Beta-lactam antibiotic sensitization and its relationship to allergic diseases in tertiary hospital nurses

Evaluation of environmental antibiotic contamination by surface wipe sampling in a large care centre

OBJECTIVES

Exposure of healthcare workers to antibiotics may cause adverse health effects. Results of environmental contamination with antibiotics, obtained by taking surface wipe samples, can be used as an indicator for potential exposure to these sensitizing drugs. The objective was to describe the results of repeated measurements of contamination with antibiotics on multiple surfaces in hospital wards. Standardized needle and syringe preparation techniques and cleaning procedures were used.

METHODS

The preparation table and the floor around the waste bin in six wards were sampled and analysed for contamination with the antibiotics amoxicillin, benzylpenicillin, cefotaxime, ceftriaxone, flucloxacillin, meropenem, piperacillin and vancomycin. Sampling was performed in four trials during 8 months. Depending on the outcome of the trials, the cleaning procedure was adapted. Liquid chromatography with tandem mass spectrometry was used for the analysis of the drugs.

RESULTS

During the four trials, contamination with all eight antibiotics was omnipresent on all preparation tables and floors in the six wards. The highest contamination was found for amoxicillin (1291 ng/cm2). Changing the cleaning procedure did not reduce the level of contamination.

CONCLUSIONS

Surface contamination with the antibiotics was widespread and most probably caused by spillage during the preparation in combination with an ineffective cleaning procedure. Strategies should be developed and implemented by institutions for safe handling of antibiotics to reduce environmental contamination and potential exposure of healthcare workers to these sensitizing drugs.

Evaluation of accompanying allergic disease in children with proven drug allergies

Background/aim

Data on the prevalence of allergic diseases in children with proven drug allergies are limited. We aim to evaluate the frequency of allergic comorbidity in children with proven common drug allergies.

Materials and methods

Children with drug hypersensitivity confirmed by diagnostic allergy tests at our center between January 2010 and December 2020 were screened retrospectively. Patients with the most common drug allergies (due to antibiotics, nonsteroidal antiinflammatory drugs [NSAIDs], and antiepileptic drugs) were selected for analysis. Age, sex, the culprit drug, initial reaction characteristics, diagnostic test results, and the study physician who diagnosed concomitant allergic diseases were noted.

Results

A total of 168 patients (boys, 51.2%) with a median age of 12 years (IQR = 8-16.3) were included in the study. The culprit drug was an antibiotic in 63% (n = 106), NSAID in 25% (n = 42) and anticonvulsant in 11.9 % (n = 20) of the patients. Drug hypersensitivity reactions were immediate in 74.4 % (n = 125) and delayed in 25.6 % (n = 43) of the patients. Seventy-five patients (44.6 %) had at least one allergic disease, most commonly rhinitis (27.3 %, n = 46) or asthma (25 %, n = 42). Fifty-five patients underwent skin prick tests with aeroallergens, producing a positive result in 60% (n = 31). The prevalence of allergic disease was not differing according to the culprit drug. The frequency of developing at least one concomitant allergic disease was 47.2% (n = 50/106) for antibiotic hypersensitivity, 52.4% (n = 22/42) for NSAID hypersensitivity, and 15% (n = 3/20) for anticonvulsant hypersensitivity (p < 0.00).Immediate drug hypersensitivity reactions were more frequent in children who had allergic diseases (80 % vs. 64.5 %; p = 0.027).

Conclusion

Nearly half (44.6%) of the children with proven drug hypersensitivity had concomitant allergic diseases and immediate reactions were more common in this group. Children evaluated for drug hypersensitivity should be assessed for other allergic diseases.

[Evaluation of the "Health management guideline on occupational allergy in nursing occupations and its primary prevention" by nursing managers]

OBJECTIVE

Individuals in nursing occupations are often exposed to various materials such as rubber products and drugs, and they comprise a population at high risk of developing occupational allergies. We therefore created a "Health management guideline on occupational allergy in nursing occupations and its primary prevention" (hereinafter referred to as "HMG") and conducted a questionnaire survey to elucidate its potential use and the challenges of implementing it in clinical practice.

