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Sáenz de Santa María R, Bogas G, Labella M, Ariza A, Salas M, Doña I, Torres MJ. Approach for delabeling beta-lactam allergy in children. FRONTIERS IN ALLERGY 2023; 4:1298335. [PMID: 38033918 PMCID: PMC10684789 DOI: 10.3389/falgy.2023.1298335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023] Open
Abstract
A considerable number of pediatric patients treated with beta-lactam (BL) antibiotics develop delayed onset of skin rashes during the course of treatment. Although the most frequent cause of these symptoms is infectious, many cases are labeled as allergic reactions to these drugs. BL allergy labels could have a negative impact, as they imply avoidance of this group of drugs and the use of second-line antibiotics, leading to a potential increase in adverse effects and the utilization of less effective therapies. This constitutes a major public health concern and economic burden, as the use of broad-spectrum antibiotics can result in multidrug-resistant organisms and prolonged hospital stays. Therefore, it is crucial to delabel patients during childhood to avoid false labeling in adult life. Although the label of BL allergy is among the most frequent causes of allergy referral, its management remains controversial, and new diagnostic perspectives are changing the paradigm of managing BL allergies in children. Traditionally, drug provocation testing (DPT) was exclusively performed in patients who had previously obtained negative results from skin tests (STs). However, the sensitivity of STs is low, and the role of in vitro testing in the pediatric population is not well defined. Recent studies have demonstrated the safety of direct DPT without prior ST or serum tests for pediatric patients who report a low-risk reaction to BLs, which is cost-effective. However, there is still a debate on the optimal allergic workup to be performed in children with a benign immediate reaction and the management of children with severe cutaneous adverse drug reactions. In this review, we will discuss the impact of the label of BL allergy and the role of the different tools currently available to efficiently address BL allergy delabeling in children.
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Affiliation(s)
- R. Sáenz de Santa María
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - G. Bogas
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. Labella
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - A. Ariza
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. Salas
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - I. Doña
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. J. Torres
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
- Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
- Departamento de Medicina, Universidad de Málaga, Facultad de Medicina, Málaga, Spain
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Taylor MG, Joerger T, Anvari S, Li Y, Gerber JS, Palazzi DL. The Quality and Management of Penicillin Allergy Labels in Pediatric Primary Care. Pediatrics 2023; 151:e2022059309. [PMID: 36740967 PMCID: PMC10680064 DOI: 10.1542/peds.2022-059309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Penicillin allergy labels are the most common drug allergy label. The objective of this study was to describe the quality and management of penicillin allergy labels in the pediatric primary care setting. METHODS Retrospective chart review of 500 of 18 015 children with penicillin allergy labels born from January 1, 2010 to June 30, 2020 randomly selected from an outpatient birth cohort from Texas Children's Pediatrics and Children's Hospital of Philadelphia networks. Penicillin allergy risk classification ("not allergy," "low risk," "moderate or high risk," "severe risk," "unable to classify") was determined based on documentation within (1) the allergy tab and (2) electronic healthcare notes. Outcomes of allergy referrals and penicillin re-exposure were noted. RESULTS Half of penicillin allergy labels were "unable to classify" based on allergy tab documentation. Risk classification agreement between allergy tabs and healthcare notes was fair (Cohen's ĸ = 0.35 ± 0.02). Primary care physicians referred 84 of 500 (16.8%) children to an allergist, but only 54 (10.8%) were seen in allergy clinic. All children who were challenged (25 of 25) passed skin testing. Removal of allergy labels was uncommon (69 of 500, 13.8%) but occurred more often following allergy appointments (26 of 54, 48%) than not (43 of 446, 9.6%, P < .001). Children delabeled by primary care physicians were as likely to tolerate subsequent penicillin-class antibiotics as those delabeled by an allergist (94% vs 93%, P = .87). CONCLUSIONS Penicillin allergy documentation within the allergy tab was uninformative, and children were infrequently referred to allergists. Future quality improvement studies should improve penicillin allergy documentation and expand access to allergy services.
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Affiliation(s)
- Margaret G Taylor
- Division of Infectious Diseases
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Torsten Joerger
- Division of Infectious Diseases
- Division of Immunology, Allergy, and Retrovirology
| | - Sara Anvari
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
- Division of Immunology, Allergy, and Retrovirology
| | - Yun Li
- Division of Immunology, Allergy, and Retrovirology
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness
- Department of Biostatistics, Epidemiology, and Informatics
| | - Jeffrey S Gerber
- Division of Infectious Diseases
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debra L Palazzi
- Division of Infectious Diseases
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Beta-lactam allergy and drug challenge test in children: a systematic review and meta-analysis. Pediatr Res 2023; 93:22-30. [PMID: 35449396 DOI: 10.1038/s41390-022-02076-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Most cases of beta-lactam allergy in children are likely to be mislabeled. This study aimed to assess the prevalence of true positives, as determined by drug challenge tests, and the rate of false negatives in children with suspected allergies and confirm the safety of the drug challenge test. METHODS We conducted a systematic review and meta-analysis according to established procedures. Study participants were children with suspected beta-lactam allergy who underwent a drug challenge. PubMed MEDLINE, Dialog EMBASE, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform, and clinicaltrials.gov were searched from inception until March 5, 2021. RESULTS The pooled prevalence of (a) positive results in the first challenge was 0.049 (95% CI, 0.041-0.057; I2 = 71%) from 78 studies; (b) serious adverse events was 0.00 (95% CI, 0.00-0.00; I2 = 0.0%) from 62 studies; and (c) positive results in the second challenge after the first negative result was 0.028 (95% CI, 0.016-0.043; I2 = 38%) from 18 studies. CONCLUSIONS The prevalence of children with suspected beta-lactam allergy with true-positive results and false-negative results from the drug challenge test was very low. Serious adverse events resulting from drug challenge tests were also very rare. IMPACT Most children with suspected beta-lactam allergy were likely to be mislabeled. Serious adverse events caused by the drug challenge test were rare. Few false-negative results were obtained from the drug challenge test.
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De-labeling Beta-lactam in Adult Population. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00316-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Liccioli G, Giovannini M, Caubet JC, Barni S, Sarti L, Parronchi P, Capone M, Tomei L, Mori F. Simplifying the drug provocation test in non-immediate hypersensitivity reactions to amoxicillin in children: The experience of a tertiary care allergy unit. Pediatr Allergy Immunol 2022; 33:e13809. [PMID: 35754120 PMCID: PMC9328376 DOI: 10.1111/pai.13809] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/29/2022] [Accepted: 05/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mild non-immediate reactions (NIR) to beta-lactams (βLs) are the most common manifestation of adverse drug reactions in children, and the drug provocation test (DPT) remains the gold standard for diagnosis. However, there are still controversies about the protocol that should be used, especially regarding the administration of doses and the DPT length. OBJECTIVE This study aimed to evaluate a pediatric population with a history of mild NIR to amoxicillin (AMX) or to amoxicillin-clavulanic acid (AMX/CL) who underwent a diagnostic workup including a DPT with the culprit drug, to understand if a graded DPT or, instead, a single full dose could be the most appropriate way of administration in clinical practice. METHODS The data of children were retrospectively analyzed for a 5-year period, with demographic and clinical characteristics collected. We reported the allergy workup and the results of the DPT performed with the administration of incremental doses and a prolonged DPT at home for a total of 5 days. RESULTS Three hundred fifty-four patients were included. Overall, 23/354 (6.5%) DPTs were positive: 11/23 patients showed a reaction after 2-8 h after the last dose on the 1st or 2nd day (1 reacted 30 min after the last dose), 1/23 reacted with urticaria 30 min after the first dose, 11/23 reacted at home on the 5th day of the DPT. CONCLUSION This paper indirectly suggests that a single therapeutic dose administered on the 1st day of a DPT could be safe in the diagnostic workup of mild NIR to AMX/CL. Moreover, this could be less time-consuming as patients would spend less time in the hospital, also considering the public health restrictions imposed during the COVID-19 pandemic.
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Affiliation(s)
- Giulia Liccioli
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Paola Parronchi
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Manuela Capone
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Leonardo Tomei
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
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Arıkoğlu T, Kuyucu S, Caubet JC. New diagnostıc perspectives in the management of pediatrıc beta-lactam allergy. Pediatr Allergy Immunol 2022; 33:e13745. [PMID: 35338725 DOI: 10.1111/pai.13745] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 12/15/2022]
Abstract
Since overdiagnosis of beta-lactam (BL) allergy is common in the pediatric population, delabeling is a critical part of antimicrobial stewardship. Undesirable consequences of inaccurate BL allergy labeling can be handled by incorporating traditional delabeling or newer risk-based strategies into antibiotic stewardship programs. Conventional assessment of BL allergy relies upon a stepwise algorithm including a clinical history with skin testing followed by drug provocation tests (DPTs). However, a growing number of studies highlighted the suboptimal diagnostic value of skin testing in children. Recently, there has been a paradigm shift in the practice of BL allergy assessment due to recent challenging data which emphasize the safety and accuracy of direct DPTs in children with a suspicion of non-immediate mild cutaneous reactions such as maculopapular eruption, delayed urticaria, and possibly also for benign immediate reactions such as urticaria/angioedema. Identifying low-risk BL allergy patients, in whom skin tests can be skipped and proceeding directly to DPTs could be safe, has become a hot topic in recent years. New risk stratification and predictive modeling studies that have the potential to better predict BL allergy risk status have recently been introduced into the field of drug allergy, particularly in adults. However, in contrast to adults, risk assessment studies in children are rare, and optimal risk definitions are controversial. In the coming years, promising potential methods to elucidate the predictors of BL allergy in children will require multidimensional approaches that may include predictive analytics, artificial intelligence techniques, and point-of-care clinical decision tools.
