1
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Celik GE, Guloglu Karatas D, Aydin O, Dogu F, Ikinciogullari A. Diagnostic utility of basophil CD203c expression in β-lactam allergy. Allergy Asthma Proc 2023; 44:200-207. [PMID: 37160747 DOI: 10.2500/aap.2023.44.230013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background: A diagnosis of immunoglobulin E (IgE) mediated reactions to β-lactam (BL) antibiotics is still challenging because of the limited availability of skin-prick test (SPT), and standardization issues, particularly with newer BLs, are still ongoing. Because encouraging data are increasingly emerging in the use of basophil activation tests in the diagnosis of IgE-mediated drug hypersensitivity reactions, in this study, we aimed to determine CD203c expression, a basophil surface marker, in the diagnosis of IgE-mediated hypersensitivity to BL antibiotics. Methods: This study included two groups of subjects. The first group (group 1) (n = 20) included patients with a diagnosis of IgE-mediated allergy to BLs as confirmed through STs or drug provocation tests, and the control group consisted of healthy volunteers (group 2) (n = 24). Expression of CD203c by flow cytometry was studied in samples stimulated by two different concentrations of six different BL antibiotics. A stimulation index ≥ 2 was considered a positive response. Results: The study groups had comparable age and sex distribution. In the entire group, the sensitivity and specificity of CD203c were 29.4% (5 out of 17) and 82.6% (19 out of 23), respectively. When considering the single reactors, two among four patients who were allergic to amoxicillin demonstrated upregulation of CD203c with amoxicillin, which makes 50% sensitivity. The specificity was 100%. Conclusion: Our data demonstrated that assessment of CD203c in the diagnosis of IgE-mediated reactions to BLs provided encouraging results, particularly with amoxicillin allergy. However, this finding needs to be verified in a larger number of cases.
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Affiliation(s)
- Gulfem Elif Celik
- From the, Department of Chest Diseases, Division of Immunology and Allergy, Ankara, Turkey, and
| | | | - Omur Aydin
- From the, Department of Chest Diseases, Division of Immunology and Allergy, Ankara, Turkey, and
| | - Figen Dogu
- Department of Pediatric Immunology and Allergy, Ankara, Turkey
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2
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Copaescu AM, Ben-Shoshan M, Trubiano JA. Tools to improve the diagnosis and management of T-cell mediated adverse drug reactions. Front Med (Lausanne) 2022; 9:923991. [PMID: 36313986 PMCID: PMC9606226 DOI: 10.3389/fmed.2022.923991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/26/2022] [Indexed: 11/25/2022] Open
Abstract
Delayed drug T-cell immune-mediated hypersensitivity reactions have a large clinical heterogeneity varying from mild maculopapular exanthema (MPE) to severe cutaneous adverse reactions (SCARs) such as acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS) and severe skin necrosis and blistering as seen in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Given the knowledge gaps related to the immunopathogenesis of these conditions, the absence of validated diagnostic tools and the significant associated morbidity and mortality, patients with SCARs often have limited drug choices. We performed a comprehensive review aiming to evaluate in vivo diagnostic tools such as delayed intradermal skin and patch testing and ex vivo/in vitro research assays such as the lymphocyte transformation test (LTT) and the enzyme-linked ImmunoSpot (ELISpot) assay. We searched through PubMed using the terms “drug allergy,” “in vivo” and “ex vivo” for original papers in the last 10 years. A detailed meticulous approach adapted to the various clinical phenotypes is recommended for the diagnostic and management of delayed drug hypersensitivity reactions. This review highlights the current diagnostic tools for the delayed drug hypersensitivity phenotypes.
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Affiliation(s)
- Ana Maria Copaescu
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia,Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre (MUHC), Montreal, QC, Canada,The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), Montreal, QC, Canada,*Correspondence: Ana Maria Copaescu,
| | - Moshe Ben-Shoshan
- The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), Montreal, QC, Canada,Division of Allergy, Immunology and Dermatology, Montreal Children’s Hospital, McGill University Health Centre (MUHC), Montreal, QC, Canada
| | - Jason A. Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia,Department of Oncology, Sir Peter MacCallum Cancer Centre, The University of Melbourne, Parkville, VIC, Australia,Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, VIC, Australia,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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3
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Cardoso‐Fernandes A, Blumenthal KG, Chiriac AM, Tarrio I, Afonso‐João D, Delgado L, Fonseca JA, Azevedo LF, Sousa‐Pinto B. Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta-analysis. Clin Transl Allergy 2021; 11:e12008. [PMID: 34161664 PMCID: PMC8215894 DOI: 10.1002/clt2.12008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Patients with a penicillin allergy label tend to have worse clinical outcomes and increased healthcare use. Drug provocation tests (DPT) are the gold-standard in the diagnostic workup of penicillin allergy, but safety concerns may hinder their performance. We aimed to assess the frequency of severe reactions following a DPT in patients with reported allergy to penicillins or other β-lactams. METHODS We performed a systematic review, searching MEDLINE, Scopus, and Web of Science. We included primary studies assessing participants with a penicillin allergy label who underwent a DPT. We performed a Bayesian meta-analysis to estimate the pooled frequency of severe reactions to penicillin DPTs. Sources of heterogeneity were explored by subgroup and metaregression analyses. RESULTS We included 112 primary studies which included a total of 26,595 participants. The pooled frequency of severe reactions was estimated at 0.06% (95% credible interval [95% CrI] = 0.01%-0.13%; I2 = 57.9%). Most severe reactions (80/93; 86.0%) consisted of anaphylaxis. Compared to studies where the index reaction was immediate, we observed a lower frequency of severe reactions for studies assessing non-immediate index reactions (OR = 0.05; 95% CrI = 0-0.31). Patients reporting anaphylaxis as their index reaction were found to be at increased risk of developing severe reactions (OR = 13.5; 95% CrI = 7.7-21.5; I2 = 0.3%). Performance of direct DPTs in low-risk patients or testing with the suspected culprit drug were not associated with clinically relevant increased risk of severe reactions. CONCLUSIONS In patients with a penicillin allergy label, severe reactions resulting from DPTs are rare. Therefore, except for patients with potentially life-threatening index reactions or patients with positive skin tests-who were mostly not assessed in this analysis -, the safety of DPTs supports their performance in the diagnostic assessment of penicillin allergy.
