1
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Lim PPC, Moore LN, Minich NM, Wessell KR, Desai AP. Inpatient allergy delabeling of pediatric patients with low-risk penicillin allergy status through direct oral amoxicillin challenge. Allergy Asthma Proc 2024; 45:61-69. [PMID: 38151739 DOI: 10.2500/aap.2024.45.230069] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Background: Less than 5% of children who report penicillin allergy have clinically pertinent type 1 immunoglobulin E mediated hypersensitivity reaction by using direct oral amoxicillin challenge. Several pathways have been developed to delabel penicillin allergy by using direct oral amoxicillin challenge, mostly in the outpatient settings, but there is relative scarcity on published outcomes of these pathways, especially in the inpatient pediatric settings. Objective: This study aimed to evaluate the performance of an institutionally derived inpatient penicillin allergy screening tool. Methods: Patients were stratified into three penicillin allergy risk categories by using an institutional screening questionnaire. Patients with a no-risk status were delabeled without challenge testing. Patients with low-risk status underwent direct graded oral amoxicillin challenge and delabeled based on their response. Patients with high-risk status were referred to allergy service. Results: Ninety-two patients were identified with penicillin allergy. Forty of the 92 patients (43%) were screened. Of the 40 patients screened, 6 (15%) were identified as no risk, 28 (70%) were identified as low risk, and 6 (15%) were identified as high risk. Twenty-four of the 28 patients at low risk (86%) were eligible for direct amoxicillin oral challenge. Seventeen of the 24 (71%) consented to oral challenge but only 12 (71%) underwent direct amoxicillin oral challenge. Eleven of the 12 who underwent oral challenge (92%) were successfully delabeled. Five of the six patients at no risk (83%) were successfully delabeled. Three of the six patients at high risk (50%) were referred for further allergy evaluation. Overall, 16 of the 40 patients screened (40%) were successfully delabeled. Conclusion: In this small pediatric inpatient study, our institutional risk stratification screening tool identified patients at low risk for penicillin allergy and direct graded oral amoxicillin challenge was safely administered to delabel penicillin allergy in these patients.Clinical trial NCT05020327, www.clinicaltrials.gov.
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Affiliation(s)
- Peter Paul C Lim
- From the Division of Infectious Diseases, Department of Pediatrics, Avera McKennan University Health Center and Sanford University of South Dakota School of Medicine, Sioux Falls, South Dakota
| | - LeAnne N Moore
- Department of Pediatric Pharmacy, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Nori Mercuri Minich
- Department of Pediatrics, Case Western Reserve University and Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Kathryn Ruda Wessell
- Division of Allergy and Immunology, Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, and
| | - Ankita P Desai
- Division of Infectious Diseases, Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio
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2
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Gao C, Ma B, Liu W, Zhu L. The state and consideration for skin test of β-lactam antibiotics in pediatrics. Front Cell Infect Microbiol 2023; 13:1147976. [PMID: 37396306 PMCID: PMC10308085 DOI: 10.3389/fcimb.2023.1147976] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/23/2023] [Indexed: 07/04/2023] Open
Abstract
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.