SUBJECTS AND METHODS

The HMG includes the following content: A. Basic knowledge of occupational allergies; B. Common occupational allergies in nursing occupations; C. Occupational allergies triggered by specific antigens in nursing occupations; D. Eczema and skincare for hands; and E. Health management for occupational allergies. A questionnaire survey was conducted on one nursing manager each from 80 hospitals, with at least 400 beds. The survey included questions to gauge the level of understanding the content described in the HMG and opinions on incorporating the management method. The ethics committee of the researcher's institution approved the study.

RESULTS

Responses were obtained from 30 nursing managers. Over 70% responded that they understood the instructions for [occupational allergies], [common occupational allergies in nursing occupations], and [eczema and skincare for hands] presented in the HMG, and 100% said they either understood or mostly understood them. For [work management], 57% said they understood the content and 90% wanted to incorporate it. Furthermore, 10% responded that they wanted to incorporate the guidelines but did not believe it was feasible, given that "achieving general awareness and efforts involving other occupations are difficult." For [work environment management], 53% said they understood the content and 83% wanted to incorporate it. Additionally, 17% responded that they wanted to incorporate it but did not believe it was feasible, amid concerns that "allergen monitoring is difficult in reality" and "installation of local ventilation systems seems difficult."

DISCUSSION AND CONCLUSIONS

The HMG was postulated to be useful in providing knowledge on occupational allergy and health management methods, and for employing in clinical practice. The study recommended that in order to specifically incorporate the management methods, it is imperative that the entire hospital, including staff from other occupations, understand the guidelines and make adjustments accordingly.

Occupational generalized urticaria and anaphylaxis after inhalation of cefuroxime in a nurse

We present the case of a 53 years old nonatopic female nurse who experienced repeated anaphylactic reactions at work without involvement in drug-specific tasks such as crushing of tablets or preparation of injections. The causal allergen was not identified until a further severe anaphylactic reaction occurred after oral use of cefuroxime during a respiratory infection. Sensitization to cefuroxime was demonstrated by specific IgE, basophil activation test and skin prick test. An inhalation challenge with a dosimeter induced generalized urticaria after a cumulative dose of about 10 μg of the drug, but no asthmatic reaction. Complete exposure cessation was initiated and a 1-year follow-up was without further allergic reactions. We conclude that work-related systemic allergic reactions to β-lactam antibiotics may occur in nurses after inhalation of low doses and without perceived association with drug-specific tasks like handling of antibiotics.

Usefulness of In Vivo and In Vitro Diagnostic Tests in the Diagnosis of Hypersensitivity Reactions to Quinolones and in the Evaluation of Cross-Reactivity: A Comprehensive Study Including the Latest Quinolone Gemifloxacin

Purpose

Reports evaluating diagnosis and cross reactivity of quinolone hypersensitivity have revealed contradictory results. Furthermore, there are no reports investigating the cross-reactivity between gemifloxacin (GFX) and the others. We aimed to detect the usefulness of diagnostic tests of hypersensitivity reactions to quinolones and to evaluate the cross reactivity between different quinolones including the latest quinolone GFX.

Methods

We studied 54 patients (mean age 42.31±10.39 years; 47 female) with 57 hypersensitivity reactions due to different quinolones and 10 nonatopic quinolone tolerable control subjects. A detailed clinical history, skin test (ST), and single-blind placebo-controlled drug provocation test (SBPCDPT), as well as basophil activation test (BAT) and lymphocyte transformation test (LTT) were performed with the culprit and alternative quinolones including ciprofloxacin (CFX), moxifloxacin (MFX), levofloxacin (LFX), ofloxacin (OFX), and GFX.

