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Morales-Palacios MP, Núñez-Córdoba JM, Tejero E, Matellanes O, D'Amelio CM, Gastaminza G. Evaluation of a Novel Automated Allergy Intradermal Skin Test Reader: A Diagnostic Accuracy Study. Clin Exp Allergy 2024. [PMID: 39151893 DOI: 10.1111/cea.14553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 07/15/2024] [Accepted: 07/18/2024] [Indexed: 08/19/2024]
Affiliation(s)
- M P Morales-Palacios
- Department of Allergy and Clinical Immunology, Clínica Universidad de Navarra, Pamplona, Spain
| | - J M Núñez-Córdoba
- Research Support Service, Central Clinical Trials Unit, Clínica Universidad de Navarra, Pamplona, Spain
| | - E Tejero
- Nexkin Medical, Donostia-San Sebastián, Spain
| | | | - C M D'Amelio
- Department of Allergy and Clinical Immunology, Clínica Universidad de Navarra, Pamplona, Spain
- RICORS red De Enfermedades Inflamatorias (REI), Madrid, Spain
| | - G Gastaminza
- Department of Allergy and Clinical Immunology, Clínica Universidad de Navarra, Pamplona, Spain
- RICORS red De Enfermedades Inflamatorias (REI), Madrid, Spain
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2
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Molina-Molina GJ, Gómez-Duque M, Vidal Guitart X, Agustí Escasany A, Labrador-Horrillo M, Luengo O, Sala-Cunill A, Galvan-Blasco P, Guilarte M, Cardona V. Challenging dogmas: Intravenous versus oral beta-lactam antibiotic provocation tests. World Allergy Organ J 2024; 17:100914. [PMID: 38855082 PMCID: PMC11153252 DOI: 10.1016/j.waojou.2024.100914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 04/26/2024] [Accepted: 04/30/2024] [Indexed: 06/11/2024] Open
Abstract
Background Drug provocation tests (DPT) are considered the gold standard procedure to ascertain the diagnosis of beta-lactam (BL) allergy. Regarding route of administration, current recommendations prioritize oral challenges, considering them safer, and reserving the intravenous route for drugs for which this is the only formulation. Objective To compare in terms of tolerance and safety two protocols of BL DPT, using an oral protocol (OR-DPT) and an intravenous protocol (IV-DPT). Methods A descriptive, retrospective study was performed, including adult patients who underwent IV-DPT or OR-DPT for suspected immediate or delayed hypersensitivity to BL antibiotics, over a period of 4 years (between January 2018 and December 2021). Demographical data, index hypersensivity reactions' characteristics and tolerance to DPT were reviewed. Results A total of 1036 patients underwent DPT, mean age of 56.8 (standard deviation, SD, 17.8) years, 655 were women (63.2%). Immediate drug hypersensitivity reactions (DHR) had occurred in 564 of patients (54.4%). OR-DPT were performed in 439 (42.4%) and IV-DPT in 597 (57.6%). The frequency of reactions during DPT, regardless of the route used, was low (3.6%): only 16 (3.6%) in OR-DPT and 21 (3.5%) in IV-DPT. From IV-DPT, 16 out 21 DHR during DPT were immediate compared with 4 out of 16 in OR-DPT. Adjusted relative risk of developing a hypersensitivity reaction during IV-DPT versus OR-DPT was 1.13 (95% confidence interval (CI)0.57-2.22). Conclusion The results suggest that OR-DPT and IV-DPT are both safe procedures when adequately performed. However, IV-DPT protocols showed a higher rate of immediate DHR during DPT probably due to the selection of basal high-risk patients to undergo IV-DPT. In conclusion, IV-DPT may be considered as an option for challenges in drug-allergy studies, entailing a precise administration.
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Affiliation(s)
| | - Manuel Gómez-Duque
- Paediatric Allergy Section, Respiratory Paediatric Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Xavier Vidal Guitart
- Clinical Pharmacology Service, Fundació Institut Català de Farmacologia, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antònia Agustí Escasany
- Clinical Pharmacology Service, Fundació Institut Català de Farmacologia, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Moisés Labrador-Horrillo
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Olga Luengo
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Anna Sala-Cunill
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Paula Galvan-Blasco
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Mar Guilarte
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Victoria Cardona
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
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3
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Romantowski J, Nazar W, Bojahr K, Popiołek I, Niedoszytko M. Analysis of Allergy and Hypersensitivity Reactions to COVID-19 Vaccines According to the EudraVigilance Database. Life (Basel) 2024; 14:715. [PMID: 38929698 PMCID: PMC11205009 DOI: 10.3390/life14060715] [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: 04/22/2024] [Revised: 05/21/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic presented a new challenge in modern medicine: the development of vaccines was followed by massive population vaccinations. A few reports on post-vaccination allergic reactions have made patients and medical personnel uneasy as to COVID-19 vaccines' allergic potential. Most of the studies in this area to date have been small, and some that were based on global databases skipped most of the allergic diseases and concentrated only on anaphylaxis. We aimed to analyze the incidence of serious allergic reactions based on the EudraVigilance (EV) database, regardless of the reported symptoms and allergy mechanism. METHODS The total number of administrated vaccine doses was extracted on 5 October 2023 from Vaccine Tracker and included all administrations since vaccinations began in the European Economic Area (EEA). Data on serious allergic reactions to COVID-19 vaccines were extracted from the EudraVigilance database with the same time point. The code names of 147 allergic symptoms or diseases were used. RESULTS The frequency of serious allergic reactions per 100,000 administered vaccine doses was 1.53 for Comirnaty, 2.16 for Spikevax, 88.6 for Vaxzevria, 2.11 for Janssen, 7.9 for Novavax, 13.3 for VidPrevtyn Beta, and 3.1 for Valneva. The most prevalent reported reactions were edema (0.46) and anaphylaxis (0.40). Only 6% of these reactions were delayed hypersensitivity-oriented. CONCLUSIONS The overall frequency of potential serious allergic reactions to COVID-19 is very rare. Therefore, COVID-19 vaccines seem to be safe for human use. The lowest frequency of allergic reaction was observed for Comirnaty and the highest for Vaxzevria.
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Affiliation(s)
- Jan Romantowski
- Department of Allergology, Medical University of Gdansk, 80-210 Gdansk, Poland (M.N.)
| | - Wojciech Nazar
- Faculty of Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland;
| | - Kinga Bojahr
- Department of Allergology, Medical University of Gdansk, 80-210 Gdansk, Poland (M.N.)
| | - Iwona Popiołek
- Department of Toxicology and Environmental Diseases, Jagiellonian University Medical College, 31-008 Krakow, Poland;
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, 80-210 Gdansk, Poland (M.N.)
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4
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Fernandez-Santamaria R, Ariza A, Bogas G, Salas M, Calvo-Serrano S, Frecha C, Mayorga C, Torres MJ, Fernandez TD. Involvement of autologous myeloid dendritic cells in the evaluation of immediate hypersensitivity reactions to betalactams. Clin Immunol 2024; 262:110166. [PMID: 38432423 DOI: 10.1016/j.clim.2024.110166] [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: 09/29/2023] [Revised: 02/01/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Amoxicillin (AX) and clavulanic acid (CLV) are the betalactam antibiotics (BLs) most used to treat bacterial infections, although they can trigger immediate hypersensitivity reactions (IDHRs). The maturation analysis of monocyte-derived dendritic cells (moDCs) and their capacity to induce proliferative response of lymphocytes are useful to test the sensitisation to a drug, although without optimal sensitivity. Nevertheless, this can be improved using directly isolated DCs such as myeloid DCs (mDCs). METHODS mDCs and moDCs were obtained from 28 allergic patients (AP), 14 to AX, 14 to CLV and from 10 healthy controls (HC). The expression of CCR7, CD40, CD80, CD83, and CD86 was analysed after stimulation with both BLs. We measured the capacity of these pre-primed DCs to induce drug-specific activation of different lymphocyte subpopulations, CD3+, CD4+, CD8+, CD4+Th1, and CD4+Th2, by flow cytometry. RESULTS Higher expression of CCR7, CD40, CD80, CD83, and CD86 was observed on mDCs compared to moDCs from AP after stimulating with the culprit BL. Similarly, mDCs induced higher proliferative response, mainly of CD4+Th2 cells, compared to moDCs, reaching up to 67% of positive results with AX, whereas of only 25% with CLV. CONCLUSIONS mDCs from selective AP efficiently recognise the culprit drug which trigger the IDHR. mDCs also trigger proliferation of lymphocytes, mainly those with a Th2 cytokine pattern, although these responses depend on the nature of the drug, mimicking the patient's reaction.
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Affiliation(s)
- Ruben Fernandez-Santamaria
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Departamento de Medicina, Universidad de Málaga-UMA, Málaga, Spain
| | - Adriana Ariza
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain.
| | - Gador Bogas
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Maria Salas
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Silvia Calvo-Serrano
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Departamento de Medicina, Universidad de Málaga-UMA, Málaga, Spain
| | - Cecilia Frecha
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
| | - Cristobalina Mayorga
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Maria Jose Torres
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Departamento de Medicina, Universidad de Málaga-UMA, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Tahia Diana Fernandez
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga-UMA, Málaga, Spain
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5
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Bennett MR, Mathioudakis AG, Wu J, Chu MMH, Tontini C, Thomas I, Simpson A. Performance Characteristics of Basophil Activation Tests for Diagnosing Penicillin Allergy: A Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:714-723.e5. [PMID: 37940090 DOI: 10.1016/j.jaip.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 09/22/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Approximately 10% of the global population identify themselves as penicillin allergic, yet 90% are not truly allergic and could safely tolerate penicillin. There is no simple way to identify these people. Current in vitro diagnostics include specific immunoglobulin E (with a sensitivity of 19% and specificity of 97%) and a basophil activation test (BAT) with undefined sensitivity and specificity. OBJECTIVE To define the sensitivity and specificity of BAT in the diagnosis of penicillin allergy METHODS: We searched PubMed and EMBASE from inception to April 2, 2023, for original studies evaluating the performance characteristics of BAT for penicillin allergy in adults. Study selection, data extraction, risk of bias, assessment with QUADAS-2 tool, certainty assessment with Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology were performed independently, in duplicate. Meta-analysis was performed using Reitsma methodology. RESULTS Twenty-two studies fulfilled the inclusion criteria. Twelve used the same positive threshold giving a summary point sensitivity 51% (95% confidence interval [95% CI]46%-56%) and specificity 89% (95% CI 85%-93%). Significant risk of bias was identified owing to patient selection. GRADE certainty of evidence rated sensitivity very low due to imprecision and specificity as low. There was great heterogeneity in methods used. Use of 1,000 basophils per test did not improve performance above 500 basophils. CONCLUSIONS BAT sensitivity is highly variable across studies and remains too low to be considered as a routine element of clinical practice. BAT specificity is not as good as specific immunoglobulin E in penicillin allergy diagnosis. Significant further work is required in this field before clinical application of BAT in routine practice.
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Affiliation(s)
- Miriam R Bennett
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK.
| | - Alexander G Mathioudakis
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK; Manchester University NHS Foundation Trust, Respiratory and Allergy, Manchester, UK
| | - Jiakai Wu
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Michael M H Chu
- Manchester University NHS Foundation Trust, Otolaryngology, Manchester, UK
| | - Chiara Tontini
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Iason Thomas
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK; Manchester University NHS Foundation Trust, Respiratory and Allergy, Manchester, UK
| | - Angela Simpson
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK; Manchester University NHS Foundation Trust, Respiratory and Allergy, Manchester, UK
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6
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Sáenz de Santa María R, Bogas G, Labella M, Ariza A, Salas M, Doña I, Torres MJ. Approach for delabeling beta-lactam allergy in children. FRONTIERS IN ALLERGY 2023; 4:1298335. [PMID: 38033918 PMCID: PMC10684789 DOI: 10.3389/falgy.2023.1298335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023] Open
Abstract
A considerable number of pediatric patients treated with beta-lactam (BL) antibiotics develop delayed onset of skin rashes during the course of treatment. Although the most frequent cause of these symptoms is infectious, many cases are labeled as allergic reactions to these drugs. BL allergy labels could have a negative impact, as they imply avoidance of this group of drugs and the use of second-line antibiotics, leading to a potential increase in adverse effects and the utilization of less effective therapies. This constitutes a major public health concern and economic burden, as the use of broad-spectrum antibiotics can result in multidrug-resistant organisms and prolonged hospital stays. Therefore, it is crucial to delabel patients during childhood to avoid false labeling in adult life. Although the label of BL allergy is among the most frequent causes of allergy referral, its management remains controversial, and new diagnostic perspectives are changing the paradigm of managing BL allergies in children. Traditionally, drug provocation testing (DPT) was exclusively performed in patients who had previously obtained negative results from skin tests (STs). However, the sensitivity of STs is low, and the role of in vitro testing in the pediatric population is not well defined. Recent studies have demonstrated the safety of direct DPT without prior ST or serum tests for pediatric patients who report a low-risk reaction to BLs, which is cost-effective. However, there is still a debate on the optimal allergic workup to be performed in children with a benign immediate reaction and the management of children with severe cutaneous adverse drug reactions. In this review, we will discuss the impact of the label of BL allergy and the role of the different tools currently available to efficiently address BL allergy delabeling in children.
