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Genis C, Kuzucu FN, Sengül Emeksiz Z, Dibek Mısırlıoglu E. Negative Predictive Value of Single-Day Drug Provocation Test for Immediate and Non-Immediate Beta-Lactam Hypersensitivity Reactions in Children. Int Arch Allergy Immunol 2024:1-9. [PMID: 39236698 DOI: 10.1159/000540796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 08/05/2024] [Indexed: 09/07/2024] Open
Abstract
INTRODUCTION Beta-lactam antibiotics (BLAs) commonly cause hypersensitivity reactions in children. These reactions are categorized into immediate reactions, which include urticaria, angioedema, bronchospasm, and anaphylaxis, and non-immediate reactions, such as maculopapular rashes and delayed-onset urticaria/angioedema. Rashes in children, often caused by infections, may be misdiagnosed as BLA allergy. However, over 90% tolerate the medication following an allergic evaluation. METHODS We aimed to evaluate patients with negative single-day drug provocation test (sdDPT) results for subsequent reactions and to determine the negative predictive value (NPV) of sdDPT for immediate (less than 1 h) and non-immediate (more than 1 h) suspected BLA allergy. In addition, non-immediate reactions were assessed by classifying them as occurring within 1-6 h or after 6 h. Patients who underwent sdDPT for suspected BLA allergy and tested negative between 2019 and 2023 were included in the study. They were questioned via telephone interviews about their reuse of the tested drug. RESULTS 404 patients who underwent sdDPT for suspected BLA allergy were evaluated. The NPV of BLA sdDPT was determined to be 97.3%. When patients were categorized based on the time interval between the last dose and the reaction, the NPV was 97% for those experiencing a reaction within the first hour of drug use and 96.7% for reactions occurring after more than 1 h. Non-immediate reactions were further evaluated, revealing an NPV of 98.7% for reactions occurring between 1 and 6 h, and 92.5% for reactions occurring after 6 h. CONCLUSION Our findings demonstrate that sdDPT has a high NPV for both immediate and non-immediate reactions. However, the NPV of sdDPT was lower for reactions occurring more than 6 h after the last dose.
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Affiliation(s)
- Cankat Genis
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Fatma Nur Kuzucu
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Zeynep Sengül Emeksiz
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Emine Dibek Mısırlıoglu
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
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Mori F, Saretta F, Riscassi S, Caimmi S, Bottau P, Liotti L, Franceschini F, Bianchi A, Valluzzi RL, Crisafulli G, Caffarelli C. Risk factors for drug hypersensitivity reactions in children. Ital J Pediatr 2024; 50:127. [PMID: 39010141 PMCID: PMC11247891 DOI: 10.1186/s13052-024-01694-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/25/2024] [Indexed: 07/17/2024] Open
Abstract
Drug hypersensitivity reactions are common in children. Risk factors predisposing to IgE-mediated drug allergies and delayed drug reactions are a matter of debate. Gender, age, previous reactions to the same drug or to another drug, reduced drug metabolism, chronic diseases, polypharmacy, drug doses are linked with the onset of hypersensitivity reactions in some children. Novel advances in genetic polymorphisms can rapidly change the approach to the prevention of reactions since gene testing can be a useful screening test for severe cutaneous adverse reactions. Viral infections may act as cofactors in susceptible individuals. Polypharmacy, high doses, repeated doses and parental route of administration are also risk factors. Clinicians should take into account risk factors to allow the risk-benefit balance to be maintained.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139, Florence, Italy
| | - Francesca Saretta
- Dipartimento Materno-Infantile, SC Pediatria, Ospedale Latisana-Palmanova, Azienda Sanitaria Universitaria Friuli Centrale, 33100, Udine, Italy
| | - Sara Riscassi
- UOC Di Pediatria, Ospedale Bolzano, Azienda Sanitaria Dell'Alto Adige, Bolzano, 39100, Italy
| | - Silvia Caimmi
- SC Di Pediatria, Fondazione IRCSS Policlinico San Matteo, 27100, Pavia, Italy
| | - Paolo Bottau
- UOC Di Pediatria E Neonatologia, Ospedale Imola (BO), Imola, 40026, Italy
| | - Lucia Liotti
- UOC Pediatria, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", 60100, Ancona, Italy
| | | | - Annamaria Bianchi
- UOC Pediatria, Azienda Ospedaliera San Camillo Forlanini, 00152, Rome, Italy
| | - Rocco Luigi Valluzzi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy
| | - Giuseppe Crisafulli
- Dipartimento Materno-Infantile, UOC Pediatria, University of Messina, Messina, 98122, Italy
| | - Carlo Caffarelli
- Department of Medicine and Surgery, Clinica Pediatrica, Azienda Ospedaliera-Universitaria, University of Parma, 43123, Parma, Italy.
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Liccioli G, Tomei L, Pessina B, Caubet JC, Barni S, Giovannini M, Sarti L, Mori F. The importance of clinical history in the diagnosis of drug hypersensitivity in children. Pediatr Allergy Immunol 2024; 35:e14091. [PMID: 38444175 DOI: 10.1111/pai.14091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
Abstract
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.
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Affiliation(s)
- Giulia Liccioli
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Leonardo Tomei
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Benedetta Pessina
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Women, Children and Adolescents, University Hospital of Geneva, Geneva, Switzerland
| | - Simona Barni
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
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Moral L, Toral T, Muñoz C, Marco N, García-Avilés B, Murcia L, Forniés MJ, González MC, Canals F, Bragado E, Martínez Olmos J, García-Magán C, Moure González JD, Cortés N, Giménez M, Gómez C, Rodríguez AB, Moreno A, Lucas JM, Quevedo S, Blasco C, Aliaga Y. Direct oral challenge for immediate and non-immediate beta-lactam allergy in children: A real-world multicenter study. Pediatr Allergy Immunol 2024; 35:e14096. [PMID: 38425150 DOI: 10.1111/pai.14096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/03/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Allergy to beta-lactam antibiotics (BLA) is frequently suspected in children, but a drug provocation test (DPT) rules it out in over 90% of cases. Direct oral DPT (DODPT), without skin or other previous tests, is increasingly been used to delabel non-immediate BLA reactions. This real-world study aimed to assess the safety and effectiveness of DODPT in children with immediate and non-immediate reactions to BLAs. METHODS Ambispective registry study in children (<15 years), attended between 2016 and 2023 for suspected BLA allergy in 15 hospitals in Spain that routinely perform DODPT. RESULTS The study included 2133 patients with generally mild reactions (anaphylaxis 0.7%). Drug provocation test with the implicated BLA was performed in 2014 patients (94.4%): 1854 underwent DODPT (86.9%, including 172 patients with immediate reactions). One hundred forty-five (7.2%) had symptoms associated with DPT, although only four reactions were severe: two episodes of anaphylaxis and two of drug-induced enterocolitis syndrome, which resolved rapidly with treatment. Of the 141 patients with mild reactions in the first DPT, a second DPT was considered in 87 and performed in 57, with 52 tolerating it without symptoms. Finally, BLA allergy was ruled out in 90.9% of the sample, confirmed in 3.4%, and remained unverified, usually due to loss to follow-up, in 5.8%. CONCLUSIONS Direct oral DPT is a safe, effective procedure even in immediate mild reactions to BLA. Many reactions observed in DPT are doubtful and require confirmation. Severe reactions are exceptional and amenable to treatment. Direct oral DPT can be considered for BLA allergy delabeling in pediatric primary care.
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Affiliation(s)
- Luis Moral
- Hospital General Universitario Dr. Balmis, ISABIAL, Alicante, Spain
| | - Teresa Toral
- Hospital General Universitario Dr. Balmis, ISABIAL, Alicante, Spain
| | | | - Nuria Marco
- Hospital Vega Baja de Orihuela, San Bartolome, Spain
| | | | | | | | | | | | - Esther Bragado
- Hospital General Universitario Santa Lucía, Cartagena, Spain
| | | | | | | | - Nuria Cortés
- Hospital Universitario Mútua de Terrassa, Terrassa, Spain
| | - Magalí Giménez
- Hospital Sant Joan de Deu, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Catalina Gómez
- Hospital Sant Joan de Deu, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | | | - Ana Moreno
- Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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5
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Mori F, Liccioli G, Tomei L, Barni S, Giovannini M, Sarti L, Pessina B, Torres MJ. How to manage drug-virus interplay underlying skin eruptions in children. World Allergy Organ J 2024; 17:100877. [PMID: 38361746 PMCID: PMC10864808 DOI: 10.1016/j.waojou.2024.100877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/18/2024] [Accepted: 01/26/2024] [Indexed: 02/17/2024] Open
Abstract
The majority of viral rashes occurring during an antibiotic therapy are considered as a drug hypersensitivity reaction (DHR). Differentiating a viral rash versus a DHR is difficult or even impossible. In delayed DHRs the interplay between viruses and drugs is summarized according to the recent literature. The question is if the same reaction will again occur in case of drug re-exposure in absence of the concomitant viral infection because of persistent immune reactivity. Epstein Barr Virus (EBV) and Human Herpes virus 6 (HHV-6) models are analyzed in case of maculopapular exanthemas (MPEs) and drug reaction with eosinophilia and systemic symptoms (DRESS) over a course of drug therapy. MPEs are the most common skin manifestation during a viral infection and a concomitant drug therapy. In type IVb reactions to drugs a hapten/pro-hapten mechanism and a pharmacological interaction (p-i mechanism) are described as the 2 major ways to make T cells response functional. Rarely the altered repertoire model is involved. The Human Leukocyte Antigen (HLA) predisposition is an additional essential factor that can facilitate DHR. In MPEs rarely a DHR is confirmed by allergy testing. Severity and duration of MPEs, the presence of eosinophilia and systemic symptoms make more reliable the persistent nature of the reaction. Research on this topic is needed in order to provide the clinicians with instruments to decide when to suspect future reactions upon drug re-exposure even in the absence of a viral infection, because those patients should be investigated by a complete drug allergy work up.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Giulia Liccioli
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Leonardo Tomei
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Benedetta Pessina
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
| | - María José Torres
- Allergy Unit, Hospital Regional Universitario de Málaga-UMA-ARADyAL, Malaga, Spain
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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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Arnold A, Coventry LL, Foster MJ, Koplin JJ, Lucas M. The Burden of Self-Reported Antibiotic Allergies in Health Care and How to Address It: A Systematic Review of the Evidence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3133-3145.e3. [PMID: 37352931 DOI: 10.1016/j.jaip.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/28/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Antibiotics are the first-line treatment for bacterial infections; however, overuse and inappropriate prescribing have made antibiotics less effective with increased antimicrobial resistance. Unconfirmed reported antibiotic allergy labels create a significant barrier to optimal antimicrobial stewardship in health care, with clinical and economic implications. OBJECTIVE A systematic review was conducted to summarize the impact of patient-reported antibiotic allergy on clinical outcomes and various strategies that have been employed to effectively assess and remove these allergy labels, improving patient care. METHODS The review was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A critical appraisal was conducted on all studies and a narrative synthesis was performed to identify themes. RESULTS Four themes emerged: the prevalence of antibiotic allergy, impact of antibiotic allergy on antimicrobial prescribing, impact of antibiotic allergy on clinical outcomes, and delabeling strategies to improve clinical outcomes. Of the 32 studies, including 1,089,675 participants, the prevalence of reported antibiotic allergy was between 5% and 35%. Patients with a reported antibiotic allergy had poorer concordance with prescribing guidelines in 30% to 60% of cases, with a higher use of alternatives such as quinolone, tetracycline, macrolide, lincosamide, and carbapenem and lower use of beta-lactam antibiotics. Antibiotic allergy delabeling was identified as an intervention and recommendation to advance the state of the science. CONCLUSIONS There is substantial evidence within the literature that antibiotic allergy labels significantly impact patient clinical outcomes and a consensus that systematic assessment of reported antibiotic allergies, commonly referred to as delabeling, improves the clinical management of patients.
