The current practice of skin testing for antibiotics in Korean hospitals

No more tears from surgical site infections in interventional pain management

As the field of interventional pain management (IPM) grows, the risk of surgical site infections (SSIs) is increasing. SSI is defined as an infection of the incision or organ/space that occurs within one month after operation or three months after implantation. It is also common to find patients with suspected infection in an outpatient clinic. The most frequent IPM procedures are performed in the spine. Even though primary pyogenic spondylodiscitis via hematogenous spread is the most common type among spinal infections, secondary spinal infections from direct inoculation should be monitored after IPM procedures. Various preventive guidelines for SSI have been published. Cefazolin, followed by vancomycin, is the most commonly used surgical antibiotic prophylaxis in IPM. Diagnosis of SSI is confirmed by purulent discharge, isolation of causative organisms, pain/tenderness, swelling, redness, or heat, or diagnosis by a surgeon or attending physician. Inflammatory markers include traditional (C-reactive protein, erythrocyte sedimentation rate, and white blood cell count) and novel (procalcitonin, serum amyloid A, and presepsin) markers. Empirical antibiotic therapy is defined as the initial administration of antibiotics within at least 24 hours prior to the results of blood culture and antibiotic susceptibility testing. Definitive antibiotic therapy is initiated based on the above culture and testing. Combination antibiotic therapy for multidrug-resistant Gram-negative bacteria infections appears to be superior to monotherapy in mortality with the risk of increasing antibiotic resistance rates. The never-ending war between bacterial resistance and new antibiotics is continuing. This article reviews prevention, diagnosis, and treatment of infection in pain medicine.

The impact of pharmacist intervention on prophylactic antibiotics use in orthopedic surgery at a hospital in China

This study aimed to assess the impact of the pharmacist-led intervention on perioperative antibiotic prophylaxis by standardizing the cephalosporin intradermal skin test in the orthopedic department.A pre-and postintervention study was conducted among patients in the Orthopedics Department at the Beijing Chao-Yang Hospital in China. Use of intradermal skin test, perioperative antibacterial prophylaxis, and cost of care were compared between the preintervention population (admitted from 6/1/2018 to 8/31/2018) and postintervention population (admitted from 1/1/2019 to 3/31/2019). Logistic regression and generalized linear regression were used to assess the intervention impact.425 patients from the preintervention period and 448 patients from the postintervention period were included in the study. After the implementation of the pharmacist intervention program, there was a decrease in the utilization of intradermal skin tests, from 95.8% to 16.5% (P < .001). Patients were more likely to have cephalosporin as prophylactic antimicrobials (OR = 5.28, P < .001) after the implementation. The cost of antimicrobials was significantly reduced by $150.21 (P < .001) for each patient.Pharmacist-involved intervention can reduce the utilization of cephalosporins skin tests and decrease the prescription of unnecessary high-cost antimicrobials.

Antibiotic Skin Testing in the Intensive Care Unit: A Systematic Review

BACKGROUND

Recent research has shown that a large majority of patients with a history of penicillin allergy are acutely tolerant of penicillins and that there is no clinically significant immunologic cross-reactivity between penicillins and cephalosporins or other β-lactams. The standard test to confirm acute tolerance is challenge with a therapeutic dose. Skin testing is useful only when the culprit antibiotic can haptenate serum proteins and induce an immunoglobulin E-mediated reaction and the clinical history demonstrates such high risk that a direct oral challenge may result in anaphylaxis.

OBJECTIVE

To review and evaluate the current practice of skin testing for antibiotics (other than penicillin) in critically ill patients by means of a systematic literature review.

METHODS

This systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Several electronic databases were searched using the following terms: antibiotics, skin test (tests, testing), intensive care, intensive care unit, ICU, critical care, critical care unit.

RESULTS

Twenty-three articles were identified for inclusion in this review. The results indicate a lack of standardized skin testing for all antibiotics in critical care settings. Oral challenge with nonirritating concentrations of antibiotics can be helpful in determining allergy to these drugs.

CONCLUSIONS

Critical care providers should evaluate antibiotic allergy using nonirritating concentrations before administering antibiotics to patients. Introduction of a standardized skin test for all antibiotics in intensive care unit patients to help select the most appropriate antibiotic treatment regimen might help save lives and reduce costs.

Results of Intradermal Skin Testing with Cefazolin according to a History of Hypersensitivity to Antibiotics

BACKGROUND

The relationship between cephalosporin hypersensitivity and a history of β-lactam hypersensitivity is unclear. We evaluated the usefulness of routine intradermal cefazolin skin testing and its relationship with the history of β-lactam hypersensitivity.

METHODS

The electronic medical records of patients who underwent intradermal cefazolin (0.3 mg/mL) skin testing without negative controls from January 2010 to January 2011 at Seoul National University Bundang Hospital were evaluated. The history of β-lactam hypersensitivity of the patients was taken. Immediate adverse reactions after cefazolin injection were evaluated by searching the electronic medical records for key words and reviewing consultation documents of allergy specialists or dermatologists. The medical records of the patients were reviewed by an allergist.

RESULTS

There were 13,153 cases of cefazolin skin testing over the 13-month study period. Among the 12,969 cases with negative skin test results, 8 had immediate hypersensitivity related to cefazolin (0.06%). The negative predictive value of cefazolin skin testing alone was 99.94%. The overall positivity rate of cefazolin skin tests was 1.4% (184/13,153). Of the cases with a history of allergy to β-lactams, 15% (6/40) showed a positive cefazolin skin test result compared to only 1.36% (178/13,113) of cases with no such history (P < 0.001) including some false-positive tests.

