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Niedoszytko M, Gorska A, Brockow K, Bonadonna P, Lange M, Kluin-Nelemans H, Oude-Elberink H, Sabato V, Shoumariyeh K, von Bubnoff D, Müller S, Illerhaus A, Doubek M, Angelova-Fischer I, Hermine O, Arock M, Elena C, Malcovati L, Yavuz AS, Schug TD, Fortina AB, Judit V, Gotlib J, Panse J, Vucinic V, Reiter A, Schwaab J, Triggiani M, Mattsson M, Breynaert C, Romantowski J, Zanotti R, Olivieri E, Zink A, van de Ven A, Stefan A, Barete S, Caroppo F, Perkins C, Kennedy V, Christen D, Jawhar M, Luebke J, Parente R, Levedahl K, Hadzijusufovic E, Hartmann K, Nedoszytko B, Sperr WR, Valent P. Prevalence of hypersensitivity reactions in various forms of mastocytosis: A pilot study of 2485 adult patients with mastocytosis collected in the ECNM registry. Allergy 2024. [PMID: 38651829 DOI: 10.1111/all.16132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Hypersensitivity reactions (HR) are common in mastocytosis. However, little is known about triggers and risk factors. The registry of the European Competence Network on Mastocytosis (ECNM) enables reliable studies in a larger cohort of mastocytosis patients. We assessed prevalence, triggers and risk factors of HR in adults with mastocytosis in the ECNM registry. METHODS Data were collected in 27 ECNM centers. We analyzed potential triggers (Hymenoptera venoms, food, drug, inhalant and others) and risk factors at diagnosis and during follow-up. The study group consisted of 2485 adults with mastocytosis, 1379 women (55.5%) and 1106 men (44.5%). Median age was 48.2 years (range 18-91 years). RESULTS Nine hundred and forty eight patients (38.1%) reported one or more HR`. Most common triggers were Hymenoptera venoms in cutaneous mastocytosis (CM) and indolent systemic mastocytosis (ISM), whereas in advanced SM (advSM), most common elicitors were drugs, including nonsteroidal anti-inflammatory agents and penicillin. In multivariate analyses, tryptase level < 90 ng/mL, <15% infiltration by mast cells in bone marrow biopsy-sections, and diagnosis of ISM were identified as independent risk factors for HR. For drug-induced HR, prominent risk factors were advSM and high tryptase levels. New reactions were observed in 4.8% of all patients during 4 years follow-up. CONCLUSIONS HR are mainly triggered by Hymenoptera venoms in patients with CM and ISM and by drugs in patients with advSM. Tryptase levels <90 ng/mL, mast cell bone marrow infiltration <15%, and WHO category ISM are predictors of HR. New HR occur in 4.8% of all patients within 4 years.
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Affiliation(s)
- Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Aleksandra Gorska
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, School of Medicine, Munich, Germany
| | - Patrizia Bonadonna
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Magdalena Lange
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Hanneke Kluin-Nelemans
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Vito Sabato
- Department of Immunology, Allergology Rheumatology University of Antwerp and Antwerp University Hospital, Edegem, Belgium
| | - Khalid Shoumariyeh
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany and German Cancer Consortium (DKTK), Partner Site Freiburg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Dagmar von Bubnoff
- Dagmar von Bubnoff, Department of Dermatology, Allergy and Venerology, University of Schleswig Holstein, Lübeck, Germany
| | - Sabine Müller
- Department of Dermatology, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | | | | | - Olivier Hermine
- Unit of Dermatology and CEREMAST, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - Michel Arock
- Department of Hematological Biology and CEREMAST, Pitié-Salpêtrière Hospital, Paris Sorbonne University, Paris, France
| | - Chiara Elena
- Department of Hematology, Fondazione IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Luca Malcovati
- Department of Hematology, Fondazione IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Akif Selim Yavuz
- Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | | | - Anna Belloni Fortina
- Pediatric Dermatology, Internal Medicine, Azienda Ospedaliera, Università di Padova, Padova, Italy
| | | | - Jason Gotlib
- Stanford University, School of Medicine, Hematology Clinic, Stanford, USA
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Center for Integrated Oncology Aachen, Bonn Cologne, Duesseldorf (CIO ABCD), Aachen, Germany