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Affiliation(s)
- António Cardoso‐Fernandes
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolHarvard UniversityBostonMassachusettsUSA
| | - Anca Mirela Chiriac
- Department of PulmonologyDivision of Allergy, Hôpital Arnaud de VilleneuveUniversity Hospital of MontpellierMontpellierFrance
- UMR‐S 1136 INSERM‐Sorbonne UniversitéEquipe Epidémiologie des Maladies Allergiques et Respiratoires (EPAR)Institut Pierre Louis d’Epidémiologie et de Santé PubliqueParisFrance
| | - Isabel Tarrio
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - David Afonso‐João
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Luís Delgado
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
- Basic and Clinical Immunology Unit, Department of Pathology, Faculty of MedicineUniversity of PortoPortoPortugal
| | - João Almeida Fonseca
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Luís Filipe Azevedo
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Bernardo Sousa‐Pinto
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
- Basic and Clinical Immunology Unit, Department of Pathology, Faculty of MedicineUniversity of PortoPortoPortugal
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Sabato V, Poorten MLVD, Ebo DG. Immediate Reactions to Cephalosporins: It is Time to Standardize the Diagnostic Essence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1658-1659. [PMID: 33838845 DOI: 10.1016/j.jaip.2021.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Vito Sabato
- Department of Immunology, Allergology, Rheumatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Marie-Line van der Poorten
- Department of Immunology, Allergology, Rheumatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium; Department of Paediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Didier G Ebo
- Department of Immunology, Allergology, Rheumatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium.
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5
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Skin Tests for Immediate Hypersensitivity. Contact Dermatitis 2021. [DOI: 10.1007/978-3-030-36335-2_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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6
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Rosti B, Mahler V. Adding a second skin prick test reading and modifying the cut‐off for beta‐lactam–specific
IgE
enhances the sensitivity in the routine diagnostic workup for immediate beta‐lactam hypersensitivity. Contact Dermatitis 2020; 83:361-371. [DOI: 10.1111/cod.13622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Bernadette Rosti
- Allergy‐Clinic of the Department of Dermatology University Hospital of Erlangen Erlangen Germany
- Dental Practice Dr. Ludwig and Colleagues MVZ GmbH Fürth Germany
| | - Vera Mahler
- Allergy‐Clinic of the Department of Dermatology University Hospital of Erlangen Erlangen Germany
- Division of Allergology Paul‐Ehrlich‐Institut Langen Germany
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7
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Li PH, Yeung HHF, Lau CS, Au EYL. Prevalence, Incidence, and Sensitization Profile of β-lactam Antibiotic Allergy in Hong Kong. JAMA Netw Open 2020; 3:e204199. [PMID: 32374398 PMCID: PMC7203606 DOI: 10.1001/jamanetworkopen.2020.4199] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE Allergy to β-lactam antibiotics is one of the most frequently reported drug reactions, but epidemiological data in Chinese populations are lacking. Ethnic- and region-specific sensitization patterns of skin testing for β-lactam antibiotic allergy are also unknown. OBJECTIVE To identify the prevalence, 1-year incidence, and sensitization patterns of β-lactam antibiotic allergy in patients in Hong Kong. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study obtained territorywide, anonymized electronic patient data from the Clinical Management Systems of the Hospital Authority, the sole publicly funded health care system in Hong Kong with facilities in 7 regions (Hong Kong East, Hong Kong West, Kowloon Central, Kowloon East, Kowloon West, New Territories East, and New Territories West). All referrals to Queen Mary Hospital for β-lactam antibiotic allergy testing from January 1, 2018, to December 31, 2019, were also analyzed for sensitization patterns. MAIN OUTCOMES AND MEASURES Prevalence and cumulative incidence of β-lactam antibiotic allergy reported in Hong Kong, and sensitization patterns according to β-lactam antibiotic allergy skin testing. RESULTS Complete records of 7 184 271 unique patients were analyzed, with a men to women ratio of 1:1.2 and with a median age of 44 years. The prevalence of physician-reported β-lactam antibiotic allergy was 2.0%, and the cumulative incidence was 107 per 100 000 population. Of the 34 402 new drug allergies reported in 2018, 8032 (23.3%) were β-lactam antibiotic allergies. Three hundred fifty-five patients with reactions suggestive of β-lactam antibiotic allergy underwent skin testing, and only 49 (13.8%; 95% CI, 10.64%-17.90%) of them had positive test results. Of these 49 patients, 14 (28.6%; 95% CI, 18.35%-44.49%) had selective reaction and 35 (71.4%; 95% CI, 59.84%-85.27%) had nonselective reaction. The sensitization rate to either benzylpenicilloyl polylysine or a minor determinant (benzylpenicilloate) was 47.0% (n = 23; 95% CI, 34.85%-63.21%), with 10 patients monosensitized to benzylpenicilloyl polylysine only (20.4%; 95% CI, 11.74%-35.48%) and 5 to benzylpenicilloate only (10.2%; 95% CI, 4.45%-23.42%). CONCLUSIONS AND RELEVANCE Results of this study suggest that patients in Hong Kong with β-lactam antibiotic allergy had much higher rates of monosensitization to benzylpenicilloyl polylysine and benzylpenicilloate, making these reagents essential in β-lactam antibiotic skin tests. Such a finding warrants future studies into whether this sensitization is specific to ethnicity or region.
