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Anderson BJ, Tanenbaum ZG, Michael A, Owen SR. Cutaneous hypersensitivity to chlorhexidine following facial fat grafting: a delayed intradermal response. J Surg Case Rep 2024; 2024:rjae103. [PMID: 38974088 PMCID: PMC11226778 DOI: 10.1093/jscr/rjae103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/11/2024] [Indexed: 07/09/2024] Open
Abstract
Chlorhexidine (CHD) is commonly included in surgical antiseptics and can be associated with adverse reactions ranging from contact dermatitis to anaphylaxis. A 32-year-old female presented to the OR for facial fat grafting. Surgical sites were prepped with CHD gluconate or topical iodine. Donor and recipient sites were infiltrated with local anesthetic injection prior to fat harvest and facial injection. Eleven days later, she presented with new painful, pruritic rash over donor sites where CHD had been applied prior to local anesthetic infiltration. Treatment with topical clobetasol and prednisone taper resulted in complete symptom resolution. This patient's response most likely represented a delayed type IV, T-cell mediated hypersensitivity. CHD is a known trigger of allergic reactions. Infiltration of local anesthetic may introduce skin prep into the subcutaneous tissue akin to intradermal testing. For those with delayed cutaneous reactions, steroids may provide symptomatic relief.
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Affiliation(s)
- Brady J Anderson
- Department of Otolaryngology Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, United States
| | - Zachary G Tanenbaum
- Department of Otolaryngology Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, United States
| | - Alexander Michael
- Department of Otolaryngology Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, United States
| | - Scott R Owen
- Department of Otolaryngology Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, United States
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Geraldes C, Tavares L, Gil S, Oliveira M. Biocides in the Hospital Environment: Application and Tolerance Development. Microb Drug Resist 2023; 29:456-476. [PMID: 37643289 DOI: 10.1089/mdr.2023.0074] [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] [Indexed: 08/31/2023] Open
Abstract
Hospital-acquired infections are a rising problem with consequences for patients, hospitals, and health care workers. Biocides can be employed to prevent these infections, contributing to eliminate or reduce microorganisms' concentrations at the hospital environment. These antimicrobials belong to several groups, each with distinct characteristics that need to be taken into account in their selection for specific applications. Moreover, their activity is influenced by many factors, such as compound concentration and the presence of organic matter. This article aims to review some of the chemical biocides available for hospital infection control, as well as the main factors that influence their efficacy and promote susceptibility decreases, with the purpose to contribute for reducing misusage and consequently for preventing the development of resistance to these antimicrobials.
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Affiliation(s)
- Catarina Geraldes
- Department of Animal Health, Centre for Interdisciplinary Research in Animal Health (CIISA), Faculty of Veterinary Medicine, University of Lisbon, Lisbon, Portugal
- Associate Laboratory for Animal and Veterinary Science (AL4AnimalS), Lisbon, Portugal
| | - Luís Tavares
- Department of Animal Health, Centre for Interdisciplinary Research in Animal Health (CIISA), Faculty of Veterinary Medicine, University of Lisbon, Lisbon, Portugal
- Associate Laboratory for Animal and Veterinary Science (AL4AnimalS), Lisbon, Portugal
| | - Solange Gil
- Department of Animal Health, Centre for Interdisciplinary Research in Animal Health (CIISA), Faculty of Veterinary Medicine, University of Lisbon, Lisbon, Portugal
- Associate Laboratory for Animal and Veterinary Science (AL4AnimalS), Lisbon, Portugal
- Department of Animal Health, Biological Isolation and Containment Unit (BICU), Veterinary Hospital, Faculty of Veterinary Medicine, University of Lisbon, Lisbon, Portugal
| | - Manuela Oliveira
- Department of Animal Health, Centre for Interdisciplinary Research in Animal Health (CIISA), Faculty of Veterinary Medicine, University of Lisbon, Lisbon, Portugal