| | | | - Andreas Reiter
- Universitätsmedizin Mannheim, III.Medizinische Klinik, Mannhein, Germany
| | - Juliana Schwaab
- Universitätsmedizin Mannheim, III.Medizinische Klinik, Mannhein, Germany
| | | | | | - Christine Breynaert
- KU Leuven Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology ResearchGroup and MASTeL, University Hospitals Leuven, Leuven, Belgium
| | - Jan Romantowski
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Roberta Zanotti
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Elisa Olivieri
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Alexander Zink
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, School of Medicine, Munich, Germany
| | - Annick van de Ven
- Department of Allergology, University Medical Center, Groningen, The Netherlands
| | - Alex Stefan
- Clinic for Hematology and Oncology, Kepler University Hospital, Linz, Austria
| | - Stephane Barete
- Unit of Dermatology and CEREMAST, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - Francesca Caroppo
- Pediatric Dermatology, Internal Medicine, Azienda Ospedaliera, Università di Padova, Padova, Italy
| | - Cecelia Perkins
- Stanford University, School of Medicine, Hematology Clinic, Stanford, USA
| | - Vanessa Kennedy
- Stanford University, School of Medicine, Hematology Clinic, Stanford, USA
| | - Deborah Christen
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Center for Integrated Oncology Aachen, Bonn Cologne, Duesseldorf (CIO ABCD), Aachen, Germany
| | - Mohamad Jawhar
- Universitätsmedizin Mannheim, III.Medizinische Klinik, Mannhein, Germany
- Department of Hematology and Oncology, Helios Pforzheim, Pforzheim, Germany
| | - Johannes Luebke
- Universitätsmedizin Mannheim, III.Medizinische Klinik, Mannhein, Germany
| | | | - Kerstin Levedahl
- Uppsala University Hospital, Uppsala, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Emir Hadzijusufovic
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Boguslaw Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland
- Invicta Fertility and Reproductive Center, Molecular Laboratory, Sopot, Poland
| | - Wolfgang R Sperr
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
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Moral L, Toral T, Muñoz C, Marco N, García-Avilés B, Murcia L, Forniés MJ, González MC, Canals F, Bragado E, Martínez Olmos J, García-Magán C, Moure González JD, Cortés N, Giménez M, Gómez C, Rodríguez AB, Moreno A, Lucas JM, Quevedo S, Blasco C, Aliaga Y. Direct oral challenge for immediate and non-immediate beta-lactam allergy in children: A real-world multicenter study. Pediatr Allergy Immunol 2024; 35:e14096. [PMID: 38425150 DOI: 10.1111/pai.14096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/03/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Allergy to beta-lactam antibiotics (BLA) is frequently suspected in children, but a drug provocation test (DPT) rules it out in over 90% of cases. Direct oral DPT (DODPT), without skin or other previous tests, is increasingly been used to delabel non-immediate BLA reactions. This real-world study aimed to assess the safety and effectiveness of DODPT in children with immediate and non-immediate reactions to BLAs. METHODS Ambispective registry study in children (<15 years), attended between 2016 and 2023 for suspected BLA allergy in 15 hospitals in Spain that routinely perform DODPT. RESULTS The study included 2133 patients with generally mild reactions (anaphylaxis 0.7%). Drug provocation test with the implicated BLA was performed in 2014 patients (94.4%): 1854 underwent DODPT (86.9%, including 172 patients with immediate reactions). One hundred forty-five (7.2%) had symptoms associated with DPT, although only four reactions were severe: two episodes of anaphylaxis and two of drug-induced enterocolitis syndrome, which resolved rapidly with treatment. Of the 141 patients with mild reactions in the first DPT, a second DPT was considered in 87 and performed in 57, with 52 tolerating it without symptoms. Finally, BLA allergy was ruled out in 90.9% of the sample, confirmed in 3.4%, and remained unverified, usually due to loss to follow-up, in 5.8%. CONCLUSIONS Direct oral DPT is a safe, effective procedure even in immediate mild reactions to BLA. Many reactions observed in DPT are doubtful and require confirmation. Severe reactions are exceptional and amenable to treatment. Direct oral DPT can be considered for BLA allergy delabeling in pediatric primary care.