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Affiliation(s)
- Philip H. Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Heather H. F. Yeung
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Chak-Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Elaine Y. L. Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
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8
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Mortz CG, Bindslev-Jensen C. Skin Tests for Immediate Hypersensitivity. Contact Dermatitis 2020. [DOI: 10.1007/978-3-319-72451-5_28-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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9
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Affiliation(s)
- Mariana Castells
- From Brigham and Women's Hospital, Boston (M.C.); UT Southwestern Medical Center, Dallas (D.A.K.); and Vanderbilt University Medical Center, Nashville (E.J.P.)
| | - David A Khan
- From Brigham and Women's Hospital, Boston (M.C.); UT Southwestern Medical Center, Dallas (D.A.K.); and Vanderbilt University Medical Center, Nashville (E.J.P.)
| | - Elizabeth J Phillips
- From Brigham and Women's Hospital, Boston (M.C.); UT Southwestern Medical Center, Dallas (D.A.K.); and Vanderbilt University Medical Center, Nashville (E.J.P.)
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10
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To challenge or not to challenge: Literature data on the positive predictive value of skin tests to beta-lactams. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2404-2408.e11. [PMID: 30844483 DOI: 10.1016/j.jaip.2019.01.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/31/2018] [Accepted: 01/14/2019] [Indexed: 12/19/2022]
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11
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Adkinson NF, Mendelson LM, Ressler C, Keogh JC. Penicillin minor determinants: History and relevance for current diagnosis. Ann Allergy Asthma Immunol 2018; 121:537-544. [PMID: 30248407 DOI: 10.1016/j.anai.2018.09.459] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/18/2018] [Accepted: 09/18/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To review the history of the penicillin minor determinants and evaluate their relevance for current diagnosis. DATA SOURCES Skin testing to detect immunoglobulin E (IgE) sensitivity to penicillins in patients with a history of penicillin allergy has been the subject of more than 55 years of published research involving tens of thousands of patients. STUDY SELECTIONS Selection of data was based on its relevance to the objective of this article. RESULTS It was established early on that testing with the major penicilloyl determinant using the polyvalent penicilloyl-polylysine (PPL) is negative in a substantial portion (10% to 64%, including recent increases) of those at risk for immediate hypersensitivity reactions. A variety of minor penicillin determinants are clinically significant in that their use in skin testing is essential to detect all those at risk. In particular, a minor determinant mixture of benzylpenicillin, benzylpenicilloate, and benzylpenilloate, used in conjunction with PPL, has been shown in numerous studies to achieve an average negative predictive value (NPV) of 97.9% in history-positive patients. Benzylpenicillin alone, as the sole minor determinant, leaves many skin test-positive patients undiscovered. Use of amoxicillin as an additional minor determinant reagent appears to identify another 2% to 8% of skin test-positive patients in some populations. CONCLUSION IgE skin testing, using both the major and appropriate minor determinants of penicillin, can identify, with a high degree of reliability (NPV ∼97%), penicillin allergy history-positive patients who can receive beta-lactam antibiotics without concern for serious acute allergy, including anaphylaxis. The few false-negative skin tests reported globally are largely confined to minor, self-limited cutaneous reactions.
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Affiliation(s)
- N Franklin Adkinson
- Division of Allergy & Clinical Immunology, Johns Hopkins Asthma & Allergy Center, Baltimore, Maryland; AllerQuest LLC, Plainville, Connecticut.
| | - Louis M Mendelson
- AllerQuest LLC, Plainville, Connecticut; University of Connecticut School of Medicine, New England Food Allergy Center, Farmington, Connecticut
| | - Charlotte Ressler
- AllerQuest LLC, Plainville, Connecticut; University of Connecticut School of Medicine, Farmington, Connecticut
| | - John C Keogh
- AllerQuest LLC, Plainville, Connecticut; Keogh Medical Writing, LLC, Guilford, Connecticut
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Romano A, Valluzzi RL, Caruso C, Maggioletti M, Gaeta F. Non-immediate Cutaneous Reactions to Beta-Lactams: Approach to Diagnosis. Curr Allergy Asthma Rep 2017; 17:23. [PMID: 28382604 DOI: 10.1007/s11882-017-0691-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Non-immediate cutaneous reactions (i.e., occurring at least 1 h after the initial drug administration), particularly maculopapular exanthemas and urticarial eruptions, are common during beta-lactam treatments. A T cell-mediated pathogenic mechanism has been demonstrated in some cutaneous reactions, such as maculopapular exanthema, fixed drug eruption, acute generalized exanthematous pustulosis, and drug-induced hypersensitivity syndrome. In the diagnostic work-up, patch testing is useful, together with delayed-reading intradermal testing. Patch tests are a simple and safe diagnostic tool, which in the case of severe reactions should be used as the first line of investigation. However, patch tests are less sensitive than intradermal tests, which are preferable in subjects with mild reactions. Lymphocyte transformation or activation tests and enzyme-linked immunosorbent spot assays can be used as complementary tests. In selected cases of mild or moderate reactions, displaying negative results in the aforesaid allergy tests, a graded challenge with the implicated beta-lactam can be performed.
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Affiliation(s)
- Antonino Romano
- Allergy Unit, Presidio Columbus, Via G. Moscati, 31, 00168, Rome, Italy. .,IRCCS Oasi Maria S.S, Troina, Italy.
