CROSS-REACTIVITY TO ANTIBIOTICS: PROPOSITIONS FOR SELECTING ALTERNATIVES

OBJECTIVE

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

PATIENTS AND METHODS

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

CONCLUSION

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

Deciphering adverse drug reactions: in vitro priming and characterization of vancomycin-specific T-cells from healthy donors expressing HLA-A*32:01

Drug rash with eosinophilia with systemic symptoms (DRESS) is a serious adverse event associated with use of the glycopeptide antibiotic vancomycin. Vancomycin-induced drug rash with eosinophilia with systemic symptoms is associated with the expression of human leukocyte antigen (HLA)-A*32:01, suggesting that the drug interacts with this HLA to activate CD8+ T cells. The purpose of this study was to utilize peripheral blood mononuclear cell from healthy donors to: (1) investigate whether expression of HLA-A*32:01 is critical for the priming naïve of T cells with vancomycin and (2) generate T-cell clones (TCC) to determine whether vancomycin exclusively activates CD8+ T cells and to define cellular phenotype, pathways of drug presentation and cross-reactivity. Dendritic cells were cultured with naïve T cells and vancomycin for 2 weeks. On day 14, cells were restimulated with vancomycin and T-cell proliferation was assessed by [³H]-thymidine incorporation. Vancomycin-specific TCC were generated by serial dilution and repetitive mitogen stimulation. Naïve T cells from HLA-A*02:01 positive and negative donors were activated with vancomycin; however the strength of the induced response was significantly stronger in donors expressing HLA-A*32:01. Vancomycin-responsive CD4+ and CD8+ TCC from HLA-A*32:01+ donors expressed high levels of CXCR3 and CCR4, and secreted IFN‐γ, IL-13, and cytolytic molecules. Activation of CD8+ TCC was HLA class I-restricted and dependent on a direct vancomycin HLA binding interaction with no requirement for processing. Several TCC displayed cross-reactivity with teicoplanin and daptomycin. To conclude, this study provides evidence that vancomycin primes naïve T cells from healthy donors expressing HLA-A*32:01 through a direct pharmacological binding interaction. Cross-reactivity of CD8+ TCC with teicoplanin provides an explanation for the teicoplanin reactions observed in vancomycin hypersensitive patients.

Neutropenia, Thrombocytopenia, and Eosinophilia: An Unusual Triad in a Patient on Long-Term Vancomycin Therapy

Patient: Female, 46-year-old

Final Diagnosis: Adverse drug reaction • epidural abscess

Symptoms: Eosinophilia • neutropenia • thrombocytopenia

Medication: —

Clinical Procedure: —

Specialty: General and Internal Medicine

Adverse reactions to vancomycin and cross-reactivity with other antibiotics

PURPOSE OF REVIEW

Glycopeptide antibiotics such as vancomycin are frequently utilized to treat resistant Gram-positive infections such as methicillin-resistant Staphylococcus aureus. The current literature on glycopeptide and lipoglycopeptide structure, hypersensitivity and potential cross-reactivity was reviewed, highlighting implications for safe prescribing.

RECENT FINDINGS

Structurally similar, glycopeptides could theoretically cross-react. Immediate reactions to vancomycin include non-IgE-mediated reactions (e.g. red man syndrome) and IgE-mediated hypersensitivity (e.g. anaphylaxis), sharing clinical features. Vancomycin can activate mast cells via MAS-related G-protein-coupled receptor X2, an IgE-independent receptor implicated in non-IgE reactions. In-vivo and in-vitro testing for suspected IgE-mediated reactions to glycopeptides remain ill-defined. Vancomycin is increasingly recognized to cause severe cutaneous adverse reactions (SCAR), with drug reaction with eosinophilia and systemic symptoms (DRESS) predominantly reported. Vancomycin DRESS has been associated with HLA-A32:-01, with a number needed to prevent of 1 in 74. Data demonstrating cross-reactivity amongst glycopeptides and lipoglycopeptides is limited to case reports/series.

SUMMARY

Further studies and in-vivo/in-vitro diagnostics are required for better differentiation between IgE and non-IgE glycopeptide reactions. Despite its association with vanomycin DRESS, utility of pharmacogenomic screening for HLA-A32: 01 is ill-defined. Although HLA-A32:01 has been associated with vancomycin DRESS, its utility for pharmacogenomic screening is ill defined. Further clinical and immunological cross-reactivity data for glycopeptide/lipoglycopeptide antibiotics is required.

