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Bland CM, Heil EL, Asbell A, Smith SE, Jones BM. Delabeling for the duration? β-Lactam prescribing in hospitalized patients after penicillin skin testing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3245-3247. [PMID: 37329955 DOI: 10.1016/j.jaip.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/01/2023] [Accepted: 06/08/2023] [Indexed: 06/19/2023]
Affiliation(s)
- Christopher M Bland
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, Ga; Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, Ga.
| | - Emily L Heil
- Department of Practice, Sciences, and Health-Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Md
| | - Ashley Asbell
- Department of Pharmacy, Trident Medical Center, North Charleston, SC
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, Ga
| | - Bruce M Jones
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, Ga; Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, Ga
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Macy E, Adkinson NF. The Evolution of Our Understanding of Penicillin Allergy: 1942-2022. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:405-413. [PMID: 36116763 DOI: 10.1016/j.jaip.2022.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/26/2022] [Accepted: 09/06/2022] [Indexed: 11/29/2022]
Abstract
This article reviews our evolving understanding of penicillin hypersensitivity at the 80th anniversary of penicillin's clinical introduction. Penicillin breakdown products covalently bond to serum proteins, leading to classic drug hypersensitivity. Penicillin remains the most frequently reported drug "allergy." Adverse reactions were presumed, in retrospect incorrectly, to implicate a risk for anaphylaxis, and therefore skin testing for IgE became the focus. Skin test positivity may wane over time. This insight has led to the radical conclusion that penicillin hypersensitivity may not be "forever." Atopic background, other drug allergies, family history, gender, and race are apparently not risk factors for penicillin hypersensitivity. Confirmed penicillin hypersensitivity has declined since the 1960s, potentially due to "cleaner" penicillin products and lower dose oral, instead of parenteral, use. Avoiding penicillins, without evaluation, caused unanticipated problems that have been appreciated only recently including longer hospital stays, increased cost of care, suboptimal outcomes from serious infections, and greater toxicities and costs with alternative antibiotics. There are personal and public health advantages with broadly implemented penicillin allergy delabeling based on a reaction history-based risk assessment. Limited skin testing followed by an oral challenge, if negative, for higher-risk histories, and direct oral challenges in lower-risk individuals are currently the reference standard tests to confirm current tolerance.
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Affiliation(s)
- Eric Macy
- Allergy Department, Kaiser Permanente Southern California, San Diego, Calif.
| | - N Franklin Adkinson
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
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Schroer B, Macy E. Another Step Forward in the Optimization of Penicillin Allergy Delabeling Strategies in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:4067-4068. [PMID: 34749949 DOI: 10.1016/j.jaip.2021.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Brian Schroer
- Department of Allergy and Immunology, Akron Children's Hospital, Akron, Ohio.
| | - Eric Macy
- Kaiser Permanente Southern California, San Diego, Calif
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Macy E, Crawford WW, Nguyen MT, Adams JL, McGlynn EA, McCormick TA. Population-Based Incidence of New Ampicillin, Cephalexin, Cefaclor, and Sulfonamide Antibiotic "Allergies" in Exposed Individuals with and without Preexisting Ampicillin, Cephalexin, or Cefaclor "Allergies". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:550-555. [PMID: 34757066 DOI: 10.1016/j.jaip.2021.10.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/01/2021] [Accepted: 10/15/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is a theoretical concern, unconfirmed by population-based challenge data, that clinically significant, immunologically mediated hypersensitivity occurs among β-lactams sharing side chains. OBJECTIVE To determine the population-based allergy incidence associated with the use of β-lactams sharing exact R1 side chains (ampicillin, cephalexin, and cefaclor [ACC]), with or without a current ACC allergy or a sulfonamide antibiotic allergy for comparison. METHODS All courses of ACC and trimethoprim-sulfamethoxazole used by any Kaiser Permanente California members in 2017 and 2018, with follow-up through January 2019, were identified along with their preexisting antibiotic allergy status and all new antibiotic-specific allergies reported within 30 days of course initiation. RESULTS A total of 1,167,713 courses of ACC were administered to individuals. No sulfonamide antibiotic or ACC allergy and 4771 new ACC allergies (0.41%) were reported. Moreover, 130,032 courses of ACC were administered to individuals with a sulfonamide antibiotic allergy; no ACC allergy and 904 new ACC allergies (0.70%) were reported. There were 5,958 courses of ACC administered to individuals with an ACC allergy; 2,341 who also had sulfonamide antibiotic allergy, as well as 52 new ACC allergies (0.87%) were reported. CONCLUSIONS The incidence of new ACC allergy reports is minimally and no-specifically increased when a preexisting ACC or sulfonamide antibiotic allergy exists greater than the baseline incidence in the population. This argues against clinically significant, immunologically mediated cross-reactivity among β-lactams sharing exact side chains in individuals with preexisting but unconfirmed β-lactam allergy. Any previously reported, even unrelated antibiotic allergy appears to be a risk factor for reporting a new antibiotic allergy.