- Associate Laboratory for Animal and Veterinary Science (AL4AnimalS), Lisbon, Portugal
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3
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Jiang Y, Yang F, Yao J, Xu C. Delayed urticaria owing to ropivacaine: a rare occurrence of local anesthetic allergy in a 11-year-old child. Minerva Anestesiol 2023; 89:945-946. [PMID: 37194241 DOI: 10.23736/s0375-9393.23.17352-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Affiliation(s)
- Yan Jiang
- School of Medicine, Department of Anesthesiology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Feilong Yang
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jun Yao
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Cheng Xu
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China -
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Immediate Hypersensitivity to Chlorhexidine: Experience from an Allergy Center in China. Anesthesiology 2023; 138:364-371. [PMID: 36630143 DOI: 10.1097/aln.0000000000004495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Chlorhexidine generally has a good safety profile. However, allergic reactions are reported with increasing frequency. In China, it is rarely reported, and its characteristics are unknown. The purpose of this study was to summarize the experience of a Chinese allergy center with chlorhexidine allergy. METHODS The authors retrospectively reviewed all patients who underwent chlorhexidine allergy testing in the Allergy Center of West China Hospital, Sichuan University (Chengdu, China), in the period February 2018 to May 2022 (n = 43 patients) and included the patients diagnosed with chlorhexidine allergy for analysis. RESULTS Ten patients who were diagnosed by skin prick and serum-specific immunoglobulin E tests were included. They experienced a total of 30 allergic reactions to chlorhexidine (mean ± SD, 3.0 ± 1.3). Five patients experienced six allergic reactions (6 of 30, 20%) during general or local anesthesia, and they may have been exposed to chlorhexidine via different routes. Only one allergic reaction (1 of 30, 3%) was recorded with exposure via a mouthwash. The other 23 allergic reactions (23 of 30, 77%) were caused via a skin disinfectant; the route of exposure was IV cannulation in 22 allergic reactions (22 of 23, 96%) and broken skin in one allergic reaction (1 of 23, 4%). The symptoms included a quick onset and great severity. Two patients (2 of 10, 20%) had been accidentally re-exposed to chlorhexidine after diagnosis. CONCLUSIONS This study conducted in China showed that the majority of reactions to chlorhexidine were attributed to skin disinfectants, and IV cannulation was the most common exposure route; in general, however, chlorhexidine allergy was easily overlooked. The potential allergenicity of chlorhexidine used for skin preparation before IV cannulation or should be considered in patients who develop allergic reactions perioperatively. EDITOR’S PERSPECTIVE
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Wanin S, Baron M, Carra S, Saf S, Bourgoin-Heck M, Chiriac AM. Chlorhexidine anaphylaxis in three children secondary to oral exposure without evidence of mucosal breach. Pediatr Allergy Immunol 2022; 33:e13897. [PMID: 36564876 DOI: 10.1111/pai.13897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/12/2022] [Accepted: 11/27/2022] [Indexed: 12/23/2022]
Affiliation(s)
| | | | - Sophie Carra
- Hopital Arnaud de Villeneuve, Montpellier, France
| | - Sarah Saf
- Assistance Publique - Hopitaux de Paris, Paris, France
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Bayerl C. Perioperative Anaphylaxie – alte Zöpfe und Neues zu den Auslösern. Laryngorhinootologie 2022; 101:882-885. [DOI: 10.1055/a-1861-7011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ZusammenfassungPerioperative Anaphylaxien werden mit mindestens 1:6000 angegeben. Neue Kenntnisse der Pathophysiologie der anaphylaktischen Reaktionen beziehen die Auslösung über das Mastzell-related G-Protein und die Komplementaktivierungs-abhängige Pseudoallergie mit ein. Neu beschriebene Auslöser sind das Chlorhexidin oder Gelatine-Produkte, eingesetzt zur Blutstillung oder blaue Farbstoffe zur intraoperativen Markierung. Wachsamkeit ist in Hinblick auf biphasische Reaktionen geboten. Propofol darf mittlerweile bei Ei- und Sojaallergikern eingesetzt werden.