Incidence of teicoplanin adverse drug reactions among patients with vancomycin-associated adverse drug reactions and its risk factors

BACKGROUND/AIMS

Teicoplanin can be used as an alternative to vancomycin when treating beta-lactam-resistant gram-positive bacterial infections. Both vancomycin and teicoplanin are associated with relatively high rates of adverse drug reactions (ADRs), including hypersensitivity reactions. There is limited data on teicoplanin-vancomycin cross-reactivity. This study examined the incidence of teicoplanin ADRs and risk factors for cross-reactivity between vancomycin and teicoplanin.

METHODS

We analyzed the incidence of teicoplanin ADRs in a retrospective study of 304 newly teicoplanin-exposed, immunocompetent, hospitalized patients at a single Korean Medical Center between January 1, 2006 and December 31, 2015.

RESULTS

Among 304 patients, 238 (78.3%) experienced vancomycin-associated ADRs prior to their teicoplanin exposure and 58 (19.1%) experienced teicoplanin- associated ADRs, which were mostly hypersensitivity reactions without acute kidney injury. The incidence of teicoplanin ADRs was higher in patients who previously experienced vancomycin-related ADRs (23.1% vs. 5.3%, p < 0.001). History of drug allergy was a statistically significant risk factor of teicoplanin ADRs. The incidence of teicoplanin ADRs significantly increased in patients with multiple organ involvement in vancomycin hypersensitivity reactions.

CONCLUSION

Teicoplanin should be administered with caution and clinicians must consider the risk factors of cross-reaction when prescribing teicoplanin to individuals with a history of vancomycin hypersensitivity.

Glycopeptide Hypersensitivity and Adverse Reactions

Glycopeptides, such as vancomycin and teicoplanin, are primarily used in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections, such as cellulitis, endocarditis, meningitis, pneumonia, and septicemia, and are some of the most commonly prescribed parenteral antimicrobials. Parenteral glycopeptides are first-line therapy for severe MRSA infections; however, oral vancomycin is used as a first-line treatment of Clostridioides difficile infections. Also, we currently have the longer-acting lipoglycopeptides, such as dalbavancin, oritavancin, and telavancin to our armamentarium for the treatment of MRSA infections. Lastly, vancomycin is often used as an alternative treatment for patients with β-lactam hypersensitivity. Common adverse effects associated with glycopeptide use include nephrotoxicity, ototoxicity, and Redman Syndrome (RMS). The RMS is often mistaken for a true allergy; however, it is a histamine-related infusion reaction rather than a true immunoglobulin E (IgE)-mediated allergic reaction. Although hypersensitivity to glycopeptides is rare, both immune-mediated and delayed reactions have been reported in the literature. We describe the various types of glycopeptide hypersensitivity reactions associated with glycopeptides and lipoglycopeptides, including IgE-mediated reactions, RMS, and linear immunoglobulin A bullous dermatosis, as well as describe cross-reactivity with other glycopeptides.

Vancomycin-Induced Thrombocytopenia: A Narrative Review

Thrombocytopenia has been reported as an adverse reaction of numerous drugs. Vancomycin is often overlooked as a culprit but has been associated with several cases of thrombocytopenia that were not well described in the literature. A literature search was conducted to find reports of thrombocytopenia induced by vancomycin. Biomedical databases including 'PubMed', 'Scopus', and 'Web of Science' were searched using terms 'vancomycin', 'platelet', 'pancytopenia', 'thrombocytopenia', and 'bleeding'. English language articles published before July 2015 were included. Thirty-nine papers including 29 case reports (30 cases), five observational studies, two clinical trials, two letters, and one case series remained for final analysis. The main route of administration was intravenous infusion. This adverse reaction seems to be duration dependent with the mean time to platelet nadir count of 8 days in reported cases. The interval may be significantly shorter in re-exposure to the drug. Platelet nadir counts ranged from 2000 to 100,000/mL in patients who experienced bleeding. Vancomycin-specific antibodies were detected in 13 of 17 patients who were tested in the case reports. Based on the Naranjo Adverse Drug Reaction Probability Scale, reaction was 'definite', 'probable', and 'possible' in 1, 15, and 14 patients, respectively. Among 30 cases, vancomycin was discontinued in 29 patients and platelets returned to normal counts within 5-6 days in 17 of them; in one patient, vancomycin was not discontinued, but platelet count recovered 11 days after the nadir time. Transfusion might be recommended if severe thrombocytopenia and bleeding occurs. Intravenous immunoglobulins, corticosteroids, rituximab, and plasma exchange should be reserved for patients with resistant thrombocytopenia and severe bleeding as mentioned in a number of reports.