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Affiliation(s)
- Chunhui Gao
- Department of Pharmacy, Tianjin Children's Hospital (Children's Hospital of Tianjin University), Tianjin, China
| | - Bowen Ma
- Department of Pharmacy, Cangzhou People's Hospital, Cangzhou, Hebei, China
| | - Wei Liu
- Tianjin Children's Hospital (Children's Hospital of Tianjin University), Tianjin, China
| | - Liqin Zhu
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, China
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3
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Ben Romdhane H, Ben Fredj N, Ben Fadhel N, Chadli Z, Abderrahmen A, Boughattas NA, Chaabane A, Aouam K. Beta-lactam hypersensitivity in children: Frequency and risk factors. Br J Clin Pharmacol 2023; 89:150-157. [PMID: 33179302 DOI: 10.1111/bcp.14647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/22/2020] [Accepted: 10/30/2020] [Indexed: 12/01/2022] Open
Abstract
AIMS To determine the frequency of an authentic β-lactam (BL) hypersensitivity (HS) amongst a large number of children and to identify clinical risk factors that predict this hypersensitivity. METHODS All children with suspected BL allergy were evaluated by skin tests (ST) with the suspected BL. A 1-day oral provocation test (OPT) was performed in children with negative ST. We defined an authentic BL-HS case if the child exhibited a positive ST or a positive OPT. Risk factors associated with BL-HS were assessed using a univariate analysis. Covariates showing a P-value <.2 were included in the multivariate logistic regression analysis to determine independent predictors. RESULTS A total of 354 patients reporting 368 suspected BL reactions were included. The diagnosis of BL-HS was established in 24 children (6.7%). All these children had a positive ST. OPT was performed in 30 patients and was negative in all of them. In 110 children with a negative ST, BL was tolerated. In the risk factors analysis, 164 children were included. Older age (>5 years) at the reaction (odds ratio = 1.11; 95% confidence interval, 1.01-1.22; P = .02) and BL administered (odds ratio = 7.7; 95% confidence interval, 2.76-21.8; P < .001) were significantly associated with authentic BL-HS. CONCLUSION BL-HS should be evaluated with an appropriate allergy work-up before strict prohibition is made. In addition, age of patient and BL involved can be used as predictive factors of developing BL-HS in this population.
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Affiliation(s)
- Haifa Ben Romdhane
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Nadia Ben Fredj
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Najah Ben Fadhel
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Zohra Chadli
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Ahlem Abderrahmen
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Naceur A Boughattas
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Amel Chaabane
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Karim Aouam
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
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4
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Liccioli G, Giovannini M, Caubet JC, Barni S, Sarti L, Parronchi P, Capone M, Tomei L, Mori F. Simplifying the drug provocation test in non-immediate hypersensitivity reactions to amoxicillin in children: The experience of a tertiary care allergy unit. Pediatr Allergy Immunol 2022; 33:e13809. [PMID: 35754120 PMCID: PMC9328376 DOI: 10.1111/pai.13809] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/29/2022] [Accepted: 05/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mild non-immediate reactions (NIR) to beta-lactams (βLs) are the most common manifestation of adverse drug reactions in children, and the drug provocation test (DPT) remains the gold standard for diagnosis. However, there are still controversies about the protocol that should be used, especially regarding the administration of doses and the DPT length. OBJECTIVE This study aimed to evaluate a pediatric population with a history of mild NIR to amoxicillin (AMX) or to amoxicillin-clavulanic acid (AMX/CL) who underwent a diagnostic workup including a DPT with the culprit drug, to understand if a graded DPT or, instead, a single full dose could be the most appropriate way of administration in clinical practice. METHODS The data of children were retrospectively analyzed for a 5-year period, with demographic and clinical characteristics collected. We reported the allergy workup and the results of the DPT performed with the administration of incremental doses and a prolonged DPT at home for a total of 5 days. RESULTS Three hundred fifty-four patients were included. Overall, 23/354 (6.5%) DPTs were positive: 11/23 patients showed a reaction after 2-8 h after the last dose on the 1st or 2nd day (1 reacted 30 min after the last dose), 1/23 reacted with urticaria 30 min after the first dose, 11/23 reacted at home on the 5th day of the DPT. CONCLUSION This paper indirectly suggests that a single therapeutic dose administered on the 1st day of a DPT could be safe in the diagnostic workup of mild NIR to AMX/CL. Moreover, this could be less time-consuming as patients would spend less time in the hospital, also considering the public health restrictions imposed during the COVID-19 pandemic.