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Affiliation(s)
- Tuğba Arıkoğlu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
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Covington EW, Durham SH, Bland CM, Bookstaver PB, Chahine EB, Cho JC, Diggs F, Jones BM, Kyle JA, Stover KR, Wagner JL, Hughes PJ. A Continuing Education Activity Durably Addressed Knowledge Gaps Related to Penicillin Allergies Among Pharmacists and Pharmacy Technicians. J Pharm Technol 2021; 38:18-25. [DOI: 10.1177/87551225211051015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Penicillin allergy is one of the most frequent self-reported allergies; however, only about 10% of reported allergies are accurate. Objectives: Through the creation of a continuing pharmacy education (CPE) activity, we sought to assess knowledge gaps and comfort levels in the management of penicillin allergies. Methods: A 1-hour enduring-content CPE activity was offered as an interactive course from September 20, 2019, to September 20, 2020. Participants completed 3 surveys (pre-survey, post-survey, and follow-up survey). Participants were pharmacists and pharmacy technicians who completed, at a minimum, the activity and both pre- and post-surveys. The primary outcome was the percentage of participants scoring >80% on knowledge-based questions on the post-survey compared with the pre-survey. Secondary outcomes included pre-post comparisons on knowledge-based questions, participants’ self-report of an allergy, and comfort levels dispensing cephalosporins in a patient with a self-reported penicillin allergy. Results: A total of 389 participants completed the CPE activity, with 176 included for analysis. Significantly more participants scored >80% on knowledge-based questions on the post-survey compared with the pre-survey (71.6% vs 22.7%, P < .001). There was no significant difference between the percentage of participants scoring >80% on the post-survey and the follow-up survey (71.6% vs 65%, P = .119). The majority of participants (74%) felt comfortable dispensing a cephalosporin in a patient with a penicillin allergy on the pre-survey, with similar percentages on the post- and follow-up surveys (77% and 90%, respectively). Conclusion: A targeted continuing education program improved overall knowledge, which was sustained for up to 2 months.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce M. Jones
- St. Joseph’s/Candler Health System, Inc, Savannah, GA, USA
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8
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Lutfeali S, Khan DA. Pediatric Drug Allergies: Updates on Beta-Lactam, Nonsteroidal Anti-Inflammatory Drug, and Chemotherapeutic Reactions. Immunol Allergy Clin North Am 2021; 41:667-683. [PMID: 34602236 DOI: 10.1016/j.iac.2021.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Adverse drug reactions are frequently reported in pediatric patients. In this review article, the authors discuss pediatric drug allergies with emphasis on the most common culprits, beta-lactam antibiotics and non-steroidal anti-inflammatory drugs. The authors also discuss reactions to non-beta-lactam antibiotics and chemotherapeutics. Skin testing has not yet been validated for many drugs, although notable exceptions include penicillin and carboplatin. The gold standard for diagnosis in most cases remains drug challenge, and the need for penicillin skin testing prior to oral provocation challenge has been questioned in recent studies. Successful desensitizations have also been reported with several drugs.
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Affiliation(s)
- Shazia Lutfeali
- Department of Internal Medicine, Division of Allergy & Immunology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8859, USA
| | - David A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8859, USA.
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9
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Prieto A, Muñoz C, Bogas G, Fernández‐Santamaría R, Palomares F, Mayorga C, Salas M, Doña I, Torres MJ. Single-dose prolonged drug provocation test, without previous skin testing, is safe for diagnosing children with mild non-immediate reactions to beta-lactams. Allergy 2021; 76:2544-2554. [PMID: 33650109 DOI: 10.1111/all.14800] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 02/02/2021] [Accepted: 02/09/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Mild non-immediate reactions (NIRs) to beta-lactams (BLs) are the most frequent manifestation of drug allergy in children. The diagnostic approach is complex as the utility of skin tests (STs) and lymphocyte transformation tests (LTTs) is controversial. Drug provocation test (DPT) is the gold standard, although no standardized protocols exist. We aimed to investigate the utility of DPT in a unique dose without previous STs, and LTTs in the diagnosis of NIRs to BLs in children. METHODS We prospectively evaluated children 0-14 years old referred to the Regional University Hospital of Málaga during 2017-2020 reporting NIRs to BLs. We performed a DPT with a unique dose followed by regular treatment at home. If positive, STs and LTTs were done after the reaction had disappeared. RESULTS We included 194 children, having 24 (12.4%) a positive DPT. The main culprit was AX (70.1%) followed by AX-clavulanic acid (CLV) (26.8%) and the main symptoms maculopapular exanthema (MPE) (49.5%) and delayed-urticaria (48.5%). A decrease (p = 0.013) in the interval of days between drug administration and onset of symptoms was observed in positive DPT compared with the original reaction (3.5 vs 6 days), with no differences in the overall percentage of MPE and delayed-appearing urticaria (p = 0.551). No severe reactions occurred during DPT. Moreover, STs were positive in 13.33% and LTTs in 52.9%. CONCLUSIONS Single-dose DPT without previous STs is a safe and useful way to assess NIRs to BLs in children. LTT has shown to be useful, confirming a T-cell mechanism involved in these reactions.
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Affiliation(s)
- Ana Prieto
- Paediatrics Unit Hospital Regional Universitario de Malaga Málaga Spain
| | - Candelaria Muñoz
- Paediatrics Unit Hospital Regional Universitario de Malaga Málaga Spain
| | - Gádor Bogas
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy UnitHospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
| | | | - Francisca Palomares
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Maria Salas
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy UnitHospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
| | - Inmaculada Doña
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy UnitHospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
| | - María José Torres
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy UnitHospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
- Medicine Department Universidad de Málaga Málaga Spain
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Broyles AD, Banerji A, Barmettler S, Biggs CM, Blumenthal K, Brennan PJ, Breslow RG, Brockow K, Buchheit KM, Cahill KN, Cernadas J, Chiriac AM, Crestani E, Demoly P, Dewachter P, Dilley M, Farmer JR, Foer D, Fried AJ, Garon SL, Giannetti MP, Hepner DL, Hong DI, Hsu JT, Kothari PH, Kyin T, Lax T, Lee MJ, Lee-Sarwar K, Liu A, Logsdon S, Louisias M, MacGinnitie A, Maciag M, Minnicozzi S, Norton AE, Otani IM, Park M, Patil S, Phillips EJ, Picard M, Platt CD, Rachid R, Rodriguez T, Romano A, Stone CA, Torres MJ, Verdú M, Wang AL, Wickner P, Wolfson AR, Wong JT, Yee C, Zhou J, Castells M. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:S16-S116. [PMID: 33039007 DOI: 10.1016/j.jaip.2020.08.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ana Dioun Broyles
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Sara Barmettler
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Catherine M Biggs
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kimberly Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Patrick J Brennan
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca G Breslow
- Division of Sports Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Josefina Cernadas
- Allergology and Immunology Service, Centro Hospitalar Universitário de S.João Hospital, Porto, Portugal
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Elena Crestani
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Pascale Dewachter
- Department of Anesthesiology and Intensive Care Medicine, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Meredith Dilley
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Ari J Fried
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Sarah L Garon
- Associated Allergists and Asthma Specialists, Chicago, Ill
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass
| | - David I Hong
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Joyce T Hsu
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Parul H Kothari
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Timothy Kyin
- Division of Asthma, Allergy & Immunology, University of Virginia, Charlottesville, Va
| | - Timothy Lax
- Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Min Jung Lee
- Allergy and Immunology at Hoag Medical Group, Newport Beach, Calif
| | - Kathleen Lee-Sarwar
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Anne Liu
- Division of Allergy / Immunology, Stanford University School of Medicine, Palo Alto, Calif
| | - Stephanie Logsdon
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Andrew MacGinnitie
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Michelle Maciag
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Samantha Minnicozzi
- Division of Allergy and Clinical Immunology, Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Sarita Patil
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Division of Allergy and Clinical Immunology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Rima Rachid
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Tito Rodriguez
- Drug Allergy Department, Al-Rashed Allergy Center, Sulaibikhat, Al-Kuwait, Kuwait
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Miriam Verdú
- Allergy Unit, Hospital Universitario de Ceuta, Ceuta, Spain
| | - Alberta L Wang
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Paige Wickner
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Johnson T Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Christina Yee
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Joseph Zhou
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Mariana Castells
- Drug hypersensitivity and Desensitization Center, Brigham and Women's Hospital, Boston, Mass
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Thimmesch M, El Abd K. Quels examens devraient être réalisés lors d’une suspicion d’allergie aux bêta-lactamines chez l’enfant ? REVUE FRANÇAISE D'ALLERGOLOGIE 2021; 61:81-86. [DOI: 10.1016/j.reval.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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12
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Schrüfer P, Brockow K, Stoevesandt J, Trautmann A. Predominant patterns of β-lactam hypersensitivity in a single German Allergy Center: exanthem induced by aminopenicillins, anaphylaxis by cephalosporins. Allergy Asthma Clin Immunol 2020; 16:102. [PMID: 33292467 PMCID: PMC7672956 DOI: 10.1186/s13223-020-00488-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/10/2020] [Indexed: 11/23/2022] Open
Abstract
Background Penicillins and other β-lactam antibiotics are the most common elicitors of allergic drug reaction. However, data on the pattern of clinical reaction types elicited by specific β-lactams are scarce and inconsistent. We aimed to determine patterns of β-latam allergy, i.e. the association of a clinical reaction type with a specific β-lactam antibiotic. Methods We retrospectively evaluated data from 800 consecutive patients with suspected β-lactam hypersensitivity over a period of 11 years in a single German Allergy Center. Results β-lactam hypersensitivity was definitely excluded in 595 patients, immediate-type (presumably IgE-mediated) hypersensitivity was diagnosed in 70 and delayed-type hypersensitivity in 135 cases. Most (59 out of 70, 84.3%) immediate-type anaphylactic reactions were induced by a limited number of cephalosporins. Delayed reactions were regularly caused by an aminopenicillin (127 out of 135, 94.1%) and usually manifested as a measles-like exanthem (117 out of 135, 86.7%). Intradermal testing proved to be the most useful method for diagnosing β-lactam allergy, but prick testing was already positive in 24 out of 70 patients with immediate-type hypersensitivity (34.3%). Patch testing in addition to intradermal testing did not provide additional information for the diagnosis of delayed-type hypersensitivity. Almost all β-lactam allergic patients tolerated at least one, usually several alternative substances out of the β-lactam group. Conclusions We identified two patterns of β-lactam hypersensitivity: aminopenicillin-induced exanthem and anaphylaxis triggered by certain cephalosporins. Intradermal skin testing was the most useful method to detect both IgE-mediated and delayed-type β-lactam hypersensitivity.