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Affiliation(s)
- Eric Macy
- Department of Allergy and Clinical Immunology, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, Calif.
| | - William W Crawford
- Department of Allergy and Clinical Immunology, Southern California Permanente Medical Group, South Bay Medical Center, Los Angeles, Calif
| | - Myngoc T Nguyen
- Department of Allergy and Clinical Immunology, Permanente Medical Group, Oakland Medical Center, Oakland, Calif
| | - John L Adams
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif; Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif
| | - Elizabeth A McGlynn
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif; Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif; Kaiser Permanente Research, Pasadena, Calif
| | - Thomas A McCormick
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif
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Macy E. Why Was There Ever a Warning Not to Use Cephalosporins in the Setting of a Penicillin "Allergy"? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3929-3933. [PMID: 34303019 DOI: 10.1016/j.jaip.2021.06.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/23/2021] [Accepted: 06/30/2021] [Indexed: 12/20/2022]
Abstract
It is now well-established that avoiding β-lactam antibiotics, when they are the drugs of choice, results in significantly worse long-term global outcomes for patients. Much of this avoidable morbidity has been caused by widespread warnings in electronic health care record systems not to use cephalosporins in the setting of penicillin allergy. High rates, up to 1000-fold higher than now seen, of immunologically mediated reactions were associated with early impure penicillin preparations. This instilled a rational fear of β-lactam-associated anaphylaxis in generations of physicians. In the late 1970s, several editorial comments regarding a potential increased risk to patients given cephalosporins who had a history of a penicillin allergy resulted in the warning that became imbedded in the culture of medicine. Over the past 40 years, compelling data have been developed that refute this warning and showed that the risks of avoiding cephalosporins outweighed the benefits. In late 2017, Kaiser Permanente Southern California completely removed all warnings not to use cephalosporins in the setting of a penicillin allergy. The results have recently been published in JAMA Network Open. This Rostrum article provides some of the backstory on the establishment and removal of this warning for physicians who trained over the past 30 years.
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Affiliation(s)
- Eric Macy
- Allergy Department, Kaiser San Diego Medical Center, Permanente Southern California, San Diego, Calif.
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Hills T, Arroll N, Duffy E, Capstick J, Jordan A, Fitzharris P. Penicillin Allergy De-labeling Results in Significant Changes in Outpatient Antibiotic Prescribing Patterns. FRONTIERS IN ALLERGY 2020; 1:586301. [PMID: 35386932 PMCID: PMC8974713 DOI: 10.3389/falgy.2020.586301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/14/2020] [Indexed: 11/13/2022] Open
Abstract
Unverified penicillin allergies are common but most patients with a penicillin allergy label can safely use penicillin antibiotics. Penicillin allergy labels are associated with poor clinical outcomes and overuse of second-line antibiotics. There is increasing focus on penicillin allergy "de-labeling" as a tool to improve antibiotic prescribing and antimicrobial stewardship. The effect of outpatient penicillin allergy de-labeling on long-term antibiotic use is uncertain. We performed a retrospective pre- and post- study of antibiotic dispensing patterns, from an electronic dispensing data repository, in patients undergoing penicillin allergy assessment at Auckland City Hospital, New Zealand. Over a mean follow-up of 4.55 years, 215/304 (70.7%) of de-labeled patients were dispensed a penicillin antibiotic. Rates of penicillin antibiotic dispensing were 0.24 (0.18-0.30) penicillin courses per year before de-labeling and 0.80 (0.67-0.93) following de-labeling with a reduction in total antibiotic use from 2.30 (2.06-2.54) to 1.79 (1.59-1.99) antibiotic courses per year. In de-labeled patients, the proportion of antibiotic courses that were penicillin antibiotics increased from 12.81 to 39.62%. Rates of macrolide, cephalosporin, trimethoprim/co-trimoxazole, fluoroquinolone, "other" non-penicillin antibiotic use, and broad-spectrum antibiotic use were all lower following de-labeling. Further, antibiotic costs were lower following de-labeling. In this study, penicillin allergy de-labeling was associated with significant changes in antibiotic dispensing patterns.
