Cephalosporin allergy

Perioperative Infection Prophylaxis With Vancomycin is a Significant Risk Factor for Deep Surgical Site Infection in Spine Surgery

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The purpose of this study was to compare the efficacy of cefazolin versus vancomycin for perioperative infection prophylaxis.

SUMMARY OF BACKGROUND DATA

The relative efficacy of cefazolin alternatives for perioperative infection prophylaxis is poorly understood.

MATERIALS AND METHODS

This study was a single-center multisurgeon retrospective review of all patients undergoing primary spine surgery from an institutional registry. Postoperative infection was defined by the combination of three criteria: irrigation and debridement within 3 months of the index procedure, clinical suspicion for infection, and positive intraoperative cultures. Microbiology records for all infections were reviewed to assess the infectious organism and organism susceptibilities. Univariate and multivariate analyses were performed.

RESULTS

A total of 10,122 patients met inclusion criteria. The overall incidence of infection was 0.78%, with an incidence of 0.73% in patients who received cefazolin and 2.03% in patients who received vancomycin (OR: 2.83, 95% CI: 1.35-5.91, P= 0.004). Use of IV vancomycin (OR: 2.83, 95% CI: 1.35-5.91, P =0.006), BMI (MD: 1.56, 95% CI: 0.32-2.79, P =0.014), presence of a fusion (OR: 1.62, 95% CI: 1.04-2.52, P =0.033), and operative time (MD: 42.04, 95% CI: 16.88-67.21, P =0.001) were significant risk factors in the univariate analysis. In the multivariate analysis, only noncefazolin antibiotics (OR: 2.48, 95% CI: 1.18-5.22, P =0.017) and BMI (MD: 1.56, 95% CI: 0.32-2.79, P =0.026) remained significant independent risk factors. Neither IV antibiotic regimen nor topical vancomycin significantly impacted Gram type, organism type, or antibiotic resistance ( P >0.05). The most common reason for antibiosis with vancomycin was a penicillin allergy (75.0%).

CONCLUSIONS

Prophylactic antibiosis with IV vancomycin leads to a 2.5 times higher risk of infection compared with IV cefazolin in primary spine surgery. We recommend the routine use of IV cefazolin for infection prophylaxis, and caution against the elective use of alternative regimens like IV vancomycin unless clinically warranted.

Kounis Syndrome: A Case Report and a Review of Recent Literature

Kounis syndrome (KS) is commonly defined as acute myocardial infarction (AMI) secondary to exposure to an allergen. There are multiple identified allergens that are associated with KS, examples include medications, food, and contrast media. After exposure to an allergen, the allergic pathway is triggered leading to vasospasm in coronary vessels which later on presents as AMI. A high index of clinical suspicion is of crucial importance as there are multiple variants of KS. Each type requires a different management approach depending on the severity of the presenting symptoms. Here, we present a case of a 65-year-old female with a history of transient ischemic attack (TIA) who presented to our hospital with symptoms of urinary tract infection and received the first dose of ceftriaxone while in the ER. She then developed symptoms of shortness of breath, chest pain, and diaphoresis associated with overall skin itchiness with ECG evidence of ST-elevation myocardial infarction (STEMI) in the inferior leads. She was given initial measures to treat possible allergic reactions including steroids and diphenhydramine and her ECG showed complete resolution after that; therefore, she was presumed to have KS after exposure to antibiotics. In this case report, we elaborate more about our case and further explore management options for KS.

Evaluation of Cross-Reactivity Between Penicillins and Cephalosporins in Children with a History of Cephalosporin Allergy

Objectives

The cross-reactivity problem between cephalosporins and penicillins has mainly been evaluated in the context of patients allergic to penicillins. However, we have little data regarding the opposite aspect of the problem, i.e. the cross-reactivity in subjects primarily sensitized to cephalosporins. This prospective study aims to evaluate the cross-reactivity to penicillins and some other cephalosporins in patients with immediate allergic reactions to cephalosporins.

Methods

The study included 21 children with immediate allergic reactions to at least one cephalosporin. Skin testing was performed with a panel of minor and major determinant mixtures of penicillins and three commonly used cephalosporins (cephazoline, cefuroxime and ceftriaxone).

Results

The children had used 5.14±4.91 (1-15) times any beta-lactam antibiotic in the previous year and the most common cephalosporins accused were ceftriaxone (42.92%), and cefuroxime, cefazolin, cefixime, cefprozil and cefotaxime (9.5% each). Skin tests were positive for any cephalosporin in 14 (66.7%) subjects and penicillin allergens in 15 (71.4%) subjects. Totally, 85.7% of children with a positive allergy history to cephalosporins were found to be sensitive to either penicillin or any one of three cephalosporins.

Conclusion

There seems to be a high risk of adverse reactions to penicillins and other cephalosporins in children with a history of type I hypersensitivity reaction to cephalosporins. Therefore, skin testing with both cephalosporins and penicillins should be performed in patients with a history of cephalosporin allergy.

The state and consideration for skin test of β-lactam antibiotics in pediatrics

β-lactam antibiotics are the most frequently used drugs and the most common drugs that cause allergic reactions in pediatrics. The occurrence of some allergic reactions can be predicted by skin testing, especially severe adverse reactions such as anaphylactic shock. Thus, penicillin and cephalosporin skin tests are widely used to predict allergic reactions before medication in pediatrics. However, false-positive results from skin tests were more often encountered in pediatrics than in adults. In fact, many children labeled as allergic to β-lactam are not allergic to the antibiotic, leading to the use of alternative antibiotics, which are less effective and more toxic, and the increase of antibiotic resistance. There has been controversy over whether β-lactam antibiotics should be tested for skin allergies before application in children. Based on the great controversy in the implementation of β-lactam antibiotic skin tests, especially the controversial cephalosporin skin tests in pediatrics, the mechanism and reasons of anaphylaxis to β-lactam antibiotics, the significance of β-lactam antibiotic skin tests, the current state of β-lactam antibiotic skin tests at home and abroad, and the problems of domestic and international skin tests were analyzed to determine a unified standard of β-lactam antibiotic skin tests in pediatrics to prevent and decrease adverse drug reactions, avoid waste of drugs, and a large amount of manpower and material resource consumption.

Timing of Symptoms of Early-Onset Sepsis after Intrapartum Antibiotic Prophylaxis: Can It Inform the Neonatal Management?

The effectiveness of "inadequate" intrapartum antibiotic prophylaxis (IAP administered < 4 h prior to delivery) in preventing early-onset sepsis (EOS) is debated. Italian prospective surveillance cohort data (2003-2022) were used to study the type and duration of IAP according to the timing of symptoms onset of group B streptococcus (GBS) and E. coli culture-confirmed EOS cases. IAP was defined "active" when the pathogen yielded in cultures was susceptible. We identified 263 EOS cases (GBS = 191; E. coli = 72). Among GBS EOS, 25% had received IAP (always active when beta-lactams were administered). Most IAP-exposed neonates with GBS were symptomatic at birth (67%) or remained asymptomatic (25%), regardless of IAP duration. Among E. coli EOS, 60% were IAP-exposed. However, IAP was active in only 8% of cases, and these newborns remained asymptomatic or presented with symptoms prior to 6 h of life. In contrast, most newborns exposed to an "inactive" IAP (52%) developed symptoms from 1 to >48 h of life. The key element to define IAP "adequate" seems the pathogen's antimicrobial susceptibility rather than its duration. Newborns exposed to an active antimicrobial (as frequently occurs with GBS infections), who remain asymptomatic in the first 6 h of life, are likely uninfected. Because E. coli isolates are often unsusceptible to beta-lactam antibiotics, IAP-exposed neonates frequently develop symptoms of EOS after birth, up to 48 h of life and beyond.