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Affiliation(s)
- Annabelle Arnold
- Immunology Department, Perth Children's Hospital, Perth, Australia; School of Nursing and Midwifery, Edith Cowan University, Perth, Australia
| | - Linda L Coventry
- School of Nursing and Midwifery, Edith Cowan University, Perth, Australia; Centre for Nursing Research, Sir Charles Gairdner Hospital, Perth, Australia
| | - Mandie J Foster
- School of Nursing and Midwifery, Edith Cowan University, Perth, Australia; Auckland University of Technology, School of Clinical Sciences, Auckland, New Zealand
| | - Jennifer J Koplin
- University of Queensland, Child Health Research Centre, Brisbane, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Michaela Lucas
- Immunology Department, Perth Children's Hospital, Perth, Australia; Medical School, University of Western Australia, Perth, Australia; Immunology Department, PathWest Laboratory Medicine WA, Perth, Australia; Immunology Department, Sir Charles Gairdner Hospital, Perth, Australia.
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8
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Wijnakker R, van Maaren MS, Bode LGM, Bulatovic M, Hendriks BJC, Loogman MCM, Lutgens SPM, Middel A, Nieuwhof CMG, Roelofsen EE, Schoones JW, Sigaloff KCE, Sprikkelman AB, de Vrankrijker AMM, de Boer MGJ. The Dutch Working Party on Antibiotic Policy (SWAB) guideline for the approach to suspected antibiotic allergy. Clin Microbiol Infect 2023:S1198-743X(23)00178-7. [PMID: 37068548 DOI: 10.1016/j.cmi.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/28/2023] [Accepted: 04/07/2023] [Indexed: 04/19/2023]
Abstract
OBJECTIVES Prudent handling of reported antibiotic allergy is an important aspect of antibiotic stewardship. The Dutch Working Party on Antibiotic Policy (SWAB) constituted a multidisciplinary expert committee to provide evidence-based recommendations for bedside decision making in antibiotic therapy in patients that report an antibiotic allergy. METHODS The guideline committee generated 12 key questions, most of which were population, intervention, comparison and outcome (PICO) questions relevant for both children and adults with suspected antibiotic allergy. For each question a systematic literature search was performed and reviewed for the best available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Quality of evidence was graded from very low to high and recommendations were formulated in structured discussions as strong or weak. RESULTS Sixty recommendations were provided for suspected allergy to beta-lactam antibiotics (BLA) and non-beta-lactam antibiotics (NBLA). Due to the absence of randomized controlled trials in this field, the underlying evidence was predominantly graded as low or very low. Available data supports that a detailed allergy history should always be performed and critically appraised. When cross-allergy between BLA groups is not to be expected due to absence of molecular similarity of the side chains, the patient can be safely exposed to the alternative BLA. An exception to this rule are severe delayed type reactions, in which reexposure to a BLA should only be considered after consultation of a multidisciplinary team. CONCLUSIONS Accumulated scientific data now supports a more liberal approach that better balances benefits of treatment with first choice and usually smaller spectrum antibiotics with appropriate avoidance of antibiotics in case of a truly high risk of a (severe) allergic reaction. In the Netherlands, a formal guideline was developed that provides recommendations for the approach towards suspected allergy to BLA and frequently used NBLA, thereby strongly supporting antimicrobial stewardship.
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Affiliation(s)
- R Wijnakker
- Department of internal medicine, Tergooi Medical Center, Hilversum & Department of infectious diseases, Leiden University Medical Center, Leiden.
| | - M S van Maaren
- Department of internal medicine, section allergology, Erasmus Medical Center, Rotterdam
| | - L G M Bode
- Department of medical microbiology and infectious diseases, Erasmus Medical Center, Rotterdam
| | - M Bulatovic
- Department of rheumatology and clinical immunology, University Medical Center Utrecht, Utrecht
| | - B J C Hendriks
- Department of clinical pharmacy and toxicology, Leiden University Medical Center, Leiden
| | - M C M Loogman
- General practioner, Dutch college of general practitioners
| | - S P M Lutgens
- Department of medical microbiology, Jeroen Bosch Hospital, 's-Hertogenbosch
| | - A Middel
- Department of internal medicine, University Medical Center Groningen, Groningen
| | - C M G Nieuwhof
- Department of internal medicine and allergology, Maastricht University Medical Center, Maastricht
| | - E E Roelofsen
- Department of clinical pharmacy, Medical Center Haaglanden, The Hague
| | - J W Schoones
- Directorate of Research Policy (formerly: Walaeus Library), Leiden University Medical Center, Leiden
| | - K C E Sigaloff
- Department of infectious diseases, Amsterdam University Medical Center, Amsterdam
| | - A B Sprikkelman
- Department of pediatric pulmonology and allergology, University Medical Center Groningen, Groningen
| | - A M M de Vrankrijker
- Department of pediatric infectious diseases, section infectious diseases, University Medical Center Utrecht, Utrecht
| | - M G J de Boer
- Department of infectious diseases and Department of Clinical Epidemiology, Leiden University Medical Center, Leiden.
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9
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Bronner H, Brunswig F, Pluta D, Krysiak Y, Bigall N, Plettenburg O, Polarz S. Cooperative Functionalities in Porous Nanoparticles for Seeking Extracellular DNA and Targeting Pathogenic Biofilms via Photodynamic Therapy. ACS APPLIED MATERIALS & INTERFACES 2023; 15. [PMID: 36892202 PMCID: PMC10037239 DOI: 10.1021/acsami.3c00210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/23/2023] [Indexed: 06/18/2023]
Abstract
Many pathogenic bacteria are getting more and more resistant against antibiotic treatment and even become up to 1.000× times more resilient in the form of a mature biofilm. Thus, one is currently prospecting for alternative methods for treating microbial infections, and photodynamic therapy is a highly promising approach by creating so-called reactive oxygen species (ROS) produced by a photosensitizer (PS) upon irradiation with light. Unfortunately, the unspecific activity of ROS is also problematic as they are harmful to healthy tissue as well. Notably, one knows that uncontrolled existence of ROS in the body plays a major role in the development of cancer. These arguments create need for advanced theranostic materials which are capable of autonomous targeting and detecting the existence of a biofilm, followed by specific activation to combat the infection. The focus of this contribution is on mesoporous organosilica colloids functionalized by orthogonal and localized click-chemistry methods. The external zone of the particles is modified by a dye of the Hoechst family. The particles readily enter a mature biofilm where adduct formation with extracellular DNA and a resulting change in the fluorescence signal occurs, but they cannot cross cellular membranes such as in healthy tissue. A different dye suitable for photochemical ROS generation, Acridine Orange, is covalently linked to the surfaces of the internal mesopores. The spectral overlap between the emission of Hoechst with the absorption band of Acridine Orange facilitates energy transfer by Förster resonance with up to 88% efficiency. The theranostic properties of the materials including viability studies were investigated in vitro on mature biofilms formed by Pseudomonas fluorescens and prove the high efficacy.
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Affiliation(s)
- Hannah Bronner
- Institute
of Inorganic Chemistry, Leibniz-University
Hannover, Callinstrasse
9, 30167 Hannover, Germany
| | - Fabian Brunswig
- Centre
of Biomolecular Drug Research (BMWZ), Institute of Organic Chemistry, Leibniz-University Hannover, Schneiderberg 1b, 30167 Hannover, Germany
- Institute
of Medicinal Chemistry (IMC), Helmholtz
Centre Munich, Ingolstädter
Landstraße 1, D-85764 Neuherberg, Germany
| | - Denis Pluta
- Institute
of Physical Chemistry, Leibniz-University
Hannover, Callinstraße
3a, 30167 D-Hannover, Germany
- Laboratory
of Nano- and Quantum Engineering, Leibniz
University Hannover, 30167 Hanover, Germany
- Cluster of
Excellence PhoenixD (Photonics, Optics and Engineering-Innovation
Across Disciplines), Leibniz University
Hannover, 30167 Hannover, Germany
| | - Yaşar Krysiak
- Institute
of Inorganic Chemistry, Leibniz-University
Hannover, Callinstrasse
9, 30167 Hannover, Germany
| | - Nadja Bigall
- Institute
of Physical Chemistry, Leibniz-University
Hannover, Callinstraße
3a, 30167 D-Hannover, Germany
- Laboratory
of Nano- and Quantum Engineering, Leibniz
University Hannover, 30167 Hanover, Germany
- Cluster of
Excellence PhoenixD (Photonics, Optics and Engineering-Innovation
Across Disciplines), Leibniz University
Hannover, 30167 Hannover, Germany
| | - Oliver Plettenburg
- Centre
of Biomolecular Drug Research (BMWZ), Institute of Organic Chemistry, Leibniz-University Hannover, Schneiderberg 1b, 30167 Hannover, Germany
- Institute
of Medicinal Chemistry (IMC), Helmholtz
Centre Munich, Ingolstädter
Landstraße 1, D-85764 Neuherberg, Germany
| | - Sebastian Polarz
- Institute
of Inorganic Chemistry, Leibniz-University
Hannover, Callinstrasse
9, 30167 Hannover, Germany
- Laboratory
of Nano- and Quantum Engineering, Leibniz
University Hannover, 30167 Hanover, Germany
- Cluster of
Excellence PhoenixD (Photonics, Optics and Engineering-Innovation
Across Disciplines), Leibniz University
Hannover, 30167 Hannover, Germany
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10
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Alzaidi AA, Alzaidi AA, AlOtaibi MT, Alsheikh RM. Case Report of Serum Sickness-like Reaction following the First Dose of the Chimpanzee Adenovirus-Vectored AstraZeneca COVID-19 Vaccine, ChAdOx1. Vaccines (Basel) 2023; 11:vaccines11020467. [PMID: 36851343 PMCID: PMC9963129 DOI: 10.3390/vaccines11020467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/31/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023] Open
Abstract
Serum sickness-like reaction from serum sickness is critical. Serum sickness-like reaction has comparable symptoms to serum sickness, but their underlying pathophysiology is distinct. This delayed hypersensitivity response was first characterized as a drug-induced reaction and is uncommon in adults; it is more common in children. COVID-19 vaccinations are now being routinely given in the COVID-19 period, and adverse reactions to immunization have been recorded. We present a case of COVID-19 vaccination-induced serum sickness-like reaction which developed after receiving the first dose of AstraZeneca COVID-19 vaccine.