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Affiliation(s)
- Philipp Schrüfer
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Knut Brockow
- Department of Dermatology and Allergy, Technical University of Munich, 80802, Munich, Germany
| | - Johanna Stoevesandt
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Axel Trautmann
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany.
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Abstract
BACKGROUND Suspected antibiotic hypersensitivity in children is a frequent reason for consultation. Skin test performance and drug provocation test (DPT) duration are controversial issues. The objective of this study was to assess the effectiveness of diagnostic tests used in the study of antibiotic hypersensitivity and to estimate an optimal duration for DPT. METHODS Sixty-two children with a suspected hypersensitivity reaction to antibiotics were studied. Skin tests were performed on all patients. In the case of negative results, DPTs were performed for a duration similar to the time elapsed from the start of treatment until the onset of the reaction. RESULTS The frequency of antibiotic hypersensitivity in the study population was 8.1% (5 of 62). Only 1 patient showed positive skin tests. The other allergic patients were diagnosed by DPT, which reproduced the reaction within the first 6 hours in all but one of them. CONCLUSIONS Shortening DPT duration may decrease the sensitivity of the test for the diagnosis of non-IgE-mediated hypersensitivity; however, it should be considered as an opportunity to reduce the resulting microbial resistances.
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14
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Romano A, Atanaskovic‐Markovic M, Barbaud A, Bircher AJ, Brockow K, Caubet J, Celik G, Cernadas J, Chiriac A, Demoly P, Garvey LH, Mayorga C, Nakonechna A, Whitaker P, Torres MJ. Towards a more precise diagnosis of hypersensitivity to beta-lactams - an EAACI position paper. Allergy 2020; 75:1300-1315. [PMID: 31749148 DOI: 10.1111/all.14122] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/08/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023]
Abstract
A recent survey of the European Academy of Allergy and Clinical Immunology (EAACI) Drug Allergy Interest Group (DAIG) on how European allergy specialists deal with beta-lactam (BL) hypersensitivity demonstrated a significant heterogeneity in current practice, suggesting the need to review and update existing EAACI guidelines in order to make the diagnostic procedures as safe and accurate, but also as cost-effective, as possible. For this purpose, a bibliographic search on large studies regarding BL hypersensitivity diagnosis was performed by an EAACI task force, which reviewed and evaluated the literature data using the GRADE system for quality of evidence and strength of recommendation. The updated guidelines provide a risk stratification in BL hypersensitivity according to index reaction(s), as well as an algorithmic approach, based on cross-reactivity studies, in patients with a suspicion of BL hypersensitivity and an immediate need for antibiotic therapy, when referral to an allergist is not feasible. Furthermore, the update addresses availability and concentrations of skin test (ST) reagents, ST and drug provocation test (DPT) protocols, and diagnostic algorithms and administration of alternative BL in allergic subjects. Specifically, distinct diagnostic algorithms are suggested depending on risk stratification of the patient into high and low risk based on the morphology and chronology of the reaction, immediate (ie, occurring within 1-6 hours after the last administered dose) or nonimmediate (ie, occurring more than 1 hour after the initial drug administration), and the reaction severity. Regarding the allergy workup, the main novelty of this document is the fact that in some low-risk nonimmediate reactions ST are not mandatory, especially in children. For DPT, further studies are necessary to provide data supporting the standardization of protocols, especially of those regarding nonimmediate reactions, for which there is currently no consensus.
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Affiliation(s)
- Antonino Romano
- Casa di Cura Quisisana Rome & Fondazione Mediterranea G.B. Catania Italy
| | | | - Annick Barbaud
- Departement of Dermatology and Allergology Institut Pierre Louis d'Epidemiologie et de Sante Publique INSERM Tenon Hospital Sorbonne Université Paris France
| | | | - Knut Brockow
- Department of Dermatology and Allergy Biederstein Technische Universität München Munich Germany
| | | | - Gulfem Celik
- Department of Immunology and Allergy Ankara University School of Medicine Ankara Turkey
| | - Josefina Cernadas
- Department of Allergy and Immunology Centro Hospitalar Universitário de S João Porto Portugal
| | - Anca‐Mirela Chiriac
- Division of Allergy Department of Pulmonology Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- UMRS 1136 Equipe ‐ EPAR ‐ IPLESP UPMC Univ Sorbonne Universités Paris France
| | - Pascal Demoly
- Division of Allergy Department of Pulmonology Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- UMRS 1136 Equipe ‐ EPAR ‐ IPLESP UPMC Univ Sorbonne Universités Paris France
| | - Lene H. Garvey
- Allergy Clinic Department of Dermatology and Allergy Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga-IBIMA Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga-UMA-ARADyAL Malaga Spain
| | - Alla Nakonechna
- Clinical Immunology and Allergy Unit Sheffield Teaching Hospital Sheffield UK
- University of Liverpool Liverpool UK
| | - Paul Whitaker
- Regional Adult Cystic Fibrosis Unit St James's Hospital Leeds UK
| | - María José Torres
- Allergy Unit Hospital Regional Universitario de Málaga-UMA-ARADyAL Malaga Spain
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15
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Brockow K. Triage Strategies for Clarifying Reported Betalactam Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:1066-1067. [PMID: 30832886 DOI: 10.1016/j.jaip.2018.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 08/20/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, München, Germany.
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16
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Stone CA, Trubiano J, Coleman DT, Rukasin CRF, Phillips EJ. The challenge of de-labeling penicillin allergy. Allergy 2020; 75:273-288. [PMID: 31049971 DOI: 10.1111/all.13848] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 03/28/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Even though 8%-25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de-labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. METHODS We performed an evidence-based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de-labeling. Over the period 1928-2018 in Pubmed and Medline, search terms used included "penicillin allergy" or "penicillin hypersensitivity" alone or in combination with "adverse events," "testing," "evaluation," "effects," "label," "de-labeling," "prick or epicutaneous," and "intradermal" skin testing, "oral challenge or provocation," "cross-reactivity," and "antimicrobial stewardship". RESULTS Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. CONCLUSIONS Operationalizing penicillin allergy de-labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de-labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.
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Affiliation(s)
- Cosby A. Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
| | - Jason Trubiano
- Department of Infectious Diseases Austin Health Heidelberg Victoria Australia
- Department of Infectious Diseases Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Medicine (Austin Health) University of Melbourne Parkville Victoria Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Parkville Victoria Australia
| | - David T. Coleman
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
| | - Christine R. F. Rukasin
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
| | - Elizabeth J. Phillips
- Division of Infectious Diseases, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
- Department of Pharmacology Vanderbilt University School of Medicine Nashville Tennessee
- Department of Pathology, Microbiology and Immunology Vanderbilt University Medical Center Nashville Tennessee
- Institute for Immunology & Infectious Diseases Murdoch University Murdoch Western Australia Australia
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Ogawa E, Shoji K, Miyairi I. Fever as a predictor of positive lymphocyte transformation test. Pediatr Int 2019; 61:951-955. [PMID: 31267605 DOI: 10.1111/ped.13937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/13/2019] [Accepted: 05/24/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Few studies have characterized the clinical manifestations of delayed antibiotic hypersensitivity (AH) diagnosed using objective methods. The lymphocyte transformation test (LTT) is a reproducible method to diagnose type IV hypersensitivity. The purpose of the study was to evaluate the characteristics of delayed AH diagnosed on LTT in children. METHODS We performed a retrospective analysis of patients who were evaluated for AH using LTT at National Center for Child Health and Development, Tokyo, from 2002 to 2014. We extracted patient demographics, type and duration of antibiotics, and clinical characteristics from the medical records. Clinical manifestations were compared between LTT-positive and LTT-negative cases. RESULTS Seventy-five cases for which 101 drugs were tested were included in this study. LTT was positive against 34 drugs in 26 cases. Median age was 5 years (IQR, 1-9 years), and 49% of patients had underlying disease. LTT was performed at a median of 18 days (IQR, 4-59 days) after the suspected episode. The median number of days from the initiation of therapy to the onset of symptoms was 4. Rash was the most common manifestation (89%). Fever (>38°C) was observed in 20 cases (27%). Onset of fever preceded the rash in nine cases (45%), appeared simultaneously in five (25%), appeared afterwards in four (20%), and was unknown in two (10%). Fever was an independent factor associated with AH when comparing LTT-positive and LTT-negative cases (OR, 3.61; 95%CI: 1.03-12.64). CONCLUSIONS Fever was a common presenting symptom of delayed AH in children aged ≤18 years.