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Hasegawa T, Tashiro S, Mihara T, Kon J, Sakurai K, Tanaka Y, Morita T, Enoki Y, Taguchi K, Matsumoto K, Nakajima K, Takesue Y. Efficacy of surgical skin preparation with chlorhexidine in alcohol according to the concentration required to prevent surgical site infection: meta-analysis. BJS Open 2022; 6:zrac111. [PMID: 36124902 PMCID: PMC9487656 DOI: 10.1093/bjsopen/zrac111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/10/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND A combination of chlorhexidine gluconate and alcohol (CHG-alcohol) is recommended for surgical skin preparation to prevent surgical site infection (SSI). Although more than 1 per cent CHG-alcohol is recommended to prevent catheter-related bloodstream infections, there is no consensus regarding the concentration of the CHG compound for the prevention of SSI. METHODS A systematic review and meta-analysis was performed. Four electronic databases were searched on 5 November 2020. SSI rates were compared between CHG-alcohol and povidone-iodine (PVP-I) according to the concentration of CHG (0.5 per cent, 2.0 per cent, 2.5 per cent, and 4.0 per cent). RESULTS In total, 106 of 2716 screened articles were retrieved for full-text review. The risk ratios (RRs) of SSI for 0.5 per cent (6 studies) and 2.0 per cent (4 studies) CHG-alcohol were significantly lower than those for PVP-I (RR = 0.71, 95 per cent confidence interval (c.i.) 0.52 to 0.97; RR = 0.52, 95 per cent c.i 0.31 to 0.86 respectively); however, no significant difference was observed in the compounds with a CHG concentration of more than 2.0 per cent. CONCLUSIONS This meta-analysis is the first study that clarifies the usefulness of an alcohol-based CHG solution with a 0.5 per cent or higher CHG concentration for surgical skin preparation to prevent SSI.
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Affiliation(s)
- Tatsuki Hasegawa
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Minato-ku, Tokyo, Japan
| | - Sho Tashiro
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Minato-ku, Tokyo, Japan
| | - Takayuki Mihara
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Minato-ku, Tokyo, Japan
| | - Junya Kon
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Minato-ku, Tokyo, Japan
| | - Kazuki Sakurai
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Minato-ku, Tokyo, Japan
| | - Yoko Tanaka
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Minato-ku, Tokyo, Japan
| | - Takumi Morita
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Minato-ku, Tokyo, Japan
| | - Yuki Enoki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Minato-ku, Tokyo, Japan
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Minato-ku, Tokyo, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Minato-ku, Tokyo, Japan
| | - Kazuhiko Nakajima
- Department of Infection Prevention and Control, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoshio Takesue
- Department of Infection Prevention and Control, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
- Department of Clinical Infectious Diseases, Tokoname City Hospital, Tokoname, Aichi, Japan
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8
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OUP accepted manuscript. Occup Med (Lond) 2022; 72:343-346. [DOI: 10.1093/occmed/kqac038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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9
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Sivaranjani M, Liu F, White AP. Synergistic activity of tetrasodium EDTA, ethanol and chlorhexidine hydrochloride against planktonic and biofilm cells of clinically relevant pathogens. J Glob Antimicrob Resist 2020; 24:148-157. [PMID: 33383260 DOI: 10.1016/j.jgar.2020.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/12/2020] [Accepted: 12/08/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Biofilms associated with implantable medical devices and wounds are clinically relevant, often requiring repeated use of antibiotics without success. A search for non-antibiotic antimicrobial and antibiofilm solutions is warranted, in line with antimicrobial stewardship. Our study aimed to evaluate the broad-spectrum antimicrobial efficacy of tetrasodium EDTA, ethanol and chlorhexidine hydrochloride (HCl) alone and in combination against clinically relevant planktonic and biofilm cells of bacterial and fungal pathogens. METHODS MICs and MBCs were determined for tetrasodium EDTA, ethanol and chlorhexidine HCl against planktonic cells of test pathogens. The MBEC Assay® biofilm inoculator device was used to evaluate the biofilm eradication ability of test antimicrobials alone and in combination against clinically relevant pathogens. The checkerboard microbroth dilution assay was performed to analyze the synergism between test antimicrobials. RESULTS Against planktonic cells, the combination of tetrasodium EDTA with ethanol or chlorhexidine HCl resulted in synergistic to indifferent activity, with no antagonism observed. Against mature biofilms, all combinations were synergistic. The MBEC of each test antimicrobial was decreased from 4- to -64-fold when used in combination as compared to when agents were used alone. We optimised the concentration of antimicrobials to achieve rapid eradication of pre-formed biofilms. A triple combination of 3% tetrasodium EDTA, 20% ethanol and 2.5 μg/mL chlorhexidine HCl completely eradicated 48-h-old biofilms of all test strains within 2 h. CONCLUSION All three antimicrobial agents can be used together for prevention and treatment of biofilms and biofilm-related infections. The observed in vitro efficacy should be tested further through in vivo and clinical studies.