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Affiliation(s)
- Thomas Hills
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Nicola Arroll
- Health Information and Technology Service, Auckland District Health Board, Auckland, New Zealand
| | - Eamon Duffy
- Depatment of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand
| | - Janice Capstick
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
| | - Anthony Jordan
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
| | - Penny Fitzharris
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
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Immune-Related Adverse Drug Reactions and Immunologically Mediated Drug Hypersensitivity. Immunol Allergy Clin North Am 2020; 40:635-647. [PMID: 33012325 DOI: 10.1016/j.iac.2020.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Biologic and other therapies used for the treatment of immune-mediated hypersensitivity conditions, and in people with immune-mediated hypersensitivity, can trigger a wide variety of immune-related adverse drug reactions and immunologically mediated drug hypersensitivities. These range from acute-onset immunoglobulin E-mediated allergies to delayed-onset T-cell-mediated hypersensitivities. Certain therapeutic and diagnostic agents can directly activate mast cells. Biologic agents used to treat immune-mediated hypersensitivity can also globally upregulate or downregulate the immune system leading to pathologic reactions, including cytokine storm and hypogammaglobulinemia.
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Alharbi HA. Antibiotic Skin Testing in the Intensive Care Unit: A Systematic Review. Crit Care Nurse 2020; 39:e1-e9. [PMID: 31961941 DOI: 10.4037/ccn2019207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Homood A Alharbi
- Homood A. Alharbi is an assistant professor, College of Nursing, King Saud University, Riyadh, Saudi Arabia
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Macy E. Optimizing Penicillin Allergy Delabeling: One Big Step Forward and Several Small Steps Sideways. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2171-2172. [DOI: 10.1016/j.jaip.2019.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 06/16/2019] [Indexed: 12/29/2022]
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Abstract
PURPOSE OF REVIEW An unconfirmed penicillin allergy is known to confer significant risk to patients. Only a small minority of patients labeled with penicillin allergy will be confirmed to be hypersensitive with the current reference standard test, an oral amoxicillin therapeutic dose challenge. Skin testing has been recommended prior to oral challenges to reduce the risk of severe acute challenge reactions. The rate of severe acute anaphylactic reactions with oral amoxicillin is currently extremely low. Unfortunately, penicillin skin testing, as commonly performed, has a high rate of false positive results. RECENT FINDINGS Encouraging skin testing in all individuals with an unconfirmed penicillin allergy, prior to a confirmatory oral challenge, would be technically difficult, make testing all individuals with an unconfirmed penicillin allergy very unlikely, and ultimately increase the risk to patients because of suboptimal antibiotic use. Most patients, who are appropriate candidates for a direct oral amoxicillin challenge, to confirm current penicillin tolerance, can be safely identified by their clinical histories. Higher risk individuals, those with a history of anaphylaxis or other acute onset potentially IgE-mediated reaction such as hives within 6 h of the first dose of the last course of a penicillin, may benefit from properly performed puncture and intradermal skin testing, using commercially available penicilloyl-polylysine, prior to an oral challenge, if skin test negative. Direct oral amoxicillin challenges in low-risk individuals are well accepted by patients and a safe and effective part of penicillin allergy delabeling.
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To challenge or not to challenge: Literature data on the positive predictive value of skin tests to beta-lactams. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2404-2408.e11. [PMID: 30844483 DOI: 10.1016/j.jaip.2019.01.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/31/2018] [Accepted: 01/14/2019] [Indexed: 12/19/2022]
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Kuruvilla M, Wolf F, Sexton M, Wiley Z, Thomas J. Perioperative use of cefazolin without preliminary skin testing in patients with reported penicillin allergy. Surgery 2019; 165:486-496. [DOI: 10.1016/j.surg.2018.05.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 10/28/2022]
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Eser Simsek I, Tuba Cogurlu M, Aydogan M. Suspected Reaction with Cephalosporin May Be a Predictive Factor for β-Lactam Allergy in Children. Int Arch Allergy Immunol 2018; 178:248-254. [PMID: 30517941 DOI: 10.1159/000494506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/12/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Most children diagnosed with β-lactam allergy based only on history are not truly allergic, and mislabeling leads to use of less effective and more costly alternative broader-spectrum antibiotics, significantly increasing drug resistance. OBJECTIVE To determine the frequency and risk factors of confirmed allergy in patients with β-lactam allergy reported by parents or their doctors and evaluate cross-reactivity between β-lactams in children with confirmed allergy. METHOD Sixty-seven children with suspected β-lactam allergy were evaluated via history, sIgE measurements, skin tests, and drug provocation tests over a period of 5 years. RESULTS β-Lactam allergy was confirmed in 10 (14.9%) patients. Six patients had a positive intradermal test result to one or more of the penicillin skin test materials or ceftriaxone, 4 patients with negative skin test results had positive test results with suspected drugs. Age, gender, time interval between evaluation and the initial reaction, personal history of atopy, parental history of drug allergy, reaction type, and multiple drug allergy history were not significantly different between allergic and tolerant patients. For culprit drugs, there was a significant different between the 2 groups; the rate of confirmed diagnosis was significantly higher for cephalosporins such as ceftriaxone, cefuroxime, and cefprozil (p = 0.03). Three patients with allergy to penicillin tolerated cefuroxime; in 4 patients with selective allergy to ceftriaxone tolerated cephalosporins with a dissimilar side chain (cefadroxil, cefuroxime, cefaclor, and cefdinir). CONCLUSION Our study indicates that most patients with a suspected β-lactam allergy tolerated this drug. An appropriate diagnostic allergy workup may prevent the use of less effective and more expensive alternatives.