| | - Rocco Luigi Valluzzi
- Allergy Unit, Presidio Columbus, Via G. Moscati, 31, 00168, Rome, Italy.,Department of Pediatrics, Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Vatican City, Italy
| | - Cristiano Caruso
- Allergy Unit, Presidio Columbus, Via G. Moscati, 31, 00168, Rome, Italy
| | | | - Francesco Gaeta
- Allergy Unit, Presidio Columbus, Via G. Moscati, 31, 00168, Rome, Italy
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Romano A, Gaeta F, Arribas Poves MF, Valluzzi RL. Cross-Reactivity among Beta-Lactams. Curr Allergy Asthma Rep 2016; 16:24. [PMID: 26898316 DOI: 10.1007/s11882-016-0594-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Penicillins and cephalosporins are the major classes of beta-lactam (BL) antibiotics in use today and one of the most frequent causes of hypersensitivity reactions to drugs. Monobactams, carbapenems, oxacephems, and beta-lactamase inhibitors constitute the four minor classes of BLs. This review takes into account mainly the prospective studies which evaluated cross-reactivity among BLs in subjects with a well-demonstrated hypersensitivity to a certain class of BLs by performing allergy tests with alternative BLs and, in case of negative results, administering them. In subjects with either IgE-mediated or T-cell-mediated hypersensitivity, cross-reactivity among BLs, particularly among penicillins and among cephalosporins, as well as between penicillins and cephalosporins, seems to be mainly related to structural similarities among their side-chain determinants. Specifically, in penicillin-allergic subjects, cross-reactivity between penicillins and cephalosporins may exceed 30% when they are administered cephalosporins with identical side chains to those of responsible penicillins. In these subjects, a few prospective studies have demonstrated a rate of cross-reactivity between penicillins and both carbapenems and aztreonam lower than 1%. With regard to subjects with an IgE-mediated hypersensitivity to cephalosporins, in a single study, about 25% of the 98 subjects with such hypersensitivity had positive results to penicillins, 3% to aztreonam, 2% to imipenem/cilastatin, and 1% to meropenem. The cross-reactivity related to the selective recognition of the BL ring by IgE or T lymphocytes, which entails positive responses to all BLs tested, appears to be exceptional. Some studies concerning cross-reactivity among BLs have found patterns of allergy-test positivity which cannot be explained by either the common BL ring or by similar or identical side chains, thus indicating the possibility of coexisting sensitivities to different BLs because of prior exposures to them.
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Affiliation(s)
- Antonino Romano
- Allergy Unit, Complesso Integrato Columbus, Via G. Moscati, 31, 00168, Rome, Italy. .,IRCCS Oasi Maria S.S., Troina, Italy.
| | - Francesco Gaeta
- Allergy Unit, Complesso Integrato Columbus, Via G. Moscati, 31, 00168, Rome, Italy
| | | | - Rocco Luigi Valluzzi
- Allergy Unit, Complesso Integrato Columbus, Via G. Moscati, 31, 00168, Rome, Italy
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Romano A, Gaeta F, Valluzzi RL, Maggioletti M, Caruso C, Quaratino D. Cross-reactivity and tolerability of aztreonam and cephalosporins in subjects with a T cell-mediated hypersensitivity to penicillins. J Allergy Clin Immunol 2016; 138:179-186. [PMID: 27016799 DOI: 10.1016/j.jaci.2016.01.025] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 01/08/2016] [Accepted: 01/12/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND The few studies performed in adults with T cell-mediated hypersensitivity to penicillins have found a rate of cross-reactivity with cephalosporins ranging from 2.8% to 31.2% and an absence of cross-reactivity with aztreonam. OBJECTIVE We sought to evaluate the possibility of using cephalosporins and aztreonam in subjects with documented delayed hypersensitivity to penicillins who especially require them. METHODS We conducted a prospective study of 214 consecutive subjects who had 307 nonimmediate reactions to penicillins (almost exclusively aminopenicillins) and had positive patch test and/or delayed-reading skin test responses to at least 1 penicillin reagent. To assess cross-reactivity with cephalosporins and aztreonam and the tolerability of such alternative β-lactams, all subjects underwent skin tests with cephalexin, cefaclor, cefadroxil, cefuroxime, ceftriaxone, and aztreonam. Subjects with negative responses were challenged with the alternative β-lactams concerned. RESULTS All subjects had negative skin test results to cefuroxime, ceftriaxone, and aztreonam and tolerated challenges. Forty (18.7%) of the 214 subjects had positive skin test responses to at least 1 aminocephalosporin. Of the 174 subjects with negative responses, 170 underwent challenges; 1 reacted to cefaclor. CONCLUSIONS These data demonstrate a rate of cross-reactivity between aminopenicillins and aminocephalosporins (ie, cephalexin, cefaclor, and cefadroxil) of around 20%, as well as the absence of cross-reactivity between penicillins and cefuroxime, ceftriaxone, and aztreonam in all subjects with T cell-mediated hypersensitivity to penicillins, almost exclusively aminopenicillins. Therefore these subjects could be treated with cefuroxime, ceftriaxone, and aztreonam. In those who especially require cephalosporin or aztreonam treatment, however, we recommend pretreatment skin tests because negative responses indicate tolerability.
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Affiliation(s)
- Antonino Romano
- Allergy Unit, Complesso Integrato Columbus, Rome, Italy; IRCCS Oasi Maria S.S., Troina, Italy.
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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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Luo Z, Du W, Zheng P, Guo P, Wu N, Tang W, Zeng A, Chang C, Fu Q. Molecularly imprinted polymer cartridges coupled to liquid chromatography for simple and selective analysis of penicilloic acid and penilloic acid in milk by matrix solid-phase dispersion. Food Chem Toxicol 2015; 83:164-73. [DOI: 10.1016/j.fct.2015.05.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 05/04/2015] [Accepted: 05/10/2015] [Indexed: 12/28/2022]
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Ónodi-Nagy K, Kinyó Á, Meszes A, Garaczi E, Kemény L, Bata-Csörgő Z. Amoxicillin rash in patients with infectious mononucleosis: evidence of true drug sensitization. Allergy Asthma Clin Immunol 2015; 11:1. [PMID: 25784943 PMCID: PMC4362637 DOI: 10.1186/1710-1492-11-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 10/08/2014] [Indexed: 11/10/2022] Open
Abstract
Background It hasn’t been clearly understood yet whether sensitization to antibiotics, the virus itself or transient loss of drug tolerance due to the virus, is responsible for the development of maculopapular exanthems following amoxicillin intake in patients with infectious mononucleosis. We aimed to examine whether sensitization to penicillin developed among patients with skin rash following amoxicillin treatment within infectious mononucleosis. Methods Ten patients were investigated for drug sensitization by lymphocyte transformation test and six patients were further tested by prick-, intradermal and patch tests employing the penicillin’s main antigens. Results Lymphocyte transformation test showed negative results with amoxicillin, while one patient had positive reaction to cefixime. Six patients with suspected sensitization to amoxicillin were then investigated by in vivo tests. Prick tests were negative in all six patients, but the intradermal tests showed positive reactions in four patients. Conclusions Our data demonstrate that in vitro testing is not sensitive enough in determining drug sensitization to penicillin. In vivo tests should be performed to detect sensitization and indeed with skin tests our results confirmed that sensitization to aminopenicillin may develop within infectious mononucleosis.