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Affiliation(s)
- R. Sáenz de Santa María
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - G. Bogas
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. Labella
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - A. Ariza
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. Salas
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - I. Doña
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. J. Torres
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
- Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
- Departamento de Medicina, Universidad de Málaga, Facultad de Medicina, Málaga, Spain
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Ali SB, Le TTA, Ahmadie A, Yuson C, Kette F, Hissaria P, Smith WB. The role of major and minor determinants in penicillin allergy testing: Time to revisit an old friend? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100132. [PMID: 37781672 PMCID: PMC10509867 DOI: 10.1016/j.jacig.2023.100132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/09/2023] [Accepted: 03/29/2023] [Indexed: 10/03/2023]
Abstract
Background Skin testing is an important step in evaluation of penicillin allergic reactions. It includes testing to the following: amoxicillin, benzyl penicillin, and products generated in vivo after penicillin administration, the major determinant hapten penicilloyl-polylysine (PPL) and the minor determinant mixture (MDM). Although PPL and MDM are available as a commercial kit, their supply and cost remain problematic. Objective We aimed to evaluate the performance and utility of PPL and MDM in penicillin allergy testing. Methods A retrospective audit over a 5-year period was undertaken for those with penicillin testing in a tertiary immunology unit. Results In all, 214 patients were identified. Of those patients, 151 (70.6%) were female and the average age was 58 years. Unspecified penicillin was the most common index drug (n = 127 [59.3%]), followed by amoxicillin (n =3 [24.8%]) and amoxicillin-clavulanic acid (n = 21 [9.7%]). The result of skin testing was positive in 23 patients (10.7%); skin prick testing was positive in 10 patients (4.7%), and intradermal testing (IDT) was positive in 13 patients (6.1%), the majority of whom had identified amoxicillin or amoxicillin-clavulanic acid as the index drug (n = 22 [95.7%]). The result of testing to PPL and/or MDM was positive with IDT only (n=5 [23.8%]). PPL and MDM positivity coexisted with a positive reaction to amoxicillin IDT in 2 patients, 1 of whom passed an amoxicillin challenge. Additionally, 2 positive tests to PPL were present with a negative result for MDM; of these 2 positive results, 1 was positive to amoxicillin IDT. In only 1 case were the results of testing for MDM and PPL both positive, with negative results to all native β-lactams tested; the patient tolerated an amoxicillin challenge. Overall, the negative predictive value for both skin prick testing and IDT was 89.5%. Conclusion Benzyl penicillin and amoxicillin alone may be sufficient for in vivo testing in suspected individuals with penicillin allergy.
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Affiliation(s)
- Syed B. Ali
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
| | - Thanh-Thao Adriana Le
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
| | - Aida Ahmadie
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
| | - Chino Yuson
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
| | - Frank Kette
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
| | - Pravin Hissaria
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
- Department of Immunopathology, SA Pathology, Adelaide, Australia
| | - William B. Smith
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
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Lumkul L, Wongyikul P, Kulalert P, Sompornrattanaphan M, Lao-Araya M, Chuamanochan M, Nochaiwong S, Phinyo P. Genetic association of beta-lactams-induced hypersensitivity reactions: A systematic review of genome-wide evidence and meta-analysis of candidate genes. World Allergy Organ J 2023; 16:100816. [PMID: 37780578 PMCID: PMC10541471 DOI: 10.1016/j.waojou.2023.100816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Importance Beta-lactams (BLs) are the most prescribed antibiotics, being the most frequent cause of drug allergy. However, the association between BL allergy and genetic variations is still unclear. Objective This systematic review and meta-analysis aimed to summarize the genetic effects of BL-induced hypersensitivity using existing evidence. Methods We searched PubMed, Medline, Scopus, EMBASE, CINAHL, and Cochrane Library from inception to September 15, 2022 with no language restriction. Genetic association studies investigating genetic variant/polymorphism and risk of drug-induced hypersensitivity reactions among individuals receiving BL-antibiotics were included. We excluded studies of acute interstitial nephritis, drug-induced liver injury, serum sickness, and isolated drug fever. Data were comprehensively synthesized and quality of study were assessed using STrengthening the Reporting of Genetic Association Studies (STREGA). The record screening, extraction and quality assessment were performed by two reviewers and discussions were made to resolve discrepancies. The effects of each variant were pooled and evaluated by modified Venice criteria. Results A total of 9276 records were identified, and 31 studies were eligible for inclusion. Twenty-seven were candidate-gene association studies (5416 cases and 5939 controls), while the others were next-generation sequencing (NGS) or genome-wide association studies (GWASs) (119 838 cases and 1 487 111 controls). Forty-nine polymorphisms were identified and most of them located in allergic reaction pathways. Meta-analyses of 15 candidate variants in a mixture of both immediate and non-immediate reactions revealed weak genetic effects of rs1801275 (8 studies; n = 1,560; odd ratio 0.73; 95%CI: 0.57-0.93) and rs20541 (4 studies; n = 1,482; odd ratio 1.34; 95%CI: 1.07-1.68) in IL4R and IL13, respectively. Results from GWASs and NGS identified, and confirmed associations in HLA regions including HLA-DRA, HLA-B, HLA-DQA, HLA-DRB1, and HLA-DRB3. Conclusion Our study summarized genetic evidence influencing BL-induced hypersensitivity and estimated effects of potential variants. We postulated that the genomic studies provide better insights to the mechanism of reactions and suggest potential effects of HLA Class II variants. However, results were inconsistent and unable to generalize in different settings. Further high-throughput studies with a well-defined function, epigenetic interaction, incorporated with clinical factors, would be beneficial for risk identification in BL-induced hypersensitivity.
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Affiliation(s)
- Lalita Lumkul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Center of Multidisciplinary Technology for Advanced Medicine (CMUTEAM), Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Pakpoom Wongyikul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Prapasri Kulalert
- Department of Clinical Epidemiology, Faculty of Medicine, Thammasat University, Pathum Thani, 12120, Thailand
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathum Thani, 12120, Thailand
| | - Mongkhon Sompornrattanaphan
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Mongkol Lao-Araya
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Mati Chuamanochan
- Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, 50200, Thailand
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Surapon Nochaiwong
- Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, 50200, Thailand
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
- Musculoskeletal Science and Translational Research (MSTR), Chiang Mai University, Chiang Mai 50200, Thailand
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Celik GE, Guloglu Karatas D, Aydin O, Dogu F, Ikinciogullari A. Diagnostic utility of basophil CD203c expression in β-lactam allergy. Allergy Asthma Proc 2023; 44:200-207. [PMID: 37160747 DOI: 10.2500/aap.2023.44.230013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background: A diagnosis of immunoglobulin E (IgE) mediated reactions to β-lactam (BL) antibiotics is still challenging because of the limited availability of skin-prick test (SPT), and standardization issues, particularly with newer BLs, are still ongoing. Because encouraging data are increasingly emerging in the use of basophil activation tests in the diagnosis of IgE-mediated drug hypersensitivity reactions, in this study, we aimed to determine CD203c expression, a basophil surface marker, in the diagnosis of IgE-mediated hypersensitivity to BL antibiotics. Methods: This study included two groups of subjects. The first group (group 1) (n = 20) included patients with a diagnosis of IgE-mediated allergy to BLs as confirmed through STs or drug provocation tests, and the control group consisted of healthy volunteers (group 2) (n = 24). Expression of CD203c by flow cytometry was studied in samples stimulated by two different concentrations of six different BL antibiotics. A stimulation index ≥ 2 was considered a positive response. Results: The study groups had comparable age and sex distribution. In the entire group, the sensitivity and specificity of CD203c were 29.4% (5 out of 17) and 82.6% (19 out of 23), respectively. When considering the single reactors, two among four patients who were allergic to amoxicillin demonstrated upregulation of CD203c with amoxicillin, which makes 50% sensitivity. The specificity was 100%. Conclusion: Our data demonstrated that assessment of CD203c in the diagnosis of IgE-mediated reactions to BLs provided encouraging results, particularly with amoxicillin allergy. However, this finding needs to be verified in a larger number of cases.
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Affiliation(s)
- Gulfem Elif Celik
- From the, Department of Chest Diseases, Division of Immunology and Allergy, Ankara, Turkey, and
| | | | - Omur Aydin
- From the, Department of Chest Diseases, Division of Immunology and Allergy, Ankara, Turkey, and
| | - Figen Dogu
- Department of Pediatric Immunology and Allergy, Ankara, Turkey
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10
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Torres-Rojas I, Pérez-Alzate D, Somoza ML, Pfeifer APM, Diaz EH, Jimenez-Rodriguez TW, Sánchez JF, Ruano FJ, Blanca M, Blanca-López N. Clavulanic Acid Is a Leading Culprit Beta-Lactam in Immediate Allergic Reactions to Penicillins. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2023; 15:201-213. [PMID: 37021506 PMCID: PMC10079519 DOI: 10.4168/aair.2023.15.2.201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/20/2022] [Accepted: 09/14/2022] [Indexed: 04/07/2023]
Abstract
PURPOSE Clavulanate, a beta-lactam associated with amoxicillin, is frequently prescribed in patients at all ages. Recent data implicate amoxicillin-clavulanate in up to 80% of beta-lactam allergy cases. We assessed clavulanate's role in inducing allergic reactions to this combination treatment, with a focus on selective immediate reactions. METHODS Adults (≥ 16 years) reporting a history of immediate reactions to amoxicillin-clavulanate were evaluated through a beta-lactam allergological workup, using modified European Academy of Allergy and Clinical Immunology guidelines. Patients first underwent skin testing, and if negative, drug provocation tests. Expected outcomes were: Group A, subjects with immediate reaction to classical penicillin group determinants (penicilloyl polylysine, minor determinants mixture, and/or penicillin G); Group B, subjects with selective immediate reaction to amoxicillin; Group C, subjects with selective immediate reaction to clavulanate and Group D, those immediate reactions with co-sensitization to clavulanate plus penicillin group determinants or amoxicillin. RESULTS Of 1,170 included patients, 104 had immediate reactions: 36.5% to penicillin group determinants (Group A), 26.9% to amoxicillin (Group B), 32.7% to clavulanate (Group C), and 3.8% to clavulanate plus penicillin determinants or amoxicillin (Group D). Diagnosis was made by skin testing in 79%, 75% and 47% of the patients, respectively, in the first 3 groups (P < 0.001). Drug provocation tests were necessary to establish most other diagnoses. Anaphylaxis predominated over urticaria/angioedema in all groups. CONCLUSIONS Selective immediate reactions to clavulanate accounted for over a third of cases with confirmed reactions after amoxicillin-clavulanate intake, with more than half experiencing anaphylaxis. Within this group, skin test sensitivity was below 50%. People taking amoxicillin-clavulanate may also be co-sensitized to both drugs.
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11
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Doña I, Guidolin L, Bogas G, Olivieri E, Labella M, Schiappoli M, Sáenz de Santa María R, Dama A, Salas M, Senna G, Bonadonna P, Torres MJ. Resensitization in suspected penicillin allergy. Allergy 2023; 78:214-224. [PMID: 36067012 PMCID: PMC10087608 DOI: 10.1111/all.15508] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/29/2022] [Accepted: 08/08/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The diagnosis of allergic reactions to penicillins (AR-PEN) is very complex as there is a loss of sensitization over time, which leads to negative skin tests (STs) and specific IgE in serum, and even to tolerance to the drug involved. However, STs may become positive after subsequent exposure to the culprit drug (resensitization), with the risk of inducing potentially severe reactions. The exact rate of resensitization to penicillins is unknown, ranging from 0% to 27.9% in published studies. OBJECTIVES To analyze the rate of resensitization in patients with suggestive AR-PEN by repeating STs (retest) after an initial evaluation (IE). MATERIAL AND METHODS Patients with suspected AR-PEN were prospectively evaluated between 2017 and 2020. They underwent STs, and a randomized group also underwent a drug provocation test (DPT) with the culprit. Only patients with negative STs and/or DPT were included. All included cases were retested by STs at 2-8 weeks. RESULTS A total of 545 patients were included: 296 reporting immediate reactions (IRs) and 249 non-immediate reactions (NIRs). Eighty (14.7%) cases had positive results in retest (RT+): 63 (21.3%) IRs and 17 (6.8%) NIRs (p < 0.0001). The rate of RT+ was higher in anaphylaxis compared with all other reactions (45.8% vs 9.1%, p < 0.0001). The risk of RT+ was higher from the fifth week after IE (OR: 4.64, CI: 2.1-11.6; p < 0.001) and increased with the patient's age (OR: 1.02; CI: 1.01-1.04; p = 0.009). CONCLUSIONS Due to the high rate of resensitization, retest should be included in the diagnostic algorithm of IRs to penicillins after an initial negative study, especially in anaphylaxis, to avoid potentially severe reactions after subsequent prescriptions of these drugs.