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Affiliation(s)
- Giulia Liccioli
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Paola Parronchi
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Manuela Capone
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Leonardo Tomei
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
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5
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Iammatteo M, Lezmi G, Confino-Cohen R, Tucker M, Ben-Shoshan M, Caubet JC. Direct Challenges for the Evaluation of Beta-Lactam Allergy: Evidence and Conditions for Not Performing Skin Testing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2947-2956. [PMID: 34366093 DOI: 10.1016/j.jaip.2021.04.073] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/19/2021] [Accepted: 04/25/2021] [Indexed: 12/11/2022]
Abstract
In the western world, up to 10% of the general population and more than 15% of hospitalized patients report penicillin allergy. After a comprehensive evaluation, more than 95% of patients who report a penicillin allergy can subsequently tolerate this antibiotic. Traditionally, the most widely accepted protocol to evaluate beta-lactam (BL) allergy consisted of skin testing (ST) followed by a drug provocation test (DPT) in ST-negative patients. DPT is the gold standard for proving or excluding BL allergy and is considered the final and definitive step in the evaluation. Recently, studies have been published that support the use of direct DPTs without preceding ST for both pediatric and adult patients who report a low-risk historical reaction to BLs. However, these studies use various risk-stratification criteria to determine eligibility for a direct DPT. A standardized protocol for DPT is also lacking. In this review, we assess the current literature and evidence for performing direct DPT in the pediatric and adult populations. On the basis of this evidence, we also present risk-based algorithms for the evaluation of BL allergy in pediatric and adult populations based on a description of the historical reaction.
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Affiliation(s)
- Melissa Iammatteo
- Division of Allergy and Immunology, Department of Medicine, Montefiore Medical Center, Bronx, NY
| | - Guillaume Lezmi
- AP-HP, Hôpital Necker-Enfants Malades, Service de Pneumologie et Allergologie Pédiatriques, Paris, France; Equipe Immunorégulation et Immunopathologie, Institut Necker Enfants Malades, Inserm UMR1151, CNRS UMR8253, Université de Paris, Paris, France
| | - Ronit Confino-Cohen
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar-Saba, Israel Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark Tucker
- Department of Allergy and Immunology, Kaiser Permanente Tacoma Medical Center, Tacoma, Wash
| | - Moshe Ben-Shoshan
- Division of Pediatric Allergy, Clinical Immunology and Dermatology, Department of Pediatrics, McGill University Health Center, Montreal, Quebec, Canada
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of the Child and Adolescent, Geneva University Hospital, Geneva, Switzerland.
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6
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Tsabouri S, Atanaskovic-Markovic M. Skin eruptions in children: Drug hypersensitivity vs viral exanthema. Pediatr Allergy Immunol 2021; 32:824-834. [PMID: 33621365 DOI: 10.1111/pai.13485] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/13/2021] [Accepted: 02/18/2021] [Indexed: 12/11/2022]
Abstract
Childhood rashes or exanthemas are common and are usually relatively benign. There are many causes of rash in children, including mainly viruses, and less often bacterial toxins, drugs, allergens and other diseases. Viral exanthema often appears while children are taking a medication in the course of a viral infection; it can mimic drug exanthema and is perceived as a drug allergy in 10% of cases. In the vast majority of cases, the distinction between virus-induced and drug-induced skin eruption during the acute phase is not possible. The drugs most commonly implicated are beta-lactams (BL) and non-steroidal anti-inflammatory drugs (NSAIDs). Viruses, commonly Epstein-Barr virus (EBV), human herpesvirus 6 (HHV6) and cytomegalovirus (CMV), and the bacterium, Mycoplasma pneumoniae, may cause exanthema either from the infection itself (active or latent) or because of interaction with drugs that are taken simultaneously. Determination of the exact diagnosis requires a careful clinical history and thorough physical examination. Haematological and biochemical investigations and histology are not always helpful in differentiating between the two types of exanthema. Serological and polymerase chain reaction (PCR) assays can be helpful, although a concomitant acute infection does not exclude drug hypersensitivity. A drug provocation test (DPT) is although considered the gold standard for the diagnosis and is not preferred by the patients. Skin tests are not well tolerated, and in vitro tests, such as the basophil activation test and lymphocyte transformation, are of low sensitivity and specificity and their relevance is debatable. Based on current evidence, we propose a systematic clinical approach for timely differential diagnosis and management of rashes in children who present a cutaneous eruption while receiving a drug.