CONCLUSION

The results suggest that routine screening involving cefazolin skin testing without negative controls is not useful for all patients, but could be helpful for those with a history of β-lactam hypersensitivity, although a large prospective study is needed to confirm this.

Hypersensitivity Reaction to Perioperative Drug Mistaken for Local Anesthetic Systemic Toxicity in a Patient under Brachial Plexus Block

Perioperative anaphylaxis, although rare, is a severe, life-threatening unexpected systemic hypersensitivity reaction. Simultaneous administration of various drugs during anesthesia, the difficulty of communicate with patients in sedation and anesthesia, and coverage of the patient with surgical drapes are considered to be factors that impede early recognition of anaphylactic reactions. It is very important to perform an intradermal skin test because antibiotics are the most common cause of perioperative anaphylaxis. We report a case of negative-intradermal skin test antibiotic anaphylaxis mistaken for local aesthetic systemic toxicity without increase of serum tryptase for confirmative diagnostic biomaker during surgery under brachial plexus block. It is not possible to exclude the danger of anaphylaxis completely, even if it is negative-intradermal skin test and normal tryptase level. Therefore, anesthesiologists should be closely monitored and treated early for antibiotics related hypersensitive reaction, like other medicines during anesthesia.

Toward jet injection by continuous-wave laser cavitation

This is a study motivated by the need to develop a needle-free device for eliminating major global healthcare problems caused by needles. The generation of liquid jets by means of a continuous-wave laser, focused into a light absorbing solution, was studied with the aim of developing a portable and affordable jet injector. We designed and fabricated glass microfluidic devices, which consist of a chamber where thermocavitation is created and a tapered channel. The growth of a vapor bubble displaces and expels the liquid through the channel as a fast traveling jet. Different parameters were varied with the purpose of increasing the jet velocity. The velocity increases with smaller channel diameters and taper ratios, whereas larger chambers significantly reduce the jet speed. It was found that the initial position of the liquid-air meniscus interface and its dynamics contribute to increased jet velocities. A maximum velocity of 94±3  m/s for a channel diameter of D=120  μm, taper ratio n=0.25, and chamber length E=200  μm was achieved. Finally, agarose gel-based skin phantoms were used to demonstrate the potential of our devices to penetrate the skin. The maximum penetration depth achieved was ∼1  mm, which is sufficient to penetrate the stratum corneum and for most medical applications. A meta-analysis shows that larger injection volumes will be required as a next step to medical relevance for laser-induced jet injection techniques in general.

The Differences and Similarities between Allergists and Non-Allergists for Penicillin Allergy Management

The purpose of this study was to compare the management of patients with a history of penicillin allergy between allergists and non-allergists in Thailand. A questionnaire was distributed to Thai physicians by online survey. The answers from 205 physicians were analyzed. The discrepancy of penicillin allergy management between allergists and non-allergists was clearly demonstrated in patients with a history of an immediate reaction in the presence of penicillin skin test (P < 0.01) and in patients with a history of Stevens-Johnson syndrome (P < 0.05) from penicillin. Allergists are more willing to confirm penicillin allergic status, more likely to carefully administer penicillin even after negative skin test, but less concerned for the potential cross-reactivity with 3rd and 4th generation cephalosporins, compared to non-allergists. The lack of penicillin skin test reagents, the reliability of penicillin allergy history, and medicolegal problem were the main reasons for prescribing alternate antibiotics without confirmation of penicillin allergic status. In summary, the different management of penicillin allergy between allergists and non-allergists was significantly demonstrated in patients with a history of severe non-immediate reaction and in patients with a history of an immediate reaction when a penicillin skin test is available.

Validation of the cephalosporin intradermal skin test for predicting immediate hypersensitivity: a prospective study with drug challenge

BACKGROUND

Cephalosporin is a major offending agent in terms of drug hypersensitivity along with penicillin. Cephalosporin intradermal skin tests (IDTs) have been widely used; however, their validity for predicting immediate hypersensitivity has not been studied. This study aimed to determine the predictive value of cephalosporin intradermal skin testing before administration of the drug.

METHODS

We prospectively conducted IDTs with four cephalosporins, one each of selected first-, second-, third-, or fourth-generation cephalosporins: ceftezol; cefotetan or cefamandole; ceftriaxone or cefotaxime; and flomoxef, respectively, as well as with penicillin G. After the skin test, whatever the result, one of the tested cephalosporins was administered intravenously and the patient was carefully observed.

RESULTS

We recruited 1421 patients who required preoperative cephalosporins. Seventy-four patients (74/1421, 5.2%) were positive to at least one cephalosporin. However, none of responders had immediate hypersensitivity reactions after a challenge dose of the same or different cephalosporin, which were positive in the skin test. Four patients who suffered generalized urticaria and itching after challenge gave negative skin tests for the corresponding drug. The IDT for cephalosporin had a sensitivity of 0%, a specificity of 97.5%, a negative predictive value of 99.7%, and a positive predictive value (PPV) of 0%, when challenged with the same drugs that were positive in the skin test.

CONCLUSION

Routine skin testing with a cephalosporin before its administration is not useful for predicting immediate hypersensitivity because of the extremely low sensitivity and PPV of the skin test (CRIS registration no. KCT0000455).