Group B Streptococcus in Pregnancy

To decrease risk of early-onset neonatal sepsis from group B streptococcus (GBS), pregnant patients should undergo screening between 36 0/7 and 37 6/7 weeks' gestation. Patients with a positive vaginal-rectal culture, GBS bacteriuria , or history of newborn with GBS disease should receive intrapartum antibiotic prophylaxis (IAP) with an agent targeting GBS. If GBS status is unknown at time of labor, IAP should be administered in cases of preterm birth, rupture of membranes for >18 hours, or intrapartum fever. The antibiotic of choice is intravenous penicillin; alternatives should be considered in cases of penicillin allergy depending on allergy severity.

Daptomycin for the treatment of acute bacterial meningitis: a narrative review

BACKGROUND

There is a growing interest in the utilization of daptomycin for the treatment of multi-drug resistant, Gram-positive infections. Pharmacokinetic studies suggest that daptomycin could penetrate into the cerebrospinal fluid, albeit to a small extent. The objective of this review was to evaluate the available clinical evidence for daptomycin use in acute bacterial meningitis of both pediatric and adult patients.

METHODS

Electronic databases were searched up to June 2022 for studies published on the topic. The inclusion criteria were met if the study reported the use of intravenous daptomycin (more than a single dose) for the treatment of diagnosed acute bacterial meningitis.

RESULTS

A total of 21 case reports were identified that met the inclusion criteria. These suggest that daptomycin could be safe and effective alternative in achieving clinical cure of meningitis. In these studies, daptomycin was used in the event of treatment failure, patient intolerance, or bacterial resistance to first-line agents.

CONCLUSIONS

Daptomycin has potential to be an alternative to standard care for meningitis caused by Gram-positive bacteria in the future; however, more robust research is required to establish an optimal dosing regimen, duration of therapy, and place in therapy for the management of meningitis.

Outcome of preoperative cefazolin use for infection prophylaxis in patients with self-reported penicillin allergy

BACKGROUND

Cephalosporins are the preferred antibiotics for prophylaxis against surgical site infections. Most studies give a rate of combined IgE and non-IgE penicillin allergy yet it is recommended that cephalosporins be avoided in patients having the former but can be used in those with the latter. Some studies use penicillin allergy while others penicillin family allergy rates. The primary goal of this study was to determine the rates of IgE and non-IgE allergy as well as cross reactions to both penicillin and the penicillin family. Secondary goals were to determine the surgical services giving preoperative cefazolin and the types of self reported reactions that patients' had to penicillin prompting their allergy status.

METHODS

All patients undergoing elective and emergency surgery at a University Health Sciences Centre were retrospectively studied. The hospital electronic medical record was used for data collection.

RESULTS

8.9% of our patients reported non-IgE reactions to penicillin with a cross reactivity rate of 0.9% with cefazolin. 4.0% of our patients reported IgE reactions to penicillin with a cross reactivity rate of 4.0% with cefazolin. 10.5% of our patients reported non-IgE reactions to the penicillin family with a cross reactivity rate of 0.8% with cefazolin. 4.3% of our patients reported IgE reactions to the penicillin family with a cross reactivity rate of 4.0% with cefazolin.

CONCLUSIONS

Our rate of combined IgE and non-IgE reactions for both penicillin and penicillin family allergy was within the range reported in the literature. Our rate of cross reactivity between cefazolin and combined IgE and non-IgE allergy both to penicillin and the penicillin family were lower than reported in the old literature but within the range of the newer literature. We found a lower rate of allergic reaction to a cephalosporin than reported in the literature. We documented a wide range of IgE and non-IgE reactions. We also demonstrated that cefazolin is frequently the preferred antibiotics for prophylaxis against surgical site infections by many surgical services and that de-labelling patients with penicillin allergy is unnecessary.

Yenidoğanlarda seftriakson kullanımının yan etkilerinin değerlendirilmesi

Amaç: Seftriakson yan etkileri nedeniyle yenidoğanda sınırlı kullanıma sahiptir. Yenidoğan enfeksiyonlarında kullanımı ile ilgili sınırlı sayıda çalışma vardır. Bu çalışma ile setriakson alan yenidoğanlarda seftriakson sonrası oluşabilecek yan etkilerin değerlendirilmesi amaçlanmıştır. Gereç ve Yöntem: Çukurova Üniversitesi Tıp Fakültesi Balcalı Hastanesi Yenidoğan Yoğun Bakım Ünitesi’nde, 2015-2016 yılları arasında yatan bebeklerin seftriakson tedavisi öncesi ve sonrası klinik ve laboratuvar verileri retrospektif olarak incelenmiştir. Bulgular: Çalışmaya 30 olgu alınmıştır. Bu bebeklerin ortalama gebelik yaşı 37 ± 3,1 (30-41) hafta, seftriakson aldığı süre 7,2 ± 2,2 (2-12) gün bulunmuştur. 30 olgudan alınan idrar kültürlerinde; 17 (%56,6) bebekte üreme saptanmıştır. Bunların 11’inde (%36,6) Escherischia coli (E. coli), 5’inde (%16,7) diğer bakteriler üremiştir. Olguların seftriakson öncesi ve sonrası laboratuvar verilerinde kan üre azotu (BUN), total bilirubin (TB) ve hematokrit değerlerinde anlamlı düşüş saptanmıştır. Seftriakson kullanımına bağlı herhangi bir yan etki izlenmemiştir. Sonuç: Çalışmamızda seftriakson sonrası komplikasyon görülmemiş olması term veya terme yakın yenidoğanlarda seftriakson kullanımı için cesaret verici olabilir. Fakat, yenidoğanda seftriaksonun yan etkilerinin ve sıklıklarının kesinleştirilmesi ve yenidoğanda kullanılan diğer antibiyotiklere karşı alternatif olup olamayacağının belirlenmesi için daha fazla araştırmalara ihtiyaç vardır.

A case report of ceftriaxone-induced cardiopulmonary arrest

Introduction

and Importance: Ceftriaxone is used frequently in treating infectious diseases. While hypersensitivity skin reactions are common with the use of ceftriaxone, anaphylactic reactions are rare.

Case presentation

A 66-year-old female presented to our hospital with complaints of headache and sinus congestion. Vital signs showed hypoxia, and the physical exam was unremarkable. A computed tomography scan of the chest revealed right upper lobe pneumonia, and the patient was started on ceftriaxone and azithromycin. The patient went into asystole 1 min after ceftriaxone administration. She did not require cardiopulmonary resuscitative measures as she spontaneously transitioned to normal sinus rhythm. Given the timing of the event immediately after ceftriaxone administration, we determined ceftriaxone was the likely culprit. The patient received alternative treatment for pneumonia and recovered without sequelae. We added ceftriaxone to her allergy list.

Clinical discussion

This case report highlights a rare adverse event associated with ceftriaxone. After an extensive literature search, we found only four other reported cases of cardiopulmonary arrest following ceftriaxone. The exact mechanism for this adverse event has not been fully elucidated.

Conclusion

Clinicians should be aware of the potential for ceftriaxone-induced asystole, perform allergy reviews and obtain informed consent before its administration.

