: 07/27/2024]
Abstract
Penicillins are the most frequently prescribed class of medications worldwide and first-line antibiotic of choice for most bacterial infections. They are also commonly labelled as the culprit of drug 'allergy'; leading to obligatory use of second-line antibiotics, suboptimal antibiotic therapy and increased antimicrobial resistance. However, the majority of reported penicillin 'allergy' labels are found to be incorrect after allergy testing, emphasising the importance of proper drug allergy testing and evaluation. Penicillin skin testing (PST) remains an important component of drug allergy diagnosis; however, its practice and policies significantly differ across the world. Inappropriate and non-evidence-based PST practices can lead to consequences associated with allergy mislabelling. Even within different regions of China, with a population exceeding 1.4 billion, there are marked differences in the implementation, execution and interpretation of PST. This review aims to examine the differences in PST between Mainland China, Hong Kong and the rest of the world. We critically analyse the current practice of 'pre-emptive' PST in Mainland China, which has a significant false-positive rate leading to high levels of penicillin allergy mislabelling. Non-evidence-based practices further compound the high false-positive rates of indiscriminatory PST. We postulate that inappropriate PST policies and practices may exacerbate the mislabelling of penicillin allergy, leading to unnecessary overuse of inappropriate second-line antibiotics, increasing antimicrobial resistance and healthcare costs. We advocate for the importance of more collaborative research to improve the contemporary workflow of penicillin allergy diagnosis, reduce mislabelling and promote the dissemination of evidence-based methods for allergy diagnosis.
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Affiliation(s)
- Weihong Shi
- Division of Rheumatology & Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Ning Liu
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Jin-Xian Huang
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Hao Xiao
- Allergy Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Juan Meng
- Allergy Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Philip H Li
- Division of Rheumatology & Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
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Wong JCY, Kan AKC, Chik TSH, Chu MY, Li TCM, Mak HWF, Chiang V, Li PH. Prospective, Multicenter, Head-to-Head Comparison Between Allergists Versus Nonallergists in Low-Risk Penicillin Allergy Delabeling: Effectiveness, Safety, and Quality of Life (HK-DADI2). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1801-1808.e2. [PMID: 38631522 DOI: 10.1016/j.jaip.2024.04.010] [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: 02/06/2024] [Revised: 04/03/2024] [Accepted: 04/06/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Penicillin "allergy" labels are prevalent but frequently misdiagnosed. Mislabelled allergies are associated with adverse outcomes and increased antimicrobial resistance. With an urgent need to delabel the overwhelming number of mislabeled allergies, nonallergist evaluations have been advocated for low-risk individuals. Despite growing interest in non-allergist-led initiatives, evidence on their effectiveness, safety, and impact by direct comparisons is lacking. OBJECTIVE To assess the comparative outcomes of penicillin allergy evaluations conducted by allergists versus nonallergists. METHODS A prospective, multicenter, pragmatic study was conducted at 4 tertiary hospitals (1 allergist- vs 3 non-allergist-led) for low-risk penicillin allergy patients in Hong Kong-the Hong Kong Drug Allergy Delabelling Initiative 2 (HK-DADI2). RESULTS Among 228 low-risk patients who underwent testing (32.9% by allergists, 67.1% by nonallergists), only 14 (6.1%) had positive penicillin allergy testing results. Delabeling rates (94.1% vs 93.3%; P = .777), positive skin test results (2.6% vs 2.7%; P > .99), and drug provocation test results (3.3% vs 2.7%; P = 1.000) were similar between allergists and nonallergists. There were no systemic reactions in either cohort. All patients had significant improvements in health-related quality of life (Drug Hypersensitivity Quality of Life Questionnaire scores -5.00 vs -8.33; P = .072). Nonallergist evaluations had shorter waiting times (0.57 vs 15.7 months; P < .001), whereas allergists required fewer consultations with higher rate of completing evaluations within a single visit (odds ratio, 0.04; P < .001). CONCLUSIONS With training and support, nonallergists can independently evaluate low-risk penicillin allergies. Compared with allergists, evaluation of low-risk penicillin allergy by nonallergists can be comparably effective, safe, and impactful on quality of life. More multidisciplinary partnerships to empower nonallergists to conduct allergy evaluations should be encouraged.
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Affiliation(s)
- Jane C Y Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Andy K C Kan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Thomas S H Chik
- Division of Infectious Diseases, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | - M Y Chu
- Division of Infectious Diseases, Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Timothy C M Li
- Division of Infectious Diseases, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong
| | - Hugo W F Mak
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
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Providencia R, Aali G, Zhu F, Leas BF, Orrell R, Ahmad M, Bray JJH, Pelone F, Nass P, Marijon E, Cassandra M, Celermajer DS, Shokraneh F. Penicillin Allergy Testing and Delabeling for Patients Who Are Prescribed Penicillin: A Systematic Review for a World Health Organization Guideline. Clin Rev Allergy Immunol 2024; 66:223-240. [PMID: 38696031 PMCID: PMC11193836 DOI: 10.1007/s12016-024-08988-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 06/23/2024]
Abstract
Secondary prevention with penicillin aims to prevent further episodes of acute rheumatic fever and subsequent development of rheumatic heart disease (RHD). Penicillin allergy, self-reported by 10% of the population, can affect secondary prevention programs. We aimed to assess the role for (i) routine penicillin allergy testing and the (ii) safety of penicillin allergy delabeling approaches in this context. We searched MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, WHO ICTRP, ISRCTN, and CPCI-S to identify the relevant reports. We found 2419 records, but no studies addressed our initial question. Following advice from the WHO-Guideline committee and experts, we identified 6 manuscripts on allergy testing focusing on other populations showing that the prevalence of allergy confirmed by testing was low and the incidence of life-threatening reactions to BPG was very low (< 1-3/1000 individuals treated). A subsequent search addressed penicillin allergy delabeling. This found 516 records, and 5 studies addressing the safety of direct oral drug challenge vs. skin testing followed by drug administration in patients with suspected penicillin allergy. Immediate allergic reactions of minor severity were observed for a minority of patients and occurred less frequently in the direct drug challenge group: 2.3% vs. 11.5%; RR = 0.25, 95%CI 0.15-0.45, P < 0.00001, I2 = 0%. No anaphylaxis or deaths were observed. Severe allergic reactions to penicillin are extremely rare and can be recognized and dealt by trained healthcare workers. Confirmation of penicillin allergy diagnosis or delabeling using direct oral drug challenge or penicillin skin testing seems to be safe and is associated with a low rate of adverse reactions.