Vancomycin-Induced Leukocytoclastic Vasculitis and Acute Renal Failure Due to Tubulointerstitial Nephritis

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and sepsis are commonly treated with intravenous vancomycin. However, vancomycin treatment is associated adverse reactions, including skin rashes and nephrotoxicity. We present a case of acute renal failure due to acute tubulointerstitial nephritis associated with a diffuse leukocytoclastic vasculitic skin eruption following intravenous vancomycin treatment. CASE REPORT A 79-year-old Caucasian male patient was treated with intravenous vancomycin for MRSA bacteremia. Prior to treatment, his creatinine was normal at 0.6 mg/dl. He presented one week later with shortness of breath, lower limb edema, and acute renal failure. He had a diffuse maculopapular rash involving the trunk and both upper and lower extremities. A renal biopsy and left arm skin biopsy were examined histologically. The skin biopsy showed leukocytoclastic vasculitis. Renal biopsy showed some sclerosed glomeruli, some with mesangial proliferation, and tubulointerstitial inflammation with eosinophils and plasma cells and mild interstitial fibrosis. Although there was some renal arteriolosclerosis, no vasculitic changes were seen, and no vascular thrombosis was present. A diagnosis of leukocytoclastic vasculitis and acute tubulointerstitial nephritis secondary to intravenous vancomycin therapy was made. CONCLUSIONS Although skin reactions associated with drug therapy are common, vancomycin-associated dermal vasculitis is rare. Tubulointerstitial nephritis is also a rare association with vancomycin treatment. This case report has highlighted that patients being treated with intravenous vancomycin should be carefully observed for acute skin rashes and deterioration in renal function, which can be managed by ceasing treatment with vancomycin, steroid challenge, and preventing future exposure to similar antimicrobial agents.

Old dog begging for new tricks: current practices and future directions in the diagnosis of delayed antimicrobial hypersensitivity

PURPOSE OF REVIEW

Antimicrobials are a leading cause of severe T cell-mediated adverse drug reactions (ADRs). The purpose of this review is to address the current understanding of antimicrobial cross-reactivity and the ready availability of and evidence for in-vitro, in-vivo, and ex-vivo diagnostics for T cell-mediated ADRs.

RECENT FINDINGS

Recent literature has evaluated the efficacy of traditional antibiotic allergy management, including patch testing, skin prick testing, intradermal testing, and oral challenge. Although patch and intradermal testing are specific for the diagnosis of immune-mediated ADRs, they suffer from drug-specific limitations in sensitivity. The use of ex-vivo diagnostics, especially enzyme-linked immunospot, has been highlighted as a promising new approach to assigning causality. Knowledge of true rates of antimicrobial cross-reactivity aids empirical antibiotic choice in the setting of previous immune-mediated ADRs.

SUMMARY

In an era of increasing antimicrobial resistance and use of broad-spectrum antimicrobial therapy, ensuring patients are assigned the correct 'allergy label' is essential. Re-exposure to implicated antimicrobials, especially in the setting of severe adverse cutaneous reaction, is associated with significant morbidity and mortality. The process through which an antibiotic label gets assigned, acted on and maintained is still imprecise. Predicting T cell-mediated ADRs via personalized approaches, including human leukocyte antigen-typing, may pave future pathways to safer antimicrobial prescribing guidelines.

DRESS Syndrome Caused by Cross-reactivity Between Vancomycin and Subsequent Teicoplanin Administration: A Case Report

BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a potentially life-threatening syndrome comprising severe skin eruption, fever, eosinophilia, lymphadenopathy, and involvement of internal organs. Here, we describe a case of DRESS syndrome caused by cross-reactivity between vancomycin and subsequent teicoplanin administration. CASE REPORT A 79-year-old male was admitted to our hospital for the treatment of injuries incurred in a traffic accident. Eosinophilia and lung dysfunction appeared after vancomycin administration. These symptoms were improved temporarily by withdrawal of vancomycin and administration of corticosteroid, but exacerbated by subsequent teicoplanin administration. These symptoms disappeared after discontinuation of teicoplanin. Based on comprehensive assessment of the overall clinical course, we judged that DRESS syndrome was induced by cross-reactivity between vancomycin and subsequent teicoplanin administration. Using the European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) scoring system, we categorized DRESS syndrome related to vancomycin and teicoplanin as "probable." We describe, for the first time, DRESS syndrome (defined using the RegiSCAR scoring system) caused by cross-reactivity between vancomycin and subsequent teicoplanin administration. CONCLUSIONS Clinicians should be aware that DRESS syndrome can be induced by cross-reactivity between vancomycin and teicoplanin.