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Affiliation(s)
- Isil Eser Simsek
- Division of Pediatric Allergy and Immunology, Kocaeli University School of Medicine, Kocaeli, Turkey,
| | - Mujde Tuba Cogurlu
- Division of Pediatric Allergy and Immunology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Metin Aydogan
- Division of Pediatric Allergy and Immunology, Kocaeli University School of Medicine, Kocaeli, Turkey
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Macy E, Vyles D. Who needs penicillin allergy testing? Ann Allergy Asthma Immunol 2018; 121:523-529. [PMID: 30092265 DOI: 10.1016/j.anai.2018.07.041] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 07/20/2018] [Accepted: 07/30/2018] [Indexed: 01/02/2023]
Affiliation(s)
- Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, California.
| | - David Vyles
- Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Iftikhar S, Sarwar MR, Saqib A, Sarfraz M. Causality and preventability assessment of adverse drug reactions and adverse drug events of antibiotics among hospitalized patients: A multicenter, cross-sectional study in Lahore, Pakistan. PLoS One 2018; 13:e0199456. [PMID: 29949616 PMCID: PMC6021047 DOI: 10.1371/journal.pone.0199456] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 06/07/2018] [Indexed: 12/29/2022] Open
Abstract
Background and objectives Adverse drug events (ADEs) are the fifth leading cause of death and thus responsible for a large number of hospital admissions in all over the globe. This study was aimed to assess the antibiotics associated preventability of ADEs and causality of adverse drug reactions (ADRs) among hospitalized patients. Methods A prospective, cross-sectional, observational study was conducted in four tertiary care public sector hospitals of Lahore, Pakistan. Study population consisted of hospitalized patients who were prescribed with one or more antibiotics. Data were collected between 1st January, 2017 and 31st June, 2017 from 1,249 patients (384 patients aged ≤ 18 years and 865 patients aged >18 years). Schumock and Thornton scale was used to assess the preventability of the ADEs. Medication errors (MEs) that caused preventable ADEs were assessed by MEs tracking form while Naranjo score was used to evaluate the causal relation of ADRs with the antibiotics. Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) and Microsoft Excel (MS Office, 2010) were used for data analysis. Results 2,686 antibiotics were prescribed to 1,249 patients. Among them, fluoroquinolones (11.8%), macrolides (11.6%) and cephalosporins (10.9%) were the most frequently prescribed antibiotics. The most affected organ system by antibiotics associated ADEs was gastrointestinal tract. A total of 486 ADEs were found. The preventability assessment revealed that most of the ADEs (58.4%) were preventable (43.6% of the ADEs were definitely preventable while 14.8% were probably preventable) and caused by MEs including wrong drug (40.1%) and monitoring errors (25.0%), during the stage of physician ordering (22.2%) and patient monitoring (21.1%). The errors were caused due to non-adherence of policies (38.4%) and lack of information about antibiotics (32%). Most of the non-preventable ADEs or ADRs among adults and children were “probable” (35.5%) and “possible” (35.8%), respectively. Logistic regression analysis revealed that ADEs were significantly less among females (OR = 0.047, 95%CI = 0.018–0.121, p-value = <0.001), patients aged 18–52 years (OR = 0.041, 95%CI = 0.013–0.130, p-value = <0.001), tuberculosis patients (OR = 0.304, 95%CI = 0.186–0.497, p-value = <0.001), patients with acute respiratory tract infections (OR = 0.004, 95%CI = 0.01−0.019, p-value = <0.001) and among the patients prescribed with 2 antibiotics per prescription (OR = 0.455, 95%CI = 0.319–0.650, p-value = <0.001). Conclusion According to preventability assessment most of the ADEs were definitely preventable and caused by MEs due to non-adherence of policies and lack of information about antibiotics. The causality assessment of non-preventable ADEs showed that most of the ADRs were probable and possible.