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Affiliation(s)
- Rui Providencia
- University College London, London, UK.
- Barts Heart Centre, London, UK.
| | - Ghazaleh Aali
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Oxford, UK
| | - Fang Zhu
- Department of Biostatistics, Systematic Review Consultants LTD, Oxford, UK
| | - Brian F Leas
- Department of Biostatistics, Systematic Review Consultants LTD, Oxford, UK
| | - Rachel Orrell
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Oxford, UK
| | - Mahmood Ahmad
- University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | | | | | - Petra Nass
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Oxford, UK
| | - Eloi Marijon
- European Georges Pompidou Hospital, Paris, France
| | | | | | - Farhad Shokraneh
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Oxford, UK
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Chiang V, Kan AKC, Saha C, Au EYL, Li PH. Identifying the most at-risk age-group and longitudinal trends of drug allergy labeling amongst 7.3 million individuals in Hong Kong. BMC Med 2024; 22:30. [PMID: 38273323 PMCID: PMC10811878 DOI: 10.1186/s12916-024-03250-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/08/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Incorrect drug 'allergy' labels remain a global public health concern. Identifying regional trends of drug allergy labeling can guide appropriate public health interventions, but longitudinal or population drug allergy studies remain scarce. We analysed the serial epidemiology of drug allergy labeling to identify specific subgroups at highest risk of drug allergy labeling for potential interventions. METHODS Longitudinal, population-wide drug allergy labels and clinical data from over 7,337,778 individuals in Hong Kong between 2016 and 2021 were analysed. RESULTS The absolute prevalence and incidence of documented drug allergy were 5.61% and 277/100,000 population, respectively. Annual incidence of new allergy labels was stable between 2016 and 2019, until a significant drop in 2020 (-16.3%) during the COVID19 pandemic. The most common allergy labels were anti-infectives (245,832 [44.5%]), non-steroidal anti-inflammatory (106,843 [19.3%]), and nervous system drugs (45,802 [8.3%]). The most common labeled culprits for the most severe immediate-type (anaphylaxis) and non-immediate-type (Stevens-Johnson syndrome) reactions were beta-lactams and nervous system drugs, respectively. For individuals at highest risk of labeling, there was significantly higher incidence of overall drug and beta-lactam allergy labeling amongst individuals aged > 40 years which contributed to the majority of newly labeled allergies (377,004, 68.2%). CONCLUSIONS Contrary to traditional dogma, we identified disproportionately higher incidence of drug allergy labeling amongst older individuals, rather than the paediatric age group. We advocate for more population-wide drug allergy studies to investigate this phenomenon in other cohorts as well as future preventative and delabeling efforts focusing on the adult population.
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Affiliation(s)
- Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Andy Ka Chun Kan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Pokfulam, Hong Kong
| | - Chinmoy Saha
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Pokfulam, Hong Kong
| | - Elaine Y L Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Pokfulam, Hong Kong.
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Kan AKC, Chiang V, Saha C, Au EYL, Li PH. Feasibility of a drug allergy registry-based excipient allergy database and call for universal mandatory drug ingredient disclosure: the case of PEG. FRONTIERS IN ALLERGY 2024; 4:1331036. [PMID: 38292585 PMCID: PMC10824824 DOI: 10.3389/falgy.2023.1331036] [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: 10/31/2023] [Accepted: 12/21/2023] [Indexed: 02/01/2024] Open
Abstract
Background Excipient allergy is a rare, but potentially lethal, form of drug allergy. Diagnosing excipient allergy remains difficult in regions without mandatory drug ingredient disclosure and is a significant barrier to drug safety. Objective To investigate the feasibility of a drug allergy registry-based excipient database to identify potential excipient culprits in patients with history of drug allergy, using polyethylene glycol (PEG) as an example. Methods An excipient registry was created by compiling the excipient lists pertaining to all available formulations of the top 50 most reported drug allergy culprits in Hong Kong. Availability of excipient information, and its relationship with total number of formulations of individual drugs were analysed. All formulations were checked for the presence or absence of PEG. Results Complete excipient information was available for 36.5% (729/2,000) of all formulations of the top 50 reported drug allergy culprits in Hong Kong. The number of formulations for each drug was associated with proportion of available excipient information (ρ = 0.466, p = 0.001). Out of 729 formulations, 109 (15.0%) and 620 (85.0%) were confirmed to contain and not contain PEG, respectively. Excipient information was not available for the other 1,271 (63.6%) formulations. We were unable to confirm the presence or absence of PEG in any of the top 50 drug allergy culprits in Hong Kong. Conclusion In countries without mandatory drug ingredient disclosure, excipient databases are unlikely able to identify potential excipient allergy in drug allergy patients. Legislations to enforce mandatory and universal ingredient disclosure are urgently needed.
