Parental-reported drug allergy in 6- to 9-yr-old urban schoolchildren

The importance of clinical history in the diagnosis of drug hypersensitivity in children

BACKGROUND

In case of suspected hypersensitivity reactions (HRs) to drugs, a challenging area for pediatricians is detecting relevant elements in the parent-reported history, in order to reach a definite diagnosis. We analyzed the concordance between the description of the HR and the medical reports documented at the time of the event. Furthermore, we studied any correlation between clinical history variables and the prediction of true allergy.

METHODS

We retrospectively collected 50 charts of children referred to our Allergy Unit, after a previous access to the Emergency Department. We compared the description of the HR at acute phase to the history told by parents. Type and timing of the HR and culprit drug were classified as "known" or "unknown." The diagnosis was confirmed or excluded at the end of the investigations. Logistic regression analysis was performed to find any significant association.

RESULTS

The type of the HR was known in 74%, the timing in 28%, and the culprit drug in 98%. We showed that having had a severe HR had an increased odds of remembering the timing; being older >6 years and having had an immediate HR had an increased odds of remembering the type; time to diagnostic was lower in patients whose parents remembered the type of HR.

CONCLUSION

Our paper underlines the importance of an accurate anamnesis at the time of the event. Providing the physicians with a standardized Case Report Form could be a useful tool to simplify the diagnostic work-up and minimize mistakes due to lack of memory.

The controversy of drug hypersensitivity in patients with cystic fibrosis and review of the literature

BACKGROUND

Cystic fibrosis (CF) is reported to be a risk factor for drug hypersensitivity. However, there are conflicting data about true prevalence of drug hypersensitivity in children with CF.

METHODS

The suspicious drug hypersensitivity reactions (DHRs) of children with CF were enquired by the European Network for Drug Allergy (ENDA) questionnaire, and skin tests and/or drug provocation tests were performed according to the established guidelines.

RESULTS

Two hundred and nineteen children (48.9% boys; median [IQR] age, 8.4 years [4.8-12.4 years]) with cystic fibrosis were included in the study, among which 22 patients with 24 suspected DHRs were evaluated. Most of the suspected DHRs were of non-immediate (n = 16, 66.6%) type, and the offending drugs were amoxicillin-clavulanic acid (n = 7), macrolides (n = 4), trimethoprim-sulfamethoxazole (TMP/SMX) (n = 2), piperacillin-tazobactam (n = 1), pancrelipase (n = 1), and ursodeoxycholic acid (n = 1). Eight (33.3%) of the DHRs were classified as immediate (ceftriaxone [n = 2], ceftazidime [n = 2], meropenem [n = 1], AmBisome [n = 2], and vancomycin [n = 1]). The main clinical presentations were maculopapular eruption (41.6%) and urticaria (37.5%), accompanied by angioedema (8.3%), flushing (12.5%), and vomiting (8.3%). Nine skin tests (with beta-lactam protocol in 6 patients) and 24 DPTs were performed, and none of the skin tests revealed a positive result; however, 2 DPTs with TMP/SMX were positive.

CONCLUSION

Actual drug hypersensitivity was demonstrated in 2 of 219 patients (0.9%) with non-beta-lactam antibiotics. These results conflict with previous researches that showed higher drug hypersensitivity rates but are consistent with some recent studies. Allergological diagnostic workup is mandatory in patients with cystic fibrosis in case of a suspicious DHR.

Knowledge gaps of drug allergy in children: a survey of primary care doctors

INTRODUCTION

There is still lack of knowledge of drug allergy in children. Proper knowledge and management of drug hypersensitivity reactions is important to physicians.

AIM

To evaluate the approach of primary care doctors regarding drug allergy in children.

MATERIAL AND METHODS

A total of 195 primary care doctors were questioned in various parts of Lithuania from 2015 to 2016. An original questionnaire was used. The incidence of a suspected drug allergy, culprit drugs, the clinical pattern and management of the suspected drug hypersensitivity were analysed.

RESULTS

The majority of primary care doctors (74.4%) reported a suspected drug allergy. The main suspected drugs were antibiotics (95.2%) and nonsteroidal anti-inflammatory drugs (32.4%). Skin symptoms (skin rash (100%) and itching (82.1%)) were the main symptoms of the suspected drug allergy. The vast majority of doctors (93.8%) withdrew the use of a suspected drug and 68.3% of respondents prescribed an alternative drug. The fact that skin tests, blood tests and provocation tests could be used in a drug allergy workup were indicated by 43.6% of doctors. Most doctors (69.2%) knew about the opportunity to test children for drug allergy in Lithuania and 41.4% of doctors referred patients for the further drug allergy workup.

CONCLUSIONS

The majority of primary care doctors reported a suspected drug allergy in children. The most common suspected drugs were antibiotics and skin symptoms were the main symptoms. Most doctors knew about the possibility to test for the drug allergy but only less than half of them referred patients for the drug allergy workup.