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Affiliation(s)
- Areej Awad Alzaidi
- Family Medicine, Family Medicine Department, Ministry of the National Guard—Health Affairs, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Jeddah 21423, Saudi Arabia
- Correspondence: ; Tel.: +966-567-254-046
| | - Arwa Awad Alzaidi
- Medical Laboratory Specialists, Maternity and Children Hospital, Ministry of Health, Makkah 24246, Saudi Arabia
| | | | - Reem M. Alsheikh
- Family Medicine, Family Medicine Department, Ministry of the National Guard—Health Affairs, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Jeddah 21423, Saudi Arabia
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11
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Srisuwatchari W, Phinyo P, Chiriac AM, Saokaew S, Kulalert P. The Safety of the Direct Drug Provocation Test in Beta-Lactam Hypersensitivity in Children: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:506-518. [PMID: 36528293 DOI: 10.1016/j.jaip.2022.11.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Direct drug provocation test (DPT) without prior skin testing (ST) has been investigated in children suspected of being at risk for beta-lactam (BL) hypersensitivity reaction (HSR). However, no systematic review and meta-analysis has investigated the efficacy and safety of direct DPT for BL-HSR in children. OBJECTIVE To investigate the prevalence of BL-HSR by direct DPT and the safety of direct DPT in children. METHODS We searched MEDLINE, EMBASE, Web of Science, and CINAHL from their inception to July 23, 2022, for studies that performed direct DPT in children with suspected BL-HSR, or for studies that performed DPT in all cases with ST results, but they ignored the ST results. The true prevalence was defined as the proportion of children who experienced an HSR during direct DPT. Safety was determined according to the proportion of children who developed a dangerous reaction following DPT. RESULTS Twenty-eight studies with 8,334 direct challenges were included. Fifteen studies included patients who presented with either immediate or nonimmediate HSR, and the majority of the index reactions were nonsevere. Amoxicillin/amoxicillin-clavulanic acid was the most commonly used during the DPT. The pooled prevalence of confirmed BL-HSR was 5.23% (95% CI 4.17-6.39; I2 = 72%). Immediate and nonimmediate HSR were reported in 0.8% (95% CI 0.43-1.25; I2 = 55.1%) and 3.69% (95% CI 2.66-4.87; I2 = 79.77%), respectively. Severe reactions were found in 3 cases with the frequency of 0.036% (95% CI 0.012-0.112; I2 = 0%). CONCLUSIONS The prevalence of BL-HSR by direct DPT was 5.23%, and the frequency of severe reactions from direct DPT was very low (0.036%). Our findings support direct DPT as a safe and effective delabeling tool in children with suspected nonsevere BL-HSR.
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Affiliation(s)
- Witchaya Srisuwatchari
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Musculoskeletal Science and Translational Research (MSTR), Chiang Mai University, Chiang Mai, Thailand
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; IDESP, UMR UA11, University of Montpellier, INSERM, Montpellier, France
| | - Surasak Saokaew
- UNIt of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Prapasri Kulalert
- Department of Clinical Epidemiology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand; Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
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12
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Ben Romdhane H, Ben Fredj N, Ben Fadhel N, Chadli Z, Abderrahmen A, Boughattas NA, Chaabane A, Aouam K. Beta-lactam hypersensitivity in children: Frequency and risk factors. Br J Clin Pharmacol 2023; 89:150-157. [PMID: 33179302 DOI: 10.1111/bcp.14647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/22/2020] [Accepted: 10/30/2020] [Indexed: 12/01/2022] Open
Abstract
AIMS To determine the frequency of an authentic β-lactam (BL) hypersensitivity (HS) amongst a large number of children and to identify clinical risk factors that predict this hypersensitivity. METHODS All children with suspected BL allergy were evaluated by skin tests (ST) with the suspected BL. A 1-day oral provocation test (OPT) was performed in children with negative ST. We defined an authentic BL-HS case if the child exhibited a positive ST or a positive OPT. Risk factors associated with BL-HS were assessed using a univariate analysis. Covariates showing a P-value <.2 were included in the multivariate logistic regression analysis to determine independent predictors. RESULTS A total of 354 patients reporting 368 suspected BL reactions were included. The diagnosis of BL-HS was established in 24 children (6.7%). All these children had a positive ST. OPT was performed in 30 patients and was negative in all of them. In 110 children with a negative ST, BL was tolerated. In the risk factors analysis, 164 children were included. Older age (>5 years) at the reaction (odds ratio = 1.11; 95% confidence interval, 1.01-1.22; P = .02) and BL administered (odds ratio = 7.7; 95% confidence interval, 2.76-21.8; P < .001) were significantly associated with authentic BL-HS. CONCLUSION BL-HS should be evaluated with an appropriate allergy work-up before strict prohibition is made. In addition, age of patient and BL involved can be used as predictive factors of developing BL-HS in this population.
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Affiliation(s)
- Haifa Ben Romdhane
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Nadia Ben Fredj
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Najah Ben Fadhel
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Zohra Chadli
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Ahlem Abderrahmen
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Naceur A Boughattas
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Amel Chaabane
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
| | - Karim Aouam
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Tunisia
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13
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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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14
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Kitsos N, Cassimos D, Trypsianis G, Xinias I, Roilides E, Grivea I, Mantadakis E, Mavroudi A. Drug allergy evaluation in children with suspected mild antibiotic allergy. FRONTIERS IN ALLERGY 2022; 3:1050048. [PMID: 36569377 PMCID: PMC9784922 DOI: 10.3389/falgy.2022.1050048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 10/24/2022] [Indexed: 12/12/2022] Open
Abstract
Background Adverse antibiotic reactions caused by an immunological mechanism are known as allergic reactions. The percentage of reported antibiotic allergies is likely to differ from the one validated after a drug provocation test (DPT) with the culprit antibiotic. This study aimed to compare the percentage of children who were thought to be allergic to a certain antibiotic with those who have a true allergy, as confirmed by DPTs. We also validated Skin Prick Tests (SPTs) and Intradermal Tests (IDTs) by assessing their sensitivity and specificity, in diagnosing antibiotic allergies using DPT as the gold standard. Furthermore, we investigated epidemiological risk factors such as personal and family history of atopic disease and eosinophilia. Methods Children with a history of possible allergic reaction to an antibiotic underwent a diagnostic procedure that included: (1) Eosinophil blood count, (2) SPTs, (3) IDTs and (4) DPTs. The parameters were compared with Pearson's Chi-Square and Fisher's Exact Test. Several risk factors that were found significant in univariate analysis, such as personal and family history of atopic disease, and positive SPTs and IDTs were examined with multiple logistic regression analysis to see if they were related to a higher risk for a positive DPT. Results Semi-synthetic penicillin was the most common group of antibiotics thought to cause allergic reactions in this study. Overall, 123 children with a personal history of an adverse reaction to a certain antibiotic, were evaluated. In 87.8% of the cases, the symptoms had occurred several hours after administration of the culprit antibiotic. Both SPTs and IDTs had low sensitivity but high specificity. Moreover, they had a high positive predictive value (PPV). In contrast, eosinophilia was not recognized as a risk factor. Seventeen patients (13.8%) had a true antibiotic allergy, as confirmed by a positive DPT. A positive IDT was a strong predictor of a positive DPT, along with a positive personal and family history of atopy. Conclusion SPTs and IDTs are very reliable in confirming antibiotic allergy when found positive. A negative result of a SPT highly predicts a negative DPT. A positive IDT and a positive personal and family history of atopy were recognized as significant risk factors for antibiotic allergy.