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Affiliation(s)
- Andy Ka Chun Kan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China
| | - Chinmoy Saha
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Elaine Y. L. Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China
| | - Philip Hei Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
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Jones NK, Morris B, Santos R, Nasser S, Gouliouris T. Characterizing Antibiotic Allergy Labels in a Large UK Hospital Population to Inform Antimicrobial Stewardship and Delabeling Assessment Strategy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2180-2189.e4. [PMID: 37088372 DOI: 10.1016/j.jaip.2023.03.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Antibiotic allergy labels are important barriers to treatment and antimicrobial stewardship, but their prevalence in UK hospitals is poorly described. OBJECTIVE To ascertain the prevalence and characteristics of antibiotic allergy labels in a large UK hospital setting and estimate the proportion of penicillin allergy labels for which point-of-care (POC) delabeling assessment would be appropriate. METHODS Electronic health records data were analyzed from all patients treated at Cambridge University Hospitals NHS Foundation Trust in 2019. Validated POC delabeling risk stratification criteria were retrospectively applied to penicillin allergy labels. RESULTS Recorded reactions to antibiotics were present in 11.8% of all patients (32,148 of 273,216), 16.3% of inpatients (13,874 of 85,230), and 9.7% of outpatients (18,274 of 187,986). Penicillins were the commonest reaction precipitant described (9.0% of patients; 24,646 of 273,216), followed by sulfonamides/trimethoprim (1.4%; 3869 of 273,216) and macrolides/lincosamides (1.3%; 3644 of 273,216). A total of 3.9% of inpatients had recorded reactions to >1 antibiotic class (3348 of 85,230). Cutaneous manifestations were the most commonly described reaction features (40.7% of labels; 15,821 of 38,902). Of 15,949 labels describing probable or possible penicillin "allergy" with sufficient detail to allow for the retrospective assessment of POC delabeling suitability, 1702 were deemed suitable for removal or downgrading of the label to "intolerance" without further investigation (10.7%), 11,887 were appropriate for POC assessment using an oral penicillin challenge (OPC) or OPC with prior bedside skin testing (74.5%), and 2360 were identified as unsuitable for any form of POC assessment (14.8%). CONCLUSIONS Antibiotic allergy labels are highly prevalent in a UK hospital setting. A large proportion of penicillin allergy labels may be suitable for POC delabeling assessment.
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Affiliation(s)
- Nick K Jones
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
| | - Bethan Morris
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Reem Santos
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Theodore Gouliouris
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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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.
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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.
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Li B, Jiang L, Wu N, Chen Y, Xu Z, Xu F, Chen H, Liu T. Potential Factors of Primary Hospital Healthcare Professionals in Hindering the Abolition of Routine Skin Test for Cephalosporin: A Cross-Sectional Study. Risk Manag Healthc Policy 2023; 16:563-571. [PMID: 37035270 PMCID: PMC10081666 DOI: 10.2147/rmhp.s402133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/21/2023] [Indexed: 04/05/2023] Open
Abstract
Background In 2021, National Health Commission of the People's Republic of Chinese issued a document that no longer recommended the routine skin test for cephalosporin (RSTC). However, there is still resistance to the cancellation of RSTC in a primary hospital. The study aimed to explore the potential factors for hindering the abolition of the RSTC in a county-level hospital based on the PRECEDE model. Methods The cross-sectional study was conducted on healthcare workers in the Pidu District People's Hospital, Chengdu, by online questionnaire from September 10 to September 25 in the 2021.The PRECEDE model was used to divide the potential factors of healthcare professionals in hindering the abolition of the RSTC into predisposing factors, enabling factors and reinforcing factors. Data were analyzed by ANOVA, Chi-square test, multiple linear and multiple logistic regression analysis. Results We collected 605 respondents' valid questionnaires. 254 healthcare professionals were against cancellation of the RSTC, accounting for 41.98%. Multiple linear regression analysis showed that working for 6~10 years (β = 1.953, P = 0.024), medium (β = 1.995, P = 0.030) or senior (β = 4.003, P = 0.007) professional qualification, pharmacists (β = 3.830, P = 0.013) and working in surgical department (β= 4.462, P < 0.001) were significantly associated with higher score of predisposing factors, enabling factors, and reinforcing factors on abolition of RSTC. Furthermore, multiple logistic regression analysis showed that pharmacists (OR=3.113, 95% CI: 1.341-7.223, P=0.030), medium professional qualification (OR=1.272, 95% CI: 0.702-2.302, P=0.008), scores of predisposing factors (OR=1.335, 95% CI: 1.033-1.726, P=0.009), and scores of enabling factors (OR=1.208, 95% CI: 1.109-1.315, P<0.001) were independently associated with the positive anticipated behavior on the abolition of RSTC. While nurses (OR=0.516, 95% CI: 0.284-0.938, P<0.001) were independently associated with anticipated negative behavior. Conclusion Pharmacists, medium professional qualification, and healthcare professionals with higher scores of predisposing and enabling factors were more likely to have a positive anticipated behavior on the abolition of RSTC, while nurses did not.