Refractory Anaphylactic Shock Requiring Emergent Venoarterial Extracorporeal Membrane Oxygenation in the Emergency Department: A Case Report

Venoarterial extracorporeal membrane oxygenation is a viable salvage intervention for patients who experience cardiopulmonary arrest or profound shock from any cause. Acute anaphylactic shock is a rare cause of cardiac arrest. We present a case of a 35-year-old male who experienced cardiac arrest owing to anaphylactic shock while receiving general anesthesia for a routine outpatient surgical procedure. Traditional advanced cardiac life support therapies were provided by paramedics en route to the emergency department of a suburban, community-based hospital. Maximal medical management including endotracheal intubation, intravenous steroids, intravenous crystalloid fluid administration, intravenous vasoactive medications, and high-quality cardiopulmonary resuscitation was provided. Although return of spontaneous circulation was achieved, profound cardiogenic shock persisted. Venoarterial extracorporeal membrane oxygenation was initiated by the emergency department provider and nursing team. The patient survived, was neurologically intact, had full recovery, and was discharged home several days later. We have extensive experience with venoarterial extracorporeal membrane oxygenation, and this case exemplifies the value of an established emergency department extracorporeal membrane oxygenation program in managing all causes of cardiac arrest or refractory shock.

CROSS-REACTIVITY TO ANTIBIOTICS: PROPOSITIONS FOR SELECTING ALTERNATIVES

OBJECTIVE

The aim: To analyze CR among antibacterials of different classes and to overcome some widespread misconceptions regarding CR between different classes of antibiotics.

PATIENTS AND METHODS

Materials and methods: The narrative review represents an assessment of the most pertinent literary sources published in English language, which dealt with the issues of cross-reactivity between individual antibiotics and different classes of these ones.

CONCLUSION

Conclusions: With a high probability of type I AR in a patient in the past, it is better to plan the treatment of patients together with an allergist / immunologist. If this probability is estimated to be low, the choice of a particular antibiotic may be based to some extent on CR data.

Drug-Related Hypersensitivity Reactions Leading to Emergency Department: Original Data and Systematic Review

The aim of the present study is to describe pharmacological characteristics of drug-related allergies and anaphylaxis leading to the emergency department (ED). An 8-year post hoc analysis on the MEREAFaPS Study database was performed (2012−2019). Subjects who experienced drug-related hypersensitivity leading to an ED visit were selected. Logistic regression analyses were used to estimate the reporting odds ratios (RORs) of drug-related allergies and anaphylaxis adjusting for sex, age classes, and ethnicity. In addition, a systematic review of observational studies evaluating drug-related hypersensitivity reactions leading to ED visits in outpatients was performed. Out of 94,073 ED visits, 14.4% cases were drug-related allergies and 0.6% were anaphylaxis. Females accounted for 56%. Multivariate logistic regression showed a higher risk of drug-related allergy among males and all age classes < 65 years, while a higher risk of anaphylaxis was observed for females (ROR 1.20 [1.01−1.42]) and adults (ROR 2.63 [2.21−3.14]). The systematic review included 37 studies. ED visits related to allergy and anaphylaxis ranged from 0.004% to 88%, and drug-related allergies and anaphylaxis ranged from 0.007% to 88%. Both in our analysis and in primary studies, antibacterials, analgesics, and radiocontrast agents were identified as the most common triggers of hypersensitivity.

Safety of Cefazolin Test Dose in Patients with Penicillin Allergy Just Prior Cardiac Device Implantation: A Single Center Experience

Background

Cephalosporins are the cornerstone of cardiac device infection prophylaxis. Owing to fears of cross-reactivity, penicillin-allergic patients are exposed to potentially more-toxic drugs, with decreased efficacy. We evaluated the safety of a cefazolin test dose (CTD) in self-reported penicillin-allergic patients.

Methods

In this single-centre study, we evaluated consecutive patients with chart documentation of penicillin allergy undergoing cardiac device implantation, over a 2-year period. A CTD was performed if no cephalosporin allergy or severe anaphylactic reaction to penicillin had been documented. Patients were given 2 doses of 100 mg IV cefazolin, and if no allergic reaction occurred after 5 minutes, the full dose (1800 mg) was administered in the electrophysiology laboratory just before the implantation procedure.

Results

A total of 2200 patients were included. The frequency of reported penicillin allergy was 9.3% (n = 204). In 80% of cases, the type of allergic reaction was not reported in medical notes or was unknown by the patient. A CTD was performed in 67.6% of patients with a penicillin allergy (n = 138). A total of 5 adverse events occurred (3.6% of patients [95% confidence interval, 1.1%-6.1%]) — 4 skin rashes and 1 tongue edema. These 5 patients became asymptomatic after antihistaminic and corticosteroid IV treatment. Even if the test dose was negative, 79% of patients also were administered vancomycin before the procedure, as it requires a 1-hour infusion prior to the CTD in the implantation procedure room.

Conclusion

A CTD in most penicillin-allergic patients appears to be safe and allows its use per recommended guidelines.

Review of Perioperative Prophylactic Antibiotic Use during Laparoscopic Cholecystectomy and Subsequent Surgical Site Infection Development at a Single Children's Hospital

OBJECTIVES

 With the rise of antibiotic resistance, the use of prophylactic preoperative antibiotics (PPA) has been questioned in cases with low rates of surgical site infection (SSI). We report PPA usage and SSI rates after elective laparoscopic cholecystectomy at our institution.

MATERIALS AND METHODS

 A retrospective review of children younger than 18 years who underwent elective outpatient laparoscopic cholecystectomy between July 2010 and August 2020 was performed. Demographic, preoperative work-up, antibiotic use, intraoperative characteristics, and SSI data were collected via chart review. SSI was defined as clinical signs of infection that required antibiotics within 30 days of surgery.

RESULTS

 A total of 502 patients met the inclusion criteria; 50% were preoperatively diagnosed with symptomatic cholelithiasis, 47% with biliary dyskinesia, 2% with hyperkinetic gallbladder, and 1% with gallbladder polyp(s). The majority were female (78%) and Caucasian (80%). In total, 60% (n = 301) of patients received PPA, while 40% (n = 201) did not; 1.3% (n = 4) of those who received PPA developed SSI, compared with 5.5% (n = 11) of those who did not receive PPA (p = 0.01). Though PPA use was associated with a 77% reduction in the risk of SSI in multivariate analysis (p = 0.01), all SSIs were superficial. One child required readmission for intravenous antibiotics, while the remainder were treated with outpatient antibiotics. Gender, age, body mass index, ethnicity, and preoperative diagnosis did not influence the likelihood of receiving PPA.

CONCLUSION

 Given the relatively low morbidity of the superficial SSI, conservative use of PPA is advised to avoid contributing to antibiotic resistance.

A Simple Algorithmic Approach Allows the Safe Use of Cephalosporin in "Penicillin-Allergic" Patients without the Need for Allergy Testing

BACKGROUND

Patients who report a penicillin allergy are often given second-line antibiotic prophylaxis during total joint arthroplasty (TJA), with only a minority of patients undergoing additional consultations and allergy testing. In an effort to increase the use of cephalosporin prophylaxis in TJA, the present study aimed to assess the effectiveness of a simple, protocol-driven penicillin allergy screening program without the need for additional work-up.