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Affiliation(s)
- Nikolaos Kitsos
- 3rd Pediatric Clinic, Aristotle University of Thessaloniki, Thessaloniki, Greece,Correspondence: Nikolaos Kitsos
| | - Dimitrios Cassimos
- Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Grigorios Trypsianis
- Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Ioannis Xinias
- 3rd Pediatric Clinic, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Emmanouil Roilides
- 3rd Pediatric Clinic, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioanna Grivea
- School of Health Sciences, University of Thessaly, Larisa, Greece
| | - Elpis Mantadakis
- Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Antigoni Mavroudi
- 3rd Pediatric Clinic, Aristotle University of Thessaloniki, Thessaloniki, Greece
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15
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Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J, Khan DA, Golden DBK, Shaker M, Stukus DR, Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333-1393. [PMID: 36122788 DOI: 10.1016/j.jaci.2022.08.028] [Citation(s) in RCA: 173] [Impact Index Per Article: 86.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Aleena Banerji
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Roland Solensky
- Corvallis Clinic, Oregon State University/Oregon Health Science University College of Pharmacy, Corvallis, Ore
| | - Andrew A White
- Department of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St Joe's Hamilton, Hamilton, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew J Greenhawt
- Food Challenge and Research Unit Section of Allergy and Immunology, Children's Hospital Colorado University of Colorado School of Medicine, Aurora, Colo
| | - Caroline C Horner
- Department of Pediatrics, Division of Allergy Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla; James A. Haley Veterans Affairs Hospital, Tampa, Fla
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | - John Oppenheimer
- Division of Allergy, Rutgers New Jersey Medical School, Rutgers, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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16
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Guarnieri KM, Xie SS, Courter JD, Liu C, Ruddy RM, Risma KA. Distinct Characteristics and Chronology of Amoxicillin-Associated Reactions in Pediatric Acute Care Settings. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2951-2957.e3. [PMID: 35872212 DOI: 10.1016/j.jaip.2022.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Amoxicillin-associated reactions (AARs) in children presenting as rashes are common, and recent data suggest that >90% tolerate amoxicillin on re-exposure. However, additional data would help pediatricians and allergists gain confidence in referring and testing children who experienced systemic symptoms perceived as "worrisome," thus leading to urgent medical evaluations. By characterizing the entire spectrum of AAR symptoms in pediatric patients presenting to emergency department (ED)/urgent care (UC) settings, we sought to increase our diagnostic acumen to guide subsequent allergy evaluations. OBJECTIVE To fully characterize clinical features of rash and systemic symptoms in children presenting to the ED/UC with AARs. METHODS A retrospective chart review of children seen in the ED/UC from July 1, 2015, to June 30, 2017, was conducted. Clinical features, chronology, and seasonality were detailed, and cases were classified into 3 previously described AAR phenotypes: maculopapular exanthem (MPE), urticaria, and serum sickness-like reactions (SSLRs), if they experienced joint symptoms. RESULTS Children (n = 668; median age: 1.8 years) presented to the ED/UC with urticaria (44%), MPE (36%), and SSLRs (11%) typically on days 7 to 10 of amoxicillin. Although children with SSLRs were more frequently treated with corticosteroids (28%, P < .0001) and exhibited higher rates of "worrisome" features (fever, angioedema, or gastrointestinal symptoms; 73%, P < .0001), delayed-onset systemic symptoms were identified frequently in all 3 groups. ED/UC reutilization was unexpectedly high with 66 children (10%) returning to the ED/UC for re-evaluation. CONCLUSION "Worrisome" symptoms are common in children presenting to the ED/UC with AARs. Future studies are needed to determine the impact on subsequent referral and allergy testing.
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Affiliation(s)
- Katharine M Guarnieri
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Susan S Xie
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joshua D Courter
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Richard M Ruddy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kimberly A Risma
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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17
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De-labeling Penicillin Allergy in Pediatric Population. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00315-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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18
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Changes in Sensitization Patterns in the Last 25 Years in 619 Patients with Confirmed Diagnoses of Immediate Hypersensitivity Reactions to Beta-Lactams. Biomedicines 2022; 10:biomedicines10071535. [PMID: 35884838 PMCID: PMC9312895 DOI: 10.3390/biomedicines10071535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 11/22/2022] Open
Abstract
Beta-lactam (BL) drugs are the antibiotics most prescribed worldwide due to their broad spectrum of action. They are also the most frequently implied in hypersensitivity reactions with a known specific immunological mechanism. Since the commercialization of benzylpenicillin, allergic reactions have been described; over the years, other new BL drugs provided alternative treatments to penicillin, and amoxicillin is now the most prescribed BL in Europe. Diagnosis of BL allergy is mainly based on skin tests and drug provocation tests, defining different sensitization patterns or phenotypes. In this study, we evaluated 619 patients with a confirmed diagnosis of BL-immediate allergy during the last 25 years, using the same diagnostic procedures with minor adaptations to the successive guidelines. The initial eliciting drug was benzylpenicillin, which changed to amoxicillin with or without clavulanic acid and cephalosporins in recent years. In skin tests, we found a decrease in sensitivity to major and minor penicillin determinants and an increase in sensitivity to amoxicillin and others; this might reflect that the changes in prescription could have influenced the sensitization patterns, thus increasing the incidence of specific reactions to side-chain selective reactions.
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19
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Hampton LL, DeBoy JT, Hornik CP, White MJ, Nazareth-Pidgeon KM. Association of Sociodemographic Factors With Reported Penicillin Allergy in Pediatric Inpatients. Hosp Pediatr 2022; 12:625-631. [PMID: 35660855 DOI: 10.1542/hpeds.2021-006462] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Characterize the association of sociodemographic factors with reported penicillin allergy in pediatric inpatients. METHODS We conducted a retrospective cohort study of pediatric inpatients admitted to general pediatric units at an academic medical center with reported penicillin allergy and reaction history. Sociodemographic factors evaluated were gender, age, race, ethnicity, language, and insurance payer. We conducted univariable and multivariable logistic regression models to evaluate associations between demographic variables and penicillin allergy. RESULTS Of 3890 pediatric inpatients, 299 (7.7%) had a reported penicillin allergy. The majority of documented reaction histories were hives, rash, or unknown. In univariable analysis, odds of penicillin allergy were lower in patients who identify as Black and who prefer a language other than English, and higher in patients of non-Hispanic/Latino ethnicity, those with private insurance, and with increasing age. In multivariable logistic regression, only Black race (adjusted odds ratio 0.42, 95% confidence interval CI 0.30-0.59) and young age were significantly associated with lower odds of penicillin allergy. CONCLUSIONS After adjustment for covariates, Black race was associated with lower odds of reported penicillin allergy in hospitalized children. Penicillin allergy reporting may be an indicator of racial differences in the prescribing of antimicrobial agents, patient-clinician communication, and access to health care.
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Affiliation(s)
- Laura L Hampton
- Division of Hospital Medicine, Department of Pediatrics, and
| | - Jason T DeBoy
- Management Engineer Team, Department of Performance Services; and
| | - Christoph P Hornik
- Department of Pediatrics, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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20
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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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21
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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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22
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Prosty C, Copaescu AM, Gabrielli S, Mule P, Ben-Shoshan M. Pediatric Drug Allergy. Immunol Allergy Clin North Am 2022; 42:433-452. [DOI: 10.1016/j.iac.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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23
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Diagnosis of non-immediate hypersensitivity to amoxicillin in children by skin test and drug provocation tests: A retrospective case-series study. Allergol Int 2022; 71:131-136. [PMID: 34384710 DOI: 10.1016/j.alit.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/12/2021] [Accepted: 06/16/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Skin rash often occurs upon oral administration of amoxicillin in children, due to non-immediate hypersensitivity. However, information on delayed hypersensitivity to amoxicillin is scarce. Moreover, the appropriate diagnostic method and actual diagnostic rate of delayed hypersensitivity to amoxicillin among Japanese children are unclear. We conducted intradermal tests (IDTs) and drug provocation tests (DPTs) and retrospectively investigated the proportion of children with a definitive diagnosis of non-immediate hypersensitivity to amoxicillin. We then evaluated the characteristics of patients with a positive allergic workup. METHODS We enrolled children referred for suspected findings of mild or moderate non-immediate hypersensitivity to amoxicillin between August 2018 and March 2020. If the IDT in the delayed phase was negative, DPT with amoxicillin (60-90 mg/kg/day) was performed for 7 days. Non-immediate hypersensitivity to amoxicillin was defined when IDT or DPT was positive. We evaluated the potential of the drug-induced lymphocyte stimulation test (DLST) to reveal hypersensitivity to amoxicillin. RESULTS This study enrolled 27 children. Fourteen children (52%) had hypersensitivity to amoxicillin, of whom 12 had positive IDTs and two had positive DPTs. No differences in age, sex, history of allergic disease, days from oral use to symptom onset, type of rash at symptom onset, generalized rash, and DLST results were observed between the hypersensitivity and non-hypersensitivity groups. CONCLUSIONS Examination should be performed for children with mild or moderate reactions because positive cases have no significant features and half of the suspected cases are negative.
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24
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Rischin KJ, Mostaghim M, Rao A, Smith B, O'Brien TA, Trubiano JA, Frith K, McMullan B. ESCAPE-Allergy: Evaluating screening for children and adolescents with penicillin allergy. J Paediatr Child Health 2022; 58:83-89. [PMID: 34323321 DOI: 10.1111/jpc.15657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/31/2022]
Abstract
AIM Penicillin allergy labels are frequently encountered in children and are associated with significant harms. Most children are falsely labelled and can safely tolerate a penicillin but delabelling strategies are underutilised and paediatric-specific resources are lacking. The aim of this study was to evaluate an allergy assessment tool for children in hospital. METHODS We evaluated a paediatric-adapted penicillin allergy assessment tool, using an online survey of clinicians in a tertiary paediatric hospital, with 10 hypothetical potential penicillin allergy or adverse reaction cases (including non-allergy reactions). For each case, respondents were asked to use the tool to assign a reaction phenotype and recommend management. We determined the tool's sensitivity, specificity and acceptability to end users. RESULTS We evaluated 30 complete survey responses from senior and junior medical staff, nurses and pharmacists. The tool's overall sensitivity was 80.7% (95% confidence interval (CI) 74.2-87.1%) for assigning the correct reaction phenotype and 85.3% (95% CI 79.4-91.3%) for appropriate management. The tool had high sensitivity for identifying immediate hypersensitivity reactions at 95.6% (95% CI 90.2-100%). Most respondents agreed or strongly agreed that they would use the tool in their practice (22/30, 73.3%). CONCLUSION This survey evaluated a paediatric-adapted penicillin allergy assessment tool in a tertiary paediatric hospital among multidisciplinary clinician groups. The tool performed well overall and had high safety in identifying immediate hypersensitivity reactions. Further research to support implementation of allergy assessment and delabelling programmes among children is required.
