Diagnosis and management of immediate hypersensitivity reactions to cephalosporins

[allergy to penicillin - no beta-lactam antibiotics?]

Drug allergies are frequently reported by patients undergoing pre-anesthesia evaluation, potentially resulting in a suboptimal treatment with alternative substances. While about 10% of patients report to be allergic to penicillin, less than 1% have a true IgE-mediated allergy. Multiple factors contribute to this large prevalence, such as misinterpretations of common gastrointestinal side effects as “allergic”, a history of penicillin treatment for infectious mononucleosis resulting in skin rashes, uncritical acceptance of the diagnosis by medical staff or neglect to the fact that most patients will lose their sensitivity after 10 years. In addition to this, cephalosporins are regularly withheld from patients with penicillin allergy due to an unwarranted fear of cross-reactivity. Therefore, a correct identification of those in which penicillins or cephalosporins are truly contraindicated is paramount to avoid an unnecessary use of antibiotics with a less favorable spectrum.

Yenidoğanlarda seftriakson kullanımının yan etkilerinin değerlendirilmesi

Amaç: Seftriakson yan etkileri nedeniyle yenidoğanda sınırlı kullanıma sahiptir. Yenidoğan enfeksiyonlarında kullanımı ile ilgili sınırlı sayıda çalışma vardır. Bu çalışma ile setriakson alan yenidoğanlarda seftriakson sonrası oluşabilecek yan etkilerin değerlendirilmesi amaçlanmıştır. Gereç ve Yöntem: Çukurova Üniversitesi Tıp Fakültesi Balcalı Hastanesi Yenidoğan Yoğun Bakım Ünitesi’nde, 2015-2016 yılları arasında yatan bebeklerin seftriakson tedavisi öncesi ve sonrası klinik ve laboratuvar verileri retrospektif olarak incelenmiştir. Bulgular: Çalışmaya 30 olgu alınmıştır. Bu bebeklerin ortalama gebelik yaşı 37 ± 3,1 (30-41) hafta, seftriakson aldığı süre 7,2 ± 2,2 (2-12) gün bulunmuştur. 30 olgudan alınan idrar kültürlerinde; 17 (%56,6) bebekte üreme saptanmıştır. Bunların 11’inde (%36,6) Escherischia coli (E. coli), 5’inde (%16,7) diğer bakteriler üremiştir. Olguların seftriakson öncesi ve sonrası laboratuvar verilerinde kan üre azotu (BUN), total bilirubin (TB) ve hematokrit değerlerinde anlamlı düşüş saptanmıştır. Seftriakson kullanımına bağlı herhangi bir yan etki izlenmemiştir. Sonuç: Çalışmamızda seftriakson sonrası komplikasyon görülmemiş olması term veya terme yakın yenidoğanlarda seftriakson kullanımı için cesaret verici olabilir. Fakat, yenidoğanda seftriaksonun yan etkilerinin ve sıklıklarının kesinleştirilmesi ve yenidoğanda kullanılan diğer antibiyotiklere karşı alternatif olup olamayacağının belirlenmesi için daha fazla araştırmalara ihtiyaç vardır.

Diagnostic Approach of Hypersensitivity Reactions to Cefazolin in a Large Prospective Cohort

BACKGROUND

Cefazolin is a common trigger of perioperative anaphylaxis. The diagnostic approach is controversial because the optimal concentration for skin testing is uncertain, drug provocation tests (DPTs) are contraindicated in severe reactions, and in vitro tests are not thoroughly validated.

OBJECTIVE

We aimed to characterize a large number of patients reporting cefazolin allergic reactions and to analyze the diagnostic role of in vivo and in vitro tests.

METHODS

We prospectively evaluated patients with suspicion for allergic reactions to cefazolin by clinical history, skin tests (STs), and, if negative, DPT. In a subgroup of patients, basophil activation test (BAT) and radioallergosorbent test were done before allergologic workup was performed and the final diagnosis was achieved.

RESULTS

We evaluated 184 patients, 76 of whom were confirmed as allergic (41.3%), 90 were nonallergic (48.9%), and 18 were nonconfirmed (9.8%). All patients reporting anaphylactic shock and most reporting anaphylaxis were confirmed to be allergic (P < .001). Forty allergic patients (52.6%) were confirmed by STs, 22 by DPT (28.9%), and 14 by clinical history (18.4%). All subjects manifesting exanthemas and pruritus were nonallergic. The BAT sensitivity was 66.7% when CD63 and CD203c were combined as activation markers. Six of 8 patients with negative STs and positive DPT had a positive BAT.