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Affiliation(s)
- Murugesan Sivaranjani
- Vaccine and Infectious Disease Organization, Saskatoon, Saskatchewan, Canada; Department of Biochemistry, Microbiology and Immunology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Fangning Liu
- Vaccine and Infectious Disease Organization, Saskatoon, Saskatchewan, Canada
| | - Aaron P White
- Vaccine and Infectious Disease Organization, Saskatoon, Saskatchewan, Canada; Department of Biochemistry, Microbiology and Immunology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
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10
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Banerji A, Bhattacharya G, Huebner E, Fu X, Camargo CA, Guyer A, Kuhlen JL, Blumenthal KG. Perioperative Allergic Reactions: Allergy Assessment and Subsequent Anesthesia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1980-1991. [PMID: 33248280 DOI: 10.1016/j.jaip.2020.11.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 10/26/2020] [Accepted: 11/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Evidence-based guidelines are needed in the United States to improve evaluation of perioperative allergic reactions including recommendations for subsequent anesthesia. OBJECTIVE To identify causative agent(s) and evaluate patients' tolerability of subsequent anesthesia in patients evaluated by Allergy/Immunology (A/I) at Massachusetts General Hospital. METHODS We performed a retrospective review of patients referred to the outpatient A/I clinic for perioperative allergic reactions between October 2003 and May 2017. Patient demographics, atopic history, and prior adverse drug reactions were reviewed. Patients underwent a comprehensive evaluation with testing including skin testing (ST), drug challenges (when appropriate), tryptase level measurement, and specific IgE to latex measurement. Tolerance of subsequent procedures requiring anesthesia was assessed. RESULTS Of 123 patients referred, 74 (60%) were female and the mean age was 46 (±18) years. At least 1 causative agent was identified in 28 patients (24%, n = 28 of 118). Seventeen of 28 (61%) patients were ST positive to an antibiotic, including 13 (46%) positive to cefazolin; 3 patients (11%) had a positive latex specific IgE. Of 85 patients who had subsequent anesthesia with a known outcome, 78 (91%) did not have another perioperative allergic reaction. Two of 5 patients with an elevated baseline tryptase level did not tolerate subsequent anesthesia. CONCLUSION The majority of patients safely received subsequent anesthesia after comprehensive A/I evaluation for their perioperative allergic reactions; however, improved algorithmic care is needed in the United States. Among ST-positive patients (24%), antibiotics (especially cefazolin) were the most common culprits. An elevated baseline tryptase level was associated with an increased risk of recurrent perioperative allergic reactions.
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Affiliation(s)
- Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - Gita Bhattacharya
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Emily Huebner
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Carlos A Camargo
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Autumn Guyer
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco, Calif
| | - James L Kuhlen
- Department of Medicine, Apex Allergy and Immunology, Greenville, SC
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass
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11
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Savic LC, Lucas DN. Anaphylaxis in obstetrics – double the trouble. Anaesthesia 2020; 75:1424-1427. [DOI: 10.1111/anae.15184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2020] [Indexed: 01/13/2023]
Affiliation(s)
- L. C. Savic
- Department of Anaesthesia Leeds Teaching Hospitals Trust Leeds UK
| | - D. N. Lucas
- Department of Anaesthesia London North West NHS Healthcare London UK
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12
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Devinck A, Bauters T, Lapeere H, Willems L. Anaphylaxis related to disinfection with chlorhexidine in a teenager treated for cancer. J Oncol Pharm Pract 2020; 27:227-231. [PMID: 32476588 DOI: 10.1177/1078155220925531] [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] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Literature shows upcoming allergy to chlorhexidine due to the widespread use of the disinfectant within and outside surgical settings. Only a few case reports have been published regarding the use of topical chlorhexidine disinfectant outside surgery and only a minority of these within the pediatric population. CASE REPORT We present a case-report of a teenager, treated for acute lymphoblastic leukemia who developed an anaphylactic shock after repeated chlorhexidine use for skin disinfection at the insertion of a central venous catheter during his chemotherapy treatment. Preceding minor symptoms such as local swelling and pruritus were not recognized as possible allergy to chlorhexidine.Management and outcome: He was treated with two doses of intramuscular adrenaline and transferred to the pediatric intensive care unit where he fully recovered. Specific IgE testing was positive for chlorhexidine. A total avoidance of chlorhexidine was instructed. DISCUSSION A similar case was published regarding an anaphylaxis after use of chlorhexidine disinfectant for a dialysis catheter. Almost all other case reports of anaphylactic shock were found within surgical settings or after insertion of an impregnated central venous catheter/urine catheter. We suggest that some of the disinfectant might have been flushed in the catheter and then caused an anaphylactic reaction. The link between symptoms and chlorhexidine was not made until an anaphylactic reaction occurred. Literature data show that chlorhexidine often causes mild preceding symptoms before an anaphylaxis occurs. So let awareness arise around this 'hidden allergen' of which warning reactions often are being missed.