Vancomycin revisited - 60 years later

Vancomycin is one of the older antibiotics that has been now in clinical use close to 60 years. Earlier on, vancomycin was associated with many side effects including vestibular and renal, most likely due to impurities contained in early vancomycin lots. Over the years, the impurities have been removed and the compound has now far less vestibular adverse effects, but still possesses renal toxicity if administered at higher doses rendering trough serum levels of >15 mcg/mL or if administered for prolonged periods of time. Vancomycin is effective against most Gram-positive cocci and bacilli with the exception of rare organisms as well as enterococci that became vancomycin resistant, mostly Enterococcus faecium. The major use of vancomycin today is for infections caused by methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE) and amoxicillin-resistant enterococci. In its oral form, vancomycin is used to treat diarrhea caused by Clsotridium difficile. With S. aureus, there are only a handful of vancomycin-resistant strains. Nevertheless, a "vancomycin creep" that is slow upward trending of vancomycin MIC from <1 mcg/mL to higher values has been noted in several parts of the world, but not globally, and strains that have MIC's of 1.5-2 mcg/mL are associated with high therapeutic failure rates. This phenomenon has also been recently recognized in methicillin-susceptible S. aureus (MSSA). While vancomycin is relatively a safe agent adverse events include the "red man" syndrome, allergic reactions, and various bone marrow effects as well as nephrotoxicity. Vancomycin has been a very important tool in our therapeutic armamentarium that remained effective for many years, it is likely remain effective as long as resistance to vancomycin remains controlled.

Stevens-Johnson syndrome induced by the cross-reactivity between teicoplanin and vancomycin

WHAT IS KNOWN AND OBJECTIVE

The glycopeptide antibiotics, vancomycin and teicoplanin, are the mainstay of therapy for severe gram-positive organisms such as methicillin-resistant Staphylococcus aureus. We report a case of Stevens-Johnson syndrome (SJS) induced by sequential therapy with teicoplanin and vancomycin, in a patient with chronic obstructive pulmonary disease (COPD).

CASE SUMMARY

A 74-year-old Han Chinese with 1-year history of COPD was admitted for treatment of infective endocarditis. After teicoplanin therapy for 12 days, he developed pruritus and maculopapular over his trunk and limbs. His rash spread rapidly to most parts of the body surface area, 7 days after his anti-infection therapy was switched to vancomycin. This was stopped, but he developed SJS when teicoplanin was re-introduced. This patient recovered from his drug eruptions when both teicoplanin and vancomycin were stopped. Pharmacogenetic analyses revealed he was heterozygous with respect to two variants (rs2844682 of MUC21 and rs750332 of BAG6).

WHAT IS NEW AND CONCLUSION

Cross-reactivity between vancomycin and teicoplanin is rare. SJS attributable to sequential treatment with these two antibiotics has not been reported previously. Care should be taken when prescribing vancomycin in patients with a previous documented skin eruption to teicoplanin, especially in those who carry any susceptibility alleles to SJS/TEN.

Multicenter prospective observational study of the comparative efficacy and safety of vancomycin versus teicoplanin in patients with health care-associated methicillin-resistant Staphylococcus aureus bacteremia

The purpose of this study was to compare the clinical efficacy and safety of vancomycin to those of teicoplanin for the treatment of adult patients with health care-associated methicillin-resistant Staphylococcus aureus (HA-MRSA) bacteremia. A multicenter observational study was prospectively conducted in 15 teaching hospitals in Korea between February 2010 and July 2011. Adult patients (≥18 years old) with HA-MRSA bacteremia who were initially treated with vancomycin (VAN) (n = 134) or teicoplanin (TEC) (n = 56) were enrolled. Clinical and microbiological responses and drug-related adverse events were compared between the two treatment groups using univariate and multivariate logistic regression analyses. The vancomycin and teicoplanin MICs were determined by Etest. The MRSA-related mortality, duration of fever, and duration of MRSA bacteremia in the treatment groups were not significantly different. There was no significant difference in the occurrence of drug-related adverse events. Among the 190 MRSA isolates, the VAN MICs ranged from 0.5 to 2 μg/ml (MIC50 and MIC90, 1.5 μg/ml), and the TEC MIC ranged from 0.5 to 8 μg/ml (MIC50, 3 μg/ml; MIC90, 6 μg/ml). In multivariate analyses, the antibiotic type (vancomycin or teicoplanin) was not associated with treatment outcomes. This study indicates that teicoplanin is an effective and safe alternative to vancomycin for the treatment of HA-MRSA bacteremia.