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Affiliation(s)
- Luis Moral
- Hospital General Universitario Dr. Balmis, ISABIAL, Alicante, Spain
| | - Teresa Toral
- Hospital General Universitario Dr. Balmis, ISABIAL, Alicante, Spain
| | | | - Nuria Marco
- Hospital Vega Baja de Orihuela, San Bartolome, Spain
| | | | | | | | | | | | - Esther Bragado
- Hospital General Universitario Santa Lucía, Cartagena, Spain
| | | | | | | | - Nuria Cortés
- Hospital Universitario Mútua de Terrassa, Terrassa, Spain
| | - Magalí Giménez
- Hospital Sant Joan de Deu, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Catalina Gómez
- Hospital Sant Joan de Deu, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | | | - Ana Moreno
- Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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Daghfous H, Moussa C, Ben Mansour A, Slim A, Ben Saad S, Tritar F. Drug reintroduction testing and beta-lactam hypersensitivity in children: Protocols and results, a 12-year experience. Int J Immunopathol Pharmacol 2023; 37:3946320231204220. [PMID: 37789550 PMCID: PMC10552452 DOI: 10.1177/03946320231204220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/12/2023] [Indexed: 10/05/2023] Open
Abstract
Introduction: Oral provocation test (OPT) to beta-lactam antibiotics (BL) is a gold standard in allergology investigation. We aimed to demonstrate the contribution of OPT in BL hypersensitivity (HS) indicated as a first step in diagnosis. Methods: We conducted a retrospective study from 2007 to 2019, in a single Tunisian tertiary care academic center. It concerned children with presumed non-severe allergic manifestations to BL, with a reaction that has occurred at least 6 months before the OPT. Results: We identified 35 children for inclusion. After the first OPT, a second OPT with a different BL was performed in case of a positive result of the first one. In 12 cases (34.2%), the OPT elicited a reaction. In eight cases the allergy was to penicillin and in two cases to cephalosporins (cefixim). Cross-reactivity was noted in two cases. Conclusion: An OPT to BL indicated in the first instance in non-severe reaction in children will allow a rapid diagnosis in case of suspicion of HS to BL.
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Affiliation(s)
- Hafaoua Daghfous
- Pneumology Department, Abderrahmen Mami Hospital, Ariana, Tunisia
- Faculty of Medicine, El Manar University, Tunis, Tunisia
| | - Chirine Moussa
- Pneumology Department, Abderrahmen Mami Hospital, Ariana, Tunisia
- Faculty of Medicine, El Manar University, Tunis, Tunisia
| | - Amani Ben Mansour
- Pneumology Department, Abderrahmen Mami Hospital, Ariana, Tunisia
- Faculty of Medicine, El Manar University, Tunis, Tunisia
| | - Azza Slim
- Pneumology Department, Abderrahmen Mami Hospital, Ariana, Tunisia
- Faculty of Medicine, El Manar University, Tunis, Tunisia
| | - Soumaya Ben Saad
- Pneumology Department, Abderrahmen Mami Hospital, Ariana, Tunisia
- Faculty of Medicine, El Manar University, Tunis, Tunisia
| | - Fatma Tritar
- Pneumology Department, Abderrahmen Mami Hospital, Ariana, Tunisia
- Faculty of Medicine, El Manar University, Tunis, Tunisia
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Chong CJ, Choo KJL, Ong KY, Tan V, Khoo JBN, Murthee KG, Hanif IM, Naing CS, Lee HY. Improving drug allergy label accuracy by supervised safety- and protocol-driven evaluation. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022. [DOI: 10.47102/annals-acadmedsg.2022118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction: Drug allergies are often self-reported but of unknown accuracy. We carried out a prospective study to examine the utility and safety of formal allergology evaluation, and to identify factors associated with accurate drug allergy labels.
Method: All patients who underwent drug allergy evaluation in our clinic during the study period were recruited. Baseline demographics, characteristics of index hypersensitivity reaction and outcomes of evaluation were recorded.