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Affiliation(s)
- Inmaculada Doña
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain.,Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | - Gádor Bogas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain.,Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | - Marina Labella
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain.,Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | - Rocío Sáenz de Santa María
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain.,Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Annarita Dama
- Allergy Unit, Verona University Hospital, Verona, Italy
| | - María Salas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain.,Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | - María José Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain.,Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain.,Departamento de Medicina, Universidad de Málaga, Málaga, Spain.,Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain
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12
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Romano A, Valluzzi RL, Gaeta F, Caruso C, Zaffiro A, Quaratino D, Ebo D, Sabato V. The Combined Use of Chronological and Morphological Criteria in the Evaluation of Immediate Penicillin Reactions: Evidence From a Large Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3238-3248.e2. [PMID: 36108927 DOI: 10.1016/j.jaip.2022.08.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 08/10/2022] [Accepted: 08/26/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Immediate hypersensitivity reactions to penicillins are often labeled on the basis of a similar set of symptoms, but a key feature of these reactions that can be reproduced in diagnostic testing may be the timing of a reaction in relation to the dose administration. OBJECTIVE To determine whether the timing of a reaction in response to the last dose of a penicillin would predict the results of diagnostic testing. METHODS We evaluated 1074 patients by performing skin tests, serum specific IgE assays (ImmunoCAP), and challenges. Patients who were evaluated by us more than 6 months after their reactions and found negative were reevaluated within 2 to 4 weeks. RESULTS Patients who had reacted within 1 hour after the first dose, within 1 hour after subsequent doses, more than 1 hour to within 6 hours after the first dose, or more than 1 hour to within 6 hours after subsequent doses were classified as group A (758 individuals), B (92), C (67), or D (157), respectively. Penicillin hypersensitivity was diagnosed in 707 patients (65.8%) by skin tests (407 patients, 57.6%), ImmunoCAP (47, 6.6%), both tests (232, 32.8%), or challenges (21, 3%). A conversion to allergy-test positivity occurred in 7 of 10 patients with anaphylactic reactions and in 1 of 28 patients with other reactions who were reevaluated after negative challenges. The rate of penicillin-allergic patients in groups A, B, C, and D was 85%, 35.9%, 35.8%, and 3.8%, respectively. Only 1 of 107 patients reporting cutaneous reactions lasting more than 1 day had positive results to allergy tests. CONCLUSIONS IgE-mediated hypersensitivity can be diagnosed by skin tests in about 70% of subjects who react within 1 hour (eg, patients from groups A and B). This hypersensitivity can be lost over time, as demonstrated by the negativization of allergy tests in follow-up studies. In subjects with anaphylactic reactions, however, it is advisable to not consider this phenomenon definitive. In fact, a conversion to allergy test positivity can be observed in up to 20% of such subjects retested after negative challenges.
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Affiliation(s)
| | - Rocco Luigi Valluzzi
- Department of Pediatrics, Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Vatican City, Italy
| | - Francesco Gaeta
- Allergy Unit, Columbus Hospital, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Cristiano Caruso
- Allergy Unit, Columbus Hospital, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | | | - Didier Ebo
- Immunology-Allergology-Rheumatology, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Vito Sabato
- Immunology-Allergology-Rheumatology, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
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13
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Chong CJ, Choo KJL, Ong KY, Tan V, Khoo JBN, Murthee KG, Hanif IM, Naing CS, Lee HY. Improving drug allergy label accuracy by supervised safety- and protocol-driven evaluation. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022. [DOI: 10.47102/annals-acadmedsg.2022118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction: Drug allergies are often self-reported but of unknown accuracy. We carried out a prospective study to examine the utility and safety of formal allergology evaluation, and to identify factors associated with accurate drug allergy labels.
Method: All patients who underwent drug allergy evaluation in our clinic during the study period were recruited. Baseline demographics, characteristics of index hypersensitivity reaction and outcomes of evaluation were recorded.
Results: A total of 331 patients from March 2019 to June 2021 completed drug allergy evaluation to index drugs of concern. There were 123 (37%) male patients, and the mean age was 49 years (standard deviation 17). There were 170 beta-lactam antibiotics, 53 peri-operative drugs, 43 others, 38 non-steroidal anti-inflammatory drugs, and 27 non-beta-lactam antibiotic evaluations. Index reaction occurred within 5 years in 165 (50%) patients, with latency of less than 4 hours in 125 (38%) patients. The most common index reactions were rash, angioedema and urticaria. There were 57 (17%) evaluations stratified as low risk, 222 (67%) moderate risk, and 52 (16%) high risk based on multidisciplinary consensus. Allergy label was found to be false (negative drug evaluation) in 248 (75%) patients, while 16/237 (7%) skin tests, 44/331 (13%) in-clinic graded challenge, and 23/134 (17%) home prolonged challenges were positive (true drug allergy). The most common evaluation reactions were rash and urticaria. No cases of anaphylaxis were elicited.
Conclusion: Seventy-five percent of drug allergy labels are inaccurate. Risk-stratified, protocolised allergy evaluation is safe. Prolonged drug challenge increases the sensitivity of drug allergy evaluation and should therefore be performed when indicated.
Keywords: Drug allergy, drug hypersensitivity, graded challenge, prolonged drug provocation, skin testing
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14
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De-labeling Penicillin Allergy in Pediatric Population. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00315-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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15
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Jagpal PK, Alshareef S, Marriott JF, Krishna MT. Characterization, epidemiology and risk factors of multiple drug allergy syndrome and multiple drug intolerance syndrome: A systematic review. Clin Transl Allergy 2022; 12:e12190. [PMID: 36017174 PMCID: PMC9395947 DOI: 10.1002/clt2.12190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/18/2022] Open
Abstract
Background Multiple drug allergy and multiple drug intolerance syndrome (MDAS/MDIS) labels are an impediment to clinical care and knowledge regarding these conditions is limited. This systematic review investigated the characterization, epidemiology, risk factors, clinical impact and pharmaco-economics of MDAS and MDIS. Methods Systematic literature search across 11 databases (01 January 2000-06 November 2020) for MDIS, MDAS and related terminology. Studies were reviewed for quality of evidence and risk of bias by employing Critical Appraisal Skills Programme cohort study checklist. A narrative synthesis approach facilitated by systematic textual descriptions, tabulation and thematic analysis was adopted. Results There was heterogeneity in terminology and methodology. Few studies applied standard drug allergy diagnostic methods. There is some evidence to suggest that multiple drug hypersensitivity syndrome (MDHS; i.e., confirmed allergies in MDAS) is a distinct clinical entity. Prevalence of MDIS and MDAS labels in unselected & selected populations varied between 2.1%-6.4% & 4.9%-90% and 1.2% & 0%-36% respectively. Reported risk factors included female gender, increasing age, body mass index, anxiety, depression, co-morbidities, concurrent allergies and increased healthcare utilization. Drugs commonly implicated were antibiotics and non-steroidal anti-inflammatory drugs. No studies relating to clinical impact and pharmaco-economics were found. Conclusion There is considerable burden of MDAS and MDIS labels. Data needs cautious interpretation as majority of studies described involved unverified labels. Despite this limitation and heterogeneity of studies, there is some evidence to suggest that MDHS is a distinct clinical entity. Well-designed multi-centre studies applying standardized terminology and diagnostic methodology are needed to gain further insight into these conditions.
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Affiliation(s)
- Parbir K Jagpal
- Institute of Clinical Sciences University of Birmingham Birmingham UK
| | - Saad Alshareef
- University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - John F Marriott
- Institute of Clinical Sciences University of Birmingham Birmingham UK
| | - Mamidipudi Thirumala Krishna
- University Hospitals Birmingham NHS Foundation Trust Birmingham UK
- Institute of Immunology and Immunotherapy University of Birmingham Birmingham UK
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16
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Gill MM, Gasner S, Banken A, Park M, Weaver A, Sharpe E, Theiler R. Improving routine prenatal penicillin allergy testing for reported penicillin allergy. BMJ Open Qual 2022; 11:e001859. [PMID: 35906008 PMCID: PMC9345039 DOI: 10.1136/bmjoq-2022-001859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/28/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Patients with self-reported antibiotic allergies have a higher cost of care, more frequent infections with resistant bacteria and worse health outcomes than patients without antibiotic allergies. Ultimately, less than 5% of patients who report a penicillin allergy have a clinically significant immune-mediated hypersensitivity reaction when tested. As 10%-30% of the population of pregnant patients are colonised for group B Streptococcus (GBS) and guidelines recommend penicillin as the treatment of choice for GBS, current recommendations support penicillin allergy testing in pregnant patients who report an allergy. METHODS AND INTERVENTION In this quality improvement project, nursing staff used an algorithm outlining inclusion and exclusion criteria to determine which patients were eligible to have penicillin allergy testing completed. Penicillin allergy testing consisted of a skin test using benzylpenicilloyl polylysine (Pre-Pen), penicillin G potassium, amoxicillin and alkaline hydrolysis mix (penicilloate) as a prick skin test, followed by intradermal skin test and finally an oral challenge with either amoxicillin or penicillin. Patient outcomes were analysed to evaluate the impact of the intervention. RESULTS Of the 1266 patients receiving prenatal care during the intervention, 236 (19%) reported a history of penicillin allergy, and 212 if these were eligible for testing. 150 of the eligible patients were offered penicillin allergy testing. 101 patients (67%) completed testing and 49 (33%) declined testing. Seven patients (7%) had positive penicillin allergy testing, while 94 patients (93%) had negative penicillin allergy testing and were immediately de-labelled as penicillin allergic. Seventeen of the de-labelled patients subsequently tested positive for GBS colonisation, and all received intrapartum penicillin without adverse events. CONCLUSIONS Pursuing penicillin allergy testing for pregnant patients with reported penicillin allergy is a safe and feasible approach, allowing for allergy de-labelling and safe, guideline-driven antimicrobial therapy during subsequent labour and delivery hospitalisations. Cost-effectiveness of the allergy testing and impact on later episodes of care should be further investigated.
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Affiliation(s)
| | - Sara Gasner
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Alisha Banken
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy Weaver
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Emily Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Regan Theiler
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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17
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Labella M, Céspedes JA, Doña I, Shamji MH, Agache I, Mayorga C, Torres MJ. The value of the basophil activation test in the evaluation of patients reporting allergic reactions to the BNT162b2 mRNA COVID-19 vaccine. Allergy 2022; 77:2067-2079. [PMID: 34689351 PMCID: PMC8653141 DOI: 10.1111/all.15148] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/21/2021] [Accepted: 09/24/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND mRNA-based COVID-19 vaccines have been reported to induce hypersensitivity reactions (HSR) in a small number of individuals. We aimed to evaluate the real-world incidence of the BNT162b2 mRNA COVID-19 vaccine HSR and to determine the value of the basophil activation test (BAT) in the allergological workup of patients reporting these reactions. METHODS We prospectively enrolled patients with a clinical history indicative of HSR to the BNT162b2 mRNA COVID-19 vaccine. The allergological workup included skin testing (STs) and BAT with polyethylene glycol (PEG) and the vaccine. In those with negative allergy assessments, the administration of the second dose of the BNT162b2 mRNA COVID-19 vaccine was offered. RESULTS Seventeen adults were included. Eleven cases (64.7%) tested negative in the allergological workup and tolerated the re-administration of the second dose of the vaccine and considered non-allergic. Six cases (35.3%) were considered allergic and classified into three groups: 2 subjects displayed positive STs and/or BAT to PEG (Group A), two individuals displayed positive BAT to the vaccine (Group B), and in 2 patients with moderate or severe reactions, the culprit was not identified, tested negative to STs and BAT to both PEG and vaccine (Group C). We further evaluated the value of BAT when the results were positive to the vaccine and negative to PEG by performing BAT in controls groups, finding positive BAT results in 50% of controls, all of them recovered from COVID-19 infection. In contrast, BAT was negative in patients who had not suffered from COVID-19 disease. CONCLUSIONS BAT can be used as a potential diagnostic tool for confirming allergy to PEG excipient but not to the vaccine as a positive result in BAT may indicate a past COVID-19 infection instead of an allergy.
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Affiliation(s)
- Marina Labella
- Allergy Research GroupInstituto de Investigación Biomédica de Málaga‐IBIMAMálagaSpain,Allergy UnitHospital Regional Universitario de MálagaMálagaSpain
| | - Jose Antonio Céspedes
- Allergy Research GroupInstituto de Investigación Biomédica de Málaga‐IBIMAMálagaSpain
| | - Inmaculada Doña
- Allergy Research GroupInstituto de Investigación Biomédica de Málaga‐IBIMAMálagaSpain,Allergy UnitHospital Regional Universitario de MálagaMálagaSpain
| | - Mohamed H. Shamji
- National Heart and Lung InstituteImperial College LondonLondonUK,NIHR Imperial Biomedical Research CentreLondonUK
| | - Ioana Agache
- Faculty of MedicineTransylvania UniversityBrasovRomania
| | - Cristobalina Mayorga
- Allergy Research GroupInstituto de Investigación Biomédica de Málaga‐IBIMAMálagaSpain
| | - Maria José Torres
- Allergy Research GroupInstituto de Investigación Biomédica de Málaga‐IBIMAMálagaSpain,Allergy UnitHospital Regional Universitario de MálagaMálagaSpain,Departamento de MedicinaUniversidad de MálagaMalagaSpain
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18
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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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19
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Ariza A, Mayorga C, Bogas G, Gaeta F, Salas M, Valluzzi RL, Labella M, Pérez-Sánchez N, Caruso C, Molina A, Fernández TD, Torres MJ, Romano A. Detection of Serum-Specific IgE by Fluoro-Enzyme Immunoassay for Diagnosing Type I Hypersensitivity Reactions to Penicillins. Int J Mol Sci 2022; 23:ijms23136992. [PMID: 35805992 PMCID: PMC9266290 DOI: 10.3390/ijms23136992] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/15/2022] [Accepted: 06/21/2022] [Indexed: 12/15/2022] Open
Abstract
Diagnosis of type I hypersensitivity reactions (IgE-mediated reactions) to penicillins is based on clinical history, skin tests (STs), and drug provocation tests (DPTs). Among in vitro complementary tests, the fluoro-enzyme immunoassay (FEIA) ImmunoCAP® (Thermo-Fisher, Waltham, MA, USA) is the most widely used commercial method for detecting drug-specific IgE (sIgE). In this study, we aimed to analyze the utility of ImmunoCAP® for detecting sIgE to penicillin G (PG) and amoxicillin (AX) in patients with confirmed penicillin allergy. The study includes 139 and 250 patients evaluated in Spain and Italy, respectively. All had experienced type I hypersensitivity reactions to penicillins confirmed by positive STs. Additionally, selective or cross-reactive reactions were confirmed by DPTs in a subgroup of patients for further analysis. Positive ImmunoCAP® results were 39.6% for PG and/or AX in Spanish subjects and 52.4% in Italian subjects. When only PG or AX sIgE where analyzed, the percentages were 15.1% and 30.4%, respectively, in Spanish patients; and 38.9% and 46% in Italian ones. The analysis of positive STs showed a statistically significant higher percentage of positive STs to PG determinants in Italian patients. False-positive results to PG (16%) were detected in selective AX patients with confirmed PG tolerance. Low and variable sensitivity values observed in a well-defined population with confirmed allergy diagnosis, as well as false-positive results to PG, suggest that ImmunoCAP® is a diagnostic tool with relevant limitations in the evaluation of subjects with type I hypersensitivity reactions to penicillins.