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Affiliation(s)
- Astrid Devinck
- Division of Pediatric Haemato-Oncology and Stem Cell Transplantation, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Tiene Bauters
- Division of Pediatric Haemato-Oncology and Stem Cell Transplantation, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium.,Pharmacy Department, Ghent University Hospital, Ghent, Belgium
| | - Hilde Lapeere
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Leen Willems
- Division of Pediatric Haemato-Oncology and Stem Cell Transplantation, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
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13
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Chiewchalermsri C, Sompornrattanaphan M, Wongsa C, Thongngarm T. Chlorhexidine Allergy: Current Challenges and Future Prospects. J Asthma Allergy 2020; 13:127-133. [PMID: 32210588 PMCID: PMC7069565 DOI: 10.2147/jaa.s207980] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 02/11/2020] [Indexed: 12/14/2022] Open
Abstract
Chlorhexidine is a synthetic bisbiguanide antiseptic and was introduced in healthcare use in 1954. Allergy to chlorhexidine has been increasingly reported particularly in the perioperative and medical procedural settings. The hypersensitivity reactions range from mild cutaneous reactions to anaphylaxis or death. There are many products and medical devices containing chlorhexidine that sometimes lack standardized labeling. With the various routes of chlorhexidine exposure, accidental or recurrent reactions in chlorhexidine-allergic patients have been reported. Therefore, we aim to review the most recent evidence in clinical manifestations, diagnostic methods, management, and preventive measures with a focus on the unique features of chlorhexidine allergy.
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Affiliation(s)
- Chirawat Chiewchalermsri
- Division of Allergy and Clinical Immunology, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand.,Department of Medicine, Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University, Nonthaburi, Thailand
| | - Mongkhon Sompornrattanaphan
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chamard Wongsa
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Torpong Thongngarm
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Avison R, Fish B, Sholtysek S, Moor J, Gordins P, Holding S, Hibbert C, Khan S. Incorporation of chlorhexidine in alcohol skin swabs is not without risks of allergic reactions including anaphylaxis. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:246-247. [PMID: 32105531 DOI: 10.12968/bjon.2020.29.4.246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Rebecca Avison
- Senior Nurse, Immunology and Allergy, Queen's Center, Castle Hill Hospital, Cottingham
| | - Beverley Fish
- Senior Nurse, Immunology and Allergy, Queen's Center, Castle Hill Hospital, Cottingham
| | - Sarah Sholtysek
- Senior Nurse, Immunology and Allergy, Queen's Center, Castle Hill Hospital, Cottingham
| | - Jackie Moor
- Specialist Nurse, Immunology and Allergy, Queen's Center, Castle Hill Hospital, Cottingham
| | - Pavel Gordins
- Consultant Immunologist, Immunology and Allergy, Queen's Center, Castle Hill Hospital, Cottingham
| | - Steve Holding
- Consultant Clinical Scientist, Immunology and Allergy, Hull Royal Infirmary
| | - Caroline Hibbert
- Consultant Anaesthetist, Department of Anaesthesia, Hull Royal Infirmary, Hull
| | - Sujoy Khan
- Consultant Immunologist, Immunology and Allergy, Queen's Center, Castle Hill Hospital, Cottingham
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15
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Fernandes M, Lourenço T, Lopes A, Spínola Santos A, Pereira Santos MC, Pereira Barbosa M. Chlorhexidine: a hidden life-threatening allergen. Asia Pac Allergy 2019; 9:e29. [PMID: 31720240 PMCID: PMC6826114 DOI: 10.5415/apallergy.2019.9.e29] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/30/2019] [Indexed: 11/19/2022] Open
Abstract
Chlorhexidine is a commonly used antiseptic and disinfectant in the health-care setting. Anaphylaxis to chlorhexidine is a rare but potentially life-threatening complication. Epidemiologic data suggest that the cases of chlorhexidine allergy appears to be increasing. In this article we report a life-threatening anaphylactic shock with cardiorespiratory arrest, during urethral catheterization due to chlorhexidine. The authors also performed a literature review of PubMed library of anaphylactic cases reports due to this antiseptic between 2014 and 2018, demonstrating the increase in the number of cases occurring worldwide and the importance of detailed anamnesis and appropriate diagnostic workup of allergic reactions to disinfectants.