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Affiliation(s)
- Sophia Tsabouri
- Child Health Department, Medical School, University of Ioannina, Ioannina, Greece
| | - Marina Atanaskovic-Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,University Children's Hospital of Belgrade, Belgrade, Serbia
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7
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Ben Fadhel N, Aroua F, Chadli Z, Ben Romdhane H, Chaabane A, Sahtout M, Boughattas NA, Ben Fredj N, Aouam K. Betalactam hypersensitivity: The importance of delabelling in primary care. Br J Clin Pharmacol 2021; 87:4619-4624. [PMID: 33899257 DOI: 10.1111/bcp.14879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/05/2021] [Accepted: 04/14/2021] [Indexed: 12/23/2022] Open
Abstract
PATIENTS AND METHODS An allergy work-up was performed on adult patients with a history of a penicillin allergy seen by primary medical care in Monastir (Tunisia) between July 2016 and February 2018. Patients with negative skin tests were challenged with amoxicillin. Patients who were delabelled were contacted by phone after 6 months to determine outcomes after any therapeutic penicillin-class antibiotic intake. RESULTS A total of 39 patients were evaluated and 33 (84.6%) were delabelled. Five patients were penicillin skin-test positive and one was oral challenge positive. We succeeded in contacting 33 delabelled patients at 6 months. Twenty-two patients tolerated a subsequent therapeutic course of amoxicillin, eight patients did not retake penicillin due to a lack of therapeutic indication, and three patients refused an indicated penicillin use fearful of another reaction. CONCLUSION This study highlights the importance of allergy work-up in the diagnosis of beta-lactam hypersensitivity. Most patients were excessively labelled as beta-lactam allergic and this mislabelling could increase healthcare costs and lead to the development of drug resistance by the use of wide-spectrum antibiotics.
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Affiliation(s)
- Najah Ben Fadhel
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Fares Aroua
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Zohra Chadli
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Haifa Ben Romdhane
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Amel Chaabane
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | | | - Naceur A Boughattas
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Nadia Ben Fredj
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Karim Aouam
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
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8
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Caubet J. Management of children with a suspicion of immediate drug hypersensitivity. Allergy 2021; 76:940-941. [PMID: 32715493 DOI: 10.1111/all.14521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/12/2020] [Accepted: 07/01/2020] [Indexed: 12/22/2022]
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9
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Akcal O, Ozen S, Taskirdi I, Haci I, Kanik E, Karkiner C, Can D. The use of in vivo and in vitro tests in children with beta lactam allergy. Allergol Immunopathol (Madr) 2020; 48:633-639. [PMID: 32473813 DOI: 10.1016/j.aller.2020.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/28/2020] [Accepted: 03/12/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Drug allergies are reactions within the context of drug hypersensitivity reactions, which are caused by immunological mechanisms due to a previously sensitising drug. Beta-lactam antibiotics (BLA) are the leading agents causing drug hypersensitivity reactions in children. The aim of this study is to evaluate the diagnostic importance of in vivo and in vitro diagnostic tests in children with suspected immediate-type BLA hypersensitivity and to investigate the frequency of their use for the final diagnosis. METHODS Patients admitted to the Outpatient Clinic of Division of Paediatric Allergy and Immunology with suspicion of immediate-type BLA hypersensitivity between December 2014 and December 2018 were investigated. Patients with a history of immediate reactions to BLA were examined by performing drug specific IgE, skin prick tests, intradermal tests and drug provocation tests (DPT). RESULTS During the study period, 148 patients were admitted to our clinic with suspected immediate-type BLA hypersensitivity. Forty-eight patients completed all assessment steps and were enrolled in the study. It has been shown that 27 patients did not have drug allergy. BLA hypersensitivity was proven in 21 patients by using in vivo test algorithm. More than half of the patients were diagnosed via skin tests with culprit drug. CONCLUSION Allergy work-up should be performed in patients with immediate reactions to BLA. A skin test can demonstrate BLA hypersensitivity in most patients. Thus, skin tests should be performed prior to the drug provocation test.