Children with reported penicillin allergy: Public health impact and safety of delabeling

OBJECTIVE

To review the relevant literature related to children with reported penicillin allergy and highlight the different ways in which children could be delabeled and to evaluate the public health impact that a penicillin allergy has for children.

DATA SOURCES

Data for this review were obtained via PubMed searches and then retrieval of articles from their respective journals for further review.

STUDY SELECTIONS

Studies regarding the safety of different ways to evaluate penicillin allergy in children were identified via PubMed searches. Any study that reported different ways of testing (3-tier, direct oral challenge, 5-day oral challenges) were included. This same format was used when selecting relevant articg:les related to the costs, prescription patterns, and stewardship trends associated with a penicillin allergy label.

RESULTS

This review found that penicillin allergy testing is a safe and effective way to delabel those with reported allergy. In children with low-risk allergy symptoms, a direct oral challenge approach may be optimal. In those children with a history of high-risk allergy symptoms, a 3-tiered approach is ideal. The review also found that there is a significant cost associated with reported penicillin allergy and that there are increased negative health benefits to those children with reported allergy.

CONCLUSION

Penicillin allergy is overdiagnosed, often incorrectly, and the label is frequently first applied during childhood. Targeting children for the removal of the incorrect penicillin allergy label provides a mechanism to reduce the use of broader-spectrum and less effective antibiotics.

Pediatric drug hypersensitivity: which diagnostic tests?

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.

Mild to moderate hypersensitivity reactions to beta-lactams in children: a single-centre retrospective review

OBJECTIVE

Beta-lactam (BL) antibiotics are the most reported drugs in hypersensitivity reactions in children. More than 90% of these children tolerate the suspected drug after diagnostic work-up. Skin tests (STs) show low sensitivity. Our aim was to assess the performance of drug provocation tests (DPTs) without previous ST in mild and moderate delayed reactions and to propose a new DPT protocol.

DESIGN OF THE STUDY

Charts from 213 children under 15 years of age referred for suspected BL allergy from 2011 to 1013 were reviewed. Prick, intradermal and patch tests were performed with major determinant penicilloyl-polylysine, minor determinant mixture, amoxicillin (AMX), cefuroxime, penicillin G and AMX-clavulamate. Children with negative skin tests underwent DPT. After an initial full dose of antibiotic, DPT was carried on for 3 days at home in patients reacting within the first 3 days of treatment. If the reaction took place from day 4 on of treatment, patients took the antibiotic for 5 days.

RESULTS

We included 108 girls and 105 boys. Mean age at the time of reaction was 3.66±3.06 years. 195 patients (91.5%) reacted to one BL. 154 reactions (67.2%) were non-immediate. Mild to moderate skin manifestations were most frequently reported. AMX-clavulanate was the most frequently involved (63.4%). DPT confirmed the diagnosis of drug hypersensitivity in 17 (7.3%) cases. These 17 patients had negative ST.

CONCLUSION

In mild and moderate cases of BL hypersensitivity, diagnosis can be performed by DPT without previous ST.

Assessing the quality of paediatric antibiotic prescribing by community paediatricians: a database analysis of prescribing in Lombardy

OBJECTIVE

To evaluate the quality of paediatricians' antibiotic prescribing using administrative databases.

METHODS

The data source was the database of reimbursed prescriptions of the Lombardy Region, Italy. Children 1-13 years were included. An index prescription was defined as the first antibiotic prescription during a year period (2011) that occurred without previous, recent, antibiotic prescriptions or hospital or emergency department admissions. The A indicator was the percentage of children, cared for by paediatricians, receiving amoxicillin at the index prescription (minimum target 50%). The B indicator was the percentage of children receiving exclusively non-penicillin antibiotics in unrelated infection episodes (maximum target 10%). Indicators were evaluated for each prescriber and geographical area.

RESULTS

Overall 424 280 children (cared for by 1164 paediatricians) received an index prescription and were included in the study. Amoxicillin alone was prescribed at the index prescription only to 23.6% of children (7.9%-46.3% within different areas of the region).The percentage of paediatricians who reached the target for the quality indicators was low (12.8% A indicator; 54.0% B indicator; 11.3% both). Almost half of the paediatricians (44.5%) showed inadequate quality of antibiotic prescribing, failing to reach the target for both indicators. Quality of prescribing was about four times worse in high prescribers and younger paediatricians. A geographical cluster of paediatricians reaching the target for both indicators was identified. These paediatricians had, for several years, previously been involved in educational programme.

CONCLUSIONS

Quality of prescribing was generally unsatisfactory, but increased in a group of paediatricians previously involved in educational interventions and increased with increasing age. Further studies are warranted in order to validate these promising indicators as a benchmarking tool in other studies, when diagnosis is unknown.

Anaphylaxis to Over-the-Counter Flurbiprofen in a Child

Non-steroidal anti-inflammatory drugs are suspected to cause drug hypersensitivity very frequently in paediatric patients. In this article, we describe the first case of anaphylaxis to flurbiprofen in a child and provide insight into the possibility of severe reactions and even anaphylaxis to over-the-counter flurbiprofen. Finally, the importance of a rigorous allergy work-up in reaching a confident diagnosis and providing the patient with a safe alternative is shown.