Results: A total of 331 patients from March 2019 to June 2021 completed drug allergy evaluation to index drugs of concern. There were 123 (37%) male patients, and the mean age was 49 years (standard deviation 17). There were 170 beta-lactam antibiotics, 53 peri-operative drugs, 43 others, 38 non-steroidal anti-inflammatory drugs, and 27 non-beta-lactam antibiotic evaluations. Index reaction occurred within 5 years in 165 (50%) patients, with latency of less than 4 hours in 125 (38%) patients. The most common index reactions were rash, angioedema and urticaria. There were 57 (17%) evaluations stratified as low risk, 222 (67%) moderate risk, and 52 (16%) high risk based on multidisciplinary consensus. Allergy label was found to be false (negative drug evaluation) in 248 (75%) patients, while 16/237 (7%) skin tests, 44/331 (13%) in-clinic graded challenge, and 23/134 (17%) home prolonged challenges were positive (true drug allergy). The most common evaluation reactions were rash and urticaria. No cases of anaphylaxis were elicited.
Conclusion: Seventy-five percent of drug allergy labels are inaccurate. Risk-stratified, protocolised allergy evaluation is safe. Prolonged drug challenge increases the sensitivity of drug allergy evaluation and should therefore be performed when indicated.
Keywords: Drug allergy, drug hypersensitivity, graded challenge, prolonged drug provocation, skin testing
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Goh SH, Chong KW, Chiang WC, Goh A, Loh W. Outcome of drug provocation testing in children with suspected beta-lactam hypersensitivity. Asia Pac Allergy 2021; 11:e3. [PMID: 33604273 PMCID: PMC7870368 DOI: 10.5415/apallergy.2021.11.e3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 01/11/2021] [Indexed: 11/19/2022] Open
Abstract
Background Suspicion of beta-lactam (BL) hypersensitivity is often based on parental report. Evaluation is important as incorrect labelling has clinical consequence. Objective To describe the outcomes of drug provocation test (DPT) in children with suspected hypersensitivity. Methods A retrospective study of patients who completed BL DPT from 1 August 2016 to 31 December 2017 at a paediatric allergy centre in Singapore. Suspected hypersensitivity reactions were classified as immediate (onset ≤1 hour) or delayed (onset > 1 hour). Patients with immediate reactions underwent skin prick test (SPT) followed by DPT if SPT was negative. Patients with delayed reactions underwent DPT directly. Results We identified 120 children who reported 121 suspected hypersensitivity reactions. The median age at reaction was 2.0 years (interquartile range [IQR], 1.0–5.0 years) and the median age at DPT was 7.4 years (IQR, 4.2–11.1 years). The timing of suspected hypersensitivity reaction was immediate in 21% (25 of 121), delayed in 66% (80 of 121), and uncertain in 13% (16 of 121). Commonly implicated drugs were amoxicillin in 45% (54 of 121), amoxicillin-clavulanate in 37% (45 of 121), and cephalexin in 8% (10 of 121). Commonly reported symptoms were maculopapular rash 44% (53 of 121), urticaria 34% (41 of 121), and angioedema 22% (27 of 121). All SPTs (n = 26) were negative. There were 118 diagnostic DPTs to index drug and 3 DPTs to alternative drug. A negative challenge result was obtained in 93% (110 of 118) of diagnostic DPTs: 92% (96 of 104) and 100% (14 of 14) of DPTs to penicillin group and cephalosporins respectively. All challenge reactions were mild. Conclusion Our study supports the opinion that prior skin tests may not be necessary for children who report nonsevere reactions and directly performing diagnostic DPT is a safe approach in the evaluation of suspected childhood BL hypersensitivity.