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10
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Kulhas Celik I, Turgay Yagmur I, Yilmaz Topal O, Toyran M, Civelek E, Karaatmaca B, Dibek Misirlioglu E. Diagnostic value and safety of penicillin skin tests in children with immediate penicillin allergy. Allergy Asthma Proc 2020; 41:442-448. [PMID: 33109310 DOI: 10.2500/aap.2020.41.200082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: The first-line method in the diagnosis of patients who describe an immediate reaction after penicillin intake is a skin test (ST) with penicillin reagents. Objectives: We aimed to determine the safety and diagnostic value of penicillin STs in the diagnosis of immediate reactions to penicillins in pediatric patients. Methods: The study included pediatric patients with suspected immediate reaction to penicillin who were subjected to STs by using a standard penicillin test kit as well as suspected penicillin and the drug provocation tests (DPT) with the suspected penicillin at our clinic. Results: A total of 191 patients (53.9% boys) with a median age of 6.83 years (interquartile range, 4.2-12 years) were included in the study. The time from drug intake to the onset of reaction was ≤1 hour in 138 patients (72.3%) and 1 to 6 hours in 53 patients (27.7%). Penicillin allergy (PA) was confirmed by diagnostic tests in 36 of the 191 patients (18.8%). In multivariate logistic regression analysis, the history of both urticaria and angioedema (odds ratio [OR] 27.683 [95% confidence interval {CI}, 3.143-243.837]; p = 0.003) and anaphylaxis (OR 56.246 [95% CI, 6.598-479.489]; p < 0.001) were the main predictors of a PA diagnosis. Although ST results were positive in 23 patients (63.8%), 13 patients (26.2%) had positive DPT results despite negative ST results. The negative predictive value (NPV) of STs was calculated 92.2% (155/168). None of our patients experienced immediate or delayed systemic and/or local reactions in relation to the STs. Conclusion: A history of urticaria with angioedema and anaphylaxis were the main predictors of true PA in children with suspected immediate reactions. STs with penicillin reagents are safe for use in children. Although STs have a high NPV, DPT is the gold standard for diagnosis. DPTs should be performed as the final step of the diagnostic evaluation of PA in patients with negative ST results.
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Affiliation(s)
- Ilknur Kulhas Celik
- From the Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Irem Turgay Yagmur
- From the Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Ozge Yilmaz Topal
- From the Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Muge Toyran
- Department of Pediatric Allergy and Immunology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Ersoy Civelek
- Department of Pediatric Allergy and Immunology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Betul Karaatmaca
- From the Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Emine Dibek Misirlioglu
- Department of Pediatric Allergy and Immunology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
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11
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Mori F, Fili L, Sarti L, Capone M, Liccioli G, Giovannini M, Barni S, Novembre EM, Parronchi P. Sensitivity and specificity of lymphocyte transformation test in children with mild delayed hypersensitivity reactions to beta-lactams. Allergy 2020; 75:2696-2699. [PMID: 32392390 DOI: 10.1111/all.14358] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Francesca Mori
- Allergy Unit Department of Pediatrics Anna Meyer Children's University Hospital Florence Italy
| | - Lucia Fili
- Department of Clinical and Experimental Medicine University of Florence Florence Italy
| | - Lucrezia Sarti