METHODS

Following implementation of a questionnaire-based screening protocol in May 2019, all patients scheduled for primary TJA were risk-stratified into low or high-risk categories. The low-risk cohort received cefazolin, and the high-risk cohort received non-cefazolin antibiotics. Patients were monitored prospectively, and data on antibiotic usage and adverse outcomes were documented. The protocol group (n = 2,078) was propensity score matched 1:1 with a control group that included patients who underwent TJA in the same institution prior to implementation of the protocol. The primary end point was the efficacy of the protocol in reducing unnecessary use of non-cephalosporin antibiotics for prophylaxis. Secondary outcomes included the rate of surgical site infections and allergic reactions to the administered antibiotic.

RESULTS

A total of 357 patients (17.2%) reported a penicillin allergy in the protocol group compared with 310 patients (14.9%) with a recorded allergy in the control group (p = 0.052). The number of patients who received non-cephalosporin antibiotics was significantly lower in the protocol group (5.7% compared with 15.2% in the control group; p < 0.001), whereas there was no difference in the rate of total allergic reactions (0.8% compared with 0.7%, respectively; p = 0.857). Of the 239 low-risk patients (66.9%) in the protocol group, only 3 (1.3%) experienced a mild cutaneous reaction following cefazolin administration. There were no differences in the rates of superficial wound, deep periprosthetic, or Clostridioides difficile infections between the protocol and control groups.

CONCLUSIONS

A simple screening protocol allowed two-thirds of patients with a self-reported allergy to receive cefazolin without the need for additional consultations or testing. We believe this protocol can be safely implemented to increase the rate of cefazolin usage without a corresponding increase in the number of allergic reactions.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness and Feasibility of Pharmacist-Driven Penicillin Allergy De-Labeling Pilot Program without Skin Testing or Oral Challenges

Documented penicillin allergies have been associated with an increased risk of adverse outcomes. The goal of this project was to assess the effectiveness and feasibility of a pharmacist-led penicillin allergy “de-labeling” process that does not involve labor-intensive skin testing or direct oral challenges. Adult patients with penicillin allergies were identified and interviewed by an infectious diseases pharmacy resident during a 3-month pilot period. Using an evidence-based standardized checklist, the pharmacist determined if an allergy qualified for de-labeling. In total, 66 patients were interviewed during the pilot period. The average time spent was 5.2 min per patient interviewed. Twelve patients (18%) met the criteria for de-labeling and consented to the removal of the allergy. Four patients (6%) met the criteria but declined removal of the allergy. In brief, 58.3% of patients (7/12) who were de-labeled and 50% of patients (2/4) who declined de-labeling but had their allergy updated to reflect intolerance were subsequently prescribed beta-lactam antibiotics and all (9/9, 100%) were able to tolerate these agents. A pharmacist-led penicillin allergy de-labeling process utilizing a standardized checklist is an effective and feasible method for removing penicillin allergies in patients without a true allergy.

Cefoperazone and sulbactam-related eosinophilic peritonitis: a case report and literature review

Eosinophilic peritonitis (EP) is a well-described complication of peritoneal dialysis that occurs because of an overreaction to constituents that are related to the catheter or tubing, peritoneal dialysate, pathogenic infection, or intraperitoneal drug use. EP caused by antibiotic use is rare. We present the case of a patient with cefoperazone and sulbactam-related EP. A 59-year-old woman who was undergoing peritoneal dialysis presented with peritonitis with abdominal pain and turbid peritoneal dialysis. Empiric intraperitoneal cefazolin in combination with cefoperazone and sulbactam was started after peritoneal dialysis effluent cultures were performed. Her peritonitis achieved remission in 2 days with the help of cephalosporin, but she developed EP 1 week later, when her dialysate eosinophil count peaked at 49% of the total dialysate white blood cells (absolute count, 110/mm³). We excluded other possible causes and speculated that cefoperazone and sulbactam was the probable cause of EP. The patient continued treatment with cefoperazone and sulbactam for 14 days. EP resolved within 48 hours after stopping cefoperazone and sulbactam. Thus, EP can be caused by cefoperazone and sulbactam use. Physicians should be able to distinguish antibiotic-related EP from refractory peritonitis to avoid technique failure.

Overview of Beta-Lactam Allergy and the Role of the Pharmacist in Management

Unverified beta-lactam allergies are a substantial public health problem, as the majority of patients labeled as beta-lactam allergic do not have clinically significant allergies that may hinder the use beta-lactam therapy when indicated. Outdated or inaccurate beta-lactam or penicillin allergies can result in serious consequences, including suboptimal antibiotic therapy, increased risk of adverse effects, and use of broader spectrum antibiotics than indicated, which may contribute to antimicrobial resistance. The purpose of this review is to provide an overview of beta-lactam allergy and highlight the role of pharmacists in managing beta-lactam allergies. Studies have shown that pharmacists can play a vital role in allergy assessment, penicillin skin testing, beta-lactam desensitization, evaluation of beta-lactam cross-reactivity and recommending appropriate antibiotic therapy in patients with beta-lactam allergies.

Eosinophilic lung disease as a sequela of MSSA pneumonia

Eosinophilic lung diseases are a rare group of lung disorders with multiple known and unknown aetiologies and the diagnosis is often challenging. We present a case of a young man who was admitted with pneumonia due to methicillin-sensitive Staphylococcus aureus and was discharged on antibiotics. He presented to the emergency department approximately 2 weeks after discharge with high-grade fever, cough and shortness of breath associated with serum and bronchoalveolar lavage eosinophilia. He was then treated with steroids with complete resolution of disease process.

Evaluation of Clinical Properties and Diagnostic Test Results of Cephalosporin Allergy in Children

INTRODUCTION

Beta-lactams (BLs) are one of the most frequent causes of drug hypersensitivity reactions (HRs), and cephalosporins are a widely used subclass of BLs, especially in children. The aim of this study was to evaluate the clinical features and diagnostic test results of pediatric patients evaluated for suspected cephalosporin allergy.

METHODS

This study included patients who presented to our pediatric allergy clinic with a history of reactions attributed to cephalosporins between January 1, 2011, and December 31, 2019, and whose diagnostic tests were completed for the diagnosis.

RESULTS

This study included 120 pediatric patients and 69 (57.5%) of them were girls. The median age was 38.63 (interquartile range 10.5-85.7) months. Reactions occurring within 1 h of drug intake were reported in 33 patients (27.5%). Reactions were maculopapular rash in 55 (45.8%) patients, urticaria and/or angioedema in 49 (40.8%), anaphylaxis in 11 (9.2%), severe cutaneous drug reaction in 4 (3.3%), and fixed drug reaction in 1 patient (0.83%). The most frequently suspected agent was cefixime in 41 patients (34.2%). In total, 30 (25%) patients were diagnosed as having cephalosporin hypersensitivity. Confirmation of HRs was also significantly more frequent among patients who were older (p: 0.000), who had taken the drug parenterally (p: 0.000) and with immediate reactions (p: 0.000).

CONCLUSION

Cephalosporin allergy has been confirmed in approximately one-fourth of the patients evaluated for suspected cephalosporin allergy. Confirmation of HRs was significantly more common among patients who were older, had immediate reactions, and had taken the drug parenterally.