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Affiliation(s)
- Adriana Ariza
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
| | - Cristobalina Mayorga
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Allergy Unit, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
- Andalusian Center for Nanomedicine and Biotechnology-BIONAND, 29590 Malaga, Spain
| | - Gádor Bogas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Allergy Unit, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
| | - Francesco Gaeta
- Allergy Unit, Columbus Hospital, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - María Salas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Allergy Unit, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
| | - Rocco L. Valluzzi
- Department of Pediatrics, Division of Allergy, Pediatric Hospital Bambino Gesù, 00165 Rome, Italy;
| | - Marina Labella
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Allergy Unit, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
| | - Natalia Pérez-Sánchez
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Allergy Unit, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
| | - Cristiano Caruso
- UOSD DH Gastroenterologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Ana Molina
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
| | - Tahia D. Fernández
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga, 29010 Malaga, Spain
| | - María José Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Allergy Unit, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
- Andalusian Center for Nanomedicine and Biotechnology-BIONAND, 29590 Malaga, Spain
- Departamento de Medicina, Universidad de Málaga, 29010 Malaga, Spain
- Correspondence: ; Tel.: +34-951290224
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Şengül Emeksiz Z, Metbulut P, Akyan Soydaş ŞS, Tuğcu G, Cinel G, Dibek Mısırlıoğlu E. Evaluation of Frequency and Characteristics of Drug Allergy in Pediatric Patients with Cystic Fibrosis. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2022; 35:74-78. [PMID: 35588286 PMCID: PMC9247676 DOI: 10.1089/ped.2021.0165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
Background: Previous studies reported that the prevalence of drug allergy is higher in patients with cystic fibrosis (CF) than in the general population. It is important to exclude or confirm the drug allergy diagnosis with detailed allergic evaluation for preventing drug allergy overdiagnosis. Our study aims to determine the actual frequency of drug allergy proven by diagnostic tests in children with CF and to compare it with the control group. Methods: Patients diagnosed with CF who were followed up in the Pediatric Pulmonology Clinic were included in the study group. Children with similar gender and age characteristics who did not have any chronic diseases and who applied to the Pediatric Polyclinics were included in the control group. We reviewed the medical data of patients with CF. Also, we evaluated the parents of the patients via phone conversation and/or during the control of the outpatient clinic and questioned them in terms of drug allergy. In addition, we assessed those with suspected drug allergies in the pediatric allergy clinic for diagnostic tests and compared it to the control group. Results: CF patients (n = 44) and control group (n = 100) were included in the study. Only 1 patient (2.2%) out of the 44 patients in the study group had a suspicion of drug-related hypersensitivity history. In the control group, 1 patient had a history of rash, provocation test was performed to rule out drug hypersensitivity reaction, and it was evaluated as a negative result. Conclusions: The result of our study showed that the frequency of drug allergy in children diagnosed with CF was not different from the control group. However, it will be useful to confirm the data of pediatric patients with CF in larger groups. In the presence of suspicion of drug allergy, a diagnostic evaluation can prevent unnecessary drug allergy diagnoses.
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Affiliation(s)
- Zeynep Şengül Emeksiz
- Department of Pediatric Allergy and Immunology, University of Health Sciences, Ankara Children's Hospital, Ankara City Hospital, Ankara, Turkey
- Address correspondence to: Zeynep Şengül Emeksiz, MD, Department of Pediatric Allergy and Immunology, Ankara Children's Hospital, Ankara City Hospital, Ankara 06800, Turkey
| | - Pınar Metbulut
- Department of Pediatric Allergy and Immunology, University of Health Sciences, Ankara Children's Hospital, Ankara City Hospital, Ankara, Turkey
| | - Şule Selin Akyan Soydaş
- Department of Pediatric Pulmonology, University of Health Sciences, Ankara Children's Hospital, Ankara City Hospital, Ankara, Turkey
| | - Gökçen Tuğcu
- Department of Pediatric Pulmonology, University of Health Sciences, Ankara Children's Hospital, Ankara City Hospital, Ankara, Turkey
| | - Güzin Cinel
- Department of Pediatric Pulmonology, Ankara Yıldırım Beyazıt University, Ankara Children's Hospital, Ankara, Turkey
| | - Emine Dibek Mısırlıoğlu
- Department of Pediatric Allergy and Immunology, University of Health Sciences, Ankara Children's Hospital, Ankara City Hospital, Ankara, Turkey
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21
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Knibb RC, Huissoon AP, Baretto R, Ekbote A, Onyango-Odera S, Screti C, Newman KL, Krishna MT. Development and Validation of the Anaphylaxis Quality of Life Scale for Adults. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1527-1533.e3. [PMID: 35259537 DOI: 10.1016/j.jaip.2022.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/17/2022] [Accepted: 02/09/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Anaphylaxis is a severe and potentially life-threatening allergic reaction that can have a detrimental impact on quality of life (QoL). There are no validated scales to measure the impact of anaphylaxis on QoL of adults. OBJECTIVE The aim of this study was to develop and assess the reliability and validity of a QoL scale for adults with anaphylaxis (Anaphylaxis Quality of Life Scale for Adults [A-QoL-Adults]). METHODS All participants were recruited from a specialist allergy clinic and had a confirmed diagnosis of anaphylaxis (as per the World Allergy Organization diagnostic criteria) to food, drugs, venom, or latex or had spontaneous anaphylaxis. Interviews were conducted with 13 adults; data were analyzed using thematic analysis to extract items for a QoL scale. A prototype QoL scale was then completed by 115 participants alongside validated scales to measure generic QoL (World Health Organization Quality of Life Scale [Brief Version] [WHOQoL BREF]), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), and stress (Perceived Stress Scale [PSS]). RESULTS The A-QoL-Adults scale has 21 items demonstrating excellent internal reliability (Cronbach α = 0.96). Factor analysis produced 3 subscales: Emotional Impact; Social Impact; and Limitations on Life. Each has excellent internal reliability (0.92, 0.92, and 0.91, respectively). Poorer anaphylaxis-related QoL (total A-QoL-Adults score and subscale scores) correlated significantly with poorer general QoL and greater anxiety, depression, and stress (all P < .01 with medium-to-large effect sizes). CONCLUSIONS The A-QoL-Adults scale is a reliable measure of QoL in adults with anaphylaxis and shows good construct validity. It will offer health care professionals a means to further understand the impact of anaphylaxis on adult patients and could help direct and monitor allergy management and the need for further psychological intervention.
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Affiliation(s)
- Rebecca C Knibb
- School of Psychology, College of Health and Life Sciences, Aston University, Birmingham, UK.
| | - Aarnoud P Huissoon
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Richard Baretto
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Anjali Ekbote
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Sham Onyango-Odera
- Research and Development, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Cassandra Screti
- School of Psychology, College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Kristina L Newman
- School of Psychology, Nottingham Trent University, Nottingham, United Kingdom
| | - Mamidipudi T Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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22
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Alvarez-Cuesta E, Madrigal-Burgaleta R, Broyles AD, Cuesta-Herranz J, Guzman-Melendez MA, Maciag MC, Phillips EJ, Trubiano JA, Wong JT, Ansotegui I. Standards for practical intravenous rapid drug desensitization & delabeling: A WAO committee statement. World Allergy Organ J 2022; 15:100640. [PMID: 35694005 PMCID: PMC9163606 DOI: 10.1016/j.waojou.2022.100640] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/27/2022] [Accepted: 03/03/2022] [Indexed: 12/16/2022] Open
Abstract
Drug hypersensitivity reactions (DHRs) to intravenous drugs can be severe and might leave patients and doctors in a difficult position where an essential treatment or intervention has to be suspended. Even if virtually any intravenous medication can potentially trigger a life-threatening DHR, chemotherapeutics, biologics, and antibiotics are amongst the intravenous drugs most frequently involved in these reactions. Admittedly, suspending such treatments may negatively impact the survival outcomes or the quality of life of affected patients. Delabeling pathways and rapid drug desensitization (RDD) can help reactive patients stay on first-choice therapies instead of turning to less efficacious, less cost-effective, or more toxic alternatives. However, these are high-complexity and high-risk techniques, which usually need expert teams and allergy-specific techniques (skin testing, in vitro testing, drug provocation testing) to ensure safety, an accurate diagnosis, and personalized management. Unfortunately, there are significant inequalities within and among countries in access to allergy departments with the necessary expertise and resources to offer these techniques and tackle these DHRs optimally. The main objective of this consensus document is to create a great benefit for patients worldwide by aiding allergists to expand the scope of their practice and support them with evidence, data, and experience from leading groups from around the globe. This statement of the Drug Hypersensitivity Committee of the World Allergy Organization (WAO) aims to be a comprehensive practical guide on the technical aspects of implementing acute-onset intravenous hypersensitivity delabeling and RDD for a wide range of drugs. Thus, the manuscript does not only focus on clinical pathways. Instead, it also provides guidance on topics usually left unaddressed, namely, internal validation, continuous quality improvement, creating a healthy multidisciplinary environment, and redesigning care (including a specific supplemental section on a real-life example of how to design a dedicated space that can combine basic and complex diagnostic and therapeutic techniques in allergy).
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Affiliation(s)
| | - Ricardo Madrigal-Burgaleta
- Allergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
- Drug Desensitisation Centre, Catalan Institute of Oncology (ICO), Barcelona, Spain
| | - Ana D. Broyles
- Division of Allergy & Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Javier Cuesta-Herranz
- Department of Allergy and Immunology, FIIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
- RETIC ARADyAL, Instituto de Salud Carlos III, Spain
| | | | - Michelle C. Maciag
- Division of Allergy & Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth J. Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason A. Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Johnson T. Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
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Arıkoğlu T, Kuyucu S, Caubet JC. New diagnostıc perspectives in the management of pediatrıc beta-lactam allergy. Pediatr Allergy Immunol 2022; 33:e13745. [PMID: 35338725 DOI: 10.1111/pai.13745] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 12/15/2022]
Abstract
Since overdiagnosis of beta-lactam (BL) allergy is common in the pediatric population, delabeling is a critical part of antimicrobial stewardship. Undesirable consequences of inaccurate BL allergy labeling can be handled by incorporating traditional delabeling or newer risk-based strategies into antibiotic stewardship programs. Conventional assessment of BL allergy relies upon a stepwise algorithm including a clinical history with skin testing followed by drug provocation tests (DPTs). However, a growing number of studies highlighted the suboptimal diagnostic value of skin testing in children. Recently, there has been a paradigm shift in the practice of BL allergy assessment due to recent challenging data which emphasize the safety and accuracy of direct DPTs in children with a suspicion of non-immediate mild cutaneous reactions such as maculopapular eruption, delayed urticaria, and possibly also for benign immediate reactions such as urticaria/angioedema. Identifying low-risk BL allergy patients, in whom skin tests can be skipped and proceeding directly to DPTs could be safe, has become a hot topic in recent years. New risk stratification and predictive modeling studies that have the potential to better predict BL allergy risk status have recently been introduced into the field of drug allergy, particularly in adults. However, in contrast to adults, risk assessment studies in children are rare, and optimal risk definitions are controversial. In the coming years, promising potential methods to elucidate the predictors of BL allergy in children will require multidimensional approaches that may include predictive analytics, artificial intelligence techniques, and point-of-care clinical decision tools.