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Affiliation(s)
- Bo Li
- Clinical Pharmacy Department, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
- Drug Clinical Trial Management Center, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
- Correspondence: Bo Li, Clinical Pharmacy Department, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China, Email
| | - Li Jiang
- Clinical Pharmacy Department, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
- Drug Clinical Trial Management Center, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
| | - Ni Wu
- Clinical Pharmacy Department, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
- Drug Clinical Trial Management Center, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
| | - Yao Chen
- Clinical Pharmacy Department, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
- Drug Clinical Trial Management Center, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
| | - Zhi Xu
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
| | - Fengcheng Xu
- Drug Clinical Trial Management Center, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
- Department of Cardiovascular Medicine, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
| | - Heping Chen
- Clinical Pharmacy Department, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
| | - Tianhu Liu
- Drug Clinical Trial Management Center, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
- Department of Cardiovascular Medicine, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China
- Tianhu Liu, Department of Cardiovascular Medicine, The Third Affiliated Hospital of Chengdu Medical College, Pidu District People’s Hospital, Chengdu, Sichuan, People’s Republic of China, Email
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Niu T, Bao X, Wei J, Shi Y, Ma W, Wang R. Impact of Penicillin Allergy-Based Alternative Antibiotics on the Risk of Postoperative Central Nervous System Infection: A Retrospective Cohort Study. World Neurosurg 2023; 171:e745-e751. [PMID: 36584894 DOI: 10.1016/j.wneu.2022.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Central nervous system (CNS) infection is one of the most serious complications after neurosurgery. This study aimed to analyze the effect of penicillin allergy (PA) and alternative prophylactic antibiotics on risk of postoperative CNS infection in patients undergoing neurosurgery. METHODS Data of patients who underwent neurosurgical procedures from January 2015 to December 2021 were analyzed retrospectively. Patients with PA were compared with patients without PA in a 1:1 ratio. A multivariate logistic regression model was used to examine whether PA was a risk factor for postoperative CNS infection. RESULTS Overall, 15,049 eligible neurosurgical records were reviewed, from which 578 surgical records of 556 patients with PA were matched to 578 records of 570 patients without PA. Patients with PA showed significantly lower probability to receive prophylactic cephalosporins (55.9% vs. 98.8%, P < 0.01), but significantly higher probability to receive clindamycin (41.86% vs. 1.03%, P < 0.01), than patients without PA. Multivariate analysis revealed that patients with PA were more likely to experience postoperative CNS infection than patients without PA (odds ratio = 2.03; 95% confidence interval, 1.15-3.56; P = 0.014). The incidence of postoperative CNS infection returned to a level comparable to that in general population when patients with suspected PA received prophylactic cephalosporins. CONCLUSIONS PA is associated with higher risk of postoperative CNS infection in patients undergoing neurosurgery. This may be attributed to the use of alternative prophylactic antibiotics other than cephalosporins, especially clindamycin.
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Affiliation(s)
- Tong Niu
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| | - Junji Wei
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yili Shi
- Department of Pharmacy, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wenbin Ma
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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10
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Xu J, Cao B. Appropriate use of antimicrobials in primary healthcare facility: a long way to go. Clin Microbiol Infect 2023; 29:563-564. [PMID: 36804909 DOI: 10.1016/j.cmi.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/06/2023] [Accepted: 02/11/2023] [Indexed: 02/18/2023]
Affiliation(s)
- Jiuyang Xu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.
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11
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Kan AKC, Hui HKS, Li TS, Chiang V, Wong JCY, Chan TS, Kwan IYK, Shum WZ, Yeung MSC, Au EYL, Ho CTK, Lau CS, Li PH. Comparative Effectiveness, Safety, and Real-World Outcomes of a Nurse-Led, Protocol-Driven Penicillin Allergy Evaluation From the Hong Kong Drug Allergy Delabelling Initiative (HK-DADI). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:474-480.e2. [PMID: 36126867 DOI: 10.1016/j.jaip.2022.08.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/13/2022] [Accepted: 08/31/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a high prevalence of unconfirmed penicillin allergy, which is associated with a multitude of adverse clinical outcomes. With the overwhelming burden of currently incorrect labels and the lack of allergy specialist services, new delabeling strategies are urgently needed. OBJECTIVE To assess the effectiveness, safety, and real-world outcomes of a nurse-led, protocol-driven evaluation of penicillin allergy, the Hong Kong Drug Allergy Delabelling Initiative (HK-DADI). METHODS Adult patients with suspected penicillin allergy were recruited into HK-DADI. Allergy and postdelabeling outcomes were retrospectively compared between patients evaluated via HK-DADI or traditional allergist evaluation. RESULTS A total of 312 completed penicillin allergy evaluation: 84 (27%) and 228 (73%) via HK-DADI and traditional pathways, respectively. Overall, 280 penicillin allergies were delabeled (90%). The delabeling rate between HK-DADI and traditional pathways was similar (90% vs 89%; P = .796). Among patients of the HK-DADI pathway, the delabeling rate was significantly higher among low-risk (LR) compared with non-LR patients (97% vs 77%; P = .010). Skin tests did not add diagnostic value among LR patients. No patients developed severe or systemic reactions during the evaluation. Upon 6- to 12-month follow-up (median, 10 months), 123 patients experienced infective episodes (44%) and 63 used penicillins again after delabeling (23%). This proportion was significantly higher in patients who were delabeled via HK-DADI compared with the traditional pathway (32% vs 19%; P = .026). CONCLUSIONS The Hong Kong Drug Allergy Delabelling Initiative, a nurse-led, protocol-driven evaluation, was safe and effective in penicillin allergy delabeling. It led to an even higher rate of future penicillin use after delabeling and mitigated the need for unnecessary skin testing among LR patients.