Results

The majority (75.9%) of the patients reported immediate type reactions to various quinolones. The most common culprit drug was CFX (52.6%) and the most common reaction type was urticaria (26.3%). A quarter of the patients (24.1%) reacted to SBPCDPTs, although their STs were negative; while false ST positivity was 3.5% and ST/SBPCDPTs concordance was only 1.8%. Both BAT and LTT were not found useful in quinolone hypersensitivity. Cross-reactivity was primarily observed between LFX and OFX (50.0%), whereas it was the least between MFX and the others, and in GFX hypersensitive patients the degree of cross-reactivity to the other quinolones was 16.7%.

Conclusions

These results suggest that STs, BAT, and LTT are not supportive in the diagnosis of a hypersensitivity reaction to quinolone as well as in the prediction of cross-reactivity. Drug provocation tests (DPTs) are necessary to identify both culprit and alternative quinolones.

How should occupational anaphylaxis be investigated and managed?

PURPOSE OF REVIEW

Anaphylaxis is a systemic allergic reaction that can be life-threatening or fatal and can result from work-related exposures. This review study focuses on the assessment, main triggers, and management of occupational anaphylaxis.

RECENT FINDINGS

Exposed workers can be sensitized through inhalation and skin contact, and the risks increase with penetration of the allergen through the skin. The main eliciting agents of occupational anaphylaxis include stinging insects and animal bites, natural rubber latex and other vegetable allergens, food products, and drugs. Workers sensitized to occupational allergens may also develop anaphylaxis outside the work environment from exposure to the same or to cross-reacting allergens. Cofactors at work such as exercise may increase the risk. The relevant medical records and laboratory tests (e.g. tryptase) performed during the episode should be reviewed.

SUMMARY

It is very important to confirm the diagnosis and to identify the specific trigger of anaphylaxis. Component-resolved diagnosis may help in the identification of primary sensitizers or cross-reactive allergens. Adrenaline must be administered to all patients experiencing anaphylaxis. Removal from exposure is mandatory to prevent further episodes. A written emergency management plan, health and safety education, and training and surveillance should be enforced in occupations at greater risk.

Occupational allergy to pharmaceutical products

PURPOSE OF REVIEW

Occupational allergy in healthcare workers is common and can lead to significant costs from both loss of productivity within the workforce as well as those associated with diagnosis and treatment. This review aims to provide an update on drugs implicated in causing occupational allergy.

RECENT FINDINGS

Drugs traditionally reported as causing occupational allergy, such as penicillin, remain problematic. However, as their use reduces and newer drugs, such as cephalosporins, are used more frequently there is a changing pattern to occupational sensitization. In some studies up to 17% of healthcare workers now appear sensitized to cephalosporins. Other drug classes also reported include proton pump inhibitors and benzodiazepines. Interestingly, drugs such as omeprazole and tetrazepam rarely cause allergy in patients but can be very sensitizing if applied topically or inhaled. Recent studies involving pharmaceutical company employees show that this problem can no longer be considered primarily related to healthcare workers.

SUMMARY

The diagnosis of occupational allergy to drugs can be complicated and has been shown to take up to 5 years from the onset of symptoms. Ultimately, workplace avoidance remains key; however, an up to date awareness of culprit drugs and the patterns of allergy seen are key to a prompt resolution of symptoms.

Occupational anaphylaxis--an EAACI task force consensus statement

Anaphylaxis is a systemic allergic reaction, potentially life-threatening that can be due to nonoccupational or, less commonly, to occupational triggers. Occupational anaphylaxis (OcAn) could be defined as anaphylaxis arising out of triggers and conditions attributable to a particular work environment. Hymenoptera stings and natural rubber latex are the commonest triggers of OcAn. Other triggers include food, medications, insect/mammal/snake bites, and chemicals. The underlying mechanisms of anaphylactic reactions due to occupational exposure are usually IgE-mediated and less frequently non-IgE-mediated allergy or nonallergic. Some aspects of work-related allergen exposure, such as route and frequency of exposure, type of allergens, and cofactors may explain the variability of symptoms in contrast to the nonoccupational setting. When assessing OcAn, both confirmation of the diagnosis of anaphylactic reaction and identification of the trigger are required. Prevention of further episodes is important and is based on removal from further exposure. Workers with a history of OcAn should immediately be provided with a written emergency management plan and an adrenaline auto-injector and educated to its use. Immunotherapy is recommended only for OcAn due to Hymenoptera stings.