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Affiliation(s)
- Eiki Ogawa
- Division of Infectious Diseases, Department of Medical Specialties, National Center for Child Health and Development, Tokyo, Japan
| | - Kensuke Shoji
- Division of Infectious Diseases, Department of Medical Specialties, National Center for Child Health and Development, Tokyo, Japan
| | - Isao Miyairi
- Division of Infectious Diseases, Department of Medical Specialties, National Center for Child Health and Development, Tokyo, Japan.,Department of Microbiology, Immunology, and Biochemistry, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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18
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Lutfeali S, Khan DA. Pediatric Drug Allergies: Updates on Beta-Lactam, Nonsteroidal Anti-Inflammatory Drug, and Chemotherapeutic Reactions. Pediatr Clin North Am 2019; 66:1035-1051. [PMID: 31466678 DOI: 10.1016/j.pcl.2019.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Adverse drug reactions are frequently reported in pediatric patients. In this review article, the authors discuss pediatric drug allergies with emphasis on the most common culprits, beta-lactam antibiotics and non-steroidal anti-inflammatory drugs. The authors also discuss reactions to non-beta-lactam antibiotics and chemotherapeutics. Skin testing has not yet been validated for many drugs, although notable exceptions include penicillin and carboplatin. The gold standard for diagnosis in most cases remains drug challenge, and the need for penicillin skin testing prior to oral provocation challenge has been questioned in recent studies. Successful desensitizations have also been reported with several drugs.
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Affiliation(s)
- Shazia Lutfeali
- Department of Internal Medicine, Division of Allergy & Immunology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8859, USA
| | - David A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8859, USA.
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19
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Regateiro F, Rezende I, Pinto N, Abreu C, Carreiro-Martins P, Gomes E. Short and extended provocation tests have similar negative predictive value in non-immediate hypersensitivity to beta-lactams in children. Allergol Immunopathol (Madr) 2019; 47:477-483. [PMID: 30910271 DOI: 10.1016/j.aller.2019.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Drug provocation tests (DPTs) are the gold-standard method to diagnose non-immediate hypersensitivity reactions (NIHSR) to beta-lactam antibiotics (BL) in children. Our aim was to compare the negative predictive value (NPV) of one-day (short) DPT versus 3-7 days (extended) DPT for the diagnosis of NIHSR to BL in paediatric age. A secondary aim was to compare confidence on drug re-exposure after short and extended negative DPTs. METHODS The occurrence of HSR on drug re-exposure and drug refusal after negative diagnostic DPTs were evaluated in children/adolescents with a history of NIHSR to BL using a questionnaire performed six months to ten years after DPT. Patients were divided into two groups according to the protocol performed: short DPT vs. extended DPT. RESULTS We enrolled 212 children and adolescents (86 females, 126 males, mean age at DPT 5.52 years, p25=3 years, p75=7.25 years): 69 tested with short DPT, and 143 with extended DPT. The NPV of both types of DPT together was 95.2%. The NPV of short DPT was 97.5% and the NPV of extended DPT was 93.8% (p=0.419). After negative DPT, beta-lactams were refused by carers in 14.75% of the children requiring subsequent treatment, 6.98% in the short DPT group and 18.99% in the extended DPT group (p=0.074). CONCLUSIONS In our paediatric sample, prolonging drug administration did not increase the NPV of diagnostic DPT for NIHSR to BL or reduce drug refusal. Altogether, the data here reported suggest that, however intuitive, prolonging DPT is not beneficial in the parameters analysed.
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20
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Barbero N, Fernández‐Santamaría R, Mayorga C, Martin‐Serrano Á, Salas M, Bogas G, Nájera F, Pérez‐Sala D, Pérez‐Inestrosa E, Fernandez TD, Montañez MI, Torres MJ. Identification of an antigenic determinant of clavulanic acid responsible for IgE-mediated reactions. Allergy 2019; 74:1490-1501. [PMID: 30829415 DOI: 10.1111/all.13761] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 01/23/2019] [Accepted: 02/18/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Selective reactions to clavulanic acid (CLV) account for around 30% of immediate reactions after administration of amoxicillin-CLV. Currently, no immunoassay is available for detecting specific IgE to CLV, and its specific recognition in patients with immediate reactions has only been demonstrated by basophil activation testing, however with suboptimal sensitivity. The lack of knowledge regarding the structure of the drug that remains bound to proteins (antigenic determinant) is hampering the development of in vitro diagnostics. We aimed to identify the antigenic determinants of CLV as well as to evaluate their specific IgE recognition and potential role for diagnosis. METHODS Based on complex CLV degradation mechanisms, we hypothesized the formation of two antigenic determinants for CLV, AD-I (N-protein, 3-oxopropanamide) and AD-II (N-protein, 3-aminopropanamide), and designed different synthetic analogs to each one. IgE recognition of these structures was evaluated in basophils from patients with selective reactions to CLV and tolerant subjects. In parallel, the CLV fragments bound to proteins were identified by proteomic approaches. RESULTS Two synthetic analogs of AD-I were found to activate basophils from allergic patients. This determinant was also detected bound to lysines 195 and 475 of CLV-treated human serum albumin. One of these analogs was able to activate basophils in 59% of patients whereas CLV only in 41%. Combining both results led to an increase in basophil activation in 69% of patients, and only in 12% of controls. CONCLUSION We have identified AD-I as one CLV antigenic determinant, which is the drug fragment that remains protein-bound.
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Affiliation(s)
- Nekane Barbero
- Andalusian Center for Nanomedicine and Biotechnology – BIONANDMálaga Spain
- Department of Organic Chemistry IBIMAUniversity of Málaga Málaga Spain
| | | | - Cristobalina Mayorga
- Andalusian Center for Nanomedicine and Biotechnology – BIONANDMálaga Spain
- Allergy Research GroupInstituto de Investigacion Biomédica de Malaga‐IBIMA Málaga Spain
- Allergy UnitHospital Regional Universitario de Malaga Málaga Spain
| | - Ángela Martin‐Serrano
- Andalusian Center for Nanomedicine and Biotechnology – BIONANDMálaga Spain
- Allergy Research GroupInstituto de Investigacion Biomédica de Malaga‐IBIMA Málaga Spain
| | - María Salas
- Allergy Research GroupInstituto de Investigacion Biomédica de Malaga‐IBIMA Málaga Spain
- Allergy UnitHospital Regional Universitario de Malaga Málaga Spain
| | - Gador Bogas
- Allergy Research GroupInstituto de Investigacion Biomédica de Malaga‐IBIMA Málaga Spain
- Allergy UnitHospital Regional Universitario de Malaga Málaga Spain
| | - Francisco Nájera
- Andalusian Center for Nanomedicine and Biotechnology – BIONANDMálaga Spain
- Department of Organic Chemistry IBIMAUniversity of Málaga Málaga Spain
| | | | - Ezequiel Pérez‐Inestrosa
- Andalusian Center for Nanomedicine and Biotechnology – BIONANDMálaga Spain
- Department of Organic Chemistry IBIMAUniversity of Málaga Málaga Spain
| | - Tahia D. Fernandez
- Allergy Research GroupInstituto de Investigacion Biomédica de Malaga‐IBIMA Málaga Spain
| | - María I. Montañez
- Andalusian Center for Nanomedicine and Biotechnology – BIONANDMálaga Spain
- Allergy Research GroupInstituto de Investigacion Biomédica de Malaga‐IBIMA Málaga Spain
| | - María J. Torres
- Andalusian Center for Nanomedicine and Biotechnology – BIONANDMálaga Spain
- Allergy Research GroupInstituto de Investigacion Biomédica de Malaga‐IBIMA Málaga Spain
- Allergy UnitHospital Regional Universitario de Malaga Málaga Spain
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Lteif L, Eiland LS. The Basics of Penicillin Allergy: What A Clinician Should Know. PHARMACY 2019; 7:E94. [PMID: 31319528 PMCID: PMC6789476 DOI: 10.3390/pharmacy7030094] [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: 06/05/2019] [Revised: 07/11/2019] [Accepted: 07/14/2019] [Indexed: 12/13/2022] Open
Abstract
Antimicrobials in the penicillin class are first line treatments for several infectious diseases in the pediatric and adult population today. In the United States, patients commonly report having a penicillin allergy, with penicillin being the most frequent beta-lactam allergy. However, very few patients experience a clinically significant immune-mediated allergic reaction to penicillin. If a true penicillin allergy exists, cross-reactivity to other beta-lactam antimicrobials may occur. Mislabeling patients with penicillin allergy can lead to a higher utilization of second line antimicrobial agents, potentially increasing costs and resistance due to a larger spectrum of activity. Pharmacists play an essential role in inquiring about patient specific reactions to presumed medication allergies and developing a further assessment plan, if needed, to determine if the medication allergy is real.
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Affiliation(s)
- Louis Lteif
- System Pharmacy Services, Sharp HealthCare, 8695 Spectrum Center Blvd, San Diego, CA 92123, USA.
| | - Lea S Eiland
- Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, 1321 Walker Building, Auburn, AL 36849, USA
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22
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W Covington E, B Wingler MJ, Jayakumar RA, White CW. Strategies for Clarifying Penicillin Allergies When Skin Testing Is Not an Option. PHARMACY 2019; 7:E69. [PMID: 31248168 PMCID: PMC6630467 DOI: 10.3390/pharmacy7020069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/10/2019] [Accepted: 06/17/2019] [Indexed: 01/08/2023] Open
Abstract
Patients with reported penicillin allergies have been proven to experience negative health consequences, such as increased cost, suboptimal antimicrobial therapy, and adverse reactions. Though skin testing has been proposed as a method to clarify penicillin allergies, many institutions may lack the resources to perform skin testing on a wide scale. This literature review describes the current literature surrounding the use of penicillin allergy interviews when skin testing is not an option. Specifically, the review highlights the steps in carrying out a successful antibiotic allergy patient interview, summarizes the clinical evidence surrounding antibiotic allergy clarifications, and addresses key advantages and disadvantages of clarifying antibiotic allergies without the availability of skin testing.