CONCLUSIONS

Patients allergic to cefazolin often reported severe immediate-type reactions. Skin tests enabled a diagnosis in half of patients when using cefazolin at 20 mg/mL. Unfortunately, DPT could not be performed in all patients owing to reaction severity, which makes BAT a promising diagnostic tool. Further research is needed to clarify the underlying mechanisms, especially in severe reactions.

ChAlPred: A web server for prediction of allergenicity of chemical compounds

BACKGROUND

Allergy is the abrupt reaction of the immune system that may occur after the exposure to allergens such as proteins, peptides, or chemicals. In the past, various methods have been generated for predicting allergenicity of proteins and peptides. In contrast, there is no method that can predict allergenic potential of chemicals. In this paper, we described a method ChAlPred developed for predicting chemical allergens as well as for designing chemical analogs with desired allergenicity.

METHOD

In this study, we have used 403 allergenic and 1074 non-allergenic chemical compounds obtained from IEDB database. The PaDEL software was used to compute the molecular descriptors of the chemical compounds to develop different prediction models. All the models were trained and tested on the 80% training data and evaluated on the 20% validation data using the 2D, 3D and FP descriptors.

RESULTS

In this study, we have developed different prediction models using several machine learning approaches. It was observed that the Random Forest based model developed using hybrid descriptors performed the best, and achieved the maximum accuracy of 83.39% and AUC of 0.93 on validation dataset. The fingerprint analysis of the dataset indicates that certain chemical fingerprints are more abundant in allergens that include PubChemFP129 and GraphFP1014. We have also predicted allergenicity potential of FDA-approved drugs using our best model and identified the drugs causing allergic symptoms (e.g., Cefuroxime, Spironolactone, Tioconazole). Our results agreed with allergenicity of these drugs reported in literature.

CONCLUSIONS

To aid the research community, we developed a smart-device compatible web server ChAlPred (https://webs.iiitd.edu.in/raghava/chalpred/) that allows to predict and design the chemicals with allergenic properties.

Cefaclor-induced hypersensitivity: Differences in the incidence of anaphylaxis relative to other 2nd and 3rd generation cephalosporins

Cefaclor, a second-generation oral cephalosporin, is the most frequently prescribed cephalosporin in Korea. Studies, however, have yet to analyze the incidence of cefaclor-associated adverse drug reactions (ADRs), including hypersensitivity (HS), according to total national usage rates. This study aimed to investigate the incidence rates and clinical features of cefaclor ADRs reported to the Korean Adverse Event Reporting System (KAERS) and Health Insurance Review and Assessment Service (HIRA) database for the most recent 5 years. Reviewing the HIRA database, which contains information on all insurance claims, including prescribed medications and patient demographics, we identified the total number of individuals who had been prescribed cefaclor and other cephalosporins including 2^nd generation without cefaclor and 3^rd generation antibiotics from January 2014 to December 2018. Additionally, we retrospectively analyzed all ADRs reported to the KAERS for these drugs over the same study period. Incidence rates for ADRs, HS, and anaphylaxis to cefaclor were 1.92/10,000 persons, 1.17/10,000 persons, and 0.38/10,000 persons, respectively, lower than those to other 2^nd and 3^rd cephalosporins. Among all ADRs, HS (60.9% vs. 43.6% vs. 44.8%, P <0.001) and anaphylaxis (19.8% vs. 4.6% vs. 4.7%, P <0.001) were more common for cefaclor than for other 2^nd and 3^rd cephalosporins. Females, individuals under 65 years of age, concomitant use of drugs, and serious ADRs were more strongly associated with HS to cefaclor than with HS to other 2^nd and 3^rd cephalosporins. In a nationwide database for the Korean population, the incidence of cefaclor-induced ADRs, particularly HS and anaphylaxis, was high. Female sex, age younger than 65 years, and concomitant use of drugs may be associated with HS to cefaclor.

Case report: SARS-CoV-2-induced urticaria or just a concomitance?