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Affiliation(s)
- Katinka Ónodi-Nagy
- Department of Dermatology and Allergology, University of Szeged, Albert Szent-Györgyi Medical Center, Korányi fasor 6, Szeged, 6720 Hungary
| | - Ágnes Kinyó
- Department of Dermatology and Allergology, University of Szeged, Albert Szent-Györgyi Medical Center, Korányi fasor 6, Szeged, 6720 Hungary
| | - Angéla Meszes
- Department of Dermatology and Allergology, University of Szeged, Albert Szent-Györgyi Medical Center, Korányi fasor 6, Szeged, 6720 Hungary
| | - Edina Garaczi
- Department of Dermatology and Allergology, University of Szeged, Albert Szent-Györgyi Medical Center, Korányi fasor 6, Szeged, 6720 Hungary
| | - Lajos Kemény
- Department of Dermatology and Allergology, University of Szeged, Albert Szent-Györgyi Medical Center, Korányi fasor 6, Szeged, 6720 Hungary ; Dermatological Research Group of the Hungarian Academy of Sciences, University of Szeged, Szeged, Hungary
| | - Zsuzsanna Bata-Csörgő
- Department of Dermatology and Allergology, University of Szeged, Albert Szent-Györgyi Medical Center, Korányi fasor 6, Szeged, 6720 Hungary ; Dermatological Research Group of the Hungarian Academy of Sciences, University of Szeged, Szeged, Hungary
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Hjortlund J, Mortz CG, Skov PS, Bindslev-Jensen C. Diagnosis of penicillin allergy revisited: the value of case history, skin testing, specific IgE and prolonged challenge. Allergy 2013; 68:1057-64. [PMID: 23889703 DOI: 10.1111/all.12195] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND Skin testing in duplicate, correlation between case history of immediate and nonimmediate reactions and challenge outcome and prolonged oral treatment with penicillin in the diagnostic evaluation of allergic reactions to β-lactam antibiotics, mimicking real-life situations, have only been addressed in few studies. METHODS A total of 342 patients suspected of having β-lactam allergy were investigated according to the European Network for Drug Allergy (ENDA) guidelines and patients found to be negative in the ENDA program were supplemented with a 7-day oral treatment with penicillin. Skin testing with penicillins was performed in duplicate. Patients with case histories of reactions to other β-lactams were also subsequently challenged with the culprit drug. RESULTS Nineteen patients were IgE-sensitized to penicillin. Then, intracutaneous tests (ICTs) were performed, in which 35 patients tested positive for allergy, 21 with delayed and 14 with immediate reactions. Only three patients tested positive for the major (PPL) and/or minor (MDM) penicillin determinants, all being positive for penicillin G in ICT. The remaining 291 patients were challenged with penicillin: 10 tested positive in single-dose challenge and 23 tested positive in the 7-day challenge. A total of 17 of 78 patients with a negative penicillin challenge tested positive during challenges with other β-lactams. We found no correlation between case histories of immediate and nonimmediate reactions and reaction time during challenge. CONCLUSION The data suggest that case history is often insufficient to discriminate between immediate reactors and nonimmediate reactors. A 7-day challenge with the culprit β-lactam may yield more positive reactions than the accepted one- or 2-day challenge. Interpretation of skin testing should be made with caution.
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Affiliation(s)
- J. Hjortlund
- Department of Dermatology and Allergy Centre; Odense University Hospital; Odense C; Denmark
| | - C. G. Mortz
- Department of Dermatology and Allergy Centre; Odense University Hospital; Odense C; Denmark
| | - P. S. Skov
- Department of Dermatology and Allergy Centre; Odense University Hospital; Odense C; Denmark
| | - C. Bindslev-Jensen
- Department of Dermatology and Allergy Centre; Odense University Hospital; Odense C; Denmark
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Celik GE, Aydin Ö, Dogu F, Çipe F, Boyvat A, Ikinciogullari A, Akyol A, Demirel YS. Diagnosis of Immediate Hypersensitivity to β-Lactam Antibiotics Can Be Made Safely with Current Approaches. Int Arch Allergy Immunol 2012; 157:311-7. [DOI: 10.1159/000328212] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 04/06/2011] [Indexed: 11/19/2022] Open
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A world allergy organization international survey on diagnostic procedures and therapies in drug allergy/hypersensitivity. World Allergy Organ J 2011; 4:257-70. [PMID: 23268453 PMCID: PMC3488913 DOI: 10.1097/wox.0b013e31823dc02c] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To study the diagnostic and treatment modalities used in drug allergy/hypersensitivity among members of the World Allergy Organization (WAO). METHODS A questionnaire comprising 39 questions was circulated electronically to member societies, associate member societies, and regional and affiliate organizations of WAO between June 29, 2009, and August 9, 2009. RESULTS Eighty-two responses were received. Skin testing was used by 74.7%, with only 71.4% having access to penicillin skin test reagents. In vitro-specific IgE tests were used by 67.4%, and basophil activation test was used by 54.4%. Lymphocyte transformation tests were used by 36.8% and patch tests by 54.7%. Drug provocation tests were used by 68.4%, the most common indication being to exclude hypersensitivity where history/symptoms were not suggestive of drug hypersensitivity/allergy (76.9%). Rapid desensitization for chemotherapy, antibiotics, or biologic agents was used by 69.6%. Systemic corticosteroid was used in the treatment of Stevens-Johnson syndrome by 72.3%, and high-dose intravenous immunoglobulins in toxic epidermal necrolysis by 50.8%. Human leukocyte antigen screening before prescription of abacavir was used by 92.9% and before prescription of carbamazepine by 21.4%. CONCLUSIONS Results of this survey form a useful framework for developing educational and training needs and for improving access to drug allergy diagnostic and treatment modalities across WAO member societies.