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Affiliation(s)
- Andy K C Kan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Harris K S Hui
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Tin Sum Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Jane C Y Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Tik Suet Chan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Ian Y K Kwan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wing Zi Shum
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Matthew S C Yeung
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Elaine Y L Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Carmen T K Ho
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
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Niu T, Zhang Y, Li Z, Bian Y, Zhang J, Wang Y. The association between penicillin allergy and surgical site infection after orthopedic surgeries: a retrospective cohort study. Front Cell Infect Microbiol 2023; 13:1182778. [PMID: 37153141 PMCID: PMC10160653 DOI: 10.3389/fcimb.2023.1182778] [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: 03/09/2023] [Accepted: 04/03/2023] [Indexed: 05/09/2023] Open
Abstract
Background Cephalosporins are used as first-line antimicrobial prophylaxis for orthopedics surgeries. However, alternative antibiotics are usually used in the presence of penicillin allergy (PA), which might increase the risk of surgical site infection (SSI). This study aimed to analyze the relationship between SSI after orthopedic surgeries and PA among surgical candidates and related alternative antibiotic use. Methods In this single-center retrospective cohort study, we compared inpatients with and without PA from January 2015 to December 2021. The primary outcome was SSI, and the secondary outcomes were SSI sites and perioperative antibiotic use. Moreover, pathogen characteristics of all SSIs were also compared between the two cohorts. Results Among the 20,022 inpatient records, 1704 (8.51%) were identified with PA, and a total of 111 (0.55%) SSI incidents were reported. Compared to patients without PA, patients with PA had higher postoperative SSI risk (1.06%, 18/1704 vs. 0.51%, 93/18318), shown both in multivariable regression analysis (odds ratio [OR] 2.11; 95% confidence interval [CI], 1.26-3.50; p= 0.004) and propensity score matching (OR 1.84; 95% CI, 1.05-3.23; p= 0.034). PA was related to elevated deep SSI risk (OR 2.79; 95% CI, 1.47-5.30; p= 0.002) and had no significant impact on superficial SSI (OR 1.39; 95% CI, 0.59-3.29; p= 0.449). The PA group used significantly more alternative antibiotics. Complete mediation effect of alternative antibiotics on SSI among these patients was found in mediation analysis. Pathogen analysis revealed gram-positive cocci as the most common pathogen for SSI in our study cohort, while patients with PA had higher infection rate from gram-positive rods and gram-negative rods than non-PA group. Conclusion Compared to patients without PA, patients with PA developed more SSI after orthopedic surgeries, especially deep SSI. The elevated infection rate could be secondary to the use of alternative prophylactic antibiotics.
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Affiliation(s)
- Tong Niu
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuelun Zhang
- Medical Research Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ziquan Li
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yanyan Bian
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yipeng Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Yipeng Wang,
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13
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A case of persistent IgE sensitisation almost two decades following ampicillin anaphylaxis. Allergol Immunopathol (Madr) 2023; 51:126-129. [PMID: 36916097 DOI: 10.15586/aei.v51i2.748] [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: 08/04/2022] [Accepted: 12/21/2022] [Indexed: 03/08/2023]
Abstract
BACKGROUND Although most immunoglobulin E (IgE)-mediated penicillin allergy wanes with time, sensitisation may occasionally persist for many years. Previous reports on the loss of penicillin-specific IgE sensitisation were based on non-anaphylaxis cases and, although uncommon, persistent sensitisation may still be possible in the minority of cases. OBJECTIVE This case highlights that irrespective of the elapsed duration since the index reaction, it is important to remain vigilant when approaching patients with a history of severe reactions. MATERIAL AND METHODS We described a case of persistent IgE sensitisation almost two decades following ampicillin anaphylaxis. RESULTS A 78-year-old male with a history of perioperative penicillin anaphylaxis in 2003 was referred for allergy workup in 2022 before his knee joint replacement surgery. The patient had strictly avoided all beta-lactams since the index reaction. However, his penicillin-specific sensitisation persisted, evidenced by positive skin tests (with generalised urticaria after intradermal testing) and basophil activation tests. CONCLUSION To our knowledge, this was the first case of positive BAT tested around two decades following the index reaction. This case illustrates that a cautious approach may still be warranted in patients with a history of severe reaction to penicillin regardless of the duration since the reported index reaction.
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14
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Mak HW, Yeung MH, Wong JC, Chiang V, Li PH. Differences in beta-lactam and penicillin allergy: Beyond the West and focusing on Asia-Pacific. FRONTIERS IN ALLERGY 2022; 3:1059321. [PMID: 36483185 PMCID: PMC9723361 DOI: 10.3389/falgy.2022.1059321] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/07/2022] [Indexed: 04/29/2024] Open
Abstract
Beta-lactam (BL) antibiotic "allergy" labels are common, but often overdiagnosed. Although much research has been focused on the BL allergy and the delabelling process in the West, studies from other parts of the world remain sparse. This review outlines the contrasting global epidemiology, shifting clinical practices and disparities of BL allergy in the Asia-Pacific region compared with the West. Innovative strategies to overcome barriers in BL allergy workup are discussed and potential directions for future research and service development are also proposed.