The association between urticaria and different virus infections has been reported in many studies. Different virus infections have been reported to be comorbidities of spontaneous urticaria. In this paper, we report the case of a male patient with acute urticaria 7 days after he left the hospital where he was treated for coronavirus disease 2019 (COVID-19). This infection may act as a causative or a facilitating factor for the initiation of acute urticaria and additional cofactors such as stress may contribute for the urticaria phenotype to be expressed. Additional facts for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) virus in future will clarify if urticarial rash is one of the COVID's multiple faces.

Perioperative approach of allergic patients

Perioperative allergic reactions are rare, yet important complications of anesthesia. Severe, generalized allergic reactions called anaphylaxis are estimated to have a mortality of 3.5-4.8%. Adequate recognition and handling of a severe perioperative anaphylactic reaction result in better outcomes, including less hypoxic-ischemic encephalopathy and death. The diagnosis of a perioperative allergic reaction can be difficult as the list of possible culprits of a perioperative allergic reaction is extensive. Making an informed guess on the causative agent and avoiding this agent in future anesthesia procedures is undesirable and unsafe. Therefore, to ensure future patient safety, a thorough investigation following a perioperative allergic reaction is mandatory. A collaborate approach by allergists and anesthesiologists is advised. In this article, we discuss the basic approach of the allergic patient and of patients with a suspected allergy to perioperatively administered medication.

Refractory Unforeseen Anaphylaxis Case in a Rural OR Unit

A 35-year-old female patient with no previously documented allergies who was admitted for elective gynaecological surgery, developed rapid onset, severe anaphylaxis, with dyspnea and cardiovascular collapse, in the operating theatre after receiving routine IV cefazolin prior to induction of anesthesia. She failed to improve with two doses of intramuscular epinephrine followed by two boluses of intravenous epinephrine, but responded to an epinephrine infusion. She was assessed by Internal Medicine and discharged home the following day. This event demonstrates the speed, severity, and profound hypotension in an allergic reaction from intravenous medication, challenges in managing anaphylaxis, and importance of prompt administration of epinephrine via IM route, followed by IV if necessary, in the OR. The case highlighted the inability to ascertain the causative agent through typical allergy testing.

Implementation of a Plan-Do-Study-Act framework to reduce unindicated surgical antimicrobial prophylaxis

PURPOSE

The goal of this study was to use a Plan-Do-Study-Act (PDSA) framework to reduce utilization of unindicated surgical antibiotic prophylaxis (SAP) for clean cases without foreign body implantation.

METHODS

This was a pre-post intervention study conducted at a single children's hospital comparing 6 months of retrospective preintervention data to 10 months of prospectively collected postintervention data. Interventions to reduce unindicated SAP included faculty meetings to review guidelines and establish consensus around inclusion criteria, publicizing guidelines with regular email reminders, and conducting ongoing compliance audits to root cause noncompliance. Early unanticipated noncompliant cases were associated with rotating trainees who prescribed SAP routinely without attending knowledge. A second PDSA cycle then included education-based emails targeting residents with mandatory feedback loop closure.

RESULTS

Preintervention, 40.4% (107/265) of patients received unindicated SAP. Postintervention, the rate of unindicated SAP decreased to 15.4% (6/39) after the first month and 6.2% (20/323) after 10 months, reflecting an 85% reduction across periods (p < 0.01). There was no difference in the rate of surgical site infections between the pre and postintervention cohorts (0.36% vs. 0.67%, p = 1.00).

CONCLUSIONS

Unindicated surgical antibiotic prophylaxis was significantly reduced by implementing a Plan-Do-Study-Act intervention targeting both faculty and trainees.

LEVEL OF EVIDENCE

Prospective comparative treatment study, level II.

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.

Cephalosporins: A Focus on Side Chains and β-Lactam Cross-Reactivity

Cephalosporins are among the most commonly prescribed antibiotic classes due to their wide clinical utility and general tolerability, with approximately 1-3% of the population reporting a cephalosporin allergy. However, clinicians may avoid the use of cephalosporins in patients with reported penicillin allergies despite the low potential for cross-reactivity. The misdiagnosis of β-lactam allergies and misunderstanding of cross-reactivity among β-lactams, including within the cephalosporin class, often leads to use of broader spectrum antibiotics with poor safety and efficacy profiles and represents a serious obstacle for antimicrobial stewardship. Risk factors for cephalosporin allergies are broad and include female sex, advanced age, and a history of another antibiotic or penicillin allergy; however, cephalosporins are readily tolerated even among individuals with true immediate-type allergies to penicillins. Cephalosporin cross-reactivity potential is related to the structural R1 side chain, and clinicians should be cognizant of R1 side chain similarities when prescribing alternate β-lactams in allergic individuals or when new cephalosporins are brought to market. Clinicians should consider the low likelihood of true cephalosporin allergy when clinically indicated. The purpose of this review is to provide an overview of the role of cephalosporins in clinical practice, and to highlight the incidence of, risk factors for, and cross-reactivity of cephalosporins with other antibiotics.