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Affiliation(s)
- Si Hui Goh
- Allergy Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Kok Wee Chong
- Allergy Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Wen Chin Chiang
- Allergy Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Anne Goh
- Allergy Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Wenyin Loh
- Allergy Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
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Tang MM, Fok JS, Thong BYH, Yun J, Li PH, Kang HR, Thien F, Yamaguchi M, Lucas M, Chang YS, Kim BK, Nagao M, Rengganis I, Tsai YG, Chung WH, Rerkpattanapipat T, Kamchaisatian W, Leung TF, Ho JY, Zhang L, Latiff AHA, Fujisawa T, Castells MC, Demoly P, Wang JY, Pawankar R. Diagnostic procedures & practices in drug allergy/hypersensitivity: a survey of 13 Asian countries. Asia Pac Allergy 2020; 10:e36. [PMID: 33178561 PMCID: PMC7610088 DOI: 10.5415/apallergy.2020.10.e36] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/10/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The issues and challenges in the diagnosis of drug allergy/hypersensitivity among children and adults in Asia are likely to be different from non-Asian countries. OBJECTIVE To study the diagnostic modalities used in the evaluation and management of drug allergy/drug hypersensitivity reactions (DHRs) among member societies of the Asia Pacific Association of Allergy, Asthma and Clinical Immunology (APAAACI). METHODS A questionnaire comprising 41 questions was circulated electronically to member societies and individual members of APAAACI between January 23, 2020 and March 6, 2020. RESULTS Twenty-six respondents from 15 member societies and 1 individual member responded. European DHR guidelines were most commonly used. Skin prick and intradermal testing was used by 100%, with only 60% having access to commercial penicillin skin test reagents. In vitro-specific IgE tests were used by 75%, and basophil activation test by 56.3% for immediate DHR. Patch tests were used by 75% in contrast to lymphocyte transformation tests by 25% for nonimmediate DHR. Drug provocation tests were used by 68.8%, the most common indication being to exclude hypersensitivity where history/symptoms were not suggestive of drug hypersensitivity/allergy (93.3%). Human leukocyte antigen (HLA) genotype testing was mandatory among 25% respondents before new carbamazepine prescriptions, and 8.3% for allopurinol prescriptions. CONCLUSIONS There was increased use of skin testing for iodinated contrast media hypersensitivity and patch testing for nonimmediate DHR. HLA genotype testing prior to new carbamazepine, allopurinol and abacavir prescriptions remain variable despite strong associations for severe cutaneous adverse reactions with Asian ethnicity. Results of this survey form a useful framework for developing educational and training needs and for improving access to drug allergy diagnostic and treatment modalities across APAAACI member societies.
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Affiliation(s)
| | - Jie Shen Fok
- Department of Respiratory Medicine, Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Melbourne, Australia
| | - Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - James Yun
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Division of Medicine, Nepean Hospital, Sydney, Australia
| | - Philip Hei Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Hye-Ryun Kang
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Drug Safety Center, Seoul National University Hospital, Seoul, Korea
| | - Francis Thien
- Eastern Health, Melbourne; Monash University, Melbourne, Australia
| | - Masao Yamaguchi
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Michaela Lucas
- Department of Immunology, Pathwest and Sir Charles Gairdner Hospital, Perth, Australia; Medical School, University of Western Australia, Perth, Australia
| | - Yoon-Seok Chang
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byung-Keun Kim
- Department of Internal Medicine, Korea University Medical Center Anam Hospital, Seoul, Korea
| | - Mizuho Nagao
- Allergy Center of Mie National Hospital, Tsu, Japan
| | - Iris Rengganis
- Department of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Yi-Giien Tsai
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung and Linkou Branches, College of Medicine, Chang Gung University, Taipei, Taiwan
| | - Ticha Rerkpattanapipat
- Allergy, Immunology and Rheumatology Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wasu Kamchaisatian
- Pediatric Allergy and Immunology Division, Samitivej Children's Hospital, Bangkok, Thailand
| | - Ting Fan Leung
- Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong
| | - Joo-Yoon Ho
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Luo Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | | | | | - Mariana C Castells
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Mastocytosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; UPMC Univ Paris 06, UMRS 1136, Equipe - EPAR - IPLESP, Sorbonne Universités, Paris, France
| | - Jiu Yao Wang
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
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Krishna MT, Misbah SA. Is direct oral amoxicillin challenge a viable approach for 'low-risk' patients labelled with penicillin allergy? J Antimicrob Chemother 2020; 74:2475-2479. [PMID: 31167024 DOI: 10.1093/jac/dkz229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Spurious penicillin allergy (PenA) is a major public health problem. Up to 10% of the population and 20% of inpatients are labelled with PenA, but only <5%-10% have a proven allergy following comprehensive investigations. PenA tests are labour intensive and require specialist input, which may not be readily available due to limited allergy services. Therefore, patients with PenA receive alternative antibiotics that are associated with higher rates of iatrogenic infections, antimicrobial resistance and a longer hospital stay with consequent increased costs. Recent evidence suggests that a supervised 'direct' oral amoxicillin challenge (without performing allergy tests) is a safe option in low-risk patients (those least likely to be allergic based on history). Patient selection for this procedure is based on a careful guideline-based risk stratification process. Further research is needed to validate this intervention in routine clinical practice and explore potential facilitators and barriers to implementation in different healthcare settings.