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Torres MJ, Romano A, Blanca-Lopez N, Doña I, Canto G, Ariza A, Aranda A, Montañez MI, Mayorga C, Blanca M. Immunoglobulin E-mediated hypersensitivity to amoxicillin: in vivo and in vitro comparative studies between an injectable therapeutic compound and a new commercial compound. Clin Exp Allergy 2011; 41:1595-601. [DOI: 10.1111/j.1365-2222.2011.03834.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Thong BYH. Update on the management of antibiotic allergy. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2010; 2:77-86. [PMID: 20358021 PMCID: PMC2846744 DOI: 10.4168/aair.2010.2.2.77] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2009] [Accepted: 10/19/2009] [Indexed: 12/18/2022]
Abstract
Drug allergy to antibiotics may occur in the form of immediate or non-immediate (delayed) hypersensitivity reactions. Immediate reactions are usually IgE-mediated whereas non-immediate hypersensitivity reactions are usually non-IgE or T-cell mediated. The clinical manifestations of antibiotic allergy may be cutaneous, organ-specific (e.g., blood dyscracias, hepatitis, interstitial nephritis), systemic (e.g., anaphylaxis, drug induced hypersensitivity syndrome) or various combinations of these. Severe cutaneous adverse reactions manifesting as Stevens Johnson syndrome or toxic epidermal necrolysis (TEN) may be potentially life-threatening. The management of antibiotic allergy begins with the identification of the putative antibiotic from a detailed and accurate drug history, complemented by validated in-vivo and in-vitro allergological tests. This will facilitate avoidance of the putative antibiotic through patient education, use of drug alert cards, and electronic medical records with in-built drug allergy/adverse drug reaction prescription and dispensing checks. Knowledge of the evidence for specific antibiotic cross-reactivities is also important in patient education. Apart from withdrawal of the putative antibiotic, immunomodulatory agents like high-dose intravenous immunoglobulins may have a role in TEN. Drug desensitization where the benefits outweigh the risks, and where no alternative antibiotics can be used for various reasons, may be considered in certain situations. Allergological issues pertaining to electronic drug allergy alerts, computerized physician prescriptions and decision support systems, and antibiotic de-escalation in antimicrobial stewardship programmes are also discussed.
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Affiliation(s)
- Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
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Demoly P, Romano A, Botelho C, Bousquet-Rouanet L, Gaeta F, Silva R, Rumi G, Rodrigues Cernadas J, Bousquet PJ. Determining the negative predictive value of provocation tests with beta-lactams. Allergy 2010; 65:327-32. [PMID: 19860790 DOI: 10.1111/j.1398-9995.2009.02228.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The beta-lactam allergic work-up is mostly standardized. However, the negative predictive value of drug provocation tests is not yet well established. METHOD A historical-prospective multicentre cohort study was conducted in four centres (one in France, one in Portugal, two in Italy) to assess the negative predictive value of provocation tests with beta-lactams in patients initially tested for a suspicion of drug allergy/hypersensitivity. Patients were contacted at least 6 months after the work-up, between 2003 and 2007. A new allergic work-up was proposed to reacting patients. RESULTS Among the 457 patients included, 365 (79.9%) were followed up (159 [79.1%] from France, 153 [82.7%] from Italy and 53 [74.6%] from Portugal). Only 118 (25.8%) were re-exposed to the negatively tested beta-lactam. Nine (7.6%) reported a non-immediate (occurring more than 1 h after drug administration) reaction: five urticaria, three exanthema and one undefined cutaneous reaction. None were severe. Only four accepted a re-challenge, negative in two cases and positive in the two others. The negative predictive value was 94.1% (89.8-98.3) (111 out of 118 patients). CONCLUSION Although the negative predictive value of drug provocation tests may not be 100%, none of the false negative patients experienced a life-threatening reaction. This should reassure doctors who might hesitate to prescribe beta-lactams, even in patients with negative allergic work-ups.
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Affiliation(s)
- P Demoly
- Exploration des Allergies, Service des Maladies Respiratoires and Inserm U657, Hôpital A de Villeneuve, University Hospital of Montpellier, avenue du Doyen Gaston Giraud, Montpellier Cedex, France
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25
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Schiavino D, Nucera E, Lombardo C, Decinti M, Pascolini L, Altomonte G, Buonomo A, Patriarca G. Cross-reactivity and tolerability of imipenem in patients with delayed-type, cell-mediated hypersensitivity to beta-lactams. Allergy 2009; 64:1644-8. [PMID: 19392998 DOI: 10.1111/j.1398-9995.2009.02058.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Administration of imipenem-cilastatin to patients with IgE-mediated hypersensitivity to beta-lactams has always been considered potentially harmful. Recent studies have demonstrated the tolerability of carbapenems (imipenem-cilastatin and meropenem) in patients with IgE-mediated hypersensitivity to beta-lactams; there are no studies on this topic regarding patients with cell-mediated allergy to beta-lactams. The aim of this study is to assess cross-reactivity and tolerability of imipenem in patients with cell-mediated allergy to beta-lactams. METHODS From our database we selected 73 patients with cell-mediated allergy to beta-lactams, diagnosed by means of immediate-type skin tests, delayed reading intradermal tests, patch tests and detection of specific IgE. Patients with negative patch tests with imipenem-cilastatin underwent an intramuscular test dosing. RESULTS Our patients had a total of 94 nonimmediate reactions to penicillins. All patients had positive patch tests and/or delayed reading intradermal tests for at least one of the penicillin reagent tested and negative immediate-type skin tests and specific IgE. Four patients out of 73 had a positive patch tests to at least one penicillin reagent and imipenem-cilastatin showing cross-reactivity. Sixty-four patients underwent the imipenem-cilastatin intramuscular test dosing and none of them had a clinical reaction. CONCLUSIONS Our rate of cross-reactivity between imipenem-cilastatin and other beta-lactams was 5.5%. This result is different from previous findings and this may be explained by the fact that we investigated patients with cell-mediated allergy to beta-lactams. Patients with cell-mediated allergy to beta-lactams should undergo patch tests and a tolerance challenge test before treatment with imipenem-cilastatin.