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Affiliation(s)
- Mara Fernandes
- Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Portugal.,Unidade de Imunoalergologia, Hospital Dr. Nélio Mendonça, SESARAM EPE, Funchal, Portugal
| | - Tatiana Lourenço
- Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Portugal
| | - Anabela Lopes
- Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Portugal
| | - Amélia Spínola Santos
- Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Portugal
| | - Maria Conceição Pereira Santos
- Laboratório de Imunologia Clínica, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Portugal.,Clínica Universitária de Imunoalergologia, Faculdade de Medicina da Universidade de Lisboa, Portugal
| | - Manuel Pereira Barbosa
- Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Portugal.,Clínica Universitária de Imunoalergologia, Faculdade de Medicina da Universidade de Lisboa, Portugal
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16
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Barnes S, Stuart R, Redley B. Health care worker sensitivity to chlorhexidine-based hand hygiene solutions: A cross-sectional survey. Am J Infect Control 2019; 47:933-937. [PMID: 30765146 DOI: 10.1016/j.ajic.2019.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Health service hand hygiene programs have seen widespread use of chlorhexidine solutions. Reports of both immediate and delayed hypersensitivity to chlorhexidine are increasing among health care workers. This study examined the prevalence of self-reported symptoms of sensitivity to chlorhexidine solutions among health care workers. METHODS This study was a cross-sectional online anonymous survey of all workers at a single health service. RESULTS Of the 1,050 completed responses, 76.3% were female, 35.3% were nurses and midwives, 28% were medical staff, and 8.7% were working in nonclinical areas. Over 95% used chlorhexidine-based hand hygiene products in their workplace. Nurses and midwives most frequently reported asthma (13.7%), contact dermatitis (27.8%), and previous testing for allergy to chlorhexidine (4.9%). There was a correlation between both the presence of atopy, eczema, or dermatitis and the self-reporting of dry skin, eczema, or dermatitis attributed to chlorhexidine use. DISCUSSION Occupational chlorhexidine allergy is an important risk to health care workers. Self-reported symptoms of sensitivity to chlorhexidine solutions revealed high reported use and presence of skin symptoms among health care workers. CONCLUSIONS Screening programs need to identify nurses who develop chlorhexidine sensitivity due to occupational exposure. Strategies to mitigate risk should provide alternatives for those with sensitization.
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Takazawa T, Sabato V, Ebo DG. In vitro diagnostic tests for perioperative hypersensitivity, a narrative review: potential, limitations, and perspectives. Br J Anaesth 2019; 123:e117-e125. [DOI: 10.1016/j.bja.2019.01.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/25/2018] [Accepted: 01/03/2019] [Indexed: 12/28/2022] Open
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18
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Gu JQ, Liu S, Zhi YX. Provocation Test-Confirmed Chlorhexidine-Induced Anaphylaxis in Dental Procedure. Chin Med J (Engl) 2019; 131:2893-2894. [PMID: 30511701 PMCID: PMC6278190 DOI: 10.4103/0366-6999.246073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jian-Qing Gu
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Shuang Liu
- Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yu-Xiang Zhi
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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19
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Chlorhexidine allergy in the perioperative setting: a narrative review. Br J Anaesth 2019; 123:e95-e103. [PMID: 30955832 DOI: 10.1016/j.bja.2019.01.033] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/04/2019] [Accepted: 01/26/2019] [Indexed: 02/03/2023] Open
Abstract
Chlorhexidine is an antiseptic with a broad spectrum of activity and a persistent effect on skin. Consequently, it has become an ubiquitous antiseptic in healthcare and the community. As use has become widespread, increasing numbers of cases of allergy have been reported in the literature, including cases of anaphylaxis to chlorhexidine gels used on mucous membranes, chlorhexidine-impregnated devices such as central venous catheters, chlorhexidine preparations used on wounds and broken skin, and cases after dental procedures. Numerous governmental warnings have been issued over recent decades to warn of the risk of allergy to chlorhexidine on mucosal surfaces or in medical devices. Whilst the number of published cases likely underestimates the true prevalence of reactions, we retrospectively surveyed clinics with experience in investigating perioperative chlorhexidine allergy. Despite differences in investigation practice before the survey took place, 13 clinics responded which together had diagnosed 252 cases of anaphylaxis to chlorhexidine, and cases of delayed allergy. In eight of 13 clinics, chlorhexidine was within the top four most commonly diagnosed causes of perioperative anaphylaxis. Despite this, the incidence of anaphylaxis to chlorhexidine is low given that patients are very commonly exposed. Sensitisation of healthcare workers can occur, but is uncommon. Before exposing patients to this antiseptic, consideration of the potential risk vs benefit should be undertaken, particularly for higher risk exposures, such as mucosal exposure or i.v. exposure via impregnated lines. Difficulties exist in protecting patients with known allergies from re-exposure to chlorhexidine, which would be improved with uniform labelling and chlorhexidine product registers.