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Affiliation(s)
- Hugo W.F. Mak
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Maegan H.Y. Yeung
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Jane C.Y. Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong, China
| | - Philip H. Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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15
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Li PH, Wong JCY, Chan JMC, Chik TSH, Chu MY, Ho GCH, Leung WS, Li TCM, Ng YY, Shum R, Sin WWY, Tso EYK, Wu AKL, Au EYL. Hong Kong Drug Allergy Delabelling Initiative (HK-DADI) consensus statements for penicillin allergy testing by nonallergists. FRONTIERS IN ALLERGY 2022; 3:974138. [PMID: 36133403 PMCID: PMC9483020 DOI: 10.3389/falgy.2022.974138] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Penicillin allergy testing has been traditionally performed by allergists, but there remains a huge deficit of specialists. A multidisciplinary effort with nonallergists would be invaluable to overcome the magnitude of penicillin allergy labels via the Hong Kong Drug Allergy Delabelling Initiative (HK-DADI). These consensus statements (CSs) offer recommendations and guidance to enable nonallergists to screen for low-risk (LR) patients and perform penicillin allergy testing. Methods CSs were formulated by the HK-DADI Group using the Delphi method. An agreement was defined as greater than or equal to 80% consensus. Results A total of 26 CSs reached consensus after multiple rounds of Delphi. CSs were categorized into risk assessment, skin testing, drug provocation testing (DPT), and post-testing management. For risk assessment, the essentials of allergy history and exclusion criteria were detailed. Patients with only LR features can proceed with testing by nonallergists. Skin tests should be performed prior to DPT. Details regarding the timing, preparation, and interpretation of skin tests were elaborated. DPT remains the gold standard to diagnose genuine allergy or tolerance and should be performed when there is a low pretest probability following negative skin testing. Details of DPT preparations, dosing protocols, and interpretation were elaborated. For post-testing management, inaccurate allergy labels should be delabeled following negative DPT with proper patient counseling. Conclusion CSs support penicillin allergy testing by nonallergists in Hong Kong. LR cases can be managed by nonallergists at Spoke Clinics, with training and support of an allergist-led Hub.
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Affiliation(s)
- Philip H. Li
- Division of Rheumatology & Clinical Immunology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
- Correspondence: Philip H. Li
| | - Jane C. Y. Wong
- Division of Rheumatology & Clinical Immunology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Jacky M. C. Chan
- Division of Infectious Diseases, Department of Medicine & Geriatrics, Kwong Wah Hospital, Hong Kong SAR, China
| | - Thomas S. H. Chik
- Division of Infectious Diseases, Department of Medicine & Geriatrics, Kwong Wah Hospital, Hong Kong SAR, China
| | - M. Y. Chu
- Division of Infectious Diseases, Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Grace C. H. Ho
- Division of Rheumatology, Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - W. S. Leung
- Division of Infectious Diseases, Department of Medicine & Geriatrics, Kwong Wah Hospital, Hong Kong SAR, China
| | - Timothy C. M. Li
- Division of Infectious Diseases, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Y. Y. Ng
- Division of Infectious Diseases, Department of Medicine & Geriatrics, Tuen Mun Hospital, Hong Kong SAR, China
| | - Rocky Shum
- Division of Microbiology, Department of Clinical Pathology, Tuen Mun Hospital, Hong Kong SAR, China
| | - Winnie W. Y. Sin
- Division of Infectious Diseases, Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR, China
| | - Eugene Y. K. Tso
- Division of Infectious Diseases, Department of Medicine & Geriatrics, United Christian Hospital, Hong Kong SAR, China
| | - Alan K. L. Wu
- Division of Microbiology, Department of Clinical Pathology, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Elaine Y. L. Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China
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16
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Wong JCY, Cheong N, Lau CS, Li PH. Prevalence and impact of misdiagnosed drug allergy labels among patients with hereditary angioedema. FRONTIERS IN ALLERGY 2022; 3:953117. [PMID: 36051898 PMCID: PMC9426770 DOI: 10.3389/falgy.2022.953117] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/27/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Hereditary angioedema (HAE) is a rare condition with presents with episodic attacks of angioedema, which is often misdiagnosed as allergy, and associated with significant morbidity and mortality. Misdiagnosed drug allergy (DA) labels are also associated with a multitude of adverse clinical outcomes. However, the prevalence and impact of incorrect DA labels on HAE remains unknown. Methods Data from the clinical records of all HAE patients in Hong Kong were collected and analysed. All HAE patients with DA labels on their medical records were recruited to proceed with DA testing, including confirmatory drug provocation tests (DPT). Results Nine (22%) out of a total of 41 HAE patients carried at least one DA label. Five of nine (56%) patients had more than 1 DA label and there was a total number of 16 DA labels. The most common DA label was to beta-lactams (37.5%). Presence of DA label was associated with delay in HAE diagnosis (23.8 ± 11.1 vs. 10.2 ± 14.3 years, p = 0.012), likelihood of HAE attacks (100% vs. 46.9%, p = 0.005) and rate of hospitalization (3.78 ± 2.68 vs. 1.32 ± 2.61, p = 0.022) per year. All (100%) of all DA labels were disproven and removed after confirmatory DPT were performed. Conclusion DA labels are prevalent among HAE patients but are frequently misdiagnosed and mislabelled. Misdiagnosed DA are associated with delay in HAE diagnosis as well as adverse clinical outcomes. Immunologists/allergists should consider pre-emptively reviewing and investigate every suspicious DA label, especially among HAE patients.