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Affiliation(s)
- D Schiavino
- Department of Allergology, Catholic University of the Sacred Heart, Rome, Italy
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26
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Qiao HL, Li Z, Yang J, Tian X, Gao N, Jia LJ. Hypersensitivity reactions to penicillins: studies in a group of patients with negative benzylpenicillin G skin test. J Clin Pharm Ther 2009; 34:249-54. [DOI: 10.1111/j.1365-2710.2008.01013.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Raja AS, Lindsell CJ, Bernstein JA, Codispoti CD, Moellman JJ. The use of penicillin skin testing to assess the prevalence of penicillin allergy in an emergency department setting. Ann Emerg Med 2009; 54:72-7. [PMID: 19217696 DOI: 10.1016/j.annemergmed.2008.12.034] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 12/11/2008] [Accepted: 12/30/2008] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE Patient-reported penicillin allergies are often unreliable and can result in unnecessary changes in antibiotic therapy. Although penicillin allergy skin testing is commonly performed in allergy clinics, it has not been used in emergency departments (EDs) to verify self-reported allergies. We hypothesize that ED-based testing is possible and that the false-positive rate of patients with self-reported penicillin allergy are greater than 90%. METHODS This prospective observational cohort study enrolled a convenience sample of ED patients with a self-reported penicillin allergy. Patients were enrolled by one of 2 emergency physicians who performed skin prick and intracutaneous tests with penicillin major and minor determinants. The total testing time was 30 minutes. The proportion of false-positive self-reported allergies was computed with 95% confidence intervals (CIs) by using the score method. RESULTS A total of 150 patients (mean age 42 years; SD 16 years; 46% men; 47% black) were enrolled. The false-positive rate for self-reported penicillin allergy was 137 of 150 (91.3%; 95% CI 85.3% to 95.1%). There were no adverse reactions associated with penicillin skin testing. Compared with patients with a false-positive penicillin allergy result (confirmed by negative penicillin skin testing result), patients reporting a true penicillin allergy confirmed by positive penicillin skin test results tended to be more frequently men (61.5% versus 44.5%; Delta 17.0%; 95% CI -13.5% to 42%), black (69.2% versus 44.5%; Delta 24.7%; 95% CI -6.9% to 46.8%), and have no family history of drug allergy (7.7% versus 17.5%; Delta9.8%; 95% CI -20.9% to 20.4%), but self-reported other drug allergies more frequently (61.5% versus 38.7%; Delta 22.9%; 95% CI -7.7% to 47.5%). CONCLUSION Penicillin skin testing is feasible in the ED setting. A substantial number of patients who self-report a penicillin allergy do not exhibit immunoglobulin E-mediated sensitization to penicillin major and minor determinants. Penicillin testing in the ED may allow the use of more appropriate antibiotics for patients presenting with a history of penicillin allergy.
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Affiliation(s)
- Ali S Raja
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH 45221-0769, USA
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28
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Romano A, Bousquet-Rouanet L, Viola M, Gaeta F, Demoly P, Bousquet PJ. Benzylpenicillin skin testing is still important in diagnosing immediate hypersensitivity reactions to penicillins. Allergy 2009; 64:249-53. [PMID: 19133924 DOI: 10.1111/j.1398-9995.2008.01874.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The fact that both Hollister-Stier and Allergopharma ceased the production of penicilloyl-polylysine (PPL) and minor determinant mixture (MDM) in 2004 is severely hampering the diagnosis of beta-lactam hypersensitivity and may produce negative consequences. OBJECTIVE To assess the contribution of skin testing with benzylpenicillin to the diagnosis of immunoglobulin E-mediated hypersensitivity to penicillins, in order to determine how much such testing could compensate for PPL and MDM unavailability. METHODS We selected patients with histories of immediate reactions to penicillins and positive results to skin tests for one or more penicillin reagents (PPL, MDM, or benzylpenicillin), one or more semi-synthetic penicillins (ampicillin, amoxicillin, or piperacillin), or both. RESULTS A total of 300 patients were selected, 105 in the French center and 195 in the Italian centers. Amoxicillin and ampicillin were the main responsible drugs. The most common clinical manifestation was anaphylaxis. The reagents most frequently positive to skin tests were amoxicillin (188, 62.7%), ampicillin (151, 50.3%), and benzylpenicillin (111, 37.0%). Among the 300 subjects, 113 (37.7%) were positive only to semi-synthetic penicillins, 109 (36.3%) to both semi-synthetic penicillins and the classic penicillin reagents, and 78 (26.0%) only to the latter. In the last group, 64 (21.3% of the 300 subjects) were positive only to PPL and/or MDM and 14 (4.7%) to benzylpenicillin, of whom 8 (2.7%) were positive only to the latter. CONCLUSIONS Skin testing with benzylpenicillin can partially compensate for PPL and MDM unavailability. Moreover, it can slightly increase the allergologic workup's sensitivity and therefore reduce the number of potentially dangerous challenges.
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Affiliation(s)
- A Romano
- Department of Internal Medicine and Geriatrics, UCSC-Allergy Unit, Complesso Integrato Columbus, Rome, Italy
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29
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Blanca M, Romano A, Torres MJ, Férnandez J, Mayorga C, Rodriguez J, Demoly P, Bousquet PJ, Merk HF, Sanz ML, Ott H, Atanasković-Marković M. Update on the evaluation of hypersensitivity reactions to betalactams. Allergy 2009. [DOI: 10.1111/j.1398-9995.2008.01924.x] [Citation(s) in RCA: 321] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nolan RC, Puy R, Deckert K, O'Hehir RE, Douglass JA. Experience with a new commercial skin testing kit to identify IgE-mediated penicillin allergy. Intern Med J 2008; 38:357-61. [PMID: 18402562 DOI: 10.1111/j.1445-5994.2008.01657.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Many patients who describe a history of allergy to penicillin do not prove to be allergic and can be treated safely with penicillin. After a period of 2 years where testing of penicillin allergy was not possible, a new commercial kit has recently become available. We report our initial experience with use of the kit with 29 patients and discuss one patient who experienced anaphylaxis during i.d. testing.