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Affiliation(s)
| | - Mary Joyce B Wingler
- Antimicrobial Stewardship Program, University of Mississippi Medical Center, Jackson, MS 39216, USA.
| | - Rebecca A Jayakumar
- Pharmacy Practice, Roseman University of Health Sciences College of Pharmacy, Henderson, NV 89014, USA.
| | - C Whitney White
- School of Pharmacy, University of Mississippi, Jackson, MS 39216, USA.
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23
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Saretta F, Mori F, Cardinale F, Liotti L, Franceschini F, Crisafulli G, Caimmi S, Bottau P, Bernardini R, Caffarelli C. Pediatric drug hypersensitivity: which diagnostic tests? ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:94-107. [PMID: 30830067 PMCID: PMC6502170 DOI: 10.23750/abm.v90i3-s.8171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/01/2019] [Indexed: 12/14/2022]
Abstract
Along with the anamnesis and clinical evaluation, diagnostic tests are one of the mainstream key points in the evaluation and management of drug hypersensitivity reactions (DHR). A wide knowledge gap, both in diagnosis and management of pediatric DHR, must be filled. Only a few published studies evaluated sensitivity and specificity of skin and in vitro tests in children. However, selected case series show that diagnostic work-up for adults could be useful, with some limitations, in pediatric age. Indeed, despite improvement in in vivo and in vitro diagnosis, drug provocation test remains the gold standard in pediatric age, too. Unmet needs in children include multi-centric studies on incidence of DHR, utility and feasibility of in vivo and in vitro diagnostic tests and specifically dedicated guidelines for the diagnosis and management of DHR in children.
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Affiliation(s)
- Francesca Saretta
- Pediatric Department, AAS2 Bassa Friulana-Isontina, Palmanova-Latisana, Italy; Pediatric Allergy Unit, Department of Medicine, Udine, Italy.
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24
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Chiriac AM, Romano A, Ben Fadhel N, Gaeta F, Molinari N, Maggioletti M, Demoly P. Follow‐up of patients with negative drug provocation tests to betalactams. Clin Exp Allergy 2019; 49:729-732. [DOI: 10.1111/cea.13314] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 09/30/2018] [Accepted: 10/16/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Anca Mirela Chiriac
- Département de Pneumologie et Addictologie Hôpital Arnaud‐de‐Villeneuve Centre Hospitalier Universitaire de Montpellier Univ Montpellier Montpellier France
- Equipe EPAR ‐ IPLESP Sorbonne Université Paris France
| | - Antonino Romano
- Allergy Unit Presidio Columbus Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
- IRCCS Oasi Maria S.S. Troina Italy
| | - Najah Ben Fadhel
- Département de Pneumologie et Addictologie Hôpital Arnaud‐de‐Villeneuve Centre Hospitalier Universitaire de Montpellier Univ Montpellier Montpellier France
- Department of Clinical Pharmacology University Hospital of Fattouma Bourguiba Monastir Tunisia
| | - Francesco Gaeta
- Allergy Unit Presidio Columbus Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
| | - Nicolas Molinari
- Department of Statistics IMAG CNRS Univ Montpellier CHU Montpellier Montpellier France
| | - Michela Maggioletti
- Allergy Unit Presidio Columbus Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
| | - Pascal Demoly
- Département de Pneumologie et Addictologie Hôpital Arnaud‐de‐Villeneuve Centre Hospitalier Universitaire de Montpellier Univ Montpellier Montpellier France
- Equipe EPAR ‐ IPLESP Sorbonne Université Paris France
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Graham F, Caubet JC. Diagnosis of drug causality in non-immediate drug hypersensitivity in children. Expert Rev Clin Pharmacol 2018; 11:655-658. [DOI: 10.1080/17512433.2018.1494570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- François Graham
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
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Tonson la Tour A, Michelet M, Eigenmann PA, Caubet JC. Natural History of Benign Nonimmediate Allergy to Beta-Lactams in Children: A Prospective Study in Retreated Patients After a Positive and a Negative Provocation Test. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1321-1326. [DOI: 10.1016/j.jaip.2017.10.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 12/01/2022]
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Trautmann A, Wurpts G. Allergien gegen Penizilline und andere β-Laktamantibiotika — Empfehlungen zu Diagnostik und Patientenmanagement. ALLERGO JOURNAL 2018. [DOI: 10.1007/s15007-018-1614-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Ibáñez MD, Rodríguez Del Río P, Lasa EM, Joral A, Ruiz-Hornillos J, Muñoz C, Gómez Traseira C, Escudero C, Olaguibel Rivera JM, Garriga-Baraut T, González-de-Olano D, Rosado A, Sanchez-García S, Pérez Bustamante S, Padial Vilchez MA, Prieto Montaño P, Candón Morillo R, Macías Iglesia E, Feliú Vila A, Valbuena T, Lopez-Patiño A, Martorell A, Sastre J, Audícana MT. Prospective assessment of diagnostic tests for pediatric penicillin allergy: From clinical history to challenge tests. Ann Allergy Asthma Immunol 2018; 121:235-244.e3. [PMID: 29803713 DOI: 10.1016/j.anai.2018.05.013] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/10/2018] [Accepted: 05/14/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diagnostic guidelines for penicillin allergy in children recommend cumbersome protocols based partially on data from adults, which may be suboptimal for pediatric use. OBJECTIVE To assess the accuracy of tools for diagnosis of penicillin allergy in children. METHODS A prospective, multicenter study was conducted in children with reported adverse events related to penicillin, excluding severe reactions. All patients underwent a uniform diagnostic protocol that consisted of clinical history, skin tests, serum specific IgE (sIgE), and, regardless of these results, drug provocation tests (DPTs). RESULTS A total of 732 children (mean age, 5.5 years; 51.2% males) completed the allergy workup, including DPTs. Amoxicillin triggered 96.9% of all reactions. None of the patients with an immediate index reaction (IR) developed a reaction on DPT. Penicillin allergy was confirmed in 35 children (4.8%): 6 immediate reactions (17%) and 29 nonimmediate reactions (83%) on the DPT. No severe reactions were recorded. The allergist diagnosis based on the clinical history was not associated with the DPT final outcome. In 30 of 33 allergic patients (91%), the results of all skin tests and sIgE tests were negative. A logistic regression model identified the following to be associated with penicillin allergy: a family history of drug allergy (odds ratio [OR], 3.03; 95% confidence interval [CI], 1.33-6.89; P = .008), an IR lasting more than 3 days vs 24 hours or less (OR, 8.96; 95% CI, 2.01-39.86; P = .004), and an IR treated with corticosteroids (OR, 2.68; 95% CI, 1.30-5.54; P = .007). CONCLUSION Conventional predictors of allergy to penicillin performed weakly. The authors propose straightforward penicillin provocation testing in controlled, experienced centers for the diagnosis of nonsevere penicillin allergy in children.
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Affiliation(s)
- María Dolores Ibáñez
- Allergy Department, Niño Jesús University Children's Hospital, Madrid, Spain; The Research Network ARADyAL RD16/0006/0026.
| | - Pablo Rodríguez Del Río
- Allergy Department, Niño Jesús University Children's Hospital, Madrid, Spain; The Research Network ARADyAL RD16/0006/0026
| | - Eva Maria Lasa
- Allergy Department, Hospital Universitario Donostia, Guipuzcoa, Spain
| | - Alejandro Joral
- Allergy Department, Hospital Universitario Donostia, Guipuzcoa, Spain
| | - Javier Ruiz-Hornillos
- Allergy Department, Hospital Universitario Infanta Elena, Valdemoro, Spain; Instituto de Investigación Sanitaria, Fundación Jiménez Díaz, Madrid, Spain
| | - Candelaria Muñoz
- Allergy Department. Children Hospital, University Regional Hospital, Málaga, Spain
| | | | - Carmelo Escudero
- Allergy Department, Niño Jesús University Children's Hospital, Madrid, Spain; The Research Network ARADyAL RD16/0006/0026
| | | | - Teresa Garriga-Baraut
- Unitat d'Al.lergologia Pediàtrica, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Grup Creixement i Desenvolupament, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | | | - Ana Rosado
- Unidad de Alergia, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Silvia Sanchez-García
- Allergy Department, Niño Jesús University Children's Hospital, Madrid, Spain; The Research Network ARADyAL RD16/0006/0026
| | - Socorro Pérez Bustamante
- Allergy Department, Torrejon University Hospital, Madrid, Spain; Allergy Department, Rincon Health Group, Vithas, Málaga, Spain
| | | | | | - Rocío Candón Morillo
- Allergy Department, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Eva Macías Iglesia
- Allergy Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Teresa Valbuena
- Servicio Alergología, Hospital Infanta Sofia, SS Reyes, Madrid, Spain
| | | | | | - Joaquín Sastre
- Instituto de Investigación Sanitaria, Fundación Jiménez Díaz, Madrid, Spain; Allergy Department, Fundación Jimenez Diaz, Madrid, Spain; Facultad de Universidad Autonoma de Madrid, Madrid, Spain
| | - María Teresa Audícana
- Allergy Department. Hospital Universitario Araba (HUA), Instituto Bioaraba, Vitoria, Spain
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Norton AE, Konvinse K, Phillips EJ, Broyles AD. Antibiotic Allergy in Pediatrics. Pediatrics 2018; 141:peds.2017-2497. [PMID: 29700201 PMCID: PMC5914499 DOI: 10.1542/peds.2017-2497] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2017] [Indexed: 12/11/2022] Open
Abstract
The overlabeling of pediatric antibiotic allergy represents a huge burden in society. Given that up to 10% of the US population is labeled as penicillin allergic, it can be estimated that at least 5 million children in this country are labeled with penicillin allergy. We now understand that most of the cutaneous symptoms that are interpreted as drug allergy are likely viral induced or due to a drug-virus interaction, and they usually do not represent a long-lasting, drug-specific, adaptive immune response to the antibiotic that a child received. Because most antibiotic allergy labels acquired in childhood are carried into adulthood, the overlabeling of antibiotic allergy is a liability that leads to unnecessary long-term health care risks, costs, and antibiotic resistance. Fortunately, awareness of this growing burden is increasing and leading to more emphasis on antibiotic allergy delabeling strategies in the adult population. There is growing literature that is used to support the safe and efficacious use of tools such as skin testing and drug challenge to evaluate and manage children with antibiotic allergy labels. In addition, there is an increasing understanding of antibiotic reactivity within classes and side-chain reactions. In summary, a better overall understanding of the current tools available for the diagnosis and management of adverse drug reactions is likely to change how pediatric primary care providers evaluate and treat patients with such diagnoses and prevent the unnecessary avoidance of antibiotics, particularly penicillins.