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Affiliation(s)
- Jane Chi Yan Wong
- Division of Rheumatology & Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Noel Cheong
- Division of Rheumatology & Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Chak Sing Lau
- Division of Rheumatology & Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Philip Hei Li
- Division of Rheumatology & Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
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Kim SR, Kim S, Kim SH, Park JS, Park HJ, Suh DI, Sim DW, Yang MS, Lee JH, Lee HY, Jung JW, Choi M, Kang HR. Expert opinion: The clinical usefulness of skin tests prior to the administration of beta-lactam antibiotics. ALLERGY ASTHMA & RESPIRATORY DISEASE 2022. [DOI: 10.4168/aard.2022.10.1.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Sung-Ryeol Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Sujeong Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong-Sook Park
- Division of Allergy and Respiratory Medicine, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Hye Jung Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Da Woon Sim
- Department of Allergy and Clinical Immunology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Min Suk Yang
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Jae-Hyun Lee
- Division of Allergy and Immunology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hwa Young Lee
- Division of Allergy, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Mira Choi
- Department of Dermatology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Hye-Ryun Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
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Abstract
PURPOSE OF REVIEW Drug allergy management has previously not been emphasized in the elderly. However, the geriatric population poses several unique characteristics, challenges for drug allergy testing and considerations in the management. Especially in the era of COVID-19, the elderly population is a vulnerable cohort and reviewing the management during this unprecedented time is both timely and relevant. RECENT FINDINGS In recent years, larger scale studies focusing on the epidemiology and prevalence trends of drug allergies among older adults has been summarized in this review. Emphasis on anaphylaxis in the older adults has been studied. SUMMARY There are many implications of these findings. Epidemiological studies are useful in realizing the burden and spectrum of drug allergies on our healthcare system. It has allowed us to identify certain barriers in drug allergy management and develop ways to overcome these challenges through. Lastly, we have proposed an approach to drug allergy management based on previous studies as well as from our perspective and local experience.
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Affiliation(s)
- Jane C Y Wong
- Division of Rheumatology & Clinical Immunology, Department of Medicine, Queen Mary Hospital, Pok Fu Lam, Hong Kong
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19
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Wong JC, Au EY, Yeung HH, Lau CS, Li PH. Piperacillin-Tazobactam Allergies: An Exception to Usual Penicillin Allergy. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2021; 13:284-294. [PMID: 33474862 PMCID: PMC7840879 DOI: 10.4168/aair.2021.13.2.284] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/20/2020] [Accepted: 07/26/2020] [Indexed: 12/17/2022]
Abstract
Purpose The majority of penicillin allergy labels are false, and skin tests (ST) have high negative predictive value (NPV) of up to 90%. Piperacillin-tazobactam (PT) allergy has been suspected to be an exception to this, but existing literature is scarce. We investigate the epidemiology, clinical characteristics, testing outcomes and predictive value of ST in patients referred for suspected PT allergies. Methods The records of all patients referred for suspected PT allergy testing and prescription rates of PT in all Hong Kong public hospitals (2015–2019) were analyzed. Results There was an increase in both PT prescriptions and number of newly reported PT allergies between 2015 and 2019. The majority (91.1%) of patients with suspected PT allergy had at least 1 underlying medical co-morbidity or immunosuppressant use leading to increased risk of infections. Thirty-six patients with suspected PT allergy completed ST. Two patients had positive ST, and 32/34 patients with negative ST underwent drug provocation testing (DPT). Nine of these patients were diagnosed with PT allergy based on positive DPT. Overall, 11/34 (32.4%) were diagnosed with PT allergy and the NPV of ST was 71.9%. Conclusions There is growing utilization of PT and corresponding cases of suspected allergies. The majority of suspected PT allergies had increased risk for recurrent infections. Unlike other penicillin allergy, there is a high rate of genuine PT allergy (up to 30%) and a poor NPV of ST (up to 70%). DPT remains the gold standard for accurate diagnosis, and all patients with a suspected allergy should undergo thorough allergy workup.
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Affiliation(s)
- Jane Cy Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Elaine Yl Au
- Division of Clinical Immunology, Department of Pathology, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Heather Hf Yeung
- Division of Clinical Immunology, Department of Pathology, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Philip Hei Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong.
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20
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Tang MM, Fok JS, Thong BYH, Yun J, Li PH, Kang HR, Thien F, Yamaguchi M, Lucas M, Chang YS, Kim BK, Nagao M, Rengganis I, Tsai YG, Chung WH, Rerkpattanapipat T, Kamchaisatian W, Leung TF, Ho JY, Zhang L, Latiff AHA, Fujisawa T, Castells MC, Demoly P, Wang JY, Pawankar R. Diagnostic procedures & practices in drug allergy/hypersensitivity: a survey of 13 Asian countries. Asia Pac Allergy 2020; 10:e36. [PMID: 33178561 PMCID: PMC7610088 DOI: 10.5415/apallergy.2020.10.e36] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/10/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The issues and challenges in the diagnosis of drug allergy/hypersensitivity among children and adults in Asia are likely to be different from non-Asian countries. OBJECTIVE To study the diagnostic modalities used in the evaluation and management of drug allergy/drug hypersensitivity reactions (DHRs) among member societies of the Asia Pacific Association of Allergy, Asthma and Clinical Immunology (APAAACI). METHODS A questionnaire comprising 41 questions was circulated electronically to member societies and individual members of APAAACI between January 23, 2020 and March 6, 2020. RESULTS Twenty-six respondents from 15 member societies and 1 individual member responded. European DHR guidelines were most commonly used. Skin prick and intradermal testing was used by 100%, with only 60% having access to commercial penicillin skin test reagents. In vitro-specific IgE tests were used by 75%, and basophil activation test by 56.3% for immediate DHR. Patch tests were used by 75% in contrast to lymphocyte transformation tests by 25% for nonimmediate DHR. Drug provocation tests were used by 68.8%, the most common indication being to exclude hypersensitivity where history/symptoms were not suggestive of drug hypersensitivity/allergy (93.3%). Human leukocyte antigen (HLA) genotype testing was mandatory among 25% respondents before new carbamazepine prescriptions, and 8.3% for allopurinol prescriptions. CONCLUSIONS There was increased use of skin testing for iodinated contrast media hypersensitivity and patch testing for nonimmediate DHR. HLA genotype testing prior to new carbamazepine, allopurinol and abacavir prescriptions remain variable despite strong associations for severe cutaneous adverse reactions with Asian ethnicity. Results of this survey form a useful framework for developing educational and training needs and for improving access to drug allergy diagnostic and treatment modalities across APAAACI member societies.
