Asthma due to inhaled chemical agents--the macrolide antibiotic Spiramycin

Occupational asthma in antibiotic manufacturing workers: case reports and systematic review

Background. The risks of occupational asthma (OA) from antibiotics are uncertain. We report 4 new cases and a systematic review of the literature. Methods. Cases were identified through a specialist clinic, each underwent specific provocation testing (SPT). We subsequently reviewed the published literature. Results. The patients were employed in the manufacture of antibiotics; penicillins were implicated in three cases, in the fourth erythromycin, not previously reported to cause OA. In two, there was evidence of specific IgE sensitisation. At SPT each developed a late asthmatic reaction and increased bronchial hyperresponsiveness. 36 case reports have been previously published, 26 (citing penicillins or cephalosporins). Seven cross-sectional workplace-based surveys found prevalences of 5-8%. Conclusions. OA in antibiotic manufacturers may be more common than is generally recognised. Its pathogenesis remains unclear; immunological tests are of uncertain value and potential cases require confirmation with SPT. Further study of its frequency, mechanisms, and diagnosis is required.

Riscos ocupacionais na fabricação de medicamentos: análise de uma indústria localizada no Nordeste brasileiro

A fabricação de medicamentos é um processo industrial complexo que exige altos investimentos em pesquisa e desenvolvimento, produção e controle de qualidade dos produtos, aquisição de substâncias, armazenagem e distribuição dos produtos, manutenção de pessoal qualificado e reciclado nos conhecimentos da área. Paradoxalmente, apesar de ser um segmento que agrega tecnologias ultramodernas e do grande suporte proporcionado pelas Boas Práticas de Fabricação (BPF) de medicamentos fixados pela legislação sanitária, a indústria de medicamentos convive com diversos riscos ambientais, aqui incluídos os riscos ao consumidor, à saúde dos seus trabalhadores e os associados ao meio ambiente. O objetivo deste trabalho é apresentar o resultado da identificação dos riscos ocupacionais de uma indústria farmacêutica pública localizada no nordeste do Brasil, obtido através das investigações e avaliações realizadas pela Comissão Interna de Prevenção de Acidentes (CIPA) da empresa, e contribuir para a realização de estudos avançados relacionados com saúde e doença dos trabalhadores na indústria farmacêutica de medicamentos.

Veterinary pharmacovigilance. Part 4. Adverse reactions in humans to veterinary medicinal products

Although seemingly rare, adverse reactions to veterinary products do occur. These may arise from inadvertent exposure during use or as a result of occupational accidents. They are often mild in nature and include adverse effects such as minor skin reactions. However, more serious reactions may occur, and they are not restricted to the effects of the veterinary medicines themselves. For example, high-pressure injection injuries may occur as a result of accidents occurring during animal vaccination operations. This paper reviews some of these events, mentions where appropriate the regulatory actions taken, and describes some of the measures used to minimise such effects in the future, and serves to bring the issues discussed here to the attention of pharmacologists, pharmacoepidemiologists and others who train those who use veterinary medicinal products.

Structural determinants of antibiotic allergy

Allergies to antibiotics, mainly the beta-lactam antibiotics (penicillins and cephalosporins), are a common, costly, and potentially dangerous clinical problem encountered in everyday practice. Although studies on the role of non-beta-lactam antibiotics in allergic diseases, particularly the development of specific diagnostic tests and the immunochemical identification of allergenic structures, have been too few and relatively superficial, the situation with the beta-lactam antibiotics is much more advanced. Good progress has been made in identifying the spectra of allergenic determinants recognized by IgE antibodies in the sera of subjects sensitized to penicillins and cephalosporins, and this is aiding the development of an appropriate battery of drug conjugates for use as diagnostic agents. Patient-sensitivity responses to the beta-lactam antibiotics are frequently heterogeneous, and this factor must be taken into account for any diagnostic strategy or future therapy with a penicillin or cephalosporin.

Adverse effects of macrolide antibacterials

The renewed interest in macrolide antibacterials with expanded indications for clinical use, as well as their markedly increased usage, justifies the continuous search for new compounds designed to offer the patient not only enhanced bioavailability but also a reduced incidence of adverse effects. Macrolides are an old and well established class of antimicrobial agents that account for 10 to 15% of the worldwide oral antibiotic market. Macrolides are considered to be one of the safest anti-infective groups in clinical use, with severe adverse reactions being rare. Newer products with improved features have recently been discovered and developed, maintaining or significantly expanding the role of macrolides in the management of infection. This review deals with the tolerability of the clinically available macrolide antibacterials. With the exception of drug interactions, adverse effects have been analysed during the last 40 years in many thousands of adult and paediatric patients. Recently developed derivatives have been compared with the older compounds, and the expected and well assessed adverse effects have been set apart from those which are unusual, very rare or questionable. Gastrointestinal reactions represent the most frequent disturbance, occurring in 15 to 20% of patients on erythromycins and in 5% or fewer patients treated with some recently developed macrolide derivatives that seldom or never induce endogenous release of motilin, such as roxithromycin, clarithromycin, dirithromycin, azithromycin and rikamycin (rokitamycin). Except for troleandomycin and some erythromycins administered at high dose and for long periods of time, the hepatotoxic potential of macrolides, which rarely or never form nitrosoalkanes, is low for josamycin, midecamycin, miocamycin, flurithromycin, clarithromycin and roxithromycin; it is negligible or absent for spiramycin, rikamycin, dirithromycin and azithromycin. Transient deafness and allergic reactions to macrolide antibacterials are highly unusual and have definitely been shown to be more common following treatment with the erythromycins than with the recently developed 14-, 15- and 16-membered macrolides. There have been case reports in the literature of 51 patients during the last 30 years who experienced uncommon or dubious adverse effects after treatment with older compounds and in which there appears to be strong evidence of a causal relationship with the drug. Only 3 cases had an unfavourable outcome, and these were patients administered erythromycin lactobionate intravenously too rapidly or at high dose. Targets of these occasional reactions are generally the heart, liver and central nervous system. Other unusual organ pathologies are related to immunomediated disorders more than to primary parenchymal toxicity, or to the rarely serious consequences of macrolide-induced alterations in intestinal microflora.(ABSTRACT TRUNCATED AT 400 WORDS)