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Affiliation(s)
- Tuğba Arıkoğlu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
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Zhou H, Liu L, Sun X, Wang H, Yu X, Su Y, You Z, An Z. The impact of pharmacist intervention on prophylactic antibiotics use in orthopedic surgery at a hospital in China. Medicine (Baltimore) 2021; 100:e28458. [PMID: 34967386 PMCID: PMC8718203 DOI: 10.1097/md.0000000000028458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 12/08/2021] [Indexed: 01/05/2023] Open
Abstract
This study aimed to assess the impact of the pharmacist-led intervention on perioperative antibiotic prophylaxis by standardizing the cephalosporin intradermal skin test in the orthopedic department.A pre-and postintervention study was conducted among patients in the Orthopedics Department at the Beijing Chao-Yang Hospital in China. Use of intradermal skin test, perioperative antibacterial prophylaxis, and cost of care were compared between the preintervention population (admitted from 6/1/2018 to 8/31/2018) and postintervention population (admitted from 1/1/2019 to 3/31/2019). Logistic regression and generalized linear regression were used to assess the intervention impact.425 patients from the preintervention period and 448 patients from the postintervention period were included in the study. After the implementation of the pharmacist intervention program, there was a decrease in the utilization of intradermal skin tests, from 95.8% to 16.5% (P < .001). Patients were more likely to have cephalosporin as prophylactic antimicrobials (OR = 5.28, P < .001) after the implementation. The cost of antimicrobials was significantly reduced by $150.21 (P < .001) for each patient.Pharmacist-involved intervention can reduce the utilization of cephalosporins skin tests and decrease the prescription of unnecessary high-cost antimicrobials.
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Affiliation(s)
- Hong Zhou
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Lihong Liu
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Xiao Sun
- Department of Epidemiology, School of Public Health, Tulane University, LA
| | - Huaguang Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaojia Yu
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ye Su
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhaoyuan You
- Nursing Department, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhuoling An
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
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25
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Torres-Rojas I, Pérez-Alzate D, Somoza ML, Haroun Diaz E, Ruano Pérez FJ, Prieto-Moreno Pfeifer A, Jimenez-Rodriguez TW, Fernandez Sánchez J, Blanca M, Canto Diez G, Blanca-López N. Patterns of response and drugs involved in hypersensitivity reactions to beta-lactams in children. Pediatr Allergy Immunol 2021; 32:1788-1795. [PMID: 34324747 DOI: 10.1111/pai.13608] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 07/19/2021] [Accepted: 07/23/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Beta-lactams generate different allergenic determinants that induce selective or cross-reactive drug hypersensitivity reactions (DHRs). We aimed to identify the drugs involved, the selectivity of the response, the mechanism, and the value of the different diagnostic tests for establishing a diagnosis in children evaluated for DHRs to beta-lactams. METHODS Prospective study evaluating children aged under 16 years reporting DHRs to beta-lactams. Reactions were classified as immediate and non-immediate reactions. The workup included sIgE, skin testing, and drug provocation tests (DPTs) for immediate reactions and patch testing and DPTs for non-immediate ones. RESULTS Of the 510 children included, 133 were evaluated for immediate reactions and confirmed in 8.3%. Skin test/in vitro IgE contributed to diagnosing half of the cases. Selective reactions occurred with amoxicillin (63%), followed by common penicillin determinants (27%) and cephalosporins (0.9%). Among non-immediate reactions (11.4% of the 377 children evaluated), most required DPTs, 52.7% of which were positive at 6-7 days of drug challenge. Selective reactions were identified with amoxicillin (80%), penicillin G (7.5%), cephalosporins (7.5%), and clavulanic acid (5%). Urticaria and maculopapular exanthema were the most frequent entities. CONCLUSIONS There were few confirmed cases of either type of reaction. Skin testing proved less valuable in non-immediate reactions, over half of which would also have been lost in a short DPT protocol. Selective responders to amoxicillin were more likely to have non-immediate reactions, while clavulanic acid selectivity was exclusive to the non-immediate typology. Over half the cases with DPTs required 6-7 days of treatment for DHR confirmation.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Miguel Blanca
- Allergy Unit, Infanta Leonor University Hospital, Madrid, Spain
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26
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Arikoglu T, Kont AO, Demirhan A, Yuksek BC, Tokmeci N, Kuyucu S. Risk stratification in beta-lactam allergy. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00295-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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27
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Blanca-Lopez N, Atanaskovic-Markovic M, Gomes ER, Kidon M, Kuyucu S, Mori F, Soyer O, Caubet JC. An EAACI Task Force report on allergy to beta-lactams in children: Clinical entities and diagnostic procedures. Pediatr Allergy Immunol 2021; 32:1426-1436. [PMID: 33931922 DOI: 10.1111/pai.13529] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/24/2021] [Indexed: 12/14/2022]
Abstract
Beta-lactam (BL) allergy suspicion is common in children and constitutes a major public health problem, with an impact on patient's health and on medical costs. However, it has been found that most of these reactions are not confirmed by a complete allergic workup. The diagnostic value of the currently available allergy tests has been investigated intensively recently by different groups throughout the world. This has led to major changes in the management of children with a suspected BL allergy. Particularly, it is now well accepted that skin tests can be skipped before the drug provocation test in children with a benign non-immediate reaction to BL. However, there is still a debate on the optimal allergic workup to perform in children with a benign immediate reaction. In addition, management of children with severe cutaneous adverse drug reactions remains difficult. In this review, based on a selection of the most relevant studies found in the literature, we will review and discuss the diagnosis of different forms of BL allergy in children.
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Affiliation(s)
| | | | - Eva R Gomes
- Allergy Unit, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Mona Kidon
- Safra Children's Hospital and the Clinical Immunology, Angioedema and Allergy Unit, Chaim Sheba Medical Center, Tel Hashomer, Faculty of Pediatric Medicine, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Francesca Mori
- Allergy Unit, Department of Pediatric, Meyer Children's Hospital, Florence, Italy
| | - Ozge Soyer
- Department of Pediatric Allergy, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
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Sokolewicz EM, Rogowska M, Lewandowski M, Puchowska M, Piechota D, Barańska-Rybak W. Antibiotic-Related Adverse Drug Reactions in Patients Treated on the Dermatology Ward of Medical University of Gdańsk. Antibiotics (Basel) 2021; 10:1144. [PMID: 34680725 PMCID: PMC8532852 DOI: 10.3390/antibiotics10101144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/29/2021] [Accepted: 09/14/2021] [Indexed: 11/25/2022] Open
Abstract
Adverse drug reactions (ADRs) are unexpected reactions to a medication administered in a correct way at a standard dose. Drug-induced skin reactions account for 60-70% of all ADRs. The aim of the study is to determine the prevalence of antibiotic-related dermatological ADR in patients treated in the department of Dermatology, Venerology and Allergology of the University Clinical Center in Gdańsk, Poland, in the years 2004-2021. A retrospective analysis of patients' medical files was conducted in order to identify cases of ADR connected with the use of antibiotics, yielding 84 cases. The most common group of antibiotics were β-lactam, causing ADR in 47 patients. β-lactam antibiotics in our study included amoxicillin, alone and combined with clavulanic acid, and cephalosporins, affecting 22, 18 and 7 patients, respectively. In conclusion, β-lactam antibiotics showed the highest prevalence among antibiotic-induced skin reactions. They accounted for 15% of cases of all dermatological drug reactions and 55% of those caused by antibiotics. Especially amoxicillin, prescribed as a single drug or in combination with clavulanic acid, was commonly the culprit. Due to its wide use in the hospital and outpatient clinic, these adverse reactions have to be kept in mind by both hospital staff and general practitioners.
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Affiliation(s)
- Ewa Maria Sokolewicz
- Department of Dermatology, Venerology and Allergology, Medical University of Gdańsk, Debinki 7 Street, 80-952 Gdańsk, Poland; (M.R.); (M.L.); (D.P.); (W.B.-R.)
| | - Martyna Rogowska
- Department of Dermatology, Venerology and Allergology, Medical University of Gdańsk, Debinki 7 Street, 80-952 Gdańsk, Poland; (M.R.); (M.L.); (D.P.); (W.B.-R.)
| | - Miłosz Lewandowski
- Department of Dermatology, Venerology and Allergology, Medical University of Gdańsk, Debinki 7 Street, 80-952 Gdańsk, Poland; (M.R.); (M.L.); (D.P.); (W.B.-R.)
| | - Monika Puchowska
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Debinki 7 Street, 90-952 Gdańsk, Poland;
| | - Dorota Piechota
- Department of Dermatology, Venerology and Allergology, Medical University of Gdańsk, Debinki 7 Street, 80-952 Gdańsk, Poland; (M.R.); (M.L.); (D.P.); (W.B.-R.)
| | - Wioletta Barańska-Rybak
- Department of Dermatology, Venerology and Allergology, Medical University of Gdańsk, Debinki 7 Street, 80-952 Gdańsk, Poland; (M.R.); (M.L.); (D.P.); (W.B.-R.)
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29
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Bogas G, Doña I, Dionicio J, Fernández TD, Mayorga C, Boteanu C, Montañez MI, Al-Ahmad M, Rondón C, Moreno E, Laguna JJ, Torres MJ. Diagnostic Approach of Hypersensitivity Reactions to Cefazolin in a Large Prospective Cohort. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4421-4430.e4. [PMID: 34464750 DOI: 10.1016/j.jaip.2021.08.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/29/2021] [Accepted: 08/11/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Cefazolin is a common trigger of perioperative anaphylaxis. The diagnostic approach is controversial because the optimal concentration for skin testing is uncertain, drug provocation tests (DPTs) are contraindicated in severe reactions, and in vitro tests are not thoroughly validated. OBJECTIVE We aimed to characterize a large number of patients reporting cefazolin allergic reactions and to analyze the diagnostic role of in vivo and in vitro tests. METHODS We prospectively evaluated patients with suspicion for allergic reactions to cefazolin by clinical history, skin tests (STs), and, if negative, DPT. In a subgroup of patients, basophil activation test (BAT) and radioallergosorbent test were done before allergologic workup was performed and the final diagnosis was achieved. RESULTS We evaluated 184 patients, 76 of whom were confirmed as allergic (41.3%), 90 were nonallergic (48.9%), and 18 were nonconfirmed (9.8%). All patients reporting anaphylactic shock and most reporting anaphylaxis were confirmed to be allergic (P < .001). Forty allergic patients (52.6%) were confirmed by STs, 22 by DPT (28.9%), and 14 by clinical history (18.4%). All subjects manifesting exanthemas and pruritus were nonallergic. The BAT sensitivity was 66.7% when CD63 and CD203c were combined as activation markers. Six of 8 patients with negative STs and positive DPT had a positive BAT. CONCLUSIONS Patients allergic to cefazolin often reported severe immediate-type reactions. Skin tests enabled a diagnosis in half of patients when using cefazolin at 20 mg/mL. Unfortunately, DPT could not be performed in all patients owing to reaction severity, which makes BAT a promising diagnostic tool. Further research is needed to clarify the underlying mechanisms, especially in severe reactions.
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Affiliation(s)
- Gador Bogas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Inmaculada Doña
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | | | - Tahia D Fernández
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Department of Cell Biology, Genetics, and Physiology, Universidad de Málaga, Málaga, Spain
| | - Cristobalina Mayorga
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain; Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain
| | - Cosmin Boteanu
- Allergy Section, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - María I Montañez
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain
| | - Mona Al-Ahmad
- Al Rashed Allergy Centre, Ministry of Health, Kuwait; Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait
| | - Carmen Rondón
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Esther Moreno
- Allergy Service, University Hospital of Salamanca., Salamanca, Spain
| | - Jose J Laguna
- Allergy Unit, Hospital de la Cruz Roja, Madrid, Spain; Faculty of Medicine, Universidad Alfonso X El Sabio, Madrid, Spain
| | - Maria J Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital de la Cruz Roja, Madrid, Spain; Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain; Department of Medicine, Universidad de Málaga, Málaga, Spain.
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Lee EH, Kim JY. Cutaneous lymphoid hyperplasia developing on the site of a positive intradermal allergy test to cefotetan. Indian J Dermatol Venereol Leprol 2021; 87:748. [PMID: 34379959 DOI: 10.25259/ijdvl_922_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 05/01/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Eun Hye Lee
- Department of Dermatology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Jun Young Kim
- Department of Dermatology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
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31
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Atanaskovic-Markovic M, Tsabouri S. Exanthematous reactions to drugs in children. Curr Opin Allergy Clin Immunol 2021; 21:335-339. [PMID: 33993141 DOI: 10.1097/aci.0000000000000749] [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: 11/26/2022]
Abstract
PURPOSE OF REVIEW The true exanthematous reactions to drugs in children are rare and overdiagnosed. Drugs may cause exanthema either due to inducing an immune response or because of their interaction with viruses, if drugs are taken in the course of a viral infection. Also, viral infections are very often in children and they can provoke an exanthema which is difficult to differentiate from exanthematous reactions to drugs. Consequently, the majority of children are incorrectly labeled as 'allergic'. RECENT FINDINGS The correct diagnosis of exanthematous drug reactions in children is still an important and hot topic. Most information about the approach and management of drug hypersensitivity in children is applied from available guidelines and consensus statement for adults. Recently, a systematic clinical approach for timely differential diagnosis and management of rashes in children who present a cutaneous exanthema while receiving a drug, is proposed. SUMMARY It is important to consider the detailed clinical history of appearing and developing exanthematous drug reaction, as well as physical examination which includes the description and the distribution of exanthema and at the end making the appropriate diagnosis. Thus, it could reduce overdiagnosis and promote appropriate procedures, that will prevent the overlabeling of drug hypersensitivity in children.