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Affiliation(s)
- Sadia Iftikhar
- Akhtar Saeed College of Pharmaceutical Sciences, Lahore, Pakistan
| | - Muhammad Rehan Sarwar
- Akhtar Saeed College of Pharmaceutical Sciences, Lahore, Pakistan
- Department of Pharmacy, The Islamia University of Bahawalpur Bahawalpur, Punjab, Pakistan
- * E-mail:
| | - Anum Saqib
- Department of Pharmacy, The Islamia University of Bahawalpur Bahawalpur, Punjab, Pakistan
| | - Muhammad Sarfraz
- Department of Pharmacy, The Islamia University of Bahawalpur Bahawalpur, Punjab, Pakistan
- College of Pharmacy, Al Ain University of Science and Technology, Al Ain, Abu Dhabi, UAE
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Saqib A, Sarwar MR, Sarfraz M, Iftikhar S. Causality and preventability assessment of adverse drug events of antibiotics among inpatients having different lengths of hospital stay: a multicenter, cross-sectional study in Lahore, Pakistan. BMC Pharmacol Toxicol 2018; 19:34. [PMID: 29941052 PMCID: PMC6019808 DOI: 10.1186/s40360-018-0222-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 06/10/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND A large number of hospital admissions are attributed to adverse drug reactions (ADRs) and they are the fifth leading cause of death worldwide. The present study aimed to assess the causality and preventability of adverse drug events (ADEs) of antibiotics among inpatients having different lengths of hospital stay. METHODS A prospective, observational study was conducted in four tertiary-care public sector hospitals of Lahore, Pakistan. Study population consisted of hospitalized patients who were prescribed one or more antibiotics. Data were collected between 1st January, 2017 and 30th June, 2017 from 1249 patients. Naranjo score, modified Schumock and Thornton scale were used for causality and preventability assessments, respectively. Medication errors (MEs) were assessed by MEs tracking form. SPSS and Microsoft Excel were used for data analysis. RESULTS A total of 2686 antibiotics were prescribed to 1249 patients and 486 ADEs were found. The preventability assessment revealed that most of the ADEs (78.8%) were found among patients having long length of stay (LOS) in hospital and were preventable (59.3% of the ADEs were definitely preventable while 44.7% were probably preventable) and caused by MEs including wrong drug (40.1%) and monitoring errors (25%). The errors were caused due to non-adherence of policies (38.4%) and lack of information about antibiotics (32%). Most of the non-preventable ADEs or ADRs among patients having long and short LOS in hospital were "probable" (35.5%) and "possible" (35.8%), respectively. Logistic regression analysis revealed that ADEs were significantly less among females (OR = 0.047, 95% CI = 0.018─0.121, p-value = < 0.001), patients aged 18─52 years (OR = 0.041, 95% CI = 0.013─0.130, p-value = < 0.001), patients with ARTIs (OR = 0.004, 95% CI = 0.01-0.019, p-value = < 0.001), patients prescribed with 2 antibiotics per prescription (OR = 0.455, 95% CI = 0.319─0.650, p-value = < 0.001) and patients with long LOS (OR = 14.825, 95% CI = 11.198─19.627, p-value = < 0.001). CONCLUSION Antibiotics associated definitely preventable ADEs were more commonly found in patients having long LOS in the inpatient departments because of MEs and lack of proper pharmacovigilance system. The ADRs showed a probable and possible causal association with both β-lactams and non β-lactams antibiotics.
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Affiliation(s)
- Anum Saqib
- Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Punjab, Pakistan
| | - Muhammad Rehan Sarwar
- Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Punjab, Pakistan. .,Akhtar Saeed College of Pharmaceutical Sciences, Lahore, Pakistan.