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20
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Opstrup MS, Jemec GBE, Garvey LH. Chlorhexidine Allergy: On the Rise and Often Overlooked. Curr Allergy Asthma Rep 2019; 19:23. [PMID: 30874959 DOI: 10.1007/s11882-019-0858-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW In recent years, the risk of allergy to chlorhexidine is increasingly recognised. In this review, we discuss why the allergy is so easily overlooked and point out several preventative initiatives that can minimise the risk of both chlorhexidine sensitisation and allergy development and accidental re-exposure in patients with chlorhexidine allergy. Testing for chlorhexidine allergy is also discussed. RECENT FINDINGS Numerous reports have been published from many different specialties. Symptoms range from mild skin symptoms to life-threatening anaphylaxis. Testing for chlorhexidine allergy is based on skin testing and in vitro testing. Recently, it was found that both skin prick testing and specific IgE have high sensitivities and specificities. This review gives an overview of chlorhexidine allergy with a special focus on preventative initiatives and testing.
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Affiliation(s)
- Morten Schjørring Opstrup
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark. .,Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital Gentofte, Kildegårdsvej 28, 2900, Hellerup, Denmark.
| | - Gregor Borut Ernst Jemec
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Heise Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital Gentofte, Kildegårdsvej 28, 2900, Hellerup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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21
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Baird PA, Cokis CJ. A case series of anaphylaxis to chlorhexidine-impregnated central venous catheters in cardiac surgical patients. Anaesth Intensive Care 2019; 47:85-89. [PMID: 30864478 DOI: 10.1177/0310057x18811814] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report a case series of anaphylaxis to chlorhexidine-coated central venous catheters (CVCs) when used in cardiac surgical patients in our institution. Our experience, together with increasing reports of anaphylaxis to chlorhexidine-coated CVCs from other sources indicates that chlorhexidine-coated CVCs are not without additional risk. Attempts to lower rates of catheter-related bloodstream infection has led to the widespread adoption of chlorhexidine-coated CVCs in the perioperative and critical care setting, including for routine cardiac surgery. However, closer scrutiny indicates that there is lack of strong evidence demonstrating a meaningful reduction in rates of sepsis or serious morbidity, especially with CVC dwell times of less than seven days. Given the lack of clear benefit, we recommend non-coated CVCs for routine cardiac surgery, with even consideration for chlorhexidine-coated CVCs when specifically indicated for patients at high risk of CVC infection.
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Affiliation(s)
- Peter A Baird
- Department of Cardiothoracic Anaesthesia, Fiona Stanley Hospital, Perth, Australia
| | - Chris J Cokis
- Department of Cardiothoracic Anaesthesia, Fiona Stanley Hospital, Perth, Australia
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22
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Abstract
Summary We report three precautionary cases of perioperative anaphylaxis to chlorhexidine isopropyl alcohol antiseptic wipes (CAW). In two cases, the patients were inadvertently re-exposed to CAW despite known chlorhexidine hypersensitivity. Chlorhexidine has been described as ‘the hidden allergen’. As a result, patients may suffer multiple reactions before chlorhexidine is confirmed as the cause. Healthcare workers may not recognize that products they use for common clinical steps contain chlorhexidine. These cases highlight the need for constant vigilance to facilitate the safe management of patients with a history of chlorhexidine anaphylaxis.