Cephalosporins' Cross-Reactivity and the High Degree of Required Knowledge. Case Report and Review of the Literature

Antibiotic cross-reactivity represents a phenomenon of considerable interest as well as antibiotic resistance. Immediate reactions to cephalosporins are reported in the literature with a prevalence of only 1%-3% of the population, while anaphylactic reactions are rarely described (approximately 0.0001%-0.1%) as well as fatalities. Allergic reaction to cephalosporins may occur because of sensitization to unique cephalosporin haptens or to determinants shared with penicillins. Cross-reactivity between cephalosporins represents, in fact, a well-known threatening event involving cephalosporins with similar or identical R1- or R2-side chains. The present report describes the case of a 79-year-old man who suddenly died after intramuscular administration of ceftriaxone. Serum dosage of mast cell tryptase from a femoral blood sample at 3 and 24 hours detected values of 87.7μg/L and 93.5μg/L, respectively (cut-off value 44.3 μg/L); the serum-specific IgE for penicillins, amoxicillin, cephaclor and also for the most common allergens were also determined. A complete post-mortem examination was performed, including gross, histological and immunohistochemical examination, with an anti-tryptase antibody. The cause of death was identified as anaphylactic shock: past administrations of cefepime sensitized the subject to cephalosporins and a fatal cross-reactivity of ceftriaxone with cefepime occurred due to the identical seven-position side chain structure in both molecules. The reported case offers food for thought regarding the study of cross-reactivity and the need to clarify the predictability and preventability of the phenomenon in fatal events.

Update on penicillin allergy delabeling

PURPOSE OF REVIEW

To review phenotyping and risk classification of penicillin allergy and provide an update on penicillin allergy delabeling strategies for primary care.

RECENT FINDINGS

Beta-lactams are considered the treatment of choice for a wide range of bacterial pathogens; however, many patients receive second-line agents due to being labeled as having an allergy to penicillin. This approach can lead to antibiotic resistance and inferior health outcomes. While 10% of the population is labeled as penicillin allergic, penicillin anaphylaxis occurs in less than 1% of patients. For patients with delayed benign skin rashes (e.g., urticaria or maculopapular exanthem >1 h after administration) attributable to beta-lactam administration occurring more than 12 months ago, direct oral challenge (rechallenge with antibiotic in the clinical setting) can be a safe and effective strategy, with immediate reactions occurring in less than 5% of such low-risk patients and delayed reactions appearing infrequently. In patients with penicillin-associated immediate urticaria, other IgE-mediated features, or anaphylaxis, further allergy evaluation and penicillin skin testing is warranted. Any severe idiosyncratic cutaneous adverse reaction is rare, but can be dangerous so prompt removal of the inciting agent is required.

SUMMARY

Penicillin allergy delabeling is a high-value service that can be effectively delivered through a multidisciplinary collaborative approach.

A comparative study of 5 different antibiotic prophylaxis regimes in 4500 total knee replacements

AIM

To compare the incidence of surgical site infection with different antibiotic regimes in elective total knee arthroplasty. We hypothesise that a single high dose of Teicoplanin and Gentamicin is as effective as other regimes.

METHODS

A retrospective study of prospectively collected data on a total of 4500 elective knee replacements over a 9-year period was conducted in a district general hospital. Data were collected on antibiotic regime, patient characteristics, infection (treatment, infective agents, sensitivities) and complications.

RESULTS

Five different antibiotic regimes that have been used in elective knee arthroplasty were identified in our institution. 40 patients in total were identified who had a deep infection. Rates of deep surgical site infection were not significantly different between the five groups (p = 0.83).

CONCLUSION

A single pre-operative dose of Teicoplanin and Gentamicin has similar efficacy of prophylaxis to other regimes for patients undergoing primary elective total knee replacements. We recommend the choice of prophylaxis regimen is made locally based on pathogen virulence, drug resistance and cost.

Results of Intradermal Skin Testing with Cefazolin according to a History of Hypersensitivity to Antibiotics

BACKGROUND

The relationship between cephalosporin hypersensitivity and a history of β-lactam hypersensitivity is unclear. We evaluated the usefulness of routine intradermal cefazolin skin testing and its relationship with the history of β-lactam hypersensitivity.

METHODS

The electronic medical records of patients who underwent intradermal cefazolin (0.3 mg/mL) skin testing without negative controls from January 2010 to January 2011 at Seoul National University Bundang Hospital were evaluated. The history of β-lactam hypersensitivity of the patients was taken. Immediate adverse reactions after cefazolin injection were evaluated by searching the electronic medical records for key words and reviewing consultation documents of allergy specialists or dermatologists. The medical records of the patients were reviewed by an allergist.

RESULTS

There were 13,153 cases of cefazolin skin testing over the 13-month study period. Among the 12,969 cases with negative skin test results, 8 had immediate hypersensitivity related to cefazolin (0.06%). The negative predictive value of cefazolin skin testing alone was 99.94%. The overall positivity rate of cefazolin skin tests was 1.4% (184/13,153). Of the cases with a history of allergy to β-lactams, 15% (6/40) showed a positive cefazolin skin test result compared to only 1.36% (178/13,113) of cases with no such history (P < 0.001) including some false-positive tests.

CONCLUSION

The results suggest that routine screening involving cefazolin skin testing without negative controls is not useful for all patients, but could be helpful for those with a history of β-lactam hypersensitivity, although a large prospective study is needed to confirm this.

Intrapartum beta-lactam antibiotics for preventing group B streptococcal early-onset disease: can we abandon the concept of 'inadequate' intrapartum antibiotic prophylaxis?

Introduction: Neonatal sepsis remains a serious and potentially fatal illness. Intrapartum antibiotic prophylaxis (IAP) prevents group B streptococcal (GBS) early-onset sepsis. The optimal duration of IAP (adequate IAP) to reduce vertical transmission of GBS has been debated. Understanding the mechanism of action of IAP may help in minimizing neonatal evaluation and unnecessary antibiotic use.Areas covered: In recent years, several studies on pharmacokinetics and clinical use of IAP have been published. Although penicillin and ampicillin are the most preferred antibiotics, the clinical efficacy of non-beta-lactam antibiotics, including clindamycin and vancomycin, used in cases of penicillin anaphylaxis-associated allergy, remains debatable. This is a narrative review of the literature regarding the impact of 'inadequate' IAP on the clinical management of women and newborns.Expert opinion: Recent evidence suggests that 'inadequate' IAP with beta-lactams is more effective in preventing vertical transmission of GBS than previously thought. Newborns exposed to intrapartum beta-lactams and who are asymptomatic at birth are likely uninfected, irrespective of IAP duration before delivery. Hence, we may abandon the concept of 'inadequate' IAP with beta-lactams in early-onset GBS sepsis, relying primarily on clinical signs observed at birth for managing IAP-exposed neonates.

Despite the Safety of Preoperative Cefazolin for Patients With Non-anaphylactic Penicillin Allergy, 20% of Practitioners Avoid Its Use

Cefazolin is commonly used for surgical site infection prophylaxis due to its low cost and effective coverage. However, it is controversial to use cefazolin in patients with a penicillin allergy despite the cross-reactivity between cefazolin and penicillin being only 1%. Ample literature shows that it is safe to use cefazolin in patients with non-anaphylactic penicillin allergies. However, there is often hesitation by anesthesiologists or orthopedists when prescribing this medication in this population. The current authors sent a 16-question survey to all the residency programs in the United States in anesthesiology and orthopedics asking physicians affiliated with these programs to answer a series of questions about their demographics, prescribing patterns, and knowledge of the cross-reactivity between penicillin and cefazolin. A total of 146 responses in each group, with 82.9% (n=121) of orthopedists and 78.8% (n=115) of anesthesiologists preferring cefazolin for patients with non-anaphylactic penicillin allergies. However, only 57.5% of anesthesiologists and 41.1% of orthopedists knew the correct cross-reactivity between cephalosporins and penicillin. If a provider knew the correct cross-reactivity between cefazolin and penicillin, he or she had an increased odds of prescribing cefazolin to patients with nonanaphylactic penicillin allergies (orthopedics odds ratio [OR], 4.77, P<.01; anesthesiologists OR, 3.59, P<.01). Therefore, this study supports that further education of orthopedic and anesthesia providers about the cross-reactivity between cefazolin and penicillin would lead to more evidence-based, cost-effective care. [Orthopedics. 2019; 42(5):e437-e442.].