| | - Muhammad Sarfraz
- College of Pharmacy, Al Ain University of Science and Technology, Al Ain, Abu Dhabi, UAE
| | - Sadia Iftikhar
- Akhtar Saeed College of Pharmaceutical Sciences, Lahore, Pakistan
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Romano A, Valluzzi RL, Caruso C, Maggioletti M, Quaratino D, Gaeta F. Cross-Reactivity and Tolerability of Cephalosporins in Patients with IgE-Mediated Hypersensitivity to Penicillins. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1662-1672. [PMID: 29408440 DOI: 10.1016/j.jaip.2018.01.020] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/10/2018] [Accepted: 01/12/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Studies performed since 1990 on samples of at least 30 subjects with a documented IgE-mediated hypersensitivity to penicillins have found a rate of positive responses to allergy tests with cephalosporins ranging from 0% to 27%. OBJECTIVE We sought to assess the cross-reactivity with cephalosporins and evaluate the possibility of using cephalosporins in penicillin-allergic subjects. METHODS We conducted a prospective study of 252 consecutive subjects who had suffered 319 immediate reactions (mostly anaphylaxis) to penicillins and had positive skin tests to at least 1 penicillin reagent. All patients underwent serum specific IgE assays for cefaclor, as well as skin tests with 3 aminocephalosporins (cephalexin, cefaclor, and cefadroxil), cefamandole, cefuroxime, ceftazidime, ceftriaxone, cefotaxime, and cefepime. Patients with negative results for the last 5 cephalosporins were challenged with cefuroxime axetil and ceftriaxone; those with negative results for aminocephalosporins were also challenged with cefaclor and cefadroxil. RESULTS Ninety-nine participants (39.3%) had positive allergy tests for cephalosporins. Specifically, 95 (37.7%) were positive to aminocephalosporins and/or cefamandole, which share similar or identical side chains with penicillins. All 244 subjects who underwent challenges with cefuroxime axetil and ceftriaxone tolerated them. Of the 170 patients who underwent aminocephalosporin challenges, 3 reacted to cefaclor and 4 to cefadroxil. CONCLUSIONS Cross-reactivity between penicillins and cephalosporins seems to be mainly related to side chain similarity or identity. Subjects with an IgE-mediated hypersensitivity to penicillins could be treated with cephalosporins such as cefuroxime and ceftriaxone that have side-chain determinants different from those of penicillins and are negative in pretreatment skin testing.
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Affiliation(s)
- Antonino Romano
- Allergy Unit, Presidio Columbus, Rome, Italy; IRCCS Oasi Maria S.S., Troina, Italy.
| | - Rocco Luigi Valluzzi
- Allergy Unit, Presidio Columbus, Rome, Italy; Department of Pediatrics, Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Italy
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Zagursky RJ, Pichichero ME. Cross-reactivity in β-Lactam Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:72-81.e1. [PMID: 29017833 DOI: 10.1016/j.jaip.2017.08.027] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/18/2017] [Accepted: 08/24/2017] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- Robert J Zagursky
- Rochester General Hospital Research Institute, Center for Infectious Diseases and Immunology, Rochester, NY
| | - Michael E Pichichero
- Rochester General Hospital Research Institute, Center for Infectious Diseases and Immunology, Rochester, NY.
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Are Cephalosporins Safe for Use in Penicillin Allergy without Prior Allergy Evaluation? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:82-89. [PMID: 28958745 DOI: 10.1016/j.jaip.2017.07.033] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 12/28/2022]
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Abstract
Ten percent of patients report penicillin allergy, but more than 90% of these individuals can tolerate penicillins. Skin testing remains the optimal method for evaluation of possible IgE-mediated penicillin allergy and is recommended by professional societies, as the harms for alternative antibiotics include antimicrobial resistance, prolonged hospitalizations, readmissions, and increased costs. Removal of penicillin allergy leads to decreased utilization of broad-spectrum antibiotics, such as fluoroquinolones and vancomycin. There is minimal allergic cross-reactivity between penicillins and cephalosporins. IgE-mediated allergy to cephalosporins is usually side-chain specific and may warrant graded challenge with cephalosporins containing dissimilar R1 or R2 group side chains.
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Affiliation(s)
- Daniel Har
- Division of Allergy and Immunology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Roland Solensky
- Division of Allergy and Immunology, The Corvallis Clinic, 3680 NW Samaritan Dr, Corvallis, OR 97330, USA; Oregon State University/Oregon Health & Science University College of Pharmacy, 1601 SW Jefferson Way, Corvallis, OR 97331, USA.