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Affiliation(s)
- Kobi J Rischin
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia
| | - Mona Mostaghim
- Pharmacy Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Arjun Rao
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Bridget Smith
- Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Tracey A O'Brien
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Katie Frith
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia.,Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Brendan McMullan
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia.,Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia
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25
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Demirhan A, Yildirim DD, Arikoglu T, Ozhan AK, Tokmeci N, Yuksek BC, Kuyucu S. A combined risk modeling strategy for clinical prediction of beta-lactam allergies in children. Allergy Asthma Proc 2021; 42:e159-e166. [PMID: 34871164 DOI: 10.2500/aap.2021.42.210068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Drug provocation test (DPT) without skin tests is increasingly recommended in the evaluation of children with low-risk beta-lactam (BL) allergies. However, risk definitions are unclear. Objective: The aim of this study was to compose a clinical predictive model that could identify the children at low risk who could safely undergo direct DPT. Methods: The clinical data of 204 children who underwent a full diagnostic algorithm for suspected BL allergy were analyzed. Clinical data were used to construct mathematical predictive model for confirmed BL allergies. A prospective new sample was used for external validation of the final model. Results: The presentations during the index reaction were anaphylaxis in 5.9% and cutaneous reactions in the majority. BL allergy was confirmed in 15.7% of suspected cases. A backward multiple logistic regression model showed that a family history of drug allergy (adjusted odds ratio [aOR], 5.52), anaphylaxis (aOR, 5.14), any atopic disease other than asthma (aOR, 4.38), and a reaction interval of 0-6 hours during the index reaction (aOR, 5.32) were significantly associated with a confirmed BL allergy. A mathematical combined model based on these factors showed a sensitivity of 77.8% and a negative predictive value (NPV) of 94.3%. The validation study replicated sensitivity and NPV values of the main cohort. Conclusion: The risk definition in BL allergies should depend on population-specific predictive models, including a combination of significant risk factors rather than empiric risk approaches. This may help to accurately determinate children at low risk who may safely proceed to direct DPT.
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Affiliation(s)
- Ali Demirhan
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Didem D. Yildirim
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Tugba Arikoglu
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Aylin K. Ozhan
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Nazan Tokmeci
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Burcu C. Yuksek
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Semanur Kuyucu
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
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26
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Leclercq C, Toutain F, Baleydier F, L'Huillier AG, Wagner N, Lironi C, Calza AM, Ansari M, Blanchard-Rohner G. Pediatric Acute B-Cell Lymphoblastic Leukemia Developing Following Recent SARS-CoV-2 Infection. J Pediatr Hematol Oncol 2021; 43:e1177-e1180. [PMID: 33480653 DOI: 10.1097/mph.0000000000002064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/11/2020] [Indexed: 11/25/2022]
Abstract
Coronavirus disease-2019 in children has been linked to various clinical presentation, from paucisymptomatic cutaneous eruptions, to multisystemic inflammatory syndrome. We report the case of an 8-year-old boy who presented with persistent fever and pancytopenia, associated to a skin rash. An extensive etiological workup showed a positive serology for severe acute respiratory syndrome coronavirus 2 and Epstein-Barr virus. A few weeks later, type B acute lymphocytic leukemia was diagnosed. This case underlines the polymorphic appearance of coronavirus disease-2019 and the need for critical appraisal.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Geraldine Blanchard-Rohner
- Paediatric Immunology and Vaccinology Unit, Geneva University Hospitals and Faculty of Medicine
- Center of Vaccinology, Geneva University Hospitals, Geneva, Switzerland
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27
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Torres-Rojas I, Pérez-Alzate D, Somoza ML, Haroun Diaz E, Ruano Pérez FJ, Prieto-Moreno Pfeifer A, Jimenez-Rodriguez TW, Fernandez Sánchez J, Blanca M, Canto Diez G, Blanca-López N. Patterns of response and drugs involved in hypersensitivity reactions to beta-lactams in children. Pediatr Allergy Immunol 2021; 32:1788-1795. [PMID: 34324747 DOI: 10.1111/pai.13608] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 07/19/2021] [Accepted: 07/23/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Beta-lactams generate different allergenic determinants that induce selective or cross-reactive drug hypersensitivity reactions (DHRs). We aimed to identify the drugs involved, the selectivity of the response, the mechanism, and the value of the different diagnostic tests for establishing a diagnosis in children evaluated for DHRs to beta-lactams. METHODS Prospective study evaluating children aged under 16 years reporting DHRs to beta-lactams. Reactions were classified as immediate and non-immediate reactions. The workup included sIgE, skin testing, and drug provocation tests (DPTs) for immediate reactions and patch testing and DPTs for non-immediate ones. RESULTS Of the 510 children included, 133 were evaluated for immediate reactions and confirmed in 8.3%. Skin test/in vitro IgE contributed to diagnosing half of the cases. Selective reactions occurred with amoxicillin (63%), followed by common penicillin determinants (27%) and cephalosporins (0.9%). Among non-immediate reactions (11.4% of the 377 children evaluated), most required DPTs, 52.7% of which were positive at 6-7 days of drug challenge. Selective reactions were identified with amoxicillin (80%), penicillin G (7.5%), cephalosporins (7.5%), and clavulanic acid (5%). Urticaria and maculopapular exanthema were the most frequent entities. CONCLUSIONS There were few confirmed cases of either type of reaction. Skin testing proved less valuable in non-immediate reactions, over half of which would also have been lost in a short DPT protocol. Selective responders to amoxicillin were more likely to have non-immediate reactions, while clavulanic acid selectivity was exclusive to the non-immediate typology. Over half the cases with DPTs required 6-7 days of treatment for DHR confirmation.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Miguel Blanca
- Allergy Unit, Infanta Leonor University Hospital, Madrid, Spain
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28
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Arikoglu T, Kont AO, Demirhan A, Yuksek BC, Tokmeci N, Kuyucu S. Risk stratification in beta-lactam allergy. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00295-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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29
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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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30
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Blanca-Lopez N, Atanaskovic-Markovic M, Gomes ER, Kidon M, Kuyucu S, Mori F, Soyer O, Caubet JC. An EAACI Task Force report on allergy to beta-lactams in children: Clinical entities and diagnostic procedures. Pediatr Allergy Immunol 2021; 32:1426-1436. [PMID: 33931922 DOI: 10.1111/pai.13529] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/24/2021] [Indexed: 12/14/2022]
Abstract
Beta-lactam (BL) allergy suspicion is common in children and constitutes a major public health problem, with an impact on patient's health and on medical costs. However, it has been found that most of these reactions are not confirmed by a complete allergic workup. The diagnostic value of the currently available allergy tests has been investigated intensively recently by different groups throughout the world. This has led to major changes in the management of children with a suspected BL allergy. Particularly, it is now well accepted that skin tests can be skipped before the drug provocation test in children with a benign non-immediate reaction to BL. However, there is still a debate on the optimal allergic workup to perform in children with a benign immediate reaction. In addition, management of children with severe cutaneous adverse drug reactions remains difficult. In this review, based on a selection of the most relevant studies found in the literature, we will review and discuss the diagnosis of different forms of BL allergy in children.
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Affiliation(s)
| | | | - Eva R Gomes
- Allergy Unit, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Mona Kidon
- Safra Children's Hospital and the Clinical Immunology, Angioedema and Allergy Unit, Chaim Sheba Medical Center, Tel Hashomer, Faculty of Pediatric Medicine, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Francesca Mori
- Allergy Unit, Department of Pediatric, Meyer Children's Hospital, Florence, Italy
| | - Ozge Soyer
- Department of Pediatric Allergy, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
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31
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Iammatteo M, Lezmi G, Confino-Cohen R, Tucker M, Ben-Shoshan M, Caubet JC. Direct Challenges for the Evaluation of Beta-Lactam Allergy: Evidence and Conditions for Not Performing Skin Testing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2947-2956. [PMID: 34366093 DOI: 10.1016/j.jaip.2021.04.073] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/19/2021] [Accepted: 04/25/2021] [Indexed: 12/11/2022]
Abstract
In the western world, up to 10% of the general population and more than 15% of hospitalized patients report penicillin allergy. After a comprehensive evaluation, more than 95% of patients who report a penicillin allergy can subsequently tolerate this antibiotic. Traditionally, the most widely accepted protocol to evaluate beta-lactam (BL) allergy consisted of skin testing (ST) followed by a drug provocation test (DPT) in ST-negative patients. DPT is the gold standard for proving or excluding BL allergy and is considered the final and definitive step in the evaluation. Recently, studies have been published that support the use of direct DPTs without preceding ST for both pediatric and adult patients who report a low-risk historical reaction to BLs. However, these studies use various risk-stratification criteria to determine eligibility for a direct DPT. A standardized protocol for DPT is also lacking. In this review, we assess the current literature and evidence for performing direct DPT in the pediatric and adult populations. On the basis of this evidence, we also present risk-based algorithms for the evaluation of BL allergy in pediatric and adult populations based on a description of the historical reaction.
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Affiliation(s)
- Melissa Iammatteo
- Division of Allergy and Immunology, Department of Medicine, Montefiore Medical Center, Bronx, NY
| | - Guillaume Lezmi
- AP-HP, Hôpital Necker-Enfants Malades, Service de Pneumologie et Allergologie Pédiatriques, Paris, France; Equipe Immunorégulation et Immunopathologie, Institut Necker Enfants Malades, Inserm UMR1151, CNRS UMR8253, Université de Paris, Paris, France
| | - Ronit Confino-Cohen
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar-Saba, Israel Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark Tucker
- Department of Allergy and Immunology, Kaiser Permanente Tacoma Medical Center, Tacoma, Wash
| | - Moshe Ben-Shoshan
- Division of Pediatric Allergy, Clinical Immunology and Dermatology, Department of Pediatrics, McGill University Health Center, Montreal, Quebec, Canada
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of the Child and Adolescent, Geneva University Hospital, Geneva, Switzerland.
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32
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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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Koosakulchai V, Sangsupawanich P, Wantanaset D, Jessadapakorn W, Jongvilaikasem P, Yuenyongviwat A. Safety of direct oral provocation testing using the Amoxicillin-2-step-challenge in children with history of non-immediate reactions to amoxicillin. World Allergy Organ J 2021; 14:100560. [PMID: 34306301 PMCID: PMC8283145 DOI: 10.1016/j.waojou.2021.100560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/23/2021] [Accepted: 06/01/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Previous studies have shown that direct oral provocation tests, without prior skin testing, in children having delayed onset, benign rashes to beta-lactam antibiotic is safe and effective. Although, this test is useful in confirming drug hypersensitivity reactions, there is no standard protocol recommendation of drug provocation tests. This study aimed to evaluate the safety of the direct oral provocation test, using the Amoxicillin-2-step-challenge without prior skin testing, in children with history of non-immediate reactions to amoxicillin. METHODS The Amoxicillin-2-step-challenge protocol was performed in children with history of non-immediate reactions to amoxicillin. This protocol is composed of 2 doses of amoxicillin, with a 30-min interval; continued for a total of 5 days. All of the patients had not undergone skin testing before the oral provocation test. RESULTS This study included 54 children, having a median age of 6.6 years, with 70.4% being male. Amoxicillin and amoxicillin-clavulanic acid were reported as the culprit drug in 75.9% and 24.1%, respectively. The index reactions were maculopapular (MP) rash in 79.6% and delayed urticarial rash/angioedema in 20.4%. Five patients (9.3%) had a reaction during the provocation test, all of these patients had delayed urticaria and were treated with oral antihistamine. However, 1 patient developed a fever alongside an MP rash. Laboratory investigation for this patient showed increased atypical lymphocytes and liver enzymes elevation. CONCLUSIONS Direct oral provocation tests, using the Amoxicillin-2-step-challenge, without prior skin testing, revealed good, immediate safety for the diagnosis of amoxicillin hypersensitivity in children with history of non-immediate reactions to amoxicillin.