Lymphocyte Transformation Tests in Workers with Occupational Exposure to Spiramycin

Pharmaceutical industry employees are exposed to drugs which can stimulate allergic reactions. Other authors have found that, in workers of pharmaceutical companies exposed to spiramycin, spiramycin-induced asthma can be diagnosed only on the basis of spiramycin inhalation tests, because IgE specific antibodies, as well as skin and patch tests, are often negative.

Since lymphocytes from humans sensitised to various agents undergo morphological transformation on exposure to sensitising antigen in culture, we used a lymphocyte transformation test (LTT) following in vitro exposure to spiramycin of cells collected from healthy workers occupationally exposed or not exposed to this antibiotic.

LTT was measured by [3H]-thymidine uptake into DNA of lymphocytes cultured for three days in medium containing 0-500μg/ml spiramycin. The number of lymphoblasts was also counted on cell smears. Lymphocytes from spiramycin-exposed subjects, incubated with spiramycin, demonstrated a statistically significant increase of [3H]-thymidine incorporation; the presence of lymphoblasts in the cultures was only slightly increased.

Although other experiments with lymphocytes obtained from patients with spiramycin-induced asthma need to be performed, this pilot study suggests that LTT may be able to be used to detect early immune response changes caused by chemical agents in occupationally exposed workers.

Occupational asthma in workers of a pharmaceutical company processing spiramycin

After investigation of one worker with occupational asthma, all 51 employees of a pharmaceutical company processing the macrolide antibiotic spiramycin were investigated to determine the frequency of the condition and the risk factors. The antibiotic was produced for short periods four to five times a year. The first part of the investigation, conducted before a production period, consisted of the following: questionnaire, skinprick tests, blood sample, spirometry, assessment of bronchial responsiveness to methacholine, and monitoring of peak expiratory flow rates (PEF). The second part of the survey was carried out in 48 of the 51 workers during the production period, and included the same assessments except for skin testing. No FEV1 values had changed by more than 9% or PEF by more than 19%. Inhalation challenge with spiramycin was performed in 12 of the 14 individuals who had a history of occupational asthma, a provocative concentration of methacholine (PC20) of 16 mg/ml or less, or a PC20 that fell by 2.5 fold or more during the production period (or a combination of these). Three subjects experienced immediate bronchoconstriction. All reported symptoms, and all had a fall in PC20 methacholine during the production period. It is concluded that the minimum frequency of occupational asthma in this company processing spiramycin is 4/51 (7.8%). The combination of a positive response to the questionnaire and a change in bronchial hyperresponsiveness during the production period appeared to be the best detector of individuals with occupational asthma, as confirmed by inhalation challenge with spiramycin.

Bronchial asthma due to spiramycin and adipic acid

Two cases of bronchial asthma due to spiramycin in workers of a pharmaceutical factory are reported. The subjects complained of cough, breathlessness and symptoms of asthma at work when coming into contact with spiramycin's powder. The symptoms cleared when away from work for more than 3 or 4 days. Inhalation challenge tests by aerosolization of solutions of spiramycin reproduced asthmatic reactions dual in type in both patients, the immediate component of the response has not been previously described for this antibiotic. Furthermore, one of the patients developed an immediate asthmatic reaction also after inhalation of a solution of adipic acid, and additive to bind spiramycin and diminish its irritant action. The reaction was obtained at a non-irritant concentration of the acid, was reproducible and inhibited by previous administration of sodium cromoglycate: this finding and the failure to elicit the reaction in the other patient suggest a hypersensitivity reaction to this substance.

Bronchial asthma and dermatitis due to spiramycin in a chick breeder

A case of bronchial asthma and dermatitis due to spiramycin is described in a non-atopic woman who worked as a chick breeder and handling poultry feed containing antibiotic or chemoterapic drugs including spiramycin, chlortetracycline and sulfadimethoxine. Patch tests showed a vigorous delayed reaction to spiramycin. Inhalation challenge test with the chick feed containing spiramycin reproduced symptoms of late asthmatic response (FEV1 fell by 14% and FEF25-75 by 25% within the 4th and 6th hour) with leucocytosis. No significant modification of FEV1 and FEF25-75 was observed within 24 hours after challenge with chick feeds containing other antibiotic or chemotherapeutic agents but not spiramycin. On leaving her job, the patient had no further skin reactions or bronchial asthma episodes. This case suggests that allergic reactions to a chemical product may involve both type III and IV hypersensitivity.

Occupational asthma due to inhaled carmine

Two patients are described with occupational asthma due to carmine, a natural dye extracted from the insect Coccus cactus. Both had dual asthmatic reactons after carmine inhalation. Oral challenge provoked gastrointestinal symptoms in one patient, and asthma in them both, perhaps accounting for their continuing symptoms. One patient worked extracting carmine from the insects and the other used carmine as a cosmetic colouring agent.

Asthma due to inhaled chemical agents--amprolium hydrochloride

A man with no previous history of allergy or chest disease developed asthma after exposure to a heavy atmospheric concentration of amprolium hydrochloride which is a constituent of a poultry-food additive. Subsequent experimental exposure produced an immediate asthmatic reaction which was inhibited by sodium cromoglycate.