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Affiliation(s)
| | - Sophia Tsabouri
- Child Health Department, Medical School, University of Ioannina, Ioannina, Greece
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Beyaz S, Coskun R, Oztop N, Aygun E, Sungur MO, Seyhan TO, Demir S, Olgac M, Unal D, Colakoglu B, Buyukozturk S, Gelincik A. Evaluation of skin test indications for general anesthetics in real life: a prospective cohort study. Braz J Anesthesiol 2021; 72:350-358. [PMID: 34324936 PMCID: PMC9373089 DOI: 10.1016/j.bjane.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 06/22/2021] [Accepted: 07/03/2021] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND In daily practice, atopic patients and those who have other drug allergies are referred to allergy clinics for evaluation of possible general anesthetic allergy despite the fact that it is not recommended in recent guidelines. OBJECTIVE The aim of this prospective study is to determine the negative predictive value of skin tests for common general anesthetic drugs prior to general anesthesia in atopic patients and in patients who had drug allergies by including the data of those who had previously tolerated or reacted to general anesthesia. METHODS A database program was constituted to collect the preoperative skin test data of patients referred to our clinic between 2013 and 2018. Demographic and clinical history, medications implemented during perioperative period, reactions, and results of skin tests performed with anesthetic drugs and latex were evaluated. RESULTS Four hundred fifty-nine out of the total 1167 patients referred fulfilled the inclusion criteria for further evaluation. Nearly 75% of the patients were female and mean age was 46.3 ± 14.3 years. History of hypersensitivity reactions (HRs) due to NSAIDs and/or antibiotics, radiocontrast agents, local anesthetics, and food were present in the 53.1%, 4.1%, 1.5%, and 2.0%, respectively. The negative predictive values of skin tests for general anesthetics were in the range of 80-100%. Only 4 patients (0,87%) experienced HRs during operation. CONCLUSION These real-life data reveal high rates of negative predictive value of skin tests with general anesthetic drugs and a low reaction rate in atopic patients and in patients with allergy to other drugs.
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Affiliation(s)
- Sengul Beyaz
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul, Turkey
| | - Raif Coskun
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul, Turkey
| | - Nida Oztop
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul, Turkey
| | - Evren Aygun
- Istanbul University, Istanbul Faculty of Medicine, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Mukadder Orhan Sungur
- Istanbul University, Istanbul Faculty of Medicine, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Tulay Ozkan Seyhan
- Istanbul University, Istanbul Faculty of Medicine, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Semra Demir
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul, Turkey
| | - Muge Olgac
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul, Turkey
| | - Derya Unal
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul, Turkey
| | - Bahauddin Colakoglu
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul, Turkey
| | - Suna Buyukozturk
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul, Turkey
| | - Asli Gelincik
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul, Turkey.
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Piotin A, Godet J, Trubiano JA, Grandbastien M, Guénard-Bilbault L, de Blay F, Metz-Favre C. Predictive factors of amoxicillin immediate hypersensitivity and validation of PEN-FAST clinical decision rule. Ann Allergy Asthma Immunol 2021; 128:27-32. [PMID: 34271183 DOI: 10.1016/j.anai.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/12/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The challenge of delabeling amoxicillin allergy is an important issue for patients and clinicians, especially when anaphylaxis is reported. A recent study has proposed a clinical decision rule, PEN-FAST, to identify low-risk penicillin allergies. OBJECTIVE To validate the PEN-FAST clinical decision rule in a population with high risk of suspected immediate amoxicillin allergy and to identify clinical predictive factors of amoxicillin immediate hypersensitivity. METHODS We retrospectively analyzed medical records of patients with a suspected immediate amoxicillin allergy who carried out an allergologic evaluation by a specialist in the Allergy Unit of Strasbourg University Hospital from 2015 to 2020. RESULTS A total of 142 adult patients (88 women [62.0%]; median age, 52 [interquartile range, 40.3-62.0] years) were analyzed. Most of them reported anaphylaxis (68.8%). Internal validation of PEN-FAST score revealed a good discrimination with area under the curve of 0.86 (95% confidence interval, 0.79-0.92). A cutoff of less than 3 points for PEN-FAST was used to classify 29 from 142 patients at low risk of allergy, of whom only 2 (6.9%) received positive results of allergy testing. The negative predictive value for successful delabeling was 0.93 (95% confidence interval, 0.77-0.99). Predictive clinical features for immediate amoxicillin hypersensitivity were time since reaction (P < .001), time elapsed between drug intake and first symptom (P < .001), severity grade reaction (P < .001), and treatment or hospitalization required (P < .001). CONCLUSION PEN-FAST has been validated to identify low-risk penicillin allergies in our European cohort of patients mainly reporting anaphylaxis. This is the first reported external validation of a penicillin allergy clinical decision rule internationally.
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Affiliation(s)
- Anays Piotin
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France.
| | - Julien Godet
- Public Health Department, Strasbourg University Hospital, Strasbourg, France
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Australia; Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Manon Grandbastien
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France
| | | | - Frédéric de Blay
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France; EA 3070 Federation of Translational Medicine, FHU Homicare, University of Strasbourg, Strasbourg, France
| | - Carine Metz-Favre
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France
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Koosakulchai V, Sangsupawanich P, Wantanaset D, Jessadapakorn W, Jongvilaikasem P, Yuenyongviwat A. Safety of direct oral provocation testing using the Amoxicillin-2-step-challenge in children with history of non-immediate reactions to amoxicillin. World Allergy Organ J 2021; 14:100560. [PMID: 34306301 PMCID: PMC8283145 DOI: 10.1016/j.waojou.2021.100560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/23/2021] [Accepted: 06/01/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Previous studies have shown that direct oral provocation tests, without prior skin testing, in children having delayed onset, benign rashes to beta-lactam antibiotic is safe and effective. Although, this test is useful in confirming drug hypersensitivity reactions, there is no standard protocol recommendation of drug provocation tests. This study aimed to evaluate the safety of the direct oral provocation test, using the Amoxicillin-2-step-challenge without prior skin testing, in children with history of non-immediate reactions to amoxicillin. METHODS The Amoxicillin-2-step-challenge protocol was performed in children with history of non-immediate reactions to amoxicillin. This protocol is composed of 2 doses of amoxicillin, with a 30-min interval; continued for a total of 5 days. All of the patients had not undergone skin testing before the oral provocation test. RESULTS This study included 54 children, having a median age of 6.6 years, with 70.4% being male. Amoxicillin and amoxicillin-clavulanic acid were reported as the culprit drug in 75.9% and 24.1%, respectively. The index reactions were maculopapular (MP) rash in 79.6% and delayed urticarial rash/angioedema in 20.4%. Five patients (9.3%) had a reaction during the provocation test, all of these patients had delayed urticaria and were treated with oral antihistamine. However, 1 patient developed a fever alongside an MP rash. Laboratory investigation for this patient showed increased atypical lymphocytes and liver enzymes elevation. CONCLUSIONS Direct oral provocation tests, using the Amoxicillin-2-step-challenge, without prior skin testing, revealed good, immediate safety for the diagnosis of amoxicillin hypersensitivity in children with history of non-immediate reactions to amoxicillin.
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Affiliation(s)
- Vanlaya Koosakulchai
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Pasuree Sangsupawanich
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Duangdee Wantanaset
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Wipa Jessadapakorn
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Pondtip Jongvilaikasem
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Araya Yuenyongviwat
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Sabato V, Gaeta F, Valluzzi RL, Van Gasse A, Ebo DG, Romano A. Urticaria: The 1-1-1 Criterion for Optimized Risk Atratification in β-Lactam Allergy Delabeling. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3697-3704. [PMID: 34146749 DOI: 10.1016/j.jaip.2021.05.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/13/2021] [Accepted: 05/31/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND A spurious label of β-lactam allergy compromises antibiotic stewardship. Delabeling protocols based on direct challenges (ie, not preceded by allergy tests) can be applied in low-risk patients. OBJECTIVE This study aims at determining the significance of the characteristics of urticaria in the risk stratification for delabeling. METHODS The characteristics of urticarial eruptions that had occurred during therapeutic courses with a β-lactam, namely the time interval between the exposure and onset, the dose (first or subsequent) after which urticaria appeared, and the duration of the eruption, were correlated to the results of a systematic allergy workup (skin tests, specific IgE measurements, and challenges). Data from 410 patients enrolled in 3 allergy centers (Rome and Troina, Italy, and Antwerp, Belgium) were analyzed. A multivariable logistic regression was performed, which included appearance within 1 hour after the first dose and regression within 1 day: a model that can be summarized as the "1-1-1" urticaria criterion. RESULTS An urticarial eruption that had appeared within 1 hour after the first dose and had regressed within 1 day was more frequently reported in the group with a positive allergy workup, with odds ratios of 17 (95% confidence interval [CI]: 9-31), 11 (95% CI: 6-20), and 48 (95% CI: 14-157), respectively (P < .005). The 1-1-1 criterion displayed a sensitivity and specificity of 85%, and a negative predictive value and a positive predictive value of 80% and 90%, respectively. CONCLUSION Patients with urticaria meeting the 1-1-1 criterion should be considered at high risk and referred for an allergy workup with skin testing and specific IgE measurement before challenging.
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Affiliation(s)
- Vito Sabato
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; Allergology Unit, AZ Jan Palfijn, Ghent, Belgium; Infla-Med Centre of Excellence, University of Antwerp, Antwerpen, Belgium
| | - Francesco Gaeta
- Allergy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rocco Luigi Valluzzi
- Multifactorial and Systemic Diseases Research Area, Predictive and Preventive Medicine Research Unit, Division of Allergy, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Athina Van Gasse
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Didier Gaston Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; Allergology Unit, AZ Jan Palfijn, Ghent, Belgium; Infla-Med Centre of Excellence, University of Antwerp, Antwerpen, Belgium.
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Cardoso‐Fernandes A, Blumenthal KG, Chiriac AM, Tarrio I, Afonso‐João D, Delgado L, Fonseca JA, Azevedo LF, Sousa‐Pinto B. Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta-analysis. Clin Transl Allergy 2021; 11:e12008. [PMID: 34161664 PMCID: PMC8215894 DOI: 10.1002/clt2.12008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Patients with a penicillin allergy label tend to have worse clinical outcomes and increased healthcare use. Drug provocation tests (DPT) are the gold-standard in the diagnostic workup of penicillin allergy, but safety concerns may hinder their performance. We aimed to assess the frequency of severe reactions following a DPT in patients with reported allergy to penicillins or other β-lactams. METHODS We performed a systematic review, searching MEDLINE, Scopus, and Web of Science. We included primary studies assessing participants with a penicillin allergy label who underwent a DPT. We performed a Bayesian meta-analysis to estimate the pooled frequency of severe reactions to penicillin DPTs. Sources of heterogeneity were explored by subgroup and metaregression analyses. RESULTS We included 112 primary studies which included a total of 26,595 participants. The pooled frequency of severe reactions was estimated at 0.06% (95% credible interval [95% CrI] = 0.01%-0.13%; I2 = 57.9%). Most severe reactions (80/93; 86.0%) consisted of anaphylaxis. Compared to studies where the index reaction was immediate, we observed a lower frequency of severe reactions for studies assessing non-immediate index reactions (OR = 0.05; 95% CrI = 0-0.31). Patients reporting anaphylaxis as their index reaction were found to be at increased risk of developing severe reactions (OR = 13.5; 95% CrI = 7.7-21.5; I2 = 0.3%). Performance of direct DPTs in low-risk patients or testing with the suspected culprit drug were not associated with clinically relevant increased risk of severe reactions. CONCLUSIONS In patients with a penicillin allergy label, severe reactions resulting from DPTs are rare. Therefore, except for patients with potentially life-threatening index reactions or patients with positive skin tests-who were mostly not assessed in this analysis -, the safety of DPTs supports their performance in the diagnostic assessment of penicillin allergy.