Beta-Lactam Hypersensitivity and Cross-Reactivity

Penicillin is the most frequently reported cause of drug allergy, and cross-reactivity of penicillins with other beta-lactam antibiotics is an area of debate. This review evaluates the available data on immunoglobulin E-mediated penicillin hypersensitivity and cross-reactivity with cephalosporin, carbapenem, and monobactam antibiotics. A MEDLINE search was conducted from 1950 to October 2013, and selected references from review articles were also evaluated. There is a wide variety in reported incidences of cross-reactivity between penicillins and cephalosporins or carbapenems, with early retrospective studies suggesting up to 41.7% and 47.4% cross-reactivity, respectively. Conversely, the use of monobactam antibiotics is frequently employed in the case of a penicillin allergy, as prescribers believe that there is no cross-reactivity between the 2 drug classes. More recent prospective studies suggest that the rates of cross-reactivity with cephalosporins and carbapenems are <5% and <1%, respectively. Similarities in penicillin and cephalosporin side chains may play a role in cross-reactivity between these classes. Cross-reactivity with monobactams is essentially negligible; however, there are some clinical data to support an interaction between ceftazidime and aztreonam, due to the similarity of their side chains. The data reviewed suggest that avoidance of other beta-lactams in patients with type 1 hypersensitivity to penicillins should be reconsidered.

Identifying genetic susceptibility to sensitization to cephalosporins in health care workers

Exposure to cephalosporins could cause occupational allergic diseases in health care workers (HCWs). We evaluated the prevalence of serum specific IgE and IgG antibodies to cephalosporin-human serum albumin (HSA) conjugate and to identify potential genetic risk factors associated with sensitization to cephalosporins in exposed HCWs. The study population consisted of 153 HCWs who had been exposed to antibiotics in a single university hospital and 86 unexposed healthy controls. A questionnaire survey of work-related symptoms (WRS) was administered. A skin-prick test (SPT) was performed, and serum-specific IgE and IgG antibodies to 3 commonly prescribed cephalosporins were measured by ELISA. Four single-nucleotide polymorphisms of the candidate genes related to IgE sensitization were genotyped. The prevalence of WRS to cephalosporins was 2.6%. The prevalence rates of serum-specific IgE and IgG antibodies to cephalosporins were 20.3% and 14.7%, respectively. The FcεR1β-109T > C polymorphism was significantly associated with IgE sensitization to cephalosporins in HCWs (P = 0.036, OR = 3.553; CI, 1.324-9.532). The in vitro functional assay demonstrated that the T allele of FcεR1β-109T had greater promoter activity than did the C allele (P < 0.001). The FcεR1β-109T > C polymorphism may be a potential genetic risk factor for increased IgE sensitization to cephalosporins.

IgE Sensitization to Cephalosporins in Health Care Workers

Purpose

Cephalosporins can induce occupational allergies, such as asthma, urticaria, and anaphylaxis. We investigated the prevalence and risk factors of sensitization to cephalosporin.

Methods

A total of 161 health care workers (HCW), including 138 nurses and 23 pharmacists, and 86 unexposed non-atopic healthy controls were recruited from a single tertiary hospital and the general population. A questionnaire regarding work-related symptoms was administered along with skin prick tests (SPT) to the three most commonly used cephalosporins (cefotiam, ceftriaxone, and ceftizoxime). Serum specific IgE antibodies to conjugates of the three cephalosporins and human serum albumin (HSA) were measured by enzyme-linked immunosorbent assay (ELISA). Binding specificities were confirmed by ELISA inhibition tests.