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Affiliation(s)
- Vanlaya Koosakulchai
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Pasuree Sangsupawanich
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Duangdee Wantanaset
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Wipa Jessadapakorn
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Pondtip Jongvilaikasem
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Araya Yuenyongviwat
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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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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Ben Fadhel N, Aroua F, Chadli Z, Ben Romdhane H, Chaabane A, Sahtout M, Boughattas NA, Ben Fredj N, Aouam K. Betalactam hypersensitivity: The importance of delabelling in primary care. Br J Clin Pharmacol 2021; 87:4619-4624. [PMID: 33899257 DOI: 10.1111/bcp.14879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/05/2021] [Accepted: 04/14/2021] [Indexed: 12/23/2022] Open
Abstract
PATIENTS AND METHODS An allergy work-up was performed on adult patients with a history of a penicillin allergy seen by primary medical care in Monastir (Tunisia) between July 2016 and February 2018. Patients with negative skin tests were challenged with amoxicillin. Patients who were delabelled were contacted by phone after 6 months to determine outcomes after any therapeutic penicillin-class antibiotic intake. RESULTS A total of 39 patients were evaluated and 33 (84.6%) were delabelled. Five patients were penicillin skin-test positive and one was oral challenge positive. We succeeded in contacting 33 delabelled patients at 6 months. Twenty-two patients tolerated a subsequent therapeutic course of amoxicillin, eight patients did not retake penicillin due to a lack of therapeutic indication, and three patients refused an indicated penicillin use fearful of another reaction. CONCLUSION This study highlights the importance of allergy work-up in the diagnosis of beta-lactam hypersensitivity. Most patients were excessively labelled as beta-lactam allergic and this mislabelling could increase healthcare costs and lead to the development of drug resistance by the use of wide-spectrum antibiotics.
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Affiliation(s)
- Najah Ben Fadhel
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Fares Aroua
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Zohra Chadli
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Haifa Ben Romdhane
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Amel Chaabane
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | | | - Naceur A Boughattas
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Nadia Ben Fredj
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Karim Aouam
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
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Sousa-Pinto B, Blumenthal KG, Courtney L, Mancini CM, Jeffres MN. Assessment of the Frequency of Dual Allergy to Penicillins and Cefazolin: A Systematic Review and Meta-analysis. JAMA Surg 2021; 156:e210021. [PMID: 33729459 PMCID: PMC7970387 DOI: 10.1001/jamasurg.2021.0021] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/17/2020] [Indexed: 12/15/2022]
Abstract
Importance Cefazolin is the preoperative antibiotic of choice because it is safer and more efficacious than second-line alternatives. Surgical patients labeled as having penicillin allergy are less likely to prophylactically receive cefazolin and more likely to receive clindamycin or vancomycin, which results in higher rates of surgical site infections. Objective To examine the incidence of dual allergy to cefazolin and natural penicillins. Data Sources MEDLINE/PubMed, Web of Science, and Embase were searched without language restrictions for relevant articles published from database inception until July 31, 2020. Study Selection In this systematic review and meta-analysis, a search of MEDLINE/PubMed, Web of Science, and Embase was performed for articles published from database inception to July 31, 2020, for studies that included patients who had index allergies to a natural penicillin and were tested for tolerability to cefazolin or that included patients who had index allergies to cefazolin and were tested for tolerability to a natural penicillin. A total of 3228 studies were identified and 2911 were screened for inclusion. Data Extraction and Synthesis Data were independently extracted by 2 authors. Bayesian meta-analysis was used to estimate the frequency of allergic reactions. Main Outcomes and Measures Dual allergy to cefazolin and a natural penicillin. Results Seventy-seven unique studies met the eligibility criteria, yielding 6147 patients. Cefazolin allergy was identified in 44 participants with a history of penicillin allergy, resulting in a dual allergy meta-analytical frequency of 0.7% (95% credible interval [CrI], 0.1%-1.7%; I2 = 74.9%). Such frequency was lower for participants with unconfirmed (0.6%; 95% CrI, 0.1%-1.3%; I2 = 54.3%) than for those with confirmed penicillin allergy (3.0%; 95% CrI, 0.01%-17.0%; I2 = 88.2%). Thirteen studies exclusively assessed surgical patients (n = 3884), among whom 0.7% (95% CrI, 0%-3.3%; I2 = 85.5%) had confirmed allergy to cefazolin. Low heterogeneity was observed for studies of patients with unconfirmed penicillin allergy who had been exposed to perioperative cefazolin (0.1%; 95% CrI, 0.1%-0.3%; I2 = 13.1%). Penicillin allergy was confirmed in 16 participants with a history of cefazolin allergy, resulting in a meta-analytical frequency of 3.7% (95% CrI, 0.03%-13.3%; I2 = 64.4%). The frequency of penicillin allergy was 4.4% (95% CrI, 0%-23.0%; I2 = 75%) for the 8 studies that exclusively assessed surgical patients allergic to cefazolin. Conclusions and Relevance These findings suggest that most patients with a penicillin allergy history may safely receive cefazolin. The exception is patients with confirmed penicillin allergy in whom additional care is warranted.
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Affiliation(s)
- Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Center for Health Technology and Services Research, University of Porto, Porto, Portugal
- Basic and Clinical Immunology Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- The Mongan Institute, Massachusetts General Hospital, Boston
| | - Lindsay Courtney
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
| | - Christian M. Mancini
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| | - Meghan N. Jeffres
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
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Anci E, Braun C, Marinosci A, Rodieux F, Midun E, Torres MJ, Caubet JC. Viral Infections and Cutaneous Drug-Related Eruptions. Front Pharmacol 2021; 11:586407. [PMID: 33776753 PMCID: PMC7988096 DOI: 10.3389/fphar.2020.586407] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/06/2020] [Indexed: 12/19/2022] Open
Abstract
In the general population, up to 10% of children treated by antibiotics have cutaneous adverse drug reaction, but allergy is confirmed in less than 20% of patients. Most of the non-allergic reactions are probably due to virus, such as enterovirus acute infection or Ebstein-Barr Virus (EBV) acute infection or reactivation. Especially in children, viruses have the propensity to induce skin lesions (maculopapular rash, urticaria) due to their skin infiltration or immunologic response. In drug-related skin eruptions, a virus can participate by activating an immune predisposition. The culprit antibiotic is then the trigger for reacting. Even in severe drug-induced reactions, such as Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome, viruses take part in immune phenomena, especially herpes viruses. Understanding the mechanisms of both virus- and drug-induced skin reaction is important to develop our clinical reflection and give an adaptive care to the patient. Our aim is to review current knowledge on the different aspects and potential roles of viruses in the different type of drug hypersensitivity reactions (DHR). Although major advances have been made those past year, further studies are needed for a better understanding of the link between viruses and DHR, to improve management of those patients.
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Affiliation(s)
- Eleonora Anci
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Camille Braun
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.,Pediatric Allergy Unit, University Lyon 1 Claude Bernard, Villeurbanne, France
| | - Annalisa Marinosci
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland
| | - Elise Midun
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.,Pediatric Allergy Unit, University Lyon 1 Claude Bernard, Villeurbanne, France
| | - Maria-Jose Torres
- Allergy Unit, Hospital Regional Universitario de Málaga, Universidad de Málaga, Ibima-Bionand-Aradyal, Málaga, Spain
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
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Jones TW, Fino N, Olson J, Hersh AL. The impact of beta-lactam allergy labels on hospitalized children. Infect Control Hosp Epidemiol 2021; 42:318-324. [PMID: 32938517 DOI: 10.1017/ice.2020.424] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Antibiotic allergy labels are common and are frequently inaccurate. Previous studies among adults demonstrate that β-lactam allergy labels may lead to adverse outcomes, including prescription of broader-spectrum antibiotics, increased costs, and increased lengths of stay, among others. However, data among pediatric patients are lacking, especially in the United States. In this study, we sought to determine the impact of β-lactam allergy labels in hospitalized children with regards to clinical and economic outcomes. METHOD This retrospective cohort study included pediatric patients 30 days to 17 years old, hospitalized at Intermountain Healthcare facilities from 2007 to 2017, who received ≥1 dose of an antibiotic during their admission. Patients with β-lactam allergies were matched to nonallergic patients based on age, sex, clinical service line, admission date, academic children's hospital or other hospital admission, and the presence of chronic, comorbid conditions. Outcomes included receipt of broader-spectrum antibiotics, clinical outcomes including length of stay and readmission, and antibiotic and hospitalization costs. RESULTS In total, 38,906 patients were identified. The prevalence of antibiotic allergy increased from 0.9% among those < 1 year peaked at 10.6% by age 17. Patients with β-lactam allergy received broader-spectrum antibiotics and experienced higher antibiotic costs than nonallergic controls. However, there were no differences in the length of stay, readmission rates, or total number of days of antibiotics between allergic and nonallergic patients. CONCLUSIONS Hospitalized pediatric patients with β-lactam allergy labels receive broader-spectrum antibiotics and experience increased antibiotic costs. This represents an important opportunity for allergy delabeling and antibiotic stewardship.