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Geng B, Eastman JJ, Mori K, Braskett M, Riedl MA. Utility of minor determinants for skin testing in inpatient penicillin allergy evaluation. Ann Allergy Asthma Immunol 2017; 119:258-261. [PMID: 28743423 DOI: 10.1016/j.anai.2017.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/09/2017] [Accepted: 06/13/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Most patients with a history of penicillin allergy can tolerate penicillin. Skin testing can identify tolerant patients, but not all known allergenic determinants are commercially available. Protocols exist that use only available reagents, but the sensitivity and safety of these protocols, particularly for hospitalized patients, are controversial. OBJECTIVE To determine the number of hospitalized patients referred for penicillin skin testing who showed unique positivity to the minor determinants penicilloate and penilloate. METHODS A retrospective chart review was conducted of all inpatients who underwent penicillin skin testing at 1 institution. Patients were referred by their treating physician. All patients underwent skin prick testing to benzylpenicilloyl polylysine (major determinant), penicillin G, penicilloate, penilloate (minor determinants), amoxicillin, and positive and negative controls. If the result was negative, then intradermal testing was done with the same penicillin determinants and the negative control. A 4-mm wheal with flare was considered a positive reaction. RESULTS Inpatient penicillin skin testing was done in 528 subjects. Any positive test reaction was found in 107 subjects (20%). Three subjects (3%) reacted to penilloate only, 25 (23%) reacted to penicilloate only, 2 (2%) reacted to penicillin G only, and 8 (8%) reacted to amoxicillin only. Sixty-eight subjects (64%) reacted to a compound other than the major determinant. CONCLUSION This study found a high rate of exclusively positive skin test reactions to the minor determinants penicilloate and penilloate. Because patients with positive test reactions are at increased risk of reaction to drug challenge, these data support the use of these reagents for penicillin skin testing in hospitalized patients.
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Affiliation(s)
- Bob Geng
- Division of Rheumatology, Allergy and Immunology, University of California-San Diego, La Jolla, California.
| | - Jacqueline J Eastman
- Division of Rheumatology, Allergy and Immunology, University of California-San Diego, La Jolla, California
| | - Karen Mori
- Faculty of Medicine, University of Campinas, Campinas, São Paulo, Brazil
| | - Melinda Braskett
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, California
| | - Marc A Riedl
- Division of Rheumatology, Allergy and Immunology, University of California-San Diego, La Jolla, California
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The Effect of Penicillin Allergy Testing on Future Health Care Utilization: A Matched Cohort Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:705-710. [PMID: 28366717 DOI: 10.1016/j.jaip.2017.02.012] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 01/21/2017] [Accepted: 02/22/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND The effect that penicillin allergy testing has on future health care utilization is uncertain. OBJECTIVE Determine whether penicillin allergy testing affects future overall health care utilization as measured by outpatient department (OPD) visits, emergency department (ED) visits, and hospital days. METHODS Potential cases and control subjects were penicillin allergic Kaiser Permanente Southern California members who had at least 2 visits between 2010 and 2012 and at least 1 year of continuous health plan coverage before their index visit. RESULTS It was possible to match 308 (73.2%) of the potential cases to 1251 unique controls, on the basis of age, sex, weighted Charlson comorbidity index, drug class allergies, OPD visits, ED visits, and hospital days during the years before their index visit. Cases and controls were then followed for an average of 3.6 and 4.0 years, respectively. Based on results analyzed using a generalized linear mixed model, cases were estimated to have 0.09 fewer OPD visits (P < .001), 0.13 fewer ED visits (P = .29), and 0.55 fewer hospital days (P < .001) per health plan coverage year during follow-up compared with controls. Cases were exposed to more penicillins and first- and second-generation cephalosporins and less clindamycin and macrolides. CONCLUSIONS Penicillin allergy testing, primarily done in the setting of an outpatient Allergy consultation, was associated with significantly less health care utilization during 3.6+ years of follow-up and greater use of narrow-spectrum antibiotics. Penicillin allergy testing has a favorable cost-benefit ratio for the incremental cost of testing versus future health care utilization and improves antibiotic stewardship.
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Desai SH, Kaplan MS, Chen Q, Macy EM. Morbidity in Pregnant Women Associated with Unverified Penicillin Allergies, Antibiotic Use, and Group B Streptococcus Infections. Perm J 2017; 21:16-080. [PMID: 28333608 DOI: 10.7812/tpp/16-080] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT The morbidity potentially associated with unverified penicillin allergy in pregnant women, with and without group B streptococcus (GBS) infections, is unknown. Penicillin allergy testing is safe during pregnancy but is done infrequently. OBJECTIVE To determine morbidity associated with antibiotic use in a large cohort of pregnant women, with and without an unverified history of penicillin allergy, and with and without GBS. DESIGN Retrospective. All pregnant women who delivered live infants in Kaiser Permanente Southern California between January 1, 2009, and December 31, 2014, were identified. MAIN OUTCOME MEASURES Penicillin allergy status at delivery, delivery method, maternal and infant hospital utilization, peripartum antibiotic exposures, new antibiotic-associated adverse drug reactions, and new Clostridium difficile infections. RESULTS There were 170,379 unique women who had 201,316 pregnancies during the study period. There were 16,084 pregnancies in women with an active, but unverified, penicillin allergy at delivery. There were 42,524 pregnancies in GBS-positive women, and 3500 also had a penicillin allergy. Women with a penicillin allergy, with or without GBS, had significantly (about 10%) higher cesarean section rates and spent significantly more (about 0.1) days in the hospital after delivery. Among GBS-positive women, those with an unverified penicillin allergy were exposed to significantly more cefazolin, clindamycin, vancomycin, and gentamicin and had significantly higher rates of adverse drug reactions associated with all antibiotic use. CONCLUSIONS Unverified penicillin allergy is associated with more hospital utilization and additional morbidity. Penicillin allergy testing of pregnant women with a history of penicillin allergy may help reduce these unwanted outcomes.