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23
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Baier C, Ipaktchi R, Schwab F, Smith A, Liu X, Ebadi E, Limbourg A, Mett TR, Bange FC, Vogt PM. Universal decolonization with octenidine: First experiences in a tertiary burn intensive care unit. BURNS OPEN 2019. [DOI: 10.1016/j.burnso.2018.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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24
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Marinho S. Perioperative anaphylaxis - Time for a NAP… 6! Clin Exp Allergy 2018; 48:1252-1254. [DOI: 10.1111/cea.13259] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Susana Marinho
- Allergy Centre; Wythenshawe Hospital; Manchester University NHS Foundation Trust; Manchester UK
- Division of Infection, Immunity and Respiratory Medicine; Faculty of Biology, Medicine and Health; Manchester Academic Health Science Centre; University of Manchester; Manchester UK
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25
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Cross-sectional study of perioperative drug and allergen exposure in UK practice in 2016: the 6th National Audit Project (NAP6) Allergen Survey. Br J Anaesth 2018; 121:146-158. [DOI: 10.1016/j.bja.2018.04.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/01/2018] [Accepted: 04/16/2018] [Indexed: 12/20/2022] Open
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26
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Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6). Br J Anaesth 2018; 121:159-171. [DOI: 10.1016/j.bja.2018.04.014] [Citation(s) in RCA: 290] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/30/2018] [Accepted: 04/13/2018] [Indexed: 12/25/2022] Open
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27
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Egner W, Cook TM, Garcez T, Marinho S, Kemp H, Lucas DN, Floss K, Farooque S, Torevell H, Thomas M, Ferguson K, Nasser S, Karanam S, Kong KL, McGuire N, Bellamy M, Warner A, Hitchman J, Farmer L, Harper NJN. Specialist perioperative allergy clinic services in the UK 2018: Results from the Royal College of Anaesthetists Sixth National Audit Project (NAP6) investigation of perioperative anaphylaxis. Clin Exp Allergy 2018; 48:846-861. [DOI: 10.1111/cea.13180] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/11/2018] [Accepted: 05/14/2018] [Indexed: 12/18/2022]
Affiliation(s)
- W. Egner
- Sheffield Teaching Hospitals NHS Trust; Sheffield UK
- Department of Infection, Immunity and Cardiovascular Disease; University of Sheffield; Sheffield UK
- Royal College of Physicians/Royal College of Pathologists Joint Committee on Immunology and Allergy; University of Sheffield; London UK
| | - T. M. Cook
- Anaesthesia and Intensive Care Medicine; Royal United Hospital; Bath UK
- University of Bristol School of Medicine; Bristol UK
- National Audit Projects Program; Royal College of Anaesthetists; London UK
| | - T. Garcez
- United Kingdom Fatal Anaphylaxis Register; Manchester UK
- Manchester University NHS Foundation Trust; Manchester UK
| | - S. Marinho
- Manchester University NHS Foundation Trust; Manchester UK
- British Society of Allergy and Clinical Immunology; London UK
| | - H. Kemp
- Research and Audit Federation of Trainees; London UK
- Imperial College London; London UK
| | - D. N. Lucas
- Obstetric Anaesthetists Association; Harrow UK
- Northwick Park Hospital; Harrow UK
| | - K. Floss
- Royal Pharmaceutical Society of Great Britain; London UK
- Anaesthetics & Critical Care; Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - S. Farooque
- Imperial College Healthcare NHS Trust; London UK
| | - H. Torevell
- Bradford Teaching Hospitals NHS Trust; Bradford UK
| | - M. Thomas
- Association of Paediatric Anaesthetists of Great Britain and Ireland; London UK
- Great Ormond Street Hospital; London UK
| | - K. Ferguson
- Association of Anaesthetists of Great Britain and Ireland; London UK
- Aberdeen Royal Infirmary; Aberdeen UK
| | - S. Nasser
- British Society for Allergy and Clinical Immunology; London UK
- Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - S. Karanam
- Sandwell and West Birmingham NHS Trust; Birmingham UK
| | - K.-L. Kong
- Sandwell and West Birmingham NHS Trust; Birmingham UK
| | - N. McGuire
- Medicines and Healthcare Regulatory Authority; London UK
| | - M. Bellamy
- Leeds Teaching Hospitals NHS Trust; Leeds UK
- Faculty of Intensive Care Medicine; Leeds University; Leeds UK
| | | | - J. Hitchman
- Lay Committee; Royal College of Anaesthetists; London UK
| | - L. Farmer
- Royal College of Anaesthetists; London UK
| | - N. J. N. Harper
- Manchester University NHS Foundation Trust; Manchester UK
- Royal College of Anaesthetists; London UK
- Manchester Academic Health Science Centre; University of Manchester; Manchester UK
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