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Affiliation(s)
- Mamidipudi T Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust and Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, UK
| | - Siraj A Misbah
- Department of Clinical Immunology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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Importance of Diagnostics Prior to Desensitization in New Drug Hypersensitivity: Chemotherapeutics and Biologicals. CURRENT TREATMENT OPTIONS IN ALLERGY 2020. [DOI: 10.1007/s40521-020-00238-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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9
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Torres MJ, Celik GE, Whitaker P, Atanaskovic-Markovic M, Barbaud A, Bircher A, Blanca M, Brockow K, Caubet JC, Cernadas JR, Chiriac A, Demoly P, Garvey LH, Merk HF, Mosbech H, Nakonechna A, Romano A. A EAACI drug allergy interest group survey on how European allergy specialists deal with β-lactam allergy. Allergy 2019; 74:1052-1062. [PMID: 30637768 DOI: 10.1111/all.13721] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/09/2018] [Accepted: 08/22/2018] [Indexed: 12/18/2022]
Abstract
An accurate diagnosis of β-lactam (BL) allergy can reduce patient morbidity and mortality. Our aim was to investigate the availability of BL reagents, their use and test procedures in different parts of Europe, as well as any differences in the diagnostic workups for evaluating subjects with BL hypersensitivity. A survey was emailed to all members of the EAACI Drug Allergy Interest Group (DAIG) between February and April 2016, and the questionnaire was meant to study the management of suspected BL hypersensitivity. The questionnaire was emailed to 82 DAIG centres and answered by 57. Amoxicillin alone or combined to clavulanic acid were the most commonly involved BL except in the Danish centre, where penicillin V was the most frequently suspected BL. All centres performed an allergy workup in subjects with histories of hypersensitivity to BL: 53 centres (93%) followed DAIG guidelines, two national guidelines and two local guidelines. However, there were deviations from DAIG recommendations concerning allergy tests, especially drug provocation tests. A significant heterogeneity exists in current practice not only among countries, but also among centres within the same country. This suggests the need to re-evaluate, update and standardize protocols on the management of patients with suspected BL allergy.
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Affiliation(s)
- Maria Jose Torres
- Allergy Unit; Regional University Hospital of Malaga-IBIMA-UMA; Malaga Spain
| | - Gulfem Elif Celik
- Department of Immunology and Allergy; Ankara University School of Medicine; Ankara Turkey
| | - Paul Whitaker
- Regional Adult Cystic Fibrosis Unit; St James's Hospital; Leeds UK
| | | | - Annick Barbaud
- Dermatology and Allergology Department; Tenon Hospital (AP-HP); Sorbonne Universities; UPMC University Paris 06; Paris France
| | | | - Miguel Blanca
- Allergy Service; Infanta Leonor University Hospital; Madrid Spain
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Munich Germany
| | | | | | - Anca Chiriac
- Division of Allergy; Department of Pulmonology; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- UMRS 1136; Equipe - EPAR - IPLESP; Sorbonne Universités; UPMC Univ Paris 06; Paris France
| | - Pascal Demoly
- Division of Allergy; Department of Pulmonology; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
| | - Lene Heise Garvey
- Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - Hans F. Merk
- Department of Dermatology and Allergology; RWTH Aachen University; Aachen Germany
| | - Holger Mosbech
- Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - Alla Nakonechna
- Allergy and Immunology Clinic; Royal Liverpool and Broadgreen University Hospitals; Liverpool UK
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10
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Diwakar L, Ewan P, Huber PAJ, Clark A, Nasser S, Krishna MT. The impact of national guidelines on venom immunotherapy practice in the United Kingdom. Clin Exp Allergy 2018; 46:749-53. [PMID: 26989871 PMCID: PMC4869676 DOI: 10.1111/cea.12728] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- L Diwakar
- University of Birmingham and University Hospitals Birmingham, Birmingham, UK
| | - P Ewan
- Allergy clinic, Addenbrookes Hospital, Cambridge, UK
| | | | - A Clark
- Allergy clinic, Addenbrookes Hospital, Cambridge, UK
| | - S Nasser
- Allergy clinic, Addenbrookes Hospital, Cambridge, UK
| | - M T Krishna