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Affiliation(s)
- António Cardoso‐Fernandes
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolHarvard UniversityBostonMassachusettsUSA
| | - Anca Mirela Chiriac
- Department of PulmonologyDivision of Allergy, Hôpital Arnaud de VilleneuveUniversity Hospital of MontpellierMontpellierFrance
- UMR‐S 1136 INSERM‐Sorbonne UniversitéEquipe Epidémiologie des Maladies Allergiques et Respiratoires (EPAR)Institut Pierre Louis d’Epidémiologie et de Santé PubliqueParisFrance
| | - Isabel Tarrio
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - David Afonso‐João
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Luís Delgado
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
- Basic and Clinical Immunology Unit, Department of Pathology, Faculty of MedicineUniversity of PortoPortoPortugal
| | - João Almeida Fonseca
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Luís Filipe Azevedo
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Bernardo Sousa‐Pinto
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
- Basic and Clinical Immunology Unit, Department of Pathology, Faculty of MedicineUniversity of PortoPortoPortugal
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Broyles AD, Banerji A, Barmettler S, Biggs CM, Blumenthal K, Brennan PJ, Breslow RG, Brockow K, Buchheit KM, Cahill KN, Cernadas J, Chiriac AM, Crestani E, Demoly P, Dewachter P, Dilley M, Farmer JR, Foer D, Fried AJ, Garon SL, Giannetti MP, Hepner DL, Hong DI, Hsu JT, Kothari PH, Kyin T, Lax T, Lee MJ, Lee-Sarwar K, Liu A, Logsdon S, Louisias M, MacGinnitie A, Maciag M, Minnicozzi S, Norton AE, Otani IM, Park M, Patil S, Phillips EJ, Picard M, Platt CD, Rachid R, Rodriguez T, Romano A, Stone CA, Torres MJ, Verdú M, Wang AL, Wickner P, Wolfson AR, Wong JT, Yee C, Zhou J, Castells M. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:S16-S116. [PMID: 33039007 DOI: 10.1016/j.jaip.2020.08.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ana Dioun Broyles
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Sara Barmettler
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Catherine M Biggs
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kimberly Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Patrick J Brennan
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca G Breslow
- Division of Sports Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Josefina Cernadas
- Allergology and Immunology Service, Centro Hospitalar Universitário de S.João Hospital, Porto, Portugal
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Elena Crestani
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Pascale Dewachter
- Department of Anesthesiology and Intensive Care Medicine, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Meredith Dilley
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Ari J Fried
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Sarah L Garon
- Associated Allergists and Asthma Specialists, Chicago, Ill
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass
| | - David I Hong
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Joyce T Hsu
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Parul H Kothari
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Timothy Kyin
- Division of Asthma, Allergy & Immunology, University of Virginia, Charlottesville, Va
| | - Timothy Lax
- Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Min Jung Lee
- Allergy and Immunology at Hoag Medical Group, Newport Beach, Calif
| | - Kathleen Lee-Sarwar
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Anne Liu
- Division of Allergy / Immunology, Stanford University School of Medicine, Palo Alto, Calif
| | - Stephanie Logsdon
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Andrew MacGinnitie
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Michelle Maciag
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Samantha Minnicozzi
- Division of Allergy and Clinical Immunology, Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Sarita Patil
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Division of Allergy and Clinical Immunology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Rima Rachid
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Tito Rodriguez
- Drug Allergy Department, Al-Rashed Allergy Center, Sulaibikhat, Al-Kuwait, Kuwait
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Miriam Verdú
- Allergy Unit, Hospital Universitario de Ceuta, Ceuta, Spain
| | - Alberta L Wang
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Paige Wickner
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Johnson T Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Christina Yee
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Joseph Zhou
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Mariana Castells
- Drug hypersensitivity and Desensitization Center, Brigham and Women's Hospital, Boston, Mass
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Sousa-Pinto B, Blumenthal KG, Macy E, Pereira AM, Azevedo LF, Delgado L, Fonseca JA. Penicillin Allergy Testing Is Cost-Saving: An Economic Evaluation Study. Clin Infect Dis 2021; 72:924-938. [PMID: 32107530 DOI: 10.1093/cid/ciaa194] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Having a penicillin allergy label is associated with the use of less appropriate and more expensive antibiotics and increased healthcare utilization. Penicillin allergy testing results in delabeling most allergy claimants and may be cost-saving. This study aimed to project whether penicillin allergy testing in patients reporting a penicillin allergy is cost-saving. METHODS In this economic evaluation study, we built decision models to project the economic impact of 2 strategies for a patient with a penicillin allergy label: (1) perform diagnostic testing (drug challenges, with or without skin tests); and (2) do not perform diagnostic testing. The health service perspective was adopted, considering costs with penicillin allergy tests, and with hospital bed-days/outpatient visits, antibiotic use, and diagnostic testing. Twenty-four base case decision models were built, accounting for differences in the diagnostic workup, setting (inpatient vs outpatient) and geographic region. Uncertainty was explored via probabilistic sensitivity analyses. RESULTS Penicillin allergy testing was cost-saving in all decision models built. For models assessing the performance of both skin tests and drug challenges, allergy testing resulted in average savings (in United States [US] dollars) of $657 for inpatients (US: $1444; Europe: $489) and $2746 for outpatients (US: $256; Europe: $6045). 75% of simulations obtained through probabilistic sensitivity analysis identified testing as the less costly option. CONCLUSIONS Penicillin allergy testing was projected to be cost-saving across different scenarios. These results are devised to inform guidelines, supporting the adoption of policies promoting widespread testing of patients with a penicillin allergy label.
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Affiliation(s)
- Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal.,Basic and Clinical Immunology Unit, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, California, USA
| | - Ana Margarida Pereira
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
| | - Luís Filipe Azevedo
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
| | - Luís Delgado
- Center for Health Technology and Services Research, Porto, Portugal.,Basic and Clinical Immunology Unit, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Almeida Fonseca
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
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Felix MMR, Aun MV, Menezes UPD, Queiroz GRESD, Rodrigues AT, D'Onofrio-Silva AC, Perelló MI, Camelo-Nunes IC, Malaman MF. Allergy to penicillin and betalactam antibiotics. EINSTEIN-SAO PAULO 2021; 19:eMD5703. [PMID: 33909756 PMCID: PMC8054529 DOI: 10.31744/einstein_journal/2021md5703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
Betalactams are the most frequent cause of hypersensitivity reactions to drugs mediated by a specific immune mechanism. Immediate reactions occur within 1 to 6 hours after betalactam administration, and are generally IgE-mediated. They clinically translate into urticaria, angioedema and anaphylaxis. Non-immediate or delayed reactions occur after 1 hour of administration. These are the most common reactions and are usually mediated by T cells. The most frequent type is the maculopapular or morbilliform exanthematous eruption. Most individuals who report allergies to penicillin and betalactams can tolerate this group of antibiotics. To make diagnosis, a detailed medical history is essential to verify whether it was an immediate or non-immediate reaction. Thereafter, in vivo and/or in vitro tests for investigation may be performed. The challenging test is considered the gold standard method for diagnosis of betalactam hypersensitivity. The first approach when suspecting a reaction to betalactam is to discontinue exposure to the drug, and the only specific treatment is desensitization, which has very precise indications. The misdiagnosis of penicillin allergy affects the health system, since the "penicillin allergy" label is associated with increased bacterial resistance, higher rate of therapeutic failure, prolonged hospitalizations, readmissions, and increased costs. Thus, it is essential to develop strategies to assist the prescription of antibiotics in patients identified with a label of "betalactam allergy" at hospitals, and to enhance education of patients and their caregivers, as well as of non-specialist physicians.
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Affiliation(s)
- Mara Morelo Rocha Felix
- Escola de Medicina e Cirurgia, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Marcelo Vivolo Aun
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Ullissis Pádua de Menezes
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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Evaluating Immediate Reactions to Cephalosporins: Time Is of the Essence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1648-1657.e1. [DOI: 10.1016/j.jaip.2020.11.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/11/2020] [Accepted: 11/13/2020] [Indexed: 12/26/2022]
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41
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Mayorga C, Montañez MI, Najera F, Bogas G, Fernandez TD, Gil DR, Palacios R, Torres MJ, Vida Y, Perez-Inestrosa E. The Role of Benzylpenicilloyl Epimers in Specific IgE Recognition. Front Pharmacol 2021; 12:585890. [PMID: 33716734 PMCID: PMC7952312 DOI: 10.3389/fphar.2021.585890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/13/2021] [Indexed: 11/13/2022] Open
Abstract
The high prevalence of allergy to β-lactam antibiotics is a worldwide issue. Accuracy of diagnostic methods is important to prove tolerance or allergy, with skin test considered the best validated in vivo method for diagnosing immediate reactions to β-lactams. Although drug provocation test is the reference standard, it cannot be performed in highly risk reactions or in those with positive skin tests. For skin tests, the inclusion of major and minor determinants of benzylpenicillin (BP) is recommended. Commercial skin test reagents have changed along time, including as minor determinants benzylpenicillin, benzylpenicilloate (BPO), and benzylpenilloate (PO). Major determinants consists of multivalent conjugates of benzylpenicilloyl coupled through amide bond to a carrier polymer, such as penicilloyl-polylysine (PPL) or benzylpenicilloyl-octalysine (BP-OL). The chemical stability of such reagents has influenced the evolution of the composition of the commercial kits, as this requirement is necessary for improving the quality and standardization of the product. In this work, we provide a detailed study of the chemical stability of BP determinants. We observed that those structures suffer from an epimerization process in C-5 at different rates. Butylamine-Benzylpenicilloyl conjugates (5R,6R)-Bu-BPO and (5S,6R)-Bu-BPO were selected as a simple model for mayor determinant to evaluate the role of the different epimers in the immunoreactivity with sera from penicillin-allergic patients. In vitro immunoassays indicate that any change in the chemical structure of the antigenic determinant of BP significantly affects IgE recognition. The inclusion of stereochemically pure compounds or mixtures may have important implications for both the reproducibility and sensitivity of in vivo and in vitro diagnostic tests.
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Affiliation(s)
- Cristobalina Mayorga
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
- Centro Andaluz de Nanomedicina y Biotecnología-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
| | - Maria I. Montañez
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain
- Centro Andaluz de Nanomedicina y Biotecnología-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
| | - Francisco Najera
- Centro Andaluz de Nanomedicina y Biotecnología-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
- Universidad de Málaga-IBIMA Departamento de Química Orgánica, Málaga, Spain
| | - Gador Bogas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Tahía D. Fernandez
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain
- Universidad de Málaga-IBIMA, Departamento de Biología celular, Genética y Fisiología, Málaga, Spain
| | | | | | - Maria J. Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
- Centro Andaluz de Nanomedicina y Biotecnología-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
- Universidad de Málaga-IBIMA, Departamento de Medicina, Málaga, Spain
| | - Yolanda Vida
- Centro Andaluz de Nanomedicina y Biotecnología-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
- Universidad de Málaga-IBIMA Departamento de Química Orgánica, Málaga, Spain
| | - Ezequiel Perez-Inestrosa
- Centro Andaluz de Nanomedicina y Biotecnología-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
- Universidad de Málaga-IBIMA Departamento de Química Orgánica, Málaga, Spain
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Thompson G, McLean-Tooke A, Lucas M. Cross With Caution: Antibiotic Cross-Reactivity and Co-Reactivity Patterns in Severe Cutaneous Adverse Reactions. Front Immunol 2021; 12:601954. [PMID: 33717082 PMCID: PMC7947317 DOI: 10.3389/fimmu.2021.601954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/12/2021] [Indexed: 12/19/2022] Open
Abstract
Current understanding of cross-reactivity in severe cutaneous adverse reactions to beta-lactam antibiotics is limited, thereby making recommendations for future prescribing difficult. The underlying immunopathogenesis of these reactions is not completely understood but involves interactions between small molecule drugs, T cells and HLA molecules. Historically, these reactions were considered to be specific to the inciting antibiotic and therefore likely to have minimal cross-reactivity. We assessed patients presenting with non-SJS/TEN severe cutaneous adverse reactions to a tertiary hospital drug allergy clinic. In our case series cross-reactivity or co-reactivity commonly occurred among the beta-lactam antibiotic class, however further research is required to investigate and understand patterns of cross-reactivity. Based on our experience we provide clinicians with a practical algorithm for testing for cross-reactivity in non-SJS/TEN severe cutaneous adverse reactions.
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Affiliation(s)
- Grace Thompson
- Queen Elizabeth II Medical Centre, Department of Clinical Immunology, Sir Charles Gairdner Hospital, Pathwest, Nedlands, WA, Australia
| | - Andrew McLean-Tooke
- Queen Elizabeth II Medical Centre, Department of Clinical Immunology, Sir Charles Gairdner Hospital, Pathwest, Nedlands, WA, Australia
| | - Michaela Lucas
- Queen Elizabeth II Medical Centre, Department of Clinical Immunology, Sir Charles Gairdner Hospital, Pathwest, Nedlands, WA, Australia.,Medical School, University of Western Australia, Nedlands, WA, Australia
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Ayuso P, García-Martín E, Agúndez JAG. Variability of the Genes Involved in the Cellular Redox Status and Their Implication in Drug Hypersensitivity Reactions. Antioxidants (Basel) 2021; 10:antiox10020294. [PMID: 33672092 PMCID: PMC7919686 DOI: 10.3390/antiox10020294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 12/13/2022] Open
Abstract
Adverse drug reactions are a major cause of morbidity and mortality. Of the great diversity of drugs involved in hypersensitivity drug reactions, the most frequent are non-steroidal anti-inflammatory drugs followed by β-lactam antibiotics. The redox status regulates the level of reactive oxygen and nitrogen species (RONS). RONS interplay and modulate the action of diverse biomolecules, such as inflammatory mediators and drugs. In this review, we address the role of the redox status in the initiation, as well as in the resolution of inflammatory processes involved in drug hypersensitivity reactions. We summarize the association findings between drug hypersensitivity reactions and variants in the genes that encode the enzymes related to the redox system such as enzymes related to glutathione: Glutathione S-transferase (GSTM1, GSTP, GSTT1) and glutathione peroxidase (GPX1), thioredoxin reductase (TXNRD1 and TXNRD2), superoxide dismutase (SOD1, SOD2, and SOD3), catalase (CAT), aldo-keto reductase (AKR), and the peroxiredoxin system (PRDX1, PRDX2, PRDX3, PRDX4, PRDX5, PRDX6). Based on current evidence, the most relevant candidate redox genes related to hypersensitivity drug reactions are GSTM1, TXNRD1, SOD1, and SOD2. Increasing the understanding of pharmacogenetics in drug hypersensitivity reactions will contribute to the development of early diagnostic or prognosis tools, and will help to diminish the occurrence and/or the severity of these reactions.