Proven Non-β-Lactam Antibiotic Allergy in Children

BACKGROUND

Parallel to the increasing use of non-β-lactam (NBL) antibiotics, allergic reactions to this drug group seem to increase. Data about NBL antibiotic hypersensitivity in children are limited. The aim of this study is to evaluate characteristic reactions to NBL antibiotics in children.

METHOD

Patients with suspected NBL allergy were assessed between 2011 and 2015. Characteristics of the reactions and results of skin and drug provocation tests (DPTs) were recorded.

RESULTS

In total, 96 patients aged 75.15 ± 56.77 months (range: 3-208) were assessed. Clarithromycin (63.6%) was the most common cause of reactions reported. After ingestion of NBL antibiotics, maculopapular rash, urticaria/angioedema and anaphylaxis presented in 48.9, 40.7 and 10.4% of the patients, respectively. Tests were performed in 85 patients. Intradermal tests were positive in 3 patients (clarithromycin, ciprofloxacin and cotrimoxazole) and DPT was positive in 1 patient (clarithromycin). Eleven patients could not be tested. Seven patients had severe anaphylaxis, and 4 patients with urticaria/angioedema had to take their medications at the time of the reaction so desensitization was performed. When only patients confirmed by tests were evaluated, NBL allergy was 4.7% (4/85) in our study group. However, when patients who could not be tested, but were regarded as suffering from drug hypersensitivity according to clinical findings, were included, the frequency of NBL allergy was 15.6% (15/96).

CONCLUSION

Most of the children with suspected NBL do not have true hypersensitivity. The frequency of confirmed hypersensitivity is low, and thus a detailed history should be taken from patients with suspected NBL hypersensitivity and DPTs should be performed in patients without contraindications.

Diagnostic evaluation and risk factors for drug allergies in children: from clinical history to skin and challenge tests

BACKGROUND

Parent or self-reported drug allergy claims frequently overestimate the real incidence of hypersensitivity reactions. A detailed and algorithmic diagnostic evaluation of drug reactions may allow a proper diagnosis.

OBJECTIVE

The aim of this study was to determine the confirmation rates and risk factors for confirmed allergic drug reactions in children.

SETTING

Mersin University Hospital in Turkey.

METHOD

The study consisted of children between ages of 8 months and 18 years with the history of suspected drug allergy as reported by the clinician or the patients. Parents were interviewed by a clinician to complete questionnaires that included questions about demographic data and characteristics of index drug reaction. Immediate reactions (IRs) were assessed with immediate-reading skin prick (SPT) and intradermal tests (IDT). Nonimmediate reactions (NIRs) were assessed with SPT, both early and delayed reading of IDT and patch tests. In case of negative skin tests, drug provocation tests were performed. The possible risk factors for confirmed drug allergy in univariate analysis (p < 0.1) were entered into the multivariate logistic regression analysis to determine independent predictors.

MAIN OUTCOME MEASURE

(1) Confirmation rates of drug allergy (2) Risk factors related to confirmed drug allergy in children.

RESULTS

We evaluated a total of 180 suspected drug allergy reactions in 97 children, mainly to antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs) and anticonvulsants. Among all suspected allergic drug reactions, 97 (53.9 %) were immediate type and 83 (46.1 %) were non-immediate type. The average time interval between the reaction and allergologic work-up was 5 months. Drug allergy confirmation rates were 30.1 % for beta-lactams, 27.2 % for non-betalactams, 21.1 % for NSAIDs and 30 % for anticonvulsants. Eight of 54 confirmed NIRs showed positivity on immediate skin tests. Regulatory T cells, TGF-β and IL-10 levels were not different between groups with and without confirmed drug allergy. A strong family and personal history of drug allergy were found to be significantly related to the confirmed allergic drug reactions.

CONCLUSION

Parent or self-reported drug allergy should be evaluated with a standardized diagnostic work-up before strict prohibitions are made. In addition, family and personal histories of drug allergy were significant risk factors related to allergic drug reactions in children.

Drug hypersensitivity in students from São Paulo, Brazil

BACKGROUND

Drug hypersensitivity is responsible for substantial mortality and morbidity, and increased health costs. However, epidemiological data on drug hypersensitivity in general or specific populations are scarce.

METHODS

We performed a cross-sectional survey of 1015 university students, using a self-reported questionnaire.

RESULTS

The prevalence of self-reported drug hypersensitivity was 12,11% (123/1015). The most frequently implicated drugs were non-steroidal anti-inflammatory drugs (45,9%) and beta-lactam and sulfonamide antibiotics (25,40%). The majority of the patients reported dermatological manifestations (99), followed by respiratory (40), digestive (23) and other (19). Forty-five patients had an immediate type reaction, and 76,72% (89) had the drug by oral route.

CONCLUSION

The results showed that drug hypersensitivity is highly prevalent in university students, and that nonsteroidal anti-inflammatory drug and antibiotics (beta-lactams and sulfonamide) are the most frequently concerned drugs.