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Affiliation(s)
- Trahern W Jones
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Jared Olson
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, Utah
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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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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40
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Beyaz Ş, Akdeniz N, Yılmaz A, Demir S, Öztop N, Çolakoğlu B, Büyüköztürk S, Deniz G, Gelincik A. Diagnostic workup including CD203c-based basophil activation test in immediate hypersensitivity due to metronidazole and ornidazole and evaluation of cross-reactivity in between. Allergy 2021; 76:842-852. [PMID: 32761620 DOI: 10.1111/all.14542] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/08/2020] [Accepted: 07/25/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Little is known about the diagnostic approaches for immediate hypersensitivity reactions (IHRs) due to 5-nitroimidazole antibiotics. The aim was to evaluate the usefulness of in vivo tests and basophil activation test (BAT) for the diagnosis of IHRs due to metronidazole and ornidazole and to determine possible cross-reactivity in between. METHODS Forty-nine patients with a clear history of IHRs due to these drugs and 20 healthy subjects who were known to tolerate these drugs were included. Skin tests (STs) and single-blind placebo-controlled drug provocation tests (SBPCDPTs) were performed with both drugs whereas BAT was applied only with the culprit drug. RESULTS The most and least common reaction types were urticaria/angioedema (34.7%) and anaphylaxis (14.3%), respectively. SBPCDPTs were positive in 15 out of 47 patients, and only 7 had positive STs. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of STs for metronidazole/ornidazole were 33.3%/16.6%, 94.2%/97.3%, 60%/50%, and 84.6%/88.1%, respectively. BAT was positive in 12 out of 15 patients and negative in 10 control subjects, giving a sensitivity rate of 71.4% (CI, 29.0%-96.3%) for metronidazole and 83.3% (CI, 35.8%-99.5%) for ornidazole. The optimal concentration of both drugs for BAT was determined as 5 mg/mL. No cross-reactivity among two drugs was observed according to in vivo tests. CONCLUSIONS Our study showed that SBPCDPT and BAT are both useful diagnostic tools for IHRs due to 5-nitroimidazole antibiotics and can be used as supplementary to each other. No cross-reactivity between metronidazole and ornidazole in IHRs exists.
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Affiliation(s)
- Şengül Beyaz
- Division of Immunology and Allergic Diseases Department of Internal Medicine Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Nilgün Akdeniz
- Department of Immunology Aziz Sancar Institute of Experimental MedicineIstanbul University Istanbul Turkey
| | - Abdullah Yılmaz
- Department of Immunology Aziz Sancar Institute of Experimental MedicineIstanbul University Istanbul Turkey
| | - Semra Demir
- Division of Immunology and Allergic Diseases Department of Internal Medicine Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Nida Öztop
- Division of Immunology and Allergic Diseases Department of Internal Medicine Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Bahauddin Çolakoğlu
- Division of Immunology and Allergic Diseases Department of Internal Medicine Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Suna Büyüköztürk
- Division of Immunology and Allergic Diseases Department of Internal Medicine Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Günnur Deniz
- Department of Immunology Aziz Sancar Institute of Experimental MedicineIstanbul University Istanbul Turkey
| | - Aslı Gelincik
- Division of Immunology and Allergic Diseases Department of Internal Medicine Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
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Yilmaz Topal O, Kulhas Celik I, Turgay Yagmur I, Toyran M, Civelek E, Karaatmaca B, Dibek Misirlioglu E. Evaluation of Clinical Properties and Diagnostic Test Results of Cephalosporin Allergy in Children. Int Arch Allergy Immunol 2021; 182:709-715. [PMID: 33611316 DOI: 10.1159/000513974] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/22/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Beta-lactams (BLs) are one of the most frequent causes of drug hypersensitivity reactions (HRs), and cephalosporins are a widely used subclass of BLs, especially in children. The aim of this study was to evaluate the clinical features and diagnostic test results of pediatric patients evaluated for suspected cephalosporin allergy. METHODS This study included patients who presented to our pediatric allergy clinic with a history of reactions attributed to cephalosporins between January 1, 2011, and December 31, 2019, and whose diagnostic tests were completed for the diagnosis. RESULTS This study included 120 pediatric patients and 69 (57.5%) of them were girls. The median age was 38.63 (interquartile range 10.5-85.7) months. Reactions occurring within 1 h of drug intake were reported in 33 patients (27.5%). Reactions were maculopapular rash in 55 (45.8%) patients, urticaria and/or angioedema in 49 (40.8%), anaphylaxis in 11 (9.2%), severe cutaneous drug reaction in 4 (3.3%), and fixed drug reaction in 1 patient (0.83%). The most frequently suspected agent was cefixime in 41 patients (34.2%). In total, 30 (25%) patients were diagnosed as having cephalosporin hypersensitivity. Confirmation of HRs was also significantly more frequent among patients who were older (p: 0.000), who had taken the drug parenterally (p: 0.000) and with immediate reactions (p: 0.000). CONCLUSION Cephalosporin allergy has been confirmed in approximately one-fourth of the patients evaluated for suspected cephalosporin allergy. Confirmation of HRs was significantly more common among patients who were older, had immediate reactions, and had taken the drug parenterally.
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Affiliation(s)
- Ozge Yilmaz Topal
- Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Ilknur Kulhas Celik
- Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Irem Turgay Yagmur
- Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Muge Toyran
- Division of Pediatric Allergy and Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Ersoy Civelek
- Division of Pediatric Allergy and Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Betul Karaatmaca
- Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Emine Dibek Misirlioglu
- Division of Pediatric Allergy and Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey,
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Delli Colli L, Gabrielli S, Abrams EM, O'Keefe A, Protudjer JL, Lavine E, Pitt T, Atkinson A, Eiwegger T, McCusker C, Ben-Shoshan M. Differentiating Between β-Lactam-Induced Serum Sickness–Like Reactions and Viral Exanthem in Children Using a Graded Oral Challenge. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:916-921. [DOI: 10.1016/j.jaip.2020.08.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/15/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022]
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Kulhas Celik I, Turgay Yagmur I, Yilmaz Topal O, Toyran M, Civelek E, Karaatmaca B, Dibek Misirlioglu E. Diagnostic value and safety of penicillin skin tests in children with immediate penicillin allergy. Allergy Asthma Proc 2020; 41:442-448. [PMID: 33109310 DOI: 10.2500/aap.2020.41.200082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: The first-line method in the diagnosis of patients who describe an immediate reaction after penicillin intake is a skin test (ST) with penicillin reagents. Objectives: We aimed to determine the safety and diagnostic value of penicillin STs in the diagnosis of immediate reactions to penicillins in pediatric patients. Methods: The study included pediatric patients with suspected immediate reaction to penicillin who were subjected to STs by using a standard penicillin test kit as well as suspected penicillin and the drug provocation tests (DPT) with the suspected penicillin at our clinic. Results: A total of 191 patients (53.9% boys) with a median age of 6.83 years (interquartile range, 4.2-12 years) were included in the study. The time from drug intake to the onset of reaction was ≤1 hour in 138 patients (72.3%) and 1 to 6 hours in 53 patients (27.7%). Penicillin allergy (PA) was confirmed by diagnostic tests in 36 of the 191 patients (18.8%). In multivariate logistic regression analysis, the history of both urticaria and angioedema (odds ratio [OR] 27.683 [95% confidence interval {CI}, 3.143-243.837]; p = 0.003) and anaphylaxis (OR 56.246 [95% CI, 6.598-479.489]; p < 0.001) were the main predictors of a PA diagnosis. Although ST results were positive in 23 patients (63.8%), 13 patients (26.2%) had positive DPT results despite negative ST results. The negative predictive value (NPV) of STs was calculated 92.2% (155/168). None of our patients experienced immediate or delayed systemic and/or local reactions in relation to the STs. Conclusion: A history of urticaria with angioedema and anaphylaxis were the main predictors of true PA in children with suspected immediate reactions. STs with penicillin reagents are safe for use in children. Although STs have a high NPV, DPT is the gold standard for diagnosis. DPTs should be performed as the final step of the diagnostic evaluation of PA in patients with negative ST results.
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Affiliation(s)
- Ilknur Kulhas Celik
- From the Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Irem Turgay Yagmur
- From the Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Ozge Yilmaz Topal
- From the Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Muge Toyran
- Department of Pediatric Allergy and Immunology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Ersoy Civelek
- Department of Pediatric Allergy and Immunology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Betul Karaatmaca
- From the Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Emine Dibek Misirlioglu
- Department of Pediatric Allergy and Immunology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
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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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Merienne C, Marchand C, Filali S, Salmon D, Pivot C, Pirot F. Measurement, analysis and prediction of amoxicillin oral dose stability from integrated molecular description approach and accelerated predictive stability (APS). PHARMACEUTICAL TECHNOLOGY IN HOSPITAL PHARMACY 2020. [DOI: 10.1515/pthp-2020-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractBackgroundStability of low amoxicillin oral dosage form (5 mg) used in reintroduction drug test was not fully documented. Furthermore, the impact of (1) salt moiety of amoxicillin and (2) amoxicillin – excipient interactions upon the antibiotic formulation stability during the storage was not characterized so that the estimation of the pharmaceutical expiration date from shelf-life was uncertain. Thus, the main goal of this study was to estimate the shelf-life of two formulations of amoxicillin, using a semi-predictive methodology.MethodsAmoxicillin sodium (AS) and amoxicillin trihydrate (ATH), corresponding to 5-mg amoxicillin, were compounded with microcrystalline cellulose (MCC) in oral hard capsules which were, then, submitted to four environmental conditions (25 °C / 60% or 80% relative humidity (RH); 40 °C / 75% RH; 60 °C / 5% RH) in climatic chambers for 45 and 84 days. Therefore, the characterization of amoxicillin-MCC mixture was assessed by attenuated total reflectance Fourier-transform infrared spectroscopy (ATR-FTIR) The profiles of amoxicillin content (determined by stability indicating chromatographic method) as a function of storage time, temperature and RH were fitted to pre-defined kinetic models performed by accelerated predictive stability (APS).ResultsATR-FTIR analysis of AS, ATH, MCC and bulk specimens stored in heated and humid atmosphere confirmed water sorption to cellulose described by a broad and unresolved 3600 to 3000 cm−1 band associated with (1) general intramolecular and intermolecular hydrogen bonding between water and hydroxyl groups of the cellulose, and with (2) free hydroxyl in cellulose. Moreover, a dramatic decrease of absorption at 1776 and 1687 cm−1 respectively characteristic of the β-lactam ring (νC=O) and amide group (νC=O), was revealed as a consequence of AS and ATH degradation caused by moisturization of bulk. Amoxicillin degradation was established by chromatographic analysis showing faster AS degradation than ATH throughout time exposure. The combined effects of temperature – RH were successfully modeled by APS, where AS and ATH showed accelerated (auto-catalysis degradation mechanism) and linear degradation, respectively. The faster AS degradation was assumed to be linked to lower hydrogen donor to hydrogen acceptor count ratio and polar surface than ATH, increasing the probability of AS hydrolysis by water adsorption to AS-MCC solid dispersion (e.g., by reduction of protective intramolecular hydrogen bonds between AS molecules). Furthermore, the compounding which involved a drastic homogenization of solids may have affected the crystalline degree of MCC with an increase of amorphous phase more sensitive to water adsorption.ConclusionsThe improvement of amoxicillin compounding for oral dose forms might be rationalized by taking into account the molecular descriptors of salt moiety and excipients, improved by the choice of an appropriate process of production, characterized from infrared vibrational spectroscopy and chromatographic analysis and finally predicted from accelerated stability assays.