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Affiliation(s)
| | - Jie Shen Fok
- Department of Respiratory Medicine, Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Melbourne, Australia
| | - Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - James Yun
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Division of Medicine, Nepean Hospital, Sydney, Australia
| | - Philip Hei Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Hye-Ryun Kang
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Drug Safety Center, Seoul National University Hospital, Seoul, Korea
| | - Francis Thien
- Eastern Health, Melbourne; Monash University, Melbourne, Australia
| | - Masao Yamaguchi
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Michaela Lucas
- Department of Immunology, Pathwest and Sir Charles Gairdner Hospital, Perth, Australia; Medical School, University of Western Australia, Perth, Australia
| | - Yoon-Seok Chang
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byung-Keun Kim
- Department of Internal Medicine, Korea University Medical Center Anam Hospital, Seoul, Korea
| | - Mizuho Nagao
- Allergy Center of Mie National Hospital, Tsu, Japan
| | - Iris Rengganis
- Department of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Yi-Giien Tsai
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung and Linkou Branches, College of Medicine, Chang Gung University, Taipei, Taiwan
| | - Ticha Rerkpattanapipat
- Allergy, Immunology and Rheumatology Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wasu Kamchaisatian
- Pediatric Allergy and Immunology Division, Samitivej Children's Hospital, Bangkok, Thailand
| | - Ting Fan Leung
- Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong
| | - Joo-Yoon Ho
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Luo Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | | | | | - Mariana C Castells
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Mastocytosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; UPMC Univ Paris 06, UMRS 1136, Equipe - EPAR - IPLESP, Sorbonne Universités, Paris, France
| | - Jiu Yao Wang
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
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Li PH, Yeung HHF, Lau CS, Au EYL. Prevalence, Incidence, and Sensitization Profile of β-lactam Antibiotic Allergy in Hong Kong. JAMA Netw Open 2020; 3:e204199. [PMID: 32374398 PMCID: PMC7203606 DOI: 10.1001/jamanetworkopen.2020.4199] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE Allergy to β-lactam antibiotics is one of the most frequently reported drug reactions, but epidemiological data in Chinese populations are lacking. Ethnic- and region-specific sensitization patterns of skin testing for β-lactam antibiotic allergy are also unknown. OBJECTIVE To identify the prevalence, 1-year incidence, and sensitization patterns of β-lactam antibiotic allergy in patients in Hong Kong. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study obtained territorywide, anonymized electronic patient data from the Clinical Management Systems of the Hospital Authority, the sole publicly funded health care system in Hong Kong with facilities in 7 regions (Hong Kong East, Hong Kong West, Kowloon Central, Kowloon East, Kowloon West, New Territories East, and New Territories West). All referrals to Queen Mary Hospital for β-lactam antibiotic allergy testing from January 1, 2018, to December 31, 2019, were also analyzed for sensitization patterns. MAIN OUTCOMES AND MEASURES Prevalence and cumulative incidence of β-lactam antibiotic allergy reported in Hong Kong, and sensitization patterns according to β-lactam antibiotic allergy skin testing. RESULTS Complete records of 7 184 271 unique patients were analyzed, with a men to women ratio of 1:1.2 and with a median age of 44 years. The prevalence of physician-reported β-lactam antibiotic allergy was 2.0%, and the cumulative incidence was 107 per 100 000 population. Of the 34 402 new drug allergies reported in 2018, 8032 (23.3%) were β-lactam antibiotic allergies. Three hundred fifty-five patients with reactions suggestive of β-lactam antibiotic allergy underwent skin testing, and only 49 (13.8%; 95% CI, 10.64%-17.90%) of them had positive test results. Of these 49 patients, 14 (28.6%; 95% CI, 18.35%-44.49%) had selective reaction and 35 (71.4%; 95% CI, 59.84%-85.27%) had nonselective reaction. The sensitization rate to either benzylpenicilloyl polylysine or a minor determinant (benzylpenicilloate) was 47.0% (n = 23; 95% CI, 34.85%-63.21%), with 10 patients monosensitized to benzylpenicilloyl polylysine only (20.4%; 95% CI, 11.74%-35.48%) and 5 to benzylpenicilloate only (10.2%; 95% CI, 4.45%-23.42%). CONCLUSIONS AND RELEVANCE Results of this study suggest that patients in Hong Kong with β-lactam antibiotic allergy had much higher rates of monosensitization to benzylpenicilloyl polylysine and benzylpenicilloate, making these reagents essential in β-lactam antibiotic skin tests. Such a finding warrants future studies into whether this sensitization is specific to ethnicity or region.
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Affiliation(s)
- Philip H. Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Heather H. F. Yeung
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Chak-Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Elaine Y. L. Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
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