- Allergy Unit Department of Pediatrics Anna Meyer Children's University Hospital Florence Italy
| | - Manuela Capone
- Department of Clinical and Experimental Medicine University of Florence Florence Italy
| | - Giulia Liccioli
- Allergy Unit Department of Pediatrics Anna Meyer Children's University Hospital Florence Italy
| | - Mattia Giovannini
- Allergy Unit Department of Pediatrics Anna Meyer Children's University Hospital Florence Italy
| | - Simona Barni
- Allergy Unit Department of Pediatrics Anna Meyer Children's University Hospital Florence Italy
| | - Elio M. Novembre
- Allergy Unit Department of Pediatrics Anna Meyer Children's University Hospital Florence Italy
| | - Paola Parronchi
- Department of Clinical and Experimental Medicine University of Florence Florence Italy
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12
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Felix MMR, Kuschnir FC. Direct Oral Provocation Test Is Safe and Effective in Diagnosing Beta-Lactam Allergy in Low-Risk Children With Mild Cutaneous Reactions. Front Pharmacol 2020; 11:1223. [PMID: 32903694 PMCID: PMC7438762 DOI: 10.3389/fphar.2020.01223] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/27/2020] [Indexed: 01/12/2023] Open
Affiliation(s)
- Mara Morelo Rocha Felix
- Department of General Medicine, School of Medicine and Surgery, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil.,Department of Pediatrics, Faculty of Medicine, Fundação Técnico Educacional Souza Marques, Rio de Janeiro, Brazil
| | - Fábio Chigres Kuschnir
- Department of Pediatrics, Faculty of Medicine, Fundação Técnico Educacional Souza Marques, Rio de Janeiro, Brazil.,Department of Pediatrics, Faculty of Medical Sciences, Rio de Janeiro State University, Rio de Janeiro, Brazil
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13
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Dias de Castro E, Carolino F, Carneiro-Leão L, Barbosa J, Ribeiro L, Cernadas J. Allergy to beta-lactam antibiotics in children: Risk factors for a positive diagnostic work-up. Allergol Immunopathol (Madr) 2020; 48:417-423. [PMID: 32460994 DOI: 10.1016/j.aller.2020.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/06/2020] [Accepted: 01/29/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Allergy to beta-lactam (βL) antibiotics is highly reported in children, but rarely confirmed. Risk factors for a positive diagnostic work-up are scarce. The primary aim was to characterize the cases of children with confirmed βL allergy, investigating potential risk factors. Secondary aims were to assess the prevalence of allergy to βL in this population and to confirm the safety of less extensive diagnostic protocols for milder reactions. METHODS We reviewed the clinical data from all children evaluated in our Department for suspected βL allergy, over a six-year period. RESULTS Two hundred and twenty children (53% females) with a mean age of 6.5±4.2 years were evaluated. Cutaneous manifestations were the most frequently reported (96.9%), mainly maculopapular exanthema (MPE). The reactions were non-immediate in 59.5% of the cases. Only 23 children (10.5%) were diagnosed with allergy to βL. The likelihood of βL allergy was significantly higher in children with a family history of drug allergy (p<0.001) and in those with a smaller time period between the reaction and the study (p=0.046). The probability of not confirming βL allergy is greater in children reporting less severe reactions (p<0.001) and MPE (p<0.001). We found the less extensive diagnostic protocol in milder reactions safe, since only 4.2% of the children presented a positive provocation test (similar reaction as the index reaction). CONCLUSION This study highlights family history of drug allergy as a risk factor for a positive diagnostic work-up. Larger series are required, particularly genetic studies to accurately determine future risk for βL allergy in children.