- Heart of England NHS Foundation Trust and Aston University, Birmingham, UK
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11
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Krishna MT, Huissoon AP, Li M, Richter A, Pillay DG, Sambanthan D, Raman SC, Nasser S, Misbah SA. Enhancing antibiotic stewardship by tackling "spurious" penicillin allergy. Clin Exp Allergy 2018; 47:1362-1373. [PMID: 29028276 DOI: 10.1111/cea.13044] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Approximately 90-99% of patients with a label of penicillin allergy (PenA) are not allergic when comprehensively investigated. An inaccurate label of PenA has major public health implications-longer hospital stay, more frequent hospital admissions, greater use of fluoroquinolones, glycopeptides, cephalosporins and other expensive antibiotics resulting in significantly higher costs to the health service and predisposing to Clostridium difficile, methicillin-resistant Staphylococcus aureus infections and vancomycin-resistant enterococcus. We describe lessons learnt from recent studies regarding possible reasons contributing to an inaccurate label of PenA as well as propose a concerted multidisciplinary approach to address this important public health problem. Given the unmet need for allergy services in the UK and several other countries and knowledge gaps regarding PenA amongst healthcare professionals, we describe the potential role for a computerized clinical decision support system to enable non-specialists rapidly identify and de-label "low-risk" hospitalized patients with a label of PenA thereby obviating the need for allergy tests. This approach however needs rigorous evaluation for feasibility, safety, patient and physician acceptability, cost-effectiveness and its compatibility with information technology systems currently employed in the health service.
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Affiliation(s)
- M T Krishna
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK.,Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, UK
| | - A P Huissoon
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
| | - M Li
- Department of Microbiology, University Hospital of Coventry and Warwickshire, Coventry, UK
| | - A Richter
- Clinical Immunology Service, Birmingham Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - D G Pillay
- Department of Microbiology, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
| | - D Sambanthan
- Tata Consultancy Services Ltd, Thoraipakkam, Chennai, India
| | - S C Raman
- Tata Consultancy Services Ltd, Thoraipakkam, Chennai, India
| | - S Nasser
- Department of Allergy, Cambridge University Hospitals, Cambridge, UK
| | - S A Misbah
- Department of Clinical Immunology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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12
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Trubiano JA, Stone CA, Grayson ML, Urbancic K, Slavin MA, Thursky KA, Phillips EJ. The 3 Cs of Antibiotic Allergy-Classification, Cross-Reactivity, and Collaboration. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:1532-1542. [PMID: 28843343 PMCID: PMC5681410 DOI: 10.1016/j.jaip.2017.06.017] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/08/2017] [Accepted: 06/16/2017] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Karen Urbancic
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia; Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia; National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Elizabeth J Phillips
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Pathology, Microbiology, Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University Medical School, Nashville, Tenn
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13
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Abstract
Penicillini allergy is a potentially serious adverse reaction that impacts on antibacterial treatment options. Although it is commonly reported and recorded in medical records, only a minority of patients with a label of penicillin allergy actually have the condition confirmed. The term 'allergy' may be incorrectly applied to adverse reactions that do not have an immunological basis and inappropriate labelling of penicillin allergy can lead to the unnecessary avoidance of penicillins and other beta-lactam antibacterials. Here, we discuss key features that help to distinguish patients at low or high risk of having a true penicillin allergy, summarise what is known about the risk of allergic reactions to other beta-lactam antibacterials in patients with penicillin allergy and discuss the steps to consider when assessing a label of penicillin allergy.