Results

The prevalence of work-related symptoms in association with cephalosporins was 17.4%. The sensitization rate to any cephalosporin was 3.1% by SPT. Sensitization rates determined by measurement of serum specific IgE antibodies were 17.4% for any cephalosporin, 10.4% for cefotiam, 6.8% for ceftriaxone, and 3.7% for ceftizoxime. A personal history of any antibiotic allergy was a risk factor for work-related symptoms (OR, 24.93; 95% CI, 2.61-238), but not for the presence of serum specific IgE antibodies to cephalosporins (OR, 0.9; 95% CI, 0.18-4.53). A personal history of atopic dermatitis was a risk factor for the presence of serum specific IgE antibodies to cefotiam-HSA conjugate (OR, 6.30; 95% CI, 1.23-32.3).

Conclusions

A high cephalosporin sensitization rate (17.4%) was detected by ELISA in HCW exposed to cephalosporins. Monitoring of serum specific IgEs to cephalosporin-HSA conjugates will be useful for detecting sensitized subjects.

Clinical characteristics of patients with drug hypersensitivity in Norway: a single-centre study

BACKGROUND

Drug hypersensitivity reactions (DHRs) represent an important public health problem. Knowledge of their clinical characteristics will provide improved diagnostic approaches to this topic.

OBJECTIVES

The aim of the present study was to describe the clinical characteristics of patients with suspected DHRs.

METHODS

The medical records of 206 outpatients with suspected DHRs, who consulted a Norwegian allergy centre from January 2005 to December 2009, were investigated in a retrospective study.

RESULTS

Mean age (range) was 44.3 (11-84) years, and 72% of the patients were women. The most common underlying diseases justifying the use of drugs were infections (49%) and pain-related diseases (23%). Antibiotics (53%), non-steroidal anti-inflammatory drugs (NSAIDs) (32%), paracetamol (15%) and other drugs (46%), used as monotherapy or combinations, were the most often suspected drugs. Cutaneous symptoms were the most frequently reported symptoms (83%). Hospitalisation or prolonged hospitalisation was needed in 38% of the cases, and anaphylaxis was reported in 28% of all the patients. Skin prick tests were performed in 185 patients, of which 14 patients had positive test results. Drug provocation tests (DPTs) were performed in only 86 patients, six of which had positive reactions. DHRs were confirmed in 24 and rejected in 81 patients. Unsettled cases (39%) were mainly due to not performing DPTs.

CONCLUSIONS

Suspected DHRs occur predominantly in women. The most common manifestations are cutaneous symptoms, but life-threatening reactions justifying hospitalisation may occur. Antibiotics and NSAIDs are the two drug families most frequently suspected. DPTs need to be included in diagnostic protocols in order to evaluate suspected DHRs.

A case of piperacillin-induced occupational anaphylaxis: detection of serum IgE to piperacillin-HSA conjugate

This is the first reported detection of serum IgE antibody to piperacillin-human serum albumin (HSA) conjugate in a patient presenting with anaphylaxis that developed after occupational exposure. A 24-yr-old nurse, who had worked at a University Hospital for 2 yr, experienced chest tightness, dizziness, generalized urticaria, abdominal pain, and diarrhea 10 min after administering a piperacillin injection. She had previously suffered from atopic dermatitis. A skin prick test for common inhalant allergens was entirely negative; in contrast, her serum total IgE was elevated (283 IU/mL). A high level of piperacillin-specific serum IgE was detected by ELISA using piperacillin-HSA conjugate. Significant inhibition upon addition of both free piperacillin and piperacillin-HSA conjugate was detected by inhibition ELISA. These data suggest that piperacillin exposure in the workplace can induce occupational anaphylaxis and urticaria mediated by an interaction of IgE with the hapten of piperacillin.