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Affiliation(s)
- Allison Eaddy Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, and
| | - Katherine Konvinse
- Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth J. Phillips
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, and,John A. Oates Institute for Experimental Therapeutics and Department of Pharmacology, School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee;,Division of Infectious Disease, Departments of Medicine and,Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee;,Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia; and
| | - Ana Dioun Broyles
- Division of Allergy and Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Efficacy and Safety of 5-Day Challenge for the Evaluation of Nonsevere Amoxicillin Allergy in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1673-1680. [PMID: 29425903 DOI: 10.1016/j.jaip.2018.01.030] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 01/17/2018] [Accepted: 01/28/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Penicillin allergy is the most frequent drug allergy, among which aminopenicillins are reputed for causing delayed rashes in children, particularly in the context of viral infections. Despite a negative allergy evaluation, a significant proportion of individuals continue to avoid penicillin antibiotics for fear of an allergic reaction. OBJECTIVE To evaluate the safety and efficacy of a 5-day challenge to amoxicillin and the proportion of subsequent use of amoxicillin. METHODS Pediatric patients with a history of a reaction to amoxicillin were prospectively recruited in the study. All patients were challenged, and those with negative immediate challenges underwent an ambulatory 5-day challenge to amoxicillin to rule out nonimmediate reactions. Patients were called 2 years after their initial allergy evaluation to assess subsequent amoxicillin use and tolerance. RESULTS One hundred thirty children with a history of amoxicillin allergy underwent a graded drug provocation test (DPT) to amoxicillin. Three patients had a positive immediate challenge, 3 had a positive nonimmediate challenge, and 2 were equivocal. Of the 122 patients with a negative challenge, 114 (93.4%) were reached 2 years after their initial allergy evaluation: 75 had used antibiotics since, of which only 1 (1.3%) had refused to reuse amoxicillin because of fear of an allergic reaction. Finally, the 5-day DPT resulted in a 24.1% decrease in future penicillin avoidance compared with classical single-dose graded DPT performed for 1 day in a historical cohort (P < .0001). CONCLUSION The 5-day challenge is a safe and effective way to rule out nonimmediate amoxicillin allergy, and it ensures better compliance with future penicillin use.
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Chiriac AM, Rerkpattanapipat T, Bousquet PJ, Molinari N, Demoly P. Optimal step doses for drug provocation tests to prove beta-lactam hypersensitivity. Allergy 2017; 72:552-561. [PMID: 27569064 DOI: 10.1111/all.13037] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Drug provocation tests (DPT) are commonly performed as part of β-lactam (BL) allergy workup, in case of negative skin tests (ST) and in the absence of contraindications. The recommendations of learned societies have created a frame for DPT performance, but protocols vary widely between centres, generating various hypothesis-driven protocols (i.e. empirical dosing, driven by both safety concerns and practical aspects). METHODS The primary objective of this retrospective analysis was to detect eliciting dose thresholds (reactive doses) during BL DPT, using the survival analysis method, in order to suggest optimal step doses. Our secondary objective was to evaluate the safety of our 30-min incremental 1-day protocol. The study included all the patients explored in the Allergy Unit of the University Hospital of Montpellier (France), between September 1996 and July 2015 for a suspicion of drug hypersensitivity reaction to BLs, with negative ST and positive DPT. RESULTS During the study period, 182 positive DPT (accounting for 171 hypersensitive patients) were analysed. We identified eliciting thresholds, and we suggest the following steps for DPT to BLs: 5-15-30-50% of daily therapeutic dose (with additional lower steps for index reactions of anaphylaxis). We confirm the safety of 1-day protocol for immediate and mild nonimmediate reactors, for both children and adults, with a surveillance period of 2 h after the last administered dose, and a prolonged surveillance after discharge of 48 h. CONCLUSION This data-driven approach in designing DPT protocols is a step forward in improving DPT standardization, starting with the most frequently tested drugs, BL antibiotics.
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Affiliation(s)
- A.-M. Chiriac
- 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
| | - T. Rerkpattanapipat
- Allergy, Immunology and Rheumatology Division; Department of Medicine; Faculty of Medicine; Ramathibodi Hospital; Mahidol University; Bangkok Thailand
| | - P.-J. Bousquet
- Division of Allergy; Department of Pulmonology; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
| | - N. Molinari
- Clinical Research Unit; Department of Clinical Information; University Hospital of Montpellier; Montpellier France
- Montpellier University; Montpellier France
- IMAG; UMR 5149; University Hospital of Montpellier; Montpellier France
| | - P. 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
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Abrams EM, Wakeman A, Gerstner TV, Warrington RJ, Singer AG. Prevalence of beta-lactam allergy: a retrospective chart review of drug allergy assessment in a predominantly pediatric population. Allergy Asthma Clin Immunol 2016; 12:59. [PMID: 27956906 PMCID: PMC5129666 DOI: 10.1186/s13223-016-0165-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/31/2016] [Indexed: 12/03/2022] Open
Abstract
Background Research suggests that 90% of patients labeled beta-lactam allergic are able to tolerate penicillins following further assessment. This study aims to define and describe the frequency of true beta-lactam allergy following allergy patient evaluation in a predominantly pediatric population. Methods 306 primary care patients referred between January 2010 and June 2015 were assessed for a suspected beta-lactam allergy. Patient demographics, history and test results were extracted from electronic medical records. Testing performed was based on specialist recommendation following review of patient history. Results 34% of the study participants had intradermal testing. Oral challenge was given to 96.7% of the sample. 96% of patients with a prior history of beta-lactam allergy were advised that they could re-introduce beta-lactam antibiotics following evaluation. Conclusions Among patients with a documented beta-lactam allergy or a recent history of a reaction there is a low rate of ‘true’ beta-lactam allergy. Consistent evaluation of beta-lactam antibiotic allergies can reduce rates of broad spectrum antibiotic prescribing, among other harmful consequences.
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Affiliation(s)
- Elissa M Abrams
- Section of Allergy and Immunology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | | | - Tom V Gerstner
- Section of Allergy and Immunology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Richard J Warrington
- Section of Allergy and Immunology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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Foong RXM, Logan K, Perkin MR, du Toit G. Lack of uniformity in the investigation and management of suspected β-lactam allergy in children. Pediatr Allergy Immunol 2016; 27:527-32. [PMID: 26920651 DOI: 10.1111/pai.12557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Beta-lactam allergy is commonly suspected in childhood with health implications for the individual and wider public. Diagnostic modalities include skin prick tests (SPT), specific immunoglobulin-E (sp-IgE) tests, intradermal tests (IDT) and drug provocation challenges (DPC). The aim of this research was to establish whether variation exists around the world in the investigation and management of beta-lactam allergy. METHODS Anonymized electronic questionnaire surveys were distributed over 3 months through International Allergy Societies for completion by clinicians who investigate drug allergy in children. RESULTS Eighty-one clinicians, practising in 16 countries, completed the questionnaire. There is variability in the selection of diagnostic tests used by clinicians around the world and poor agreement on positive cut-off values (sp-IgE, SPT and IDT) and practical techniques used to measure SPT or IDT wheal diameters. DPC were considered the gold standard investigation with 94% of respondents undertaking DPC over the last 12 months; 64% of respondents considered DPC extremely useful for both exclusion and confirmation of beta-lactam allergy. However, there is a lack of consensus on when and how DPC should be performed. Overall, DPC are safe - only 3% of our respondents had patients who required intramuscular adrenaline and none had patients requiring admission to intensive care. CONCLUSIONS There is lack of consistency amongst clinicians in different countries in the diagnosis and management of suspected beta-lactam allergy. The development of a standardized approach is a priority.