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Affiliation(s)
- Pedro Ayuso
- Correspondence: ; Tel.: +34-927257000 (ext. 51038)
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44
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Casimir-Brown RS, Kennard L, Kayode OS, Siew LQC, Makris M, Tsilochristou O, Chytiroglou E, Nakonechna A, Rutkowski K, Mirakian R, Wagner A. Piperacillin-Tazobactam Hypersensitivity: A Large, Multicenter Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2001-2009. [PMID: 33444815 DOI: 10.1016/j.jaip.2020.12.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/03/2020] [Accepted: 12/16/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Piperacillin/tazobactam is a broad-spectrum penicillin. Hypersensitivity reactions are less commonly reported than with other penicillins except in patients with cystic fibrosis. OBJECTIVE Detailed clinical characterization of a patient cohort referred with suspected piperacillin-tazobactam hypersensitivity. METHODS Retrospective analysis of the demographic characteristics, clinical presentation, investigation, and management of 87 patients presenting to 5 European allergy centers. Patients underwent skin prick and intradermal testing with piperacillin/tazobactam, major (penicilloyl-polylysine) and minor (sodium penilloate) determinants, amoxicillin, benzylpenicillin, flucloxacillin, co-amoxiclav, clavulanic acid, and meropenem with immediate and, where appropriate, delayed reading of tests. Skin test-negative patients underwent drug provocation to piperacillin/tazobactam and/or other penicillins. A multistep protocol was used, depending on risk assessment. RESULTS Forty-eight of 87 (55%) patients were diagnosed with hypersensitivity to piperacillin/tazobactam with either positive skin or drug provocation test results, of whom 10 (21%) had a diagnosis of cystic fibrosis. Twenty-six (54%) patients presented with immediate and 22 (45%) with nonimmediate hypersensitivity. Patients with cystic fibrosis predominantly presented with nonimmediate hypersensitivity (70%). Reactions were severe in 52% of immediate reactors (Brown's anaphylaxis grade 3) and moderately severe (systemic involvement) in 75% of nonimmediate reactors. The number of patients with negative skin test results tolerating reintroduction was comparable in immediate (80%) and nonimmediate (88%) hypersensitivity. One-third of patients were cross-sensitized to other penicillins. The cross-sensitization pattern raised the possibility of tazobactam allergy in 3 patients. In 21 patients selectively sensitized to piperacillin/tazobactam (12 immediate, 9 nonimmediate), tolerance to other beta-lactams was demonstrated by drug provocation testing. CONCLUSIONS Piperacillin-tazobactam caused immediate and nonimmediate hypersensitivity with similar frequency. Most patients were selectively sensitized and tolerated other penicillins. Some patients may be allergic to the beta-lactamase inhibitor only.
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Affiliation(s)
| | - Lucinda Kennard
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Leonard Q C Siew
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Michael Makris
- Allergy Unit, 2nd Department of Dermatology and Venereology, Medical School, National and Kapodistrian University of Athens, University General Hospital "Attikon", Athens, Greece
| | - Olympia Tsilochristou
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Peter Gorer Department of Immunobiology, King's College London, London, United Kingdom
| | - Evangelia Chytiroglou
- Allergy Unit, 2nd Department of Dermatology and Venereology, Medical School, National and Kapodistrian University of Athens, University General Hospital "Attikon", Athens, Greece
| | - Alla Nakonechna
- Clinical Immunology & Allergy Unit, Sheffield Teaching Hospital, Sheffield, United Kingdom; Royal Preston Hospital, Lancashire Teaching Hospitals, NHS Foundation Trust, Lancashire, United Kingdom; University of Liverpool, Liverpool, United Kingdom
| | - Krzysztof Rutkowski
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Rita Mirakian
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Annette Wagner
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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45
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Al-Ahmad M, Edin J, Musa F, Rodriguez-Bouza T. Drug Allergy Profile From a National Drug Allergy Registry. Front Pharmacol 2021; 11:555666. [PMID: 33542684 PMCID: PMC7851708 DOI: 10.3389/fphar.2020.555666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 11/09/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Drug hypersensitivity reactions (DHRs) are among the most frequent reasons for consultation in allergy departments and are becoming more common due to increasing prevalence and case complexity. Objective: To describe the most common drugs associated with clinical reactions, diagnostic methods used, and outcomes of allergic evaluations of a national drug allergy registry over a 12-year period were used. Methods: An observational, prospective, patient’s data registry-based study was conducted to analyze all referrals to the drug allergy outpatient clinics at Al-Rashed Allergy Center, Kuwait, between 2007 and 2019. Demographics, description of DHRs, and results of allergy tests to potential causative medications were reviewed. Diagnostic methods were focused mainly on skin tests (STs) and drug provocation test (DPT), when indicated. Results: We evaluated 1,553 patients with reported DHRs. The mean age of the population was 41.52 ± 16.93 years, and the study population consisted of 63.7% female patients. Hypersensitivity was finally confirmed in 645 (41.5%) of patients, probable in 199 (12.8%), and not confirmed/nonallergic in 709 (45.6%) patients. Anti-inflammatory drugs and analgesics contributed to 39.22% of all confirmed drug allergies, followed by antibiotics 38.1% (β-lactam antibiotics (BLs) constituted 73.98% of all antibiotics and 28.21% of all drugs), anesthetics 1.8%, and radio-contrast media 0.31%. The majority of reactions were non-immediate 51.44%. The most commonly presenting symptoms among confirmed patients were urticaria 57.80%, angioedema 42.50%, respiratory symptoms 47.60%, and erythema 33.60%. Symptoms of anaphylaxis/anaphylactic shock were reported by 284 patients (44.00%) among confirmed cases. The most common method of diagnosis was a positive clinical history (54.4% in BLs and 90.45% in nonsteroidal anti-inflammatory drugs (NSAIDs). Among confirmed allergy to BLs, a positive ST was obtained in 31.9% of patients and positive DPT in 13.7%. Conclusion: NSAIDs and antibiotics, mainly BLs, are the most commonly implicated in confirmed allergy. In both confirmed and not confirmed/nonallergic cases, BLs are the most frequently involved DHRs which are mainly immediate, and the most commonly presenting symptoms were urticaria, angioedema, and respiratory symptoms. Diagnosis was confirmed mainly by a positive clinical history and when indicated, by positive STs or a DPT.
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Affiliation(s)
- Mona Al-Ahmad
- Al Rashed Allergy Centre, Ministry of Health, Kuwait.,Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait
| | - Jusufovic Edin
- Medical Faculty, University of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Fardous Musa
- Al Rashed Allergy Centre, Ministry of Health, Kuwait
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46
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Savic L, Thomas C, Fallaha D, Wilson M, Hopkins PM, Savic S, Clark SH. DALES, Drug Allergy Labels in Elective Surgical patients: a prospective multicentre cross-sectional study of incidence, risks, and attitudes in penicillin de-labelling strategies. Br J Anaesth 2020; 125:962-969. [DOI: 10.1016/j.bja.2020.07.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 12/12/2022] Open
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47
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Stingeni L, Bianchi L, Tramontana M, Pigatto PD, Patruno C, Corazza M, Foti C, Fabbrocini G, Micali G, Romita P, Napolitano M, Hansel K. Skin tests in the diagnosis of adverse drug reactions. GIORN ITAL DERMAT V 2020; 155:602-621. [DOI: 10.23736/s0392-0488.20.06698-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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48
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Sobrino-García M, Moreno EM, Muñoz-Bellido FJ, Gracia-Bara MT, Laffond E, Doña I, Martín C, Macías EM, de Arriba S, Campanón V, Gallardo A, Dávila I. Analysis of the Costs Associated With the Elective Evaluation of Patients Labelled as Allergic to Beta-Lactams or Nonsteroidal Antiinflamatory Agents. Front Pharmacol 2020; 11:584633. [PMID: 33746738 PMCID: PMC7970755 DOI: 10.3389/fphar.2020.584633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/14/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Being labelled as allergic to different drugs results in patients receiving other treatments, which are more toxic, less effective and more expensive. We aimed to analyze different studies of the costs of drug hypersensitivity assessment. Methods: A bibliographic search on studies regarding this issue was performed, including the available scientific evidence up to June 2020. We searched three databases with terms related to costs and allergy testing in drug hypersensitivity reactions. Results: Our search revealed 1,430 publications, of which 20 met the inclusion criteria. In the manuscript, prospective studies evaluating the costs of the evaluation of patients with suspected allergy to beta-lactams or non-steroidal anti-inflammatory drugs are analyzed. Also, comment is made on the costs associated with incorrect labeling as non-steroidal anti-inflammatory drug or penicillin hypersensitivity. Conclusions: Taking all costs into account, the study of drug hypersensitivity is not expensive, particularly considering the economic and clinical consequences of labeling a patient with hypersensitivity to drugs.
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Affiliation(s)
| | - Esther M Moreno
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Department of Biomedical and Diagnostic Sciences, Faculty of Medicine, University of Salamanca, Salamanca, Spain.,Asthma, Allergic and Adverse Reactions (ARADyAL), Network for Cooperative Research in Health of Instituto de Salud Carlos III, Salamanca University Hospital, Salamanca, Spain
| | - Francisco J Muñoz-Bellido
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Department of Biomedical and Diagnostic Sciences, Faculty of Medicine, University of Salamanca, Salamanca, Spain
| | - Maria T Gracia-Bara
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Elena Laffond
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Department of Biomedical and Diagnostic Sciences, Faculty of Medicine, University of Salamanca, Salamanca, Spain
| | - Inmaculada Doña
- Asthma, Allergic and Adverse Reactions (ARADyAL), Network for Cooperative Research in Health of Instituto de Salud Carlos III, Salamanca University Hospital, Salamanca, Spain.,Allergy Service, University Hospital of Malaga, Malaga, Spain.,Biomedical Research Institute of Malaga (IBIMA), Malaga, Spain
| | - Cristina Martín
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Eva M Macías
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Department of Biomedical and Diagnostic Sciences, Faculty of Medicine, University of Salamanca, Salamanca, Spain
| | - Sonia de Arriba
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Department of Biomedical and Diagnostic Sciences, Faculty of Medicine, University of Salamanca, Salamanca, Spain
| | - Valle Campanón
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain
| | - Alicia Gallardo
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain
| | - Ignacio Dávila
- Allergy Service, University Hospital of Salamanca, Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Department of Biomedical and Diagnostic Sciences, Faculty of Medicine, University of Salamanca, Salamanca, Spain.,Asthma, Allergic and Adverse Reactions (ARADyAL), Network for Cooperative Research in Health of Instituto de Salud Carlos III, Salamanca University Hospital, Salamanca, Spain
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The use of direct oral challenge to confirm allergies to penicillin class antibiotics in Danish children. BMC Pediatr 2020; 20:523. [PMID: 33190633 PMCID: PMC7667840 DOI: 10.1186/s12887-020-02407-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background A high number of children are referred to pediatric departments with a suspected allergic reaction to antibiotics. The prevalence of true allergy is considered to be significantly lower than shown from clinical history and symptoms alone. This study investigated the historical use of direct oral challenges at three specialist pediatric departments in Denmark. Methods In this retrospective medical record review study, 141 children (69 boys and 72 girls) with a clinical history of suspected penicillin class allergy were investigated. A standardized questionnaire for drug allergy was completed in the beginning of the investigation, which also included a skin prick test (SPT), measurement of IgE to different types of penicillin, and a drug challenge (DC). Results Only four (2.8%) of the patients referred for further investigation in our study had a positive DC. We found no correlation between a positive DC, positive SPT or elevated specific IgE. None of the patients with a positive DC reacted with a rash alone prior to investigation. Conclusions Allergy to penicillin in children is rare and probably overestimated. In children reacting to penicillin with a rash alone, our study indicated that the rash was probably not related to allergy and treatment should thus be continued.
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Leecyous B, Bakhtiar F, Tang M, Yadzir Z, Abdullah N. Minimal agreement between basophil activation test and immunoassay in diagnosis of penicillin allergy. Allergol Immunopathol (Madr) 2020; 48:626-632. [PMID: 32532468 DOI: 10.1016/j.aller.2020.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/17/2020] [Accepted: 01/29/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Basophil activation test (BAT) and immunoassays are the most widely used in vitro tests to diagnose IgE-mediated allergic reactions to penicillin. However, studies to determine if one test is interdependent from another are limited. OBJECTIVE The present study aimed to measure the agreement between BAT and immunoassay in diagnosis of penicillin allergy. METHOD BAT was performed using penicillin G (Pen G), penicillin V (Pen V), penicilloyl-polylysine (PPL), minor determinant mix (MDM), amoxicillin (Amx) and ampicillin (Amp) in 25 patients. Immunoassay of total IgE (tIgE) and specific IgE (sIgE) antibodies to Pen G, Pen V, Amx and Amp were quantified. Skin prick test (SPT) using PPL-MDM, Amx, Amp and Clavulanic acid were also performed. RESULTS Minimal agreement was observed between BAT and immunoassay (k=0.25). Of two BAT-positive patients, one patient is positive to Amx (59.27%, SI=59) and Amp (82.32%, SI=82) but sIgE-negative to all drug tested. This patient is also SPT-positive to both drugs. Another patient is BAT-positive to Pen G (10.18%, SI=40), Pen V (25.07%, SI=100) and Amp (19.52%, SI=79). In sIgE immunoassay, four patients were sIgE-positive to at least one of the drugs tested. The sIgE level of three patients was between low and moderate and they were BAT-negative. One BAT-positive patient had a high level of sIgE antibodies (3.50-17.5kU/L) along with relatively high specific to total IgE ratio ≥0.002 (0.004-0.007). CONCLUSIONS The agreement between BAT and immunoassay is minimal. Performing both tests provides little increase in the sensitivity of allergy diagnosis work-up for immediate reactions to penicillin.
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