Comparative epidemiology of suspected perioperative hypersensitivity reactions

Suspected perioperative hypersensitivity reactions are rare but contribute significantly to the morbidity and mortality of surgical procedures. Recent publications have highlighted the differences between countries concerning the respective risk of different drugs, and changes in patterns of causal agents and the emergence of new allergens. This review summarises recent information on the epidemiology of perioperative hypersensitivity reactions, with specific consideration of differences between geographic areas for the most frequently involved offending agents.

Presumed β-Lactam Allergy and Cross-reactivity in the Operating Theater: A Practical Approach

A β-lactam allergy is the most common suspected in-hospital drug allergy. This article aims to provide a practical approach to a patient with presumed β-lactam allergy in the perioperative setting.

Supplemental Digital Content is available in the text.

Incidence of cephalosporin-induced anaphylaxis and clinical efficacy of screening intradermal tests with cephalosporins: A large multicenter retrospective cohort study

BACKGROUND

Few studies have investigated the incidence of anaphylaxis induced by individual or structurally similar cephalosporins. The aims of the study were to assess the incidence of cephalosporin-induced anaphylaxis and evaluate the clinical efficacy of screening skin tests.

METHODS

In this retrospective cohort study, we obtained information on total cephalosporin use and cephalosporin-induced anaphylaxis in intravenous cephalosporin recipients in 12 general hospitals between 2013 and 2015. Cephalosporins were divided into 4 groups according to similar side-chain structures. The incidence of cephalosporin-induced anaphylaxis was assessed for each cephalosporin, cephalosporin generation, and side-chain group. To verify the efficacy of screening intradermal tests (IDT) with cephalosporin, the 12 hospitals were assigned to the intervention or control group depending on whether they performed screening IDT before the administration of cephalosporins.

RESULTS

We identified 76 cases of cephalosporin-induced anaphylaxis with 1 123 345 exposures to intravenous cephalosporins (6.8 per 100 000 exposures), and the incidence of fatal anaphylaxis by cephalosporin was 0.1 cases per 100 000 exposures. The highest incidences of anaphylaxis occurred in the ceftizoxime (13.0 cases per 100 000 exposures) and side-chain group 1 (cefepime, cefotaxime, ceftizoxime, ceftriaxone, and cefuroxime; 9.3 per 100 000). There was no case of anaphylaxis induced by cefoxitin, cefmetazole, cefminox, and cefotiam. The clinical effectiveness of routine screening IDT was not significant (P = .06).

CONCLUSIONS

The incidence of cephalosporin-induced anaphylaxis differed according to individual drugs and side-chain structure. Screening IDT showed no clinical efficacy at a population level.

Perioperative Anaphylaxis Including Kounis Syndrome due to Selective Cefazolin Allergy

BACKGROUND

Perioperative use of cefazolin has been associated with severe allergic reactions, and patients are usually labelled as allergic to penicillin afterwards. The aim of our study was to describe a group of patients with immediate reactions to cefazolin, with proven selective hypersensitivity reactions.

METHODS

Systematic review of all patients followed at our drug centre with cefazolin-related reactions, between January 2012 and December 2016. All patients were investigated according to the European Network for Drug Allergy (ENDA) recommendations through skin testing (major and minor penicillin determinants, penicillin, amoxicillin, cefazolin, cefuroxime and ceftriaxone) and oral challenges tests.

RESULTS

We included 7 patients (median age 40 years) with perioperative anaphylactic reactions immediately after cefazolin injection, 4 with hypotension and 1 with Kounis syndrome (KS) type I. The presence of a selective IgE-mediated hypersensitivity through positive skin tests to cefazoline has been proven in all patients. Two patients experienced systemic reactions during skin testing. All patients were successfully challenged with amoxicillin, and they tolerated cefuroxime.