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Kulhas Celik I, Guvenir H, Hurmuzlu S, Toyran M, Civelek E, Kocabas CN, Dibek Misirlioglu E. The negative predictive value of 5-day drug provocation test in nonimmediate beta-lactam allergy in children. Ann Allergy Asthma Immunol 2020; 124:494-499. [PMID: 31923549 DOI: 10.1016/j.anai.2019.12.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 12/27/2019] [Accepted: 12/31/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Extending the drug provocation test (DPT) period is recommended for patients with suspected nonimmediate beta-lactam antibiotic (BLA) allergy and negative DPT. No consensus has been reached regarding the duration of prolonged provocation. OBJECTIVE We aimed to determine the negative predictive value (NPV) of the 5-day extended DPT. METHODS Parents of patients with suspected nonimmediate mild cutaneous reactions with BLAs who had been subjected to 5-day DPT with culprit drugs were questioned by telephone interview about reexposure to the tested drug. Patients with reported reaction during reexposure were reevaluated. Skin tests and serum-specific immunoglobulin E (IgE) analysis were not performed before first DPT. RESULTS A total of 355 patients had negative results in 5-day DPT. The median age at DPT was 4.2 years, and 52.9% were male. The families of 255 patients (72%) could be contacted. Of these 255 patients, 179 (70%) had used the same drug, and reactions were reported for 6 (3.4%) of those patients, who were subsequently reevaluated. Five of the 6 patients had DPT with amoxicillin-clavulanate and 1 with cefixime. When detailed history was taken, 2 of the 5 patients with amoxicillin-clavulanate reaction were found to have used the drug unintentionally after their reaction to reexposure and did not have any symptoms. One of the patients underwent allergy workup and tested negative, and the other 2 refused the test. The patient with reported cefixime reaction underwent repeated allergy workup and tested negative. Therefore, the NPV of 5-day prolonged DPT was 98.9%. CONCLUSION The 5-day prolonged DPT has high NPV and seems appropriate in duration for children with suspected nonimmediate-BLA allergy.
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Affiliation(s)
- Ilknur Kulhas Celik
- University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Division of Pediatrics Allergy and Immunology, Ankara, Turkey.
| | - Hakan Guvenir
- University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Division of Pediatrics Allergy and Immunology, Ankara, Turkey
| | - Selen Hurmuzlu
- University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Division of Pediatrics, Ankara, Turkey
| | - Muge Toyran
- University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Division of Pediatrics Allergy and Immunology, Ankara, Turkey
| | - Ersoy Civelek
- University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Division of Pediatrics Allergy and Immunology, Ankara, Turkey
| | - Can Naci Kocabas
- Division of Pediatric Allergy and Immunology, Department of Children's Health and Diseases, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Emine Dibek Misirlioglu
- University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Division of Pediatrics Allergy and Immunology, Ankara, Turkey
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Risk Stratification and Prediction in Beta-Lactam Allergic Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2182-2184. [DOI: 10.1016/j.jaip.2019.05.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/10/2019] [Indexed: 11/23/2022]
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Saretta F, Mori F, Cardinale F, Liotti L, Franceschini F, Crisafulli G, Caimmi S, Bottau P, Bernardini R, Caffarelli C. Pediatric drug hypersensitivity: which diagnostic tests? ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:94-107. [PMID: 30830067 PMCID: PMC6502170 DOI: 10.23750/abm.v90i3-s.8171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/01/2019] [Indexed: 12/14/2022]
Abstract
Along with the anamnesis and clinical evaluation, diagnostic tests are one of the mainstream key points in the evaluation and management of drug hypersensitivity reactions (DHR). A wide knowledge gap, both in diagnosis and management of pediatric DHR, must be filled. Only a few published studies evaluated sensitivity and specificity of skin and in vitro tests in children. However, selected case series show that diagnostic work-up for adults could be useful, with some limitations, in pediatric age. Indeed, despite improvement in in vivo and in vitro diagnosis, drug provocation test remains the gold standard in pediatric age, too. Unmet needs in children include multi-centric studies on incidence of DHR, utility and feasibility of in vivo and in vitro diagnostic tests and specifically dedicated guidelines for the diagnosis and management of DHR in children.
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Affiliation(s)
- Francesca Saretta
- Pediatric Department, AAS2 Bassa Friulana-Isontina, Palmanova-Latisana, Italy; Pediatric Allergy Unit, Department of Medicine, Udine, Italy.
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DaVeiga SP, Saretta F. Prolonged Beta-Lactam Provocation Challenges in Children: Do Extended Protocols Offer Any Benefit? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:270-271. [PMID: 30598179 DOI: 10.1016/j.jaip.2018.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 08/08/2018] [Indexed: 06/09/2023]
Affiliation(s)
- Sigrid Payne DaVeiga
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Francesca Saretta
- Pediatric Department, Allergy Service, AAS2 Bassa Friulana-Isontina, Palmanova, Italy
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