Antimicrobial Desensitization: A Review of Published Protocols

Antimicrobial desensitization represents a last-line option for patients with no alternative therapies, where the benefits of this intensive process must outweigh the potential harm from drug exposure. The goal of antimicrobial desensitization procedures is to establish a temporary state of tolerance to drugs that may otherwise cause hypersensitivity reactions. While no universal antimicrobial desensitization protocols exist, this review critically analyzes previously published desensitization protocols. The purpose of this review is to provide a greater insight for clinicians and institutions to ensure desensitization procedures are efficacious while minimizing potential for patient harm. With an increasing rate of antimicrobial resistance and the critical need to preserve antimicrobial agents, desensitization may represent another option in our antimicrobial stewardship toolkit.

Cephalosporins: A Focus on Side Chains and β-Lactam Cross-Reactivity

Cephalosporins are among the most commonly prescribed antibiotic classes due to their wide clinical utility and general tolerability, with approximately 1-3% of the population reporting a cephalosporin allergy. However, clinicians may avoid the use of cephalosporins in patients with reported penicillin allergies despite the low potential for cross-reactivity. The misdiagnosis of β-lactam allergies and misunderstanding of cross-reactivity among β-lactams, including within the cephalosporin class, often leads to use of broader spectrum antibiotics with poor safety and efficacy profiles and represents a serious obstacle for antimicrobial stewardship. Risk factors for cephalosporin allergies are broad and include female sex, advanced age, and a history of another antibiotic or penicillin allergy; however, cephalosporins are readily tolerated even among individuals with true immediate-type allergies to penicillins. Cephalosporin cross-reactivity potential is related to the structural R1 side chain, and clinicians should be cognizant of R1 side chain similarities when prescribing alternate β-lactams in allergic individuals or when new cephalosporins are brought to market. Clinicians should consider the low likelihood of true cephalosporin allergy when clinically indicated. The purpose of this review is to provide an overview of the role of cephalosporins in clinical practice, and to highlight the incidence of, risk factors for, and cross-reactivity of cephalosporins with other antibiotics.

Prevention of Group B Streptococcal Early-Onset Disease in Newborns: ACOG Committee Opinion, Number 782

Group B streptococcus (GBS) is the leading cause of newborn infection. The primary risk factor for neonatal GBS early-onset disease (EOD) is maternal colonization of the genitourinary and gastrointestinal tracts. Approximately 50% of women who are colonized with GBS will transmit the bacteria to their newborns. Vertical transmission usually occurs during labor or after rupture of membranes. In the absence of intrapartum antibiotic prophylaxis, 1-2% of those newborns will develop GBS EOD. Other risk factors include gestational age of less than 37 weeks, very low birth weight, prolonged rupture of membranes, intraamniotic infection, young maternal age, and maternal black race. The key obstetric measures necessary for effective prevention of GBS EOD continue to include universal prenatal screening by vaginal-rectal culture, correct specimen collection and processing, appropriate implementation of intrapartum antibiotic prophylaxis, and coordination with pediatric care providers. The American College of Obstetricians and Gynecologists now recommends performing universal GBS screening between 36 0/7 and 37 6/7 weeks of gestation. All women whose vaginal-rectal cultures at 36 0/7-37 6/7 weeks of gestation are positive for GBS should receive appropriate intrapartum antibiotic prophylaxis unless a prelabor cesarean birth is performed in the setting of intact membranes. Although a shorter duration of recommended intrapartum antibiotics is less effective than 4 or more hours of prophylaxis, 2 hours of antibiotic exposure has been shown to reduce GBS vaginal colony counts and decrease the frequency of a clinical neonatal sepsis diagnosis. Obstetric interventions, when necessary, should not be delayed solely to provide 4 hours of antibiotic administration before birth. This Committee Opinion, including , , and , updates and replaces the obstetric components of the CDC 2010 guidelines, "Prevention of Perinatal Group B Streptococcal Disease: Revised Guidelines From CDC, 2010."

Susceptibility of Neisseria gonorrhoeae to Gentamicin-Gonococcal Isolate Surveillance Project, 2015-2016

The gentamicin minimum inhibitory concentrations (MICs) of Neisseria gonorrhoeae isolates were determined. Seventy-three percent of isolates demonstrated an MIC range of 8 to 16 μg/mL, and 27% demonstrated an MIC of 4 μg/mL or less. Significant associations between gentamicin MIC and resistance or reduced susceptibility to other antimicrobials were found.

Evaluation of the Potential Risk Factors for Drug-Induced Anaphylaxis in Adult Patients

AIM

To investigate the potential risk factors in patients who have experienced anaphylaxis from drugs.

METHOD

The study included 281 adult patients (median age 40 years; 76.5% female) who experienced immediate types of hypersensitivity reaction to a drug. The patients were divided into an anaphylaxis group and a nonanaphylaxis group. The anaphylaxis group was diagnosed according to the criteria of the World Allergy Organization. Skin testing with culprit drugs was performed. In the nonanaphylaxis group, drug provocation tests were performed with culprit drugs, including aspirin or diclofenac, to determine nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity. Atopy was determined by skin prick tests with the common inhalant allergens. Patients' demographics, clinical features, and baseline tryptase and total IgE levels were compared between the 2 groups.

RESULTS

The median interval between the last reaction in the patient's history and the study evaluation was 7 months (range 1-120 months). In 52.3% of the patients, reactions were defined as anaphylaxis. The most common culprit drugs were NSAIDs (56.9%) and β-lactams (34.7%). The culprit drugs were used parenterally in 13.2% of the patients. 34.9% of the patients had comorbid diseases and 24.6% used additional drugs, the most common being antihypertensives (10%). Atopy was determined in 28.8% and 28.1% of the patients were smokers. The median serum level of baseline tryptase and total IgE was 3.5 µg/L and 77 kU/L, respectively. In 46.3% of the patients, skin tests with culprit drugs were positive and the positivity ratio was higher in the anaphylaxis group (p = 0.002). Anapyhlaxis was more common in patients who were: hypertensive, atopic, using angio-tensin-converting enzyme inhibitors/angiotensin receptor blockers, and received the culprit drug parenterally (p = 0.034, p = 0.04, p = 0.03, p = 0.035, p = 0.013, and p < 0.001). In the multivariate analysis, it was observed that the parenteral usage of the drug and the presence of atopy were significantly higher in the anaphylaxis group (p < 0.001, odds ratio [OR] = 20.05, confidence interval [CI] 4.75-88.64; p = 0.012, OR = 2.1, CI 1.17-3.74). Age, smoking, family history, and serum levels of baseline tryptase and total IgE did not differ between groups.

CONCLUSION

The parenteral route and atopy increase the risk of drug-induced anaphylaxis. IgE-mediated sensitivity to the culprit drug seems to facilitate anaphylaxis.