CONCLUSIONS

Cefazolin can be responsible for immediate severe allergic reactions in perioperative setting, including KS. Allergological workup is essential for an accurate diagnosis and to explore cross-reactivity between cefazolin and other beta-lactams. Our experience confirmed that patients with IgE-mediated hypersensitivity reactions to cefazolin can tolerate other beta-lactams. This selective pattern of clinical reactivity may be explained by its particular chemical structure, whose R1 side-chain is different from other beta-lactams.

Cross-reactivity in β-Lactam Allergy

β-Lactam drugs (penicillins, amoxicillin, and cephalosporins) account for 42.6% of all severe drug-induced anaphylaxis. In this review, we focus on clinically significant immunologic cross-reactivity in patients with confirmed penicillin allergy to cephalosporins, and the structural involvement of the R₁ and R₂ chemical side chains of the cephalosporins causing IgE-mediated cross-reactivity with penicillin and other cephalosporins. Skin tests predict IgE-mediated reactions and showed cross-reactivity between penicillins and early generation cephalosporins that shared side chains, but confirmatory challenge data are lacking. Later-generation cephalosporins, which have distinct side chains, do not have any skin test cross-reactivity with penicillin/amoxicillin. There is debate as to the involvement of R₂ side chains as the antigenic determinants that cause IgE-mediated hypersensitivity with various cephalosporins. Avoidance of cephalosporins, when they are the drug of choice in a penicillin-allergic individual, results in significant morbidity that outweighs the low risk of anaphylaxis. We conclude that there is ample evidence to allow the safe use of cephalosporins in patients with isolated confirmed penicillin or amoxicillin allergy.

[Hypersensitivity reactions to beta-lactam antibiotics]

Allergy to beta-lactam antibiotics is a common condition and about 10% of patients report being allergic to penicillin. However, this diagnosis is largely overestimated. Two types of allergy should be distinguished and include immediate hypersensitivity that can lead to anaphylactic shock and delayed hypersensitivity, ranging from the most common maculopapular exanthema to severe bullous toxidermia or life-threatening DRESS. Allergy challenge with oriented skin tests according to the clinical features, supplemented with oral challenge in the absence of contraindication, will confirm or invalidate the diagnosis of beta-lactam allergy and will help to identify if necessary safe alternatives to beta-lactams.

Anaesthetic hypersensitivity reactions in France between 2011 and 2012: the 10th GERAP epidemiologic survey

BACKGROUND

Immediate hypersensitivity reactions during anaesthesia are rare but potentially life-threatening. The epidemiology changes with time and evolving professional practice, and hence needs to be monitored. Our objective was to follow this epidemiology.

METHODS

This was a retrospective, observational study in French hospital clinics, conducted by GERAP members (Groupe d'Étude des Réactions Anaphylactoïdes Périopératoires). Consecutive patients seen in allergo-anaesthesia outpatient clinics, who had experienced a hypersensitivity reaction during anaesthesia between 1 January 2011 and 31 December 2012, were included. Demographic data, allergy history, drugs received before the reaction, symptoms of the reaction, results of blood samples (histamine, tryptase, IgE-specific assays), and results of the allergy assessment were recorded.

RESULTS

The most common causes of allergic reactions were (Neuromuscular Blocking Agents) NMBAs (N = 302; 60.6%), antibiotics (N = 91, 18.2%, Cephalosporin N = 49, 10%) and dyes (N = 27; 5.4%). Latex as an allergic agent was involved in 26 cases (5.2%), hypnotics in 11 cases (2.2%) and opioids in seven cases (1.4%). Of the NMBAs, Rocuronium had the highest proportion of reactions (13.8 reactions/100,000 vials sold) followed by Suxamethonium (13.3/100,000 vials sold). Cisatracurium had the lowest proportion of reactions (0.4/100,000 vials sold). Patients were sensitized to two or more NMBAs in 48.9% of cases and without testing, cross-sensitivity cannot be predicted.

CONCLUSIONS

When compared with the previous GERAP studies, NMBAs are still the most frequently triggering allergens, with marked differences between individual NMBAs, but they are now followed by antibiotics (of which greater than 50% were cephalosporins) and dyes. Anaesthetists must be aware of the differences between drugs and of the pattern of emerging allergens. For the future of safe anaesthesia, allergy assessment is essential.