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Affiliation(s)
- R C Nolan
- Department of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
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31
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Demoly P, Pichler W, Pirmohamed M, Romano A. Important questions in Allergy: 1--drug allergy/hypersensitivity. Allergy 2008; 63:616-9. [PMID: 18394136 DOI: 10.1111/j.1398-9995.2008.01693.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- P Demoly
- Exploration des Allergies - Inserm U657, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
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Atanasković-Marković M, Gaeta F, Medjo B, Viola M, Nestorović B, Romano A. Tolerability of meropenem in children with IgE-mediated hypersensitivity to penicillins. Allergy 2008; 63:237-40. [PMID: 18186815 DOI: 10.1111/j.1398-9995.2007.01532.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Administration of meropenem to penicillin-allergic patients who might benefit from this treatment is usually avoided because of a 47.4% rate of cross-reactivity to imipenem, the prototype of the carbapenem class of beta-lactam antibiotics, demonstrated in a single study on the basis of positive responses to skin tests with imipenem reagents. However, recent studies of ours have demonstrated a very low rate of cross-reactivity between penicillins and both meropenem and imipenem in adults. OBJECTIVE To assess cross-reactivity and tolerability of meropenem in children with documented penicillin allergy. METHODS One hundred and eight consecutive children who had suffered a total of 129 immediate reactions (120 urticarial and/or angioedematous manifestations and 9 anaphylactic shocks) to penicillins and had positive results to skin tests for at least one of the penicillin reagents tested underwent skin tests with meropenem and negative subjects were challenged with it. RESULTS One subject (0.9%) displayed a positive intradermal test to meropenem. The remaining 107 subjects with negative skin tests to meropenem tolerated challenges. Challenges were not followed by full therapeutic courses. CONCLUSIONS Our results demonstrate a low rate of cross-reactivity between penicillins and meropenem. Therefore, the practice of avoiding meropenem in children with immunoglobulin E-mediated hypersensitivity could be abandoned; in those who especially require meropenem treatment, prophylactic skin tests are advisable, because negative results indicate tolerability.
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Affiliation(s)
- M Atanasković-Marković
- Department of Allergology and Pulmonology, University Children's Hospital, Belgrade, Serbia
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33
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Bousquet PJ, Pipet A, Bousquet-Rouanet L, Demoly P. Oral challenges are needed in the diagnosis of beta-lactam hypersensitivity. Clin Exp Allergy 2007; 38:185-90. [PMID: 17976216 DOI: 10.1111/j.1365-2222.2007.02867.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND beta-lactams continue to remain the most commonly involved drug family in allergic drug reactions. They are often essential and there is a cost-effective and favourable risk-benefit ratio for the exploration of all suspicions of beta-lactam allergy. A firm diagnosis is always based on skin tests and sometimes on provocation tests. Recommendations have been published by allergy societies and distinguished scientists but they are not always concordant and can lead to some confusion for the practicing allergologist. The situation has even worsened since the world wide withdrawal of these penicillin determinants and since the predominance of amoxicillin and cephalosporin prescriptions in most countries. OBJECTIVE - METHOD: In a recent article, it was stated that patients with a penicillin allergy history and negative skin tests to major and minor penicillin determinants are at a low risk of relapse (0-5%) when receiving a beta-lactam. In this paper, our Drug Allergy and Hypersensitivity Database, a cohort database, was used to demonstrate that this statement is false. Standardized European Network for Drug Allergy questionnaires, skin test and challenge procedures were followed. RESULTS One-thousand two-hundred and eighteen subjects, 69.8% of female, 51.7% of atopics, were included. 21.1% had a true beta-lactam allergy confirmed by skin tests (178, 69.3%) or by drug provocation (79, 30.7%). 17.4% of the patients with negative skin tests to major and minor penicillin determinants were positive for a beta-lactam. CONCLUSION In the diagnosis of beta-lactams allergy, if all skin tests are negative, skin tests with other determinants and provocation tests under strict surveillance are mandatory.
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Affiliation(s)
- P J Bousquet
- Exploration des Allergies, Maladies Respiratoires and INSERM, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier Cedex 5, France
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Abstract
PURPOSE OF REVIEW The present review addresses the most recent literature regarding the diagnosis of drug hypersensitivity reactions, which can be classified as immediate or nonimmediate according to the time interval between the last drug administration and the onset. Immediate reactions occur within 1 h; nonimmediate ones occur after more than 1 h. RECENT FINDINGS Clinical and immunological studies suggest that type-I (IgE-mediated) and type-IV (cell-mediated) pathogenic mechanisms are involved in most immediate and nonimmediate reactions, respectively. New diagnostic tools, such as the basophil activation test and the lymphocyte activation test, have been developed and are under validation. SUMMARY In diagnosis, the patient's history is fundamental; the allergologic examination includes in-vivo and in-vitro tests selected on the basis of the clinical features. Prick, patch, and intradermal tests are the most readily available forms of allergy testing. Determination of specific IgE levels is still the most common in-vitro method for diagnosing immediate reactions. The sensitivity of allergologic tests is not 100%; in selected cases, therefore, provocation tests are necessary. The routine use of the basophil activation test and the lymphocyte activation test could increase the sensitivity of diagnostic work-ups, thus reducing the need for drug provocation tests.
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Affiliation(s)
- Antonino Romano
- Allergy Unit of Integrated Complex Columbus, Catholic University of Sacred Heart, Rome, Italy.
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