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14
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Mirakian R, Leech SC, Krishna MT, Richter AG, Huber PAJ, Farooque S, Khan N, Pirmohamed M, Clark AT, Nasser SM. Management of allergy to penicillins and other beta-lactams. Clin Exp Allergy 2015; 45:300-27. [PMID: 25623506 DOI: 10.1111/cea.12468] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 10/29/2014] [Accepted: 11/07/2014] [Indexed: 12/15/2022]
Abstract
The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and an expert panel have prepared this guidance for the management of immediate and non-immediate allergic reactions to penicillins and other beta-lactams. The guideline is intended for UK specialists in both adult and paediatric allergy and for other clinicians practising allergy in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking, the panel reached consensus. During the development of the guideline, all BSACI members were consulted using a Web-based process and all comments carefully considered. Included in the guideline are epidemiology of allergic reactions to beta-lactams, molecular structure, formulations available in the UK and a description of known beta-lactam antigenic determinants. Sections on the value and limitations of clinical history, skin testing and laboratory investigations for both penicillins and cephalosporins are included. Cross-reactivity between penicillins and cephalosporins is discussed in detail. Recommendations on oral provocation and desensitization procedures have been made. Guidance for beta-lactam allergy in children is given in a separate section. An algorithm to help the clinician in the diagnosis of patients with a history of penicillin allergy has also been included.
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Affiliation(s)
- R Mirakian
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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15
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Blankestijn MA, Boyle RJ, Gore R, Hawrylowicz C, Jarvis D, Knulst AC, Wardlaw AJ. Developments in the field of allergy in 2013 through the eyes of Clinical and Experimental Allergy. Clin Exp Allergy 2015; 44:1436-57. [PMID: 25346287 DOI: 10.1111/cea.12442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
2013 was another exciting year for allergy in general and Clinical and Experimental Allergy in particular. In the field of asthma and rhinitis, there continued to be a focus on heterogeneity and phenotypes with increasing use of biostatistical techniques to determine clusters of similar populations. Obesity- and aspirin-associated disease are intriguing associations with asthma which were explored in a number of papers. We published a number of excellent papers on mechanisms of airway inflammation and how this relates to physiology, pathology, genetics and biomarkers in both human and experimental model systems. In terms of mechanisms, there is less on individual cell types in allergic disease at the moment, but the immunology of allergic disease continued to fascinate our authors. Another area that was popular both in the mechanisms and in the epidemiology sections was early life events and how these lead to allergic disease, with an increasing focus on the role of the microbiome and how this influences immune tolerance. In the clinical allergy section, oral immunotherapy for food allergy is clearly a major topic of interest at the moment as was in vitro testing to distinguish between sensitization and allergic disease. There was less on inhalant allergy this year, but a good representation from the drug allergy community including some interesting work on non-IgE-mediated mechanisms. In the allergen section, important new allergens continue to be discovered, but the major focus as in the last couple of years was on working out how component-resolved approaches can improve diagnosis and management of food and venom allergy.
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Affiliation(s)
- M A Blankestijn
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
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16
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Nasr I, Chua I, Alam S, Rotiroti G, Blanca M, Lukawska J. Penicillin allergy diagnosis and desensitization. Br J Hosp Med (Lond) 2014; 75:C98-100, C102. [PMID: 25152939 DOI: 10.12968/hmed.2014.75.sup7.c98] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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17
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Ward C, Kasternow B, Haque R, Klein J. Inpatient allergy testing in patients with infective endocarditis: an un-met need? J Infect 2014; 70:206-7. [PMID: 25063340 DOI: 10.1016/j.jinf.2014.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 07/11/2014] [Accepted: 07/15/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Christopher Ward
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, England SE1 7EH, UK.
| | - Bogusia Kasternow
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, England SE1 7EH, UK
| | - Rubaiyat Haque
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, England SE1 7EH, UK
| | - John Klein
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, England SE1 7EH, UK
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