Skin testing and drug challenge outcomes in antibiotic-allergic patients with immediate-type hypersensitivity

BACKGROUND

The evaluation of antibiotic immediate-type hypersensitivity is intricate because of nonstandardized skin testing and challenge method variability.

OBJECTIVE

To determine the safety outcomes and risk factors for antibiotic challenge reactions in patients reporting a history of antibiotic immediate-type hypersensitivity.

METHODS

A 5-year retrospective review of patients evaluated for immediate-type antibiotic allergy was conducted. Data analyzed included patient demographics, index reaction details, and outcomes of skin testing and challenges, classified as single-step or multistep.

RESULTS

Antibiotic hypersensitivity history was identified in 211 patients: 78% to penicillins, 10% to fluoroquinolones, 7.6% to cephalosporins, and 3.8% to carbapenems. In total, 179 patients completed the challenges (median age 67 years, range 50-76 years, 56% women), and compared with nonchallenged patients, they reported nonanaphylactic (P < .001) and remote index (P = .003) reactions. Sixteen patients (8.9%) experienced challenge reactions (5 of 28 for single-step challenge, 11 of 151 for multistep challenge), and 11 of these patients had negative skin testing results before the challenge. Challenge-reactive patients were significantly younger (P = .007), more often women (P = .036), and had additional reported antibiotic allergies (P = .005). No correlation was detected between the reported index and observed challenge reaction severities (κ = -0.05, 95% confidence interval -0.34 to 0.24). Anaphylactic rates were similar during single-step and multistep challenges (3.6% vs 3.3%).

CONCLUSION

In the present population, younger women with multiple reported antibiotic allergies were at greatest risk for challenge reactions. Negative skin testing results did not exclude reactions, and index severity was not predictive of challenge outcome. The multistep and full-dose methods demonstrated a comparable reaction risk for anaphylaxis.

Special endpoint and product specific considerations in pharmaceutical acceptable daily exposure derivation

Recently, a guideline has been published by the European Medicines Agency (EMA) on setting safe limits, permitted daily exposures (PDE) [also called acceptable daily exposures (ADE)], for medicines manufactured in multi-product facilities. The ADE provides a safe exposure limit for inadvertent exposure of a drug due to cross-contamination in manufacturing. The ADE determination encompasses a standard risk assessment, requiring an understanding of the toxicological and pharmacological effects, the mechanism of action, drug compound class, and the dose-response as well as the pharmacokinetic properties of the compound. While the ADE concept has broad application in pharmaceutical safety there are also nuances and specific challenges associated with some toxicological endpoints or drug product categories. In this manuscript we discuss considerations for setting ADEs when the following specific adverse health endpoints may constitute the critical effect: genotoxicity, developmental and reproductive toxicity (DART), and immune system modulation (immunostimulation or immunosuppression), and for specific drug classes, including antibody drug conjugates (ADCs), emerging medicinal therapeutic compounds, and compounds with limited datasets. These are challenging toxicological scenarios that require a careful evaluation of all of the available information in order to establish a health-based safe level.

Progress and Prospect: A Bibliometric Analysis of Research Papers by Korean Allergists Over Recent Five Years (2009-2013)

Since the establishment of the academic society in 1972, Korean allergists have made continuous efforts to elucidate pathogenic mechanisms and therapeutic advances for allergic diseases. The present study aimed to summarize recent progress and explore future prospects of research performance by Korean allergists. We performed a comprehensive bibliometric analysis for research papers published in the Science Citation Index (SCI) or SCI-expanded journals by Korean allergists between 2009 and 2013. Research performance was quantitatively analyzed for the numbers of papers by publication year, research type, and main topic. In addition, the performance was also examined for qualitative indices, such as impact factor and citation number. A total of 1,091 papers were identified. The number of publication increased continuously, with an annual increase rate of 12.3%. Clinical and basic studies were the most frequent types of research, and recently the number of epidemiological studies has increased. By research topic, asthma was the most commonly studied, accounting for 20.9% of the total number of publications. Notably, the amount of rhinitis/rhinosinusitis research has risen steeply in 2013. Qualitative analyses also indicated continuous progress; the median impact factor of published journals increased from 1.918 in 2009 to 2.746 in 2013, yielding an annual increase rate of 7.4%. In conclusion, the present analyses identified a continuous increase in the research performance of Korean allergists over a recent 5 year period (2009-2013), both quantitatively and qualitatively. A more significant contribution is expected in the forthcoming era.