Drug allergy

Drug allergy encompasses a spectrum of immunologically-mediated hypersensitivity reactions with varying mechanisms and clinical presentations. This type of adverse drug reaction not only affects patient quality of life, but may also lead to delayed treatment, unnecessary investigations, and even mortality. Given the myriad of symptoms associated with the condition, diagnosis is often challenging. Therefore, referral to an allergist experienced in the identification, diagnosis and management of drug allergy is recommended if a drug-induced allergic reaction is suspected. Diagnosis relies on a careful history and physical examination and, in some instances, skin testing and graded challenges. Induction of drug tolerance procedures may also be required. The most effective strategy for the management of drug allergy is avoidance or discontinuation of the offending drug. When available, alternative medications with unrelated chemical structures should be substituted. Cross-reactivity among drugs should be taken into consideration when choosing alternative agents. Additional therapy for drug hypersensitivity reactions is largely supportive and may include topical corticosteroids, oral antihistamines and, in severe cases, systemic corticosteroids. In the event of anaphylaxis, the treatment of choice is injectable epinephrine. If a particular drug to which the patient is allergic is indicated and there is no suitable alternative, induction of drug tolerance procedures may be considered to induce temporary tolerance to the drug. This article provides a background on drug allergy and strategies for the diagnosis and management of some of the most common drug-induced allergic reactions, such as penicillin, sulfonamides, cephalosporins, radiocontrast media, local anesthetics, general anesthetics, acetylsalicylic acid and non-steroidal anti-inflammatory drugs, and therapeutic monoclonal antibodies.

Maternal anaphylactic shock in pregnancy: A case report

RATIONALE

Anaphylaxis is a very rare event in pregnancy, triggering maternal hypotension leading to intrapartum hypoxic-ischemic encephalopathy in infant. Furthermore, cesarean sections are performed at a high rate in anaphylactic pregnant women.

PATIENT CONCERNS

A 34-year-old pregnant woman presented with maternal anaphylaxis following prophylactic antibiotic injection for cesarean section. Within a few minutes after initiation of intradermal skin test with cefotetan, the pregnant woman developed generalized itchy rash, chest tightness, and dyspnea.

DIAGNOSES

Several minutes after the injection of antibiotics, a diffuse urticarial rash was detected over her face and trunk followed by complaints of chest tightness and dyspnea. She was diagnosed with hypotension and hypoxia. Further, fetal heart tones showed bradycardia. A presumptive diagnosis of anaphylactic reaction induced by cefotetan was made for surgical prophylaxis.

INTERVENTIONS

The patient was managed for anaphylaxis, via administration of epinephrine, glucocorticoid, and antihistamine. Emergency cesarean section performed under general anesthesia resulted in a favorable perinatal outcome for the fetus.

OUTCOMES

Maternal and fetal outcomes were good after prompt treatment for anaphylaxis and emergency cesarean section.

LESSONS

This is the first reported case of anaphylaxis following cefotetan administration in pregnancy. Cefotetan, a second-generation cephalosporin, is a commonly prescribed antibiotic used to treat a wide range of bacterial infections. The case demonstrated life-threatening anaphylactic reaction during pregnancy. Even a skin test using antibiotics alone triggered anaphylaxis.

Incidence of cephalosporin-induced anaphylaxis and clinical efficacy of screening intradermal tests with cephalosporins: A large multicenter retrospective cohort study

BACKGROUND

Few studies have investigated the incidence of anaphylaxis induced by individual or structurally similar cephalosporins. The aims of the study were to assess the incidence of cephalosporin-induced anaphylaxis and evaluate the clinical efficacy of screening skin tests.

METHODS

In this retrospective cohort study, we obtained information on total cephalosporin use and cephalosporin-induced anaphylaxis in intravenous cephalosporin recipients in 12 general hospitals between 2013 and 2015. Cephalosporins were divided into 4 groups according to similar side-chain structures. The incidence of cephalosporin-induced anaphylaxis was assessed for each cephalosporin, cephalosporin generation, and side-chain group. To verify the efficacy of screening intradermal tests (IDT) with cephalosporin, the 12 hospitals were assigned to the intervention or control group depending on whether they performed screening IDT before the administration of cephalosporins.

RESULTS

We identified 76 cases of cephalosporin-induced anaphylaxis with 1 123 345 exposures to intravenous cephalosporins (6.8 per 100 000 exposures), and the incidence of fatal anaphylaxis by cephalosporin was 0.1 cases per 100 000 exposures. The highest incidences of anaphylaxis occurred in the ceftizoxime (13.0 cases per 100 000 exposures) and side-chain group 1 (cefepime, cefotaxime, ceftizoxime, ceftriaxone, and cefuroxime; 9.3 per 100 000). There was no case of anaphylaxis induced by cefoxitin, cefmetazole, cefminox, and cefotiam. The clinical effectiveness of routine screening IDT was not significant (P = .06).

CONCLUSIONS

The incidence of cephalosporin-induced anaphylaxis differed according to individual drugs and side-chain structure. Screening IDT showed no clinical efficacy at a population level.

The prevalence of cross-reactivity of cephalosporin in penicillin-allergic patients: A cross-sectional study in Thailand

Background:

Cross-reactivity between penicillin and cephalosporin is of crucial concern among patients who have had a previous allergic reaction to penicillin, and cephalosporin is the first choice for their diseases. There is very little evidence concerning the prevalence of cross-reactivity in the Asian population.

Objectives:

This study aims to explore the cross-reactivity between penicillin and cephalosporin in the Asian population.

Methods:

This study included patients who were registered at Lampang Hospital from January 2011 to January 2018. Only patients who were prescribed penicillins and cephalosporins at least once as recorded in the electronic medical records (EMR), were included. Patients having penicillin and cephalosporin allergies were defined as those who were diagnosed in the EMR as allergic to drugs in the penicillin/ cephalosporin groups, in either the probable or definite categories with respect to the Naranjo’s algorithm. Cross-reactivity is defined as patients who were diagnosed as being allergic to both penicillin and cephalosporin. Data about characteristics and types of allergic reactions (type I & IV) were obtained from the EMR.

Results:

A total of 13,959 patients were included in the study. Of these, 99 penicillin-allergic and 13,860 non-penicillin-allergic patients were identified. The prevalence of cross-reactivity among patients with a history of penicillin allergy was 8.1%. Results showed high cross-reactivity rates among patients with type 1 (16.7%) and type 4 (13.3%) hypersensitivity, in relation to other allergic manifestations (3.4%).

Conclusions:

This study raises the possibility that cross-reactivity reported in previous research may differ from that in the Asian population. More Asian-based studies are needed to evaluate this cross-reaction so that this information can further assist medical professionals in clinical decision-making.

Laser-Assisted Indocyanine Green Imaging for Assessment of Perioperative Maxillary Perfusion During Le Fort I Osteotomy: A Pilot Study

PURPOSE

To determine the changes in maxillary perfusion during different stages of Le Fort I osteotomies as measured by laser-assisted indocyanine green imaging (LAICGI) and to determine whether various clinical factors affect maxillary vascular perfusion.

MATERIALS AND METHODS

The medical records of those who had undergone Le Fort I osteotomy with LAICGI at the University of Illinois from 2016 to 2017 were reviewed retrospectively. The maxillary perfusion levels using LAICGI were measured before induction, after induction, after down fracture, after segmentalization (for segmental osteotomies), and after wound closure. The effects of clinical variables, including gender, race, American Society of Anesthesiologists physical status, type of Le Fort I osteotomy, intraoperative status of the descending palatine vessels, maxillary movements (anteroposterior, vertical, transverse), and hemodynamic data (mean arterial blood pressure, heart rate), were analyzed.