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Affiliation(s)
- Ru-Xin Melanie Foong
- Department of Paediatric Allergy, Guys and St. Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Kirsty Logan
- Department of Paediatric Allergy, Guys and St. Thomas' Hospitals NHS Foundation Trust, London, UK
| | | | - George du Toit
- Department of Paediatric Allergy, Guys and St. Thomas' Hospitals NHS Foundation Trust, London, UK.,Division of Asthma, Allergy and Lung Biology, Department of Allergy, King's College London, St. Thomas' Hospital, London, UK
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Atanaskovic-Markovic M, Caubet JC. Management of drug hypersensitivity in the pediatric population. Expert Rev Clin Pharmacol 2016; 9:1341-1349. [DOI: 10.1080/17512433.2016.1213131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Urriola N, Paganini L, Riminton S, Limaye S. Oral amoxicillin-associated anaphylaxis, 1 year after negative penicillin testing and oral amoxicillin challenge. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:763-4. [DOI: 10.1016/j.jaip.2016.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/18/2016] [Accepted: 01/29/2016] [Indexed: 10/22/2022]
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Vezir E, Dibek Misirlioglu E, Civelek E, Capanoglu M, Guvenir H, Ginis T, Toyran M, Kocabas CN. Direct oral provocation tests in non-immediate mild cutaneous reactions related to beta-lactam antibiotics. Pediatr Allergy Immunol 2016; 27:50-4. [PMID: 26619970 DOI: 10.1111/pai.12493] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND Skin testing has a limited role in the diagnosis of non-immediate beta-lactam hypersensitivity in children. The aim of this study was to report the results of oral provocation tests performed without skin tests in children with non-immediate mild cutaneous reactions without systemic symptoms caused by beta-lactam antibiotics. METHODS Oral provocation tests with suspected antibiotics were performed to patients with non-immediate mild cutaneous reactions without systemic symptoms caused by beta-lactam antibiotics. Skin tests were not performed before provocation tests. A total of five doses were administered with half-an-hour intervals in increasing doses. Provocation was continued for 5 days. RESULTS A total of 119 patients with a median age of 4.3 (IQR: 2-7.5) years, of whom 58% were males, were included in the study. Amoxicillin-clavulanic acid was the most frequently responsible agent in 87 (73.1%) patients, and most common type of rash was maculopapular in 74 (62.2%) patients. Four patients (3.4%) had an urticarial reaction during the provocation test. CONCLUSION We did not experience any severe reactions during oral provocation test without previous skin tests performed to children with non-immediate mild cutaneous reactions without systemic symptoms. Omitting skin tests before oral provocation test in this group of children can help decreasing the burden of allergy clinics and alleviating the discomfort of children.
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Affiliation(s)
- Emine Vezir
- Pediatric Allergy and Immunology, Ankara Children's Hematology Oncology Education and Research Hospital, Ankara, Turkey
| | - Emine Dibek Misirlioglu
- Pediatric Allergy and Immunology, Ankara Children's Hematology Oncology Education and Research Hospital, Ankara, Turkey
| | - Ersoy Civelek
- Pediatric Allergy and Immunology, Ankara Children's Hematology Oncology Education and Research Hospital, Ankara, Turkey
| | - Murat Capanoglu
- Pediatric Allergy and Immunology, Ankara Children's Hematology Oncology Education and Research Hospital, Ankara, Turkey
| | - Hakan Guvenir
- Pediatric Allergy and Immunology, Ankara Children's Hematology Oncology Education and Research Hospital, Ankara, Turkey
| | - Tayfur Ginis
- Pediatric Allergy and Immunology, Ankara Children's Hematology Oncology Education and Research Hospital, Ankara, Turkey
| | - Muge Toyran
- Pediatric Allergy and Immunology, Ankara Children's Hematology Oncology Education and Research Hospital, Ankara, Turkey
| | - Can N Kocabas
- Pediatric Allergy and Immunology, Mugla Sitki Kocman University Faculty of Medicine, Mugla, Turkey
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Gomes ER, Brockow K, Kuyucu S, Saretta F, Mori F, Blanca-Lopez N, Ott H, Atanaskovic-Markovic M, Kidon M, Caubet JC, Terreehorst I. Drug hypersensitivity in children: report from the pediatric task force of the EAACI Drug Allergy Interest Group. Allergy 2016; 71:149-61. [PMID: 26416157 DOI: 10.1111/all.12774] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2015] [Indexed: 12/22/2022]
Abstract
When questioned, about 10% of the parents report suspected hypersensitivity to at least one drug in their children. However, only a few of these reactions can be confirmed as allergic after a diagnostic workup. There is still a lack of knowledge on drug hypersensitivity (DH) epidemiology, clinical spectrum, and appropriate diagnostic methods particularly in children. Meanwhile, the tools used for DH management in adults are applied also for children. Whereas this appears generally acceptable, some aspects of DH and management differ with age. Most reactions in children are still attributed to betalactams. Some manifestations, such as nonsteroidal anti-inflammatory drug-associated angioedema and serum sickness-like reactions, are more frequent among young patients as compared to adults. Risk factors such as viral infections are particularly frequent in children, making the diagnosis challenging. The practicability and validity of skin test and other diagnostic procedures need further assessment in children. This study presents an up-to-date review on epidemiology, clinical spectrum, diagnostic tools, and current management of DH in children. A new general algorithm for the study of these reactions in children is proposed. Data are presented focusing on reported differences between pediatric and adult patients, also identifying unmet needs to be addressed in further research.
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Affiliation(s)
- E. R. Gomes
- Allergology Department; Centro Hospitalar do Porto; Porto Portugal
| | - K. Brockow
- Division Environmental Dermatology and Allergology Helmholtz Zentrum München/TUM; Department of Dermatology und AllergologyBiederstein; Technical University Munich; Munich Germany
| | - S. Kuyucu
- Department of Pediatric Allergy and Clinical Immunology; Faculty of Medicine; Mersin University; Mersin Turkey
| | - F. Saretta
- Pediatric Department; Hospital of Palmanova; A.S.S.5 ‘Bassa Friulana’; Palmanova UD Italy
| | - F. Mori
- Allergy Unit; Department of Pediatric; Anna Meyer Children's Hospital; University of Florence; Florence Italy
| | - N. Blanca-Lopez
- Allergy Department; Infanta Leonor University Hospital; Madrid Spain
| | - H. Ott
- Division of Pediatric Dermatology; Children's Hospital Auf der Bult; Hannover Germany
| | - M. Atanaskovic-Markovic
- University Children's Hospital of Belgrade; Medical Faculty University of Belgrade; Belgrade Serbia
| | - M. Kidon
- Allergy and Clinical Immunology Unit and Institute for Pediatric Pulmonology and National CF Center; Safra Children's Hospital; Tel Hashomer Israel
| | - J.-C. Caubet
- Division of Pediatric Allergy; University Hospital of Geneva; Geneva Switzerland
| | - I. Terreehorst
- Department of ENT and Pediatrics; AMC; Amsterdam The Netherlands
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Weisser C, Ben-Shoshan M. Immediate and non-immediate allergic reactions to amoxicillin present a diagnostic dilemma: a case series. J Med Case Rep 2016; 10:10. [PMID: 26781593 PMCID: PMC4717649 DOI: 10.1186/s13256-016-0801-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 01/04/2016] [Indexed: 12/16/2022] Open
Abstract
Background Allergic reactions to amoxicillin are very common occurrences in the pediatric age group; however, onset of symptoms can present a diagnostic dilemma. Case presentation We present a case series that describes three children (8-year-old white girl, 2-year-old white boy and 14-month-old Chinese boy) who presented with varied onset of allergic reactions to amoxicillin, specifically immediate (within the first hour after exposure) and non-immediate onset. One child developed immediate onset allergy to oral challenge with amoxicillin although his clinical history was evident for non-immediate onset allergy to amoxicillin. He was the only case that had a positive skin test to penicillin. Two other children presented with reactions toward the end of their treatment course of amoxicillin, yet one patient developed immediate onset allergy while the other patient developed non-immediate onset allergy after challenge. Conclusions This case series demonstrates diagnostic challenges facing physicians assessing allergic reactions to amoxicillin. As onset of reactions can dictate severity and pathogenic type of allergy, a thorough clinical history and subsequent appropriate diagnostic testing including medication challenge can help establish the diagnosis.
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Affiliation(s)
- Caroline Weisser
- Division of Pediatrics, Department of Pediatrics, Janeway Children's Hospital, St. John's, Newfoundland, Canada.
| | - Moshe Ben-Shoshan
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada
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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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Fox SJ, Park MA. Penicillin skin testing is a safe and effective tool for evaluating penicillin allergy in the pediatric population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 2:439-44. [PMID: 25017533 DOI: 10.1016/j.jaip.2014.04.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 03/30/2014] [Accepted: 04/30/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Penicillin skin testing has been validated in the evaluation of adult patients with penicillin allergy. However, the commercially available benzylpenicilloyl polylysine (Pre-Pen) is not indicated in the pediatric population. Moreover, the safety and validity of penicillin skin testing in the pediatric population has not been well studied. OBJECTIVE We describe the safety and validity of penicillin skin testing in the evaluation of children with a history of penicillin allergy. METHODS Children (<18 years) with a history of penicillin allergy were evaluated with penicillin skin tests and were reviewed for basic demographics, penicillin skin test results, adverse drug reaction to penicillin after penicillin skin test, and adverse reaction to penicillin skin test. By using the χ(2) test, we compared the differences in the proportion of children and adults with a positive penicillin skin test. P value (<.05) was considered statistically significant. The institutional review board approved the study, and all the subjects signed written informed consents. RESULTS A total of 778 children underwent penicillin skin testing; 703 of 778 patients had a negative penicillin skin test (90.4%), 66 had a positive test (8.5%), and 9 had an equivocal test (1.1%). Children were more likely to have a positive penicillin skin test (P < .0001) compared with adults (64 of 1759 [3.6%]); 369 of 703 patients with negative penicillin skin test (52%) were challenged with penicillin, and 14 of 369 patients (3.8%) had an adverse drug reaction. No adverse reactions to penicillin skin testing were observed. CONCLUSION Penicillin skin testing was safe and effective in the evaluation of children with a history of penicillin allergy.