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Affiliation(s)
- Camille Merienne
- Service Pharmaceutique, Groupement Hospitalier Centre Edouard Herriot, Place d’Arsonval, 69437 Lyon Cedex 03, Lyon, France
| | - Chloe Marchand
- Service Pharmaceutique, Groupement Hospitalier Centre Edouard Herriot, Place d’Arsonval, 69437 Lyon Cedex 03, Lyon, France
| | - Samira Filali
- Service Pharmaceutique, Groupement Hospitalier Centre Edouard Herriot, Place d’Arsonval, 69437 Lyon Cedex 03, Lyon, France
| | - Damien Salmon
- Service Pharmaceutique, Groupement Hospitalier Centre Edouard Herriot, Place d’Arsonval, 69437 Lyon Cedex 03, Lyon, France
- Laboratoire de Recherche et Développement de Pharmacie Galénique Industrielle, UMR 5305, Plateforme Fripharm, Faculté de Pharmacie, Université Claude Bernard Lyon 1, Lyon, France
| | - Christine Pivot
- Service Pharmaceutique, Groupement Hospitalier Centre Edouard Herriot, Place d’Arsonval, 69437 Lyon Cedex 03, Lyon, France
| | - Fabrice Pirot
- Service Pharmaceutique, Groupement Hospitalier Centre Edouard Herriot, Place d’Arsonval, 69437 Lyon Cedex 03, Lyon, France
- Laboratoire de Recherche et Développement de Pharmacie Galénique Industrielle, UMR 5305, Plateforme Fripharm, Faculté de Pharmacie, Université Claude Bernard Lyon 1, Lyon, France
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Porto J. Allergy to beta-lactam antibiotics in children: Looking for a practical approach. Allergol Immunopathol (Madr) 2020; 48:415-416. [PMID: 32958141 DOI: 10.1016/j.aller.2020.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 11/27/2022]
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Dias de Castro E, Carolino F, Carneiro-Leão L, Barbosa J, Ribeiro L, Cernadas J. Allergy to beta-lactam antibiotics in children: Risk factors for a positive diagnostic work-up. Allergol Immunopathol (Madr) 2020; 48:417-423. [PMID: 32460994 DOI: 10.1016/j.aller.2020.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/06/2020] [Accepted: 01/29/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Allergy to beta-lactam (βL) antibiotics is highly reported in children, but rarely confirmed. Risk factors for a positive diagnostic work-up are scarce. The primary aim was to characterize the cases of children with confirmed βL allergy, investigating potential risk factors. Secondary aims were to assess the prevalence of allergy to βL in this population and to confirm the safety of less extensive diagnostic protocols for milder reactions. METHODS We reviewed the clinical data from all children evaluated in our Department for suspected βL allergy, over a six-year period. RESULTS Two hundred and twenty children (53% females) with a mean age of 6.5±4.2 years were evaluated. Cutaneous manifestations were the most frequently reported (96.9%), mainly maculopapular exanthema (MPE). The reactions were non-immediate in 59.5% of the cases. Only 23 children (10.5%) were diagnosed with allergy to βL. The likelihood of βL allergy was significantly higher in children with a family history of drug allergy (p<0.001) and in those with a smaller time period between the reaction and the study (p=0.046). The probability of not confirming βL allergy is greater in children reporting less severe reactions (p<0.001) and MPE (p<0.001). We found the less extensive diagnostic protocol in milder reactions safe, since only 4.2% of the children presented a positive provocation test (similar reaction as the index reaction). CONCLUSION This study highlights family history of drug allergy as a risk factor for a positive diagnostic work-up. Larger series are required, particularly genetic studies to accurately determine future risk for βL allergy in children.
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Abstract
The drug allergy "label" may have a lifetime of consequences for a child. Many children with alleged drug allergies are proven to be tolerant to the culprit medication when challenged. The field of drug hypersensitivity is a recently evolving field of research, but studies on its epidemiology and diagnostic tools are lacking in children. Clinical history is significant in the diagnosis and classification of drug hypersensitivity in children. Diagnostic tools have been evaluated in a limited number of children; therefore, the guidelines are mainly in line with those for adults. Here, we review the clinical characteristics, main drugs, risk factors, and diagnosis of drug hypersensitivity to aid in its accurate diagnosis in children.
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Affiliation(s)
- Ji Soo Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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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: 167] [Impact Index Per Article: 41.8] [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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Wurpts G, Aberer W, Dickel H, Brehler R, Jakob T, Kreft B, Mahler V, Merk HF, Mülleneisen N, Ott H, Pfützner W, Röseler S, Ruëff F, Sitter H, Sunderkötter C, Trautmann A, Treudler R, Wedi B, Worm M, Brockow K. Guideline on diagnostic procedures for suspected hypersensitivity to beta-lactam antibiotics: Guideline of the German Society for Allergology and Clinical Immunology (DGAKI) in collaboration with the German Society of Allergology (AeDA), German Society for Pediatric Allergology and Environmental Medicine (GPA), the German Contact Dermatitis Research Group (DKG), the Austrian Society for Allergology and Immunology (ÖGAI), and the Paul-Ehrlich Society for Chemotherapy (PEG). Allergol Select 2020; 4:11-43. [PMID: 32568254 PMCID: PMC7304290 DOI: 10.5414/alx02104e] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This guideline on diagnostic procedures for suspected beta-lactam antibiotic (BLA) hypersensitivity was written by the German and Austrian professional associations for allergology, and the Paul-Ehrlich Society for Chemotherapy in a consensus procedure according to the criteria of the German Association of Scientific Medical Societies. BLA such as penicillins and cephalosporins represent the drug group that most frequently triggers drug allergies. However, the frequency of reports of suspected allergy in patient histories clearly exceeds the number of confirmed cases. The large number of suspected BLA allergies has a significant impact on, e.g., the quality of treatment received by the individual patient and the costs to society as a whole. Allergies to BLA are based on different immunological mechanisms and often manifest as maculopapular exanthema, as well as anaphylaxis; and there are also a number of less frequent special clinical manifestations of drug allergic reactions. All BLA have a beta-lactam ring. BLA are categorized into different classes: penicillins, cephalosporins, carbapenems, monobactams, and beta-lactamase inhibitors with different chemical structures. Knowledge of possible cross-reactivity is of considerable clinical significance. Whereas allergy to the common beta-lactam ring occurs in only a small percentage of all BLA allergic patients, cross-reactivity due to side chain similarities, such as aminopenicillins and aminocephalosporins, and even methoxyimino cephalosporins, are more common. However, the overall picture is complex and its elucidation may require further research. Diagnostic procedures used in BLA allergy are usually made up of four components: patient history, laboratory diagnostics, skin testing (which is particularly important), and drug provocation testing. The diagnostic approach - even in cases where the need to administer a BLA is acute - is guided by patient history and risk - benefit ratio in the individual case. Here again, further studies are required to extend the present state of knowledge. Performing allergy testing for suspected BLA hypersensitivity is urgently recommended not only in the interests of providing the patient with good medical care, but also due to the immense impact of putative BLA allergies on society as a whole.
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Affiliation(s)
- Gerda Wurpts
- Clinic for Dermatology and Allergology, Aachen Comprehensive Allergy Center (ACAC), Uniklinik RWTH Aachen, Germany
| | - Werner Aberer
- Department of Dermatology, Graz Medical University, Graz, Austria,
| | - Heinrich Dickel
- Department of Dermatology, Venereology and Allergology, St. Josef Hospital, University Hospital of the Ruhr University Bochum, Bochum,
| | - Randolf Brehler
- Department of Dermatology, University Hospital Münster, Münster,
| | - Thilo Jakob
- Department of Dermatology and Allergology, University Hospital Gießen und Marburg, Gießen Site, Gießen,
| | - Burkhard Kreft
- Department of Dermatology and Venereology, University, Hospital Halle (Saale), Halle (Saale),
| | - Vera Mahler
- Paul-Ehrlich Institute, Langen,
- Department of Dermatology, University Hospital Erlangen, Erlangen,
| | - Hans F. Merk
- Clinic for Dermatology and Allergology, Aachen Comprehensive Allergy Center (ACAC), Uniklinik RWTH Aachen, Germany
| | | | - Hagen Ott
- Division of Pediatric Dermatology and Allergology, Auf der Bult Children’s Hospital, Hannover,
| | - Wolfgang Pfützner
- Department of Dermatology and Allergology, University Hospital Gießen und Marburg, Marburg Site, Marburg,
| | - Stefani Röseler
- Clinic for Dermatology and Allergology, Aachen Comprehensive Allergy Center (ACAC), Uniklinik RWTH Aachen, Germany
| | - Franziska Ruëff
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich,
| | - Helmut Sitter
- Institute of Surgical Research, Philipps University Marburg, Marburg,
| | - Cord Sunderkötter
- Department of Dermatology and Venereology, University, Hospital Halle (Saale), Halle (Saale),
| | - Axel Trautmann
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, Würzburg,
| | - Regina Treudler
- Department of Dermatology, Venereology, and Allergology and Leipzig Interdisciplinary Center for Allergology – LICA-CAC, University of Leipzig, Leipzig,
| | - Bettina Wedi
- Department of Dermatology and Allergy, Comprehensive Allergy Center, Hannover Medical School, Hannover,
| | - Margitta Worm
- Department of Dermatology, Venereology, and Allergology, Charité University Hospital Berlin, Allergy Center Charité (ACC), Berlin, and
| | - Knut Brockow
- Department of Dermatology and Allergology am Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
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