RESULTS

Compared with the preoperative baseline values, the indocyanine green (ICG) levels decreased after down fracture and mobilization, segmentalization, and wound closure; no statistically significant differences were found among these 3 points. Segmentalization did not affect the ICG levels compared with the nonsegmentalized cases. Male gender and the amount of maxillary impaction were significantly associated statistically with decreased ICG levels, although the difference was not clinically significant.

CONCLUSIONS

Compared with the baseline levels, maxillary perfusion, as measured by LAICGI, decreased from down fracture to wound closure. Segmentalization did not appear to influence maxillary perfusion, although male gender and impaction were associated with decreased perfusion. Because of its safety and convenience, LAICGI shows promise as a method of assessing maxillary perfusion in future largescale prospective studies linking perioperative perfusion to the occurrence of aseptic necrosis.

Prophylactic Antibiotics for Elective Laparoscopic Cholecystectomy

Surgical site infections with elective laparoscopic cholecystectomy are less frequent and less severe, leading some to suggest that prophylactic antibiotics (PA) are no longer indicated. We compared the incidence of surgical site infections before and after an institutional practice change of withholding PA for elective laparoscopic cholecystectomy. Between May 7, 2013, and March 11, 2015, no PA were given to patients selected for elective cholecystectomy by two surgeons at a single center. The only patients excluded were those who received antibiotics before surgery for any reason. All others, including those at high risk for infection, were included. The incidence and severity of infections were compared with historical controls treated with prophylaxis by the same two surgeons from November 6, 2011, to January 13, 2013. There were 268 patients in the study group and 119 patients in the control group. Infection occurred in 3.0 per cent in the study group compared with 0.9 per cent in the controls ( P = 0.29). All infections were mild except one. Based on these data, the routine use of PA for elective laparoscopic cholecystectomy is not supported.

Occupational generalized urticaria and anaphylaxis after inhalation of cefuroxime in a nurse

We present the case of a 53 years old nonatopic female nurse who experienced repeated anaphylactic reactions at work without involvement in drug-specific tasks such as crushing of tablets or preparation of injections. The causal allergen was not identified until a further severe anaphylactic reaction occurred after oral use of cefuroxime during a respiratory infection. Sensitization to cefuroxime was demonstrated by specific IgE, basophil activation test and skin prick test. An inhalation challenge with a dosimeter induced generalized urticaria after a cumulative dose of about 10 μg of the drug, but no asthmatic reaction. Complete exposure cessation was initiated and a 1-year follow-up was without further allergic reactions. We conclude that work-related systemic allergic reactions to β-lactam antibiotics may occur in nurses after inhalation of low doses and without perceived association with drug-specific tasks like handling of antibiotics.

The 3 Cs of Antibiotic Allergy-Classification, Cross-Reactivity, and Collaboration

Antibiotic allergy labeling is highly prevalent and negatively impacts patient outcomes and antibiotic appropriateness. Reducing the prevalence and burden of antibiotic allergies requires the engagement of key stakeholders such as allergists, immunologists, pharmacists, and infectious diseases physicians. To help address this burden of antibiotic allergy overlabeling, we review 3 key antibiotic allergy domains: (1) antibiotic allergy classification, (2) antibiotic cross-reactivity, and (3) multidisciplinary collaboration. We review the available evidence and research gaps of currently used adverse drug reaction classification systems, antibiotic allergy cross-reactivity, and current and future models of antibiotic allergy care.

Cross-reactivity in β-Lactam Allergy

β-Lactam drugs (penicillins, amoxicillin, and cephalosporins) account for 42.6% of all severe drug-induced anaphylaxis. In this review, we focus on clinically significant immunologic cross-reactivity in patients with confirmed penicillin allergy to cephalosporins, and the structural involvement of the R₁ and R₂ chemical side chains of the cephalosporins causing IgE-mediated cross-reactivity with penicillin and other cephalosporins. Skin tests predict IgE-mediated reactions and showed cross-reactivity between penicillins and early generation cephalosporins that shared side chains, but confirmatory challenge data are lacking. Later-generation cephalosporins, which have distinct side chains, do not have any skin test cross-reactivity with penicillin/amoxicillin. There is debate as to the involvement of R₂ side chains as the antigenic determinants that cause IgE-mediated hypersensitivity with various cephalosporins. Avoidance of cephalosporins, when they are the drug of choice in a penicillin-allergic individual, results in significant morbidity that outweighs the low risk of anaphylaxis. We conclude that there is ample evidence to allow the safe use of cephalosporins in patients with isolated confirmed penicillin or amoxicillin allergy.

A New Pathway for Protein Haptenation by β-Lactams

The covalent binding of β-lactams to proteins upon photochemical activation has been demonstrated by using an integrated approach that combines photochemical, proteomic and computational studies, selecting human serum albumin (HSA) as a target protein and ezetimibe (1) as a probe. The results have revealed a novel protein haptenation pathway for this family of drugs that is an alternative to the known nucleophilic ring opening of β-lactams by the free amino group of lysine residues. Thus, photochemical ring splitting of the β-lactam ring, following a formal retro-Staudinger reaction, gives a highly reactive ketene intermediate that is trapped by the neighbouring lysine residues, leading to an amide adduct. For the investigated 1/HSA system, covalent modification of residues Lys414 and Lys525, which are located in sub-domains IIIA and IIIB, respectively, occurs. The observed photobinding may constitute the key step in the sequence of events leading to photoallergy. Docking and molecular dynamics simulation studies provide an insight into the molecular basis of the selectivity of 1 for these HSA sub-domains and the covalent modification mechanism. Computational studies also reveal positive cooperative binding of sub-domain IIIB that explains the experimentally observed modification of Lys414, which is located in a barely accessible pocket (sub-domain IIIA).

Clinical outcomes following inpatient penicillin allergy testing: A systematic review and meta-analysis

BACKGROUND

A documented penicillin allergy is associated with increased morbidity including length of hospital stay and an increased incidence of resistant infections attributed to use of broader-spectrum antibiotics. The aim of the systematic review was to identify whether inpatient penicillin allergy testing affected clinical outcomes during hospitalization.

METHODS

We performed an electronic search of Ovid MEDLINE/PubMed, Embase, Web of Science, Scopus, and the Cochrane Library over the past 20 years. Inpatients having a documented penicillin allergy that underwent penicillin allergy testing were included.

RESULTS

Twenty-four studies met eligibility criteria. Study sample size was between 24 and 252 patients in exclusively inpatient cohorts. Penicillin skin testing (PST) with or without oral amoxicillin challenge was the main intervention described (18 studies). The population-weighted mean for a negative PST was 95.1% [CI 93.8-96.1]. Inpatient penicillin allergy testing led to a change in antibiotic selection that was greater in the intensive care unit (77.97% [CI 72.0-83.1] vs 54.73% [CI 51.2-58.2], P<.01). An increased prescription of penicillin (range 9.9%-49%) and cephalosporin (range 10.7%-48%) antibiotics was reported. Vancomycin and fluoroquinolone use was decreased. Inpatient penicillin allergy testing was associated with decreased healthcare cost in four studies.

CONCLUSIONS

Inpatient penicillin allergy testing is safe and effective in ruling out penicillin allergy. The rate of negative tests is comparable to outpatient and perioperative data. Patients with a documented penicillin allergy who require penicillin should be tested during hospitalization given its benefit for individual patient outcomes and antibiotic stewardship.