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Affiliation(s)
| | - Miguel A Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn.
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Agache I, Bilò M, Braunstahl GJ, Delgado L, Demoly P, Eigenmann P, Gevaert P, Gomes E, Hellings P, Horak F, Muraro A, Werfel T, Jutel M. In vivo diagnosis of allergic diseases--allergen provocation tests. Allergy 2015; 70:355-65. [PMID: 25640808 DOI: 10.1111/all.12586] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2015] [Indexed: 12/31/2022]
Abstract
The allergen challenge test has been the mainstay of diagnosis of allergic diseases for a long time since it offers a direct proof of the clinical relevance of a particular allergen for the allergic disease symptoms and severity. Standardisation and availability for daily practice (including safety issues) are still to be refined but most of the challenge tests have safely crossed the border from research tools to diagnostic tests available for daily practice for a well trained clinical staff.
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Affiliation(s)
- I. Agache
- Transylvania University Brasov; Brasov Romania
| | - M. Bilò
- Internal Medicine; Allergy Unit; Ancona Italy
| | | | - L. Delgado
- Faculty of Medicine; Allergy Division; Porto University; Porto Portugal
| | - P. Demoly
- Allergy; University Hospital of Montpellier; Montpellier France
| | - P. Eigenmann
- Paediatrics; University Hospital Geneva; Geneva Switzerland
| | - P. Gevaert
- Otorhinolaryngology; Ghent University; Ghent Belgium
| | - E. Gomes
- Servico de Imunoalergologia; Hospital Maria Pia; Porto Portugal
| | - P. Hellings
- Department of Orothinolaryngology; University Hospitals Leuven; Leuven Belgium
| | - F. Horak
- Department of Allergy Research; Allergy Center Wien West; Vienna Austria
| | - A. Muraro
- Department of Pediatrics; Referral Centre for Food Allergy; Padua General University Hospital; Padua Italy
| | - T. Werfel
- Dermatology and Allergy; Hannover Medical School; Hannover Austria
| | - M. Jutel
- Department of Clinical Immunology; Wroclaw Medical University; Wroclaw Poland
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Mori F, Cianferoni A, Barni S, Pucci N, Rossi ME, Novembre E. Amoxicillin allergy in children: five-day drug provocation test in the diagnosis of nonimmediate reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:375-80.e1. [PMID: 25609343 DOI: 10.1016/j.jaip.2014.11.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 10/30/2014] [Accepted: 11/03/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND The drug provocation test (DPT) is the gold standard to rule out drug hypersensitivity. There are standardized DPT protocols to diagnose immediate reactions to drugs, but not for nonimmediate reactions. OBJECTIVE The aim of this study was to show the sensitivity and specificity of an allergy work-up that included a 5-day DPT in children with histories of nonimmediate reactions to amoxicillin through focusing on a pediatric population with histories of immediate and nonimmediate reactions to amoxicillin. METHODS Two hundred consecutive patients with histories of amoxicillin reactions referred to the Allergy Unit of Anna Meyer Children's Hospital for suspected drug allergy from 2008 to 2011 underwent in vivo tests with the culprit drug according to European Academy of Allergy and Clinical Immunology guidelines. Moreover, most of those children, regardless of the skin tests results, were challenged with amoxicillin for a total of 5 days. RESULTS In 4 years, 200 patients were evaluated for a history of drug hypersensitivity to amoxicillin. The majority of patients (76%) had a history of mild nonimmediate reactions. All 200 patients underwent skin tests, and 9 of 200 tested positive. A total of 177 DPTs were performed with amoxicillin for 5 days in each child. Diagnosis of amoxicillin allergy was confirmed by a DPT in 17 patients (9.6%); 14/17 had history of nonimmediate reactions; 4/14 (26.6%) reacted on day 5. CONCLUSION According to our results, a long-term DPT protocol increases the sensitivity of the allergy work-up, and it should be recommended for patients with a history of amoxicillin nonimmediate reaction.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy.
| | | | - Simona Barni
- Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
| | - Neri Pucci
- Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
| | - Maria Elisabetta Rossi
- Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
| | - Elio Novembre
- Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
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Misirlioglu ED, Toyran M, Capanoglu M, Kaya A, Civelek E, Kocabas CN. Negative predictive value of drug provocation tests in children. Pediatr Allergy Immunol 2014; 25:685-90. [PMID: 25283219 DOI: 10.1111/pai.12286] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The negative predictive value of the drug provocation test is important for both the patient and the physician. However, in children, this predictive value is unresolved. METHODS The study included patients who had drug provocation test with a suspected drug and was diagnosed as 'not allergic to the drug'. Three months after allergy workup, the patients were contacted and asked for reexposure to the tested drug. Patients who have reported reactions during reexposure were reevaluated with skin tests and drug provocation. RESULTS During the study period, 217 provocations were performed to 203 patients. Of these, 163 patients (80.3%) with 175 negative drug provocation tests could be contacted. Ninety-one (52%) of the 175 cases reported to use the tested drug again, and 11 (12%) of these cases declared that they had a new reaction. Two of the eleven cases refused reevaluation. Nine cases were evaluated by drug allergy workup. Two of the nine cases were classified as allergic after retests. Collectively, the negative predictive value was 95.6% (87 of 91 cases) for all drug challenges. CONCLUSIONS The negative predictive value of the drug provocation test is abundant in children; however, negative drug provocation tests do not necessarily predict tolerance for the drug.
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Affiliation(s)
- Emine D Misirlioglu
- Department of Pediatric Allergy and Immunology, Ankara Children's Hematology Oncology Training and Research Hospital, Ankara, Turkey
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Romano A, Caubet JC. Antibiotic allergies in children and adults: from clinical symptoms to skin testing diagnosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:3-12. [PMID: 24565763 DOI: 10.1016/j.jaip.2013.11.006] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 11/20/2013] [Accepted: 11/21/2013] [Indexed: 11/15/2022]
Abstract
Hypersensitivity reactions to β-lactam and non-β-lactam antibiotics are commonly reported. They can be classified as immediate or nonimmediate according to the time interval between the last drug administration and their onset. Immediate reactions occur within 1 hour after the last drug administration and are manifested clinically by urticaria and/or angioedema, rhinitis, bronchospasm, and anaphylactic shock; they may be mediated by specific IgE-antibodies. Nonimmediate reactions occur more than 1 hour after the last drug administration. The most common manifestations are maculopapular exanthems; specific T lymphocytes may be involved in this type of manifestation. The diagnostic evaluation of hypersensitivity reactions to antibiotics is usually complex. The patient's history is fundamental; the allergic examination is based mainly on in vivo tests selected on the basis of the clinical features and the type of reaction, immediate or nonimmediate. Immediate reactions can be assessed by immediate-reading skin tests and, in selected cases, drug provocation tests. Nonimmediate reactions can be assessed by delayed-reading skin tests, patch tests, and drug provocation tests. However, skin tests have been well validated mainly for β-lactams but less for other classes of antibiotics.
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Affiliation(s)
- Antonino Romano
- Allergy Unit, Complesso Integrato Columbus, Rome, Italy; Istituto di Ricovero e Cura a Carattere Scientifico Oasi Maria S.S., Troina, Italy
| | - Jean-Christoph Caubet
- Department of Child and Adolescent, University Hospitals of Geneva and Medical School of The University of Geneva, Geneva, Switzerland.
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Richter AG, Nasser SM, Krishna MT. A UK national survey of investigations for beta-lactam hypersensitivity - heterogeneity in practice and a need for national guidelines - on behalf of British Society for Allergy and Clinical Immunology (BSACI). Clin Exp Allergy 2014; 43:941-9. [PMID: 23889247 DOI: 10.1111/cea.12134] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 02/21/2013] [Accepted: 04/04/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND Beta lactams (BL) are the most widely prescribed antibiotics in the UK and the commonest cause of hypersensitivity reactions. There are no UK guidelines for BL testing and the most relevant guidelines were devised by the European Network for Drug Allergy (ENDA) on behalf of the European Academy of Allergy and Clinical Immunology. OBJECTIVE Delivery of allergy services differs across Europe, so this survey was designed to investigate how closely UK practice adhered to these guidelines. METHODS An online survey, using surveymonkey.com software, was sent to all consultants offering an allergy service in the UK and who were members of either BSACI or 'Travellers' (Immunology consultant group). RESULTS The response rate was 48% (n=81/165) and BL allergy testing was undertaken by 78% of respondents. All responders requested SsIgE, although four responders stated they rarely requested. Skin testing was undertaken by 87% of respondents who perform beta lactam testing with 17% undertaking skin prick testing (SPT) only, 77% SPT followed by intra-dermal testing (IDT) if the former were negative or indeterminate and 6% SPT and IDT in all cases. The drugs, doses and protocols for skin testing varied considerably. Drug provocation testing was undertaken by 87% of respondents who undertake beta lactam testing with significant heterogeneity in protocols. Respondents that investigated ≤ 20 patients per year demonstrated lower adherence to ENDA recommendations compared to those who saw > 20. Following positive testing, 79% advised avoidance of all penicillins only and the remainder advised additional drug avoidance. CONCLUSION AND CLINICAL RELEVANCE This survey revealed variation in the investigation and management of BL hypersensitivity in the UK with some centres reporting procedures that could potentially put patients at risk of anaphylaxis if allergy was falsely excluded. This survey highlights an urgent need for evidence based national guidelines and standardisation of practice.
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Affiliation(s)
- A G Richter
- School of Immunity and Infection, University of Birmingham, Birmingham, UK.
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Barbaud A. Drug skin tests and systemic cutaneous adverse drug reactions: an update. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.2.4.481] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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