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Affiliation(s)
- Shilpa H Desai
- Fellow-In-Training in the Allergy Department of the Los Angeles Medical Center in CA.
| | | | - Qiaoling Chen
- Research Analyst in the Department of Research and Evaluation for Kaiser Foundation Health Plan in Pasadena, CA.
| | - Eric M Macy
- Allergy Specialist and Researcher in the Department of Allergy at the San Diego Medical Center. He is a Partner Physician with the Southern California Permanente Medical Group, and an Assistant Clinical Professor of Medicine at the University of California, San Diego.
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Penicillin allergy: optimizing diagnostic protocols, public health implications, and future research needs. Curr Opin Allergy Clin Immunol 2016; 15:308-13. [PMID: 26110680 DOI: 10.1097/aci.0000000000000173] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Unverified penicillin allergy is being increasingly recognized as a public health concern. The ideal protocol for verifying true clinically significant IgE-mediated penicillin allergy needs to use only commercially available materials, be well tolerated and easy to perform in both the inpatient and outpatient settings, and minimize false-positive determinations. This review concentrates on articles published in 2013 and 2014 that present new data relating to the diagnosis and management of penicillin allergy. RECENT FINDINGS Penicillin allergy can be safely evaluated at this time, in patients with an appropriate clinical history of penicillin allergy, using only penicilloyl-poly-lysine and native penicillin G as skin test reagents, if an oral challenge with amoxicillin 250 mg, followed by 1 h of observation, is given to all skin test negative individuals. SUMMARY Millions of individuals falsely labeled with penicillin allergy need to be evaluated to safely allow them to use penicillin-class antibiotics and avoid morbidity associated with penicillin avoidance. Further research is needed to determine optimal protocol(s). There will still be a 1-2% rate of adverse reactions reported with all future therapeutic penicillin-class antibiotic use, even with optimal methods used to determine acute penicillin tolerance. Only a small minority of these new reactions will be IgE-mediated.
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Solensky R, Macy E. Minor Determinants Are Essential for Optimal Penicillin Allergy Testing: A Pro/Con Debate. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:883-7. [DOI: 10.1016/j.jaip.2015.05.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 05/14/2015] [Accepted: 05/15/2015] [Indexed: 10/23/2022]
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Misirlioglu ED, Toyran M, Capanoglu M, Kaya A, Civelek E, Kocabas CN. Negative predictive value of drug provocation tests in children. Pediatr Allergy Immunol 2014; 25:685-90. [PMID: 25283219 DOI: 10.1111/pai.12286] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The negative predictive value of the drug provocation test is important for both the patient and the physician. However, in children, this predictive value is unresolved. METHODS The study included patients who had drug provocation test with a suspected drug and was diagnosed as 'not allergic to the drug'. Three months after allergy workup, the patients were contacted and asked for reexposure to the tested drug. Patients who have reported reactions during reexposure were reevaluated with skin tests and drug provocation. RESULTS During the study period, 217 provocations were performed to 203 patients. Of these, 163 patients (80.3%) with 175 negative drug provocation tests could be contacted. Ninety-one (52%) of the 175 cases reported to use the tested drug again, and 11 (12%) of these cases declared that they had a new reaction. Two of the eleven cases refused reevaluation. Nine cases were evaluated by drug allergy workup. Two of the nine cases were classified as allergic after retests. Collectively, the negative predictive value was 95.6% (87 of 91 cases) for all drug challenges. CONCLUSIONS The negative predictive value of the drug provocation test is abundant in children; however, negative drug provocation tests do not necessarily predict tolerance for the drug.
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Affiliation(s)
- Emine D Misirlioglu
- Department of Pediatric Allergy and Immunology, Ankara Children's Hematology Oncology Training and Research Hospital, Ankara, Turkey
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Abstract
Penicillin is the most common beta-lactam antibiotic allergy and the most common drug class allergy, reported in about 8% of individuals using health care in the USA. Only about 1% of individuals using health care in the USA have a cephalosporin allergy noted in their medical record, and other specific non-penicillin, non-cephalosporin beta-lactam allergies are even rarer. Most reported penicillin allergy is not associated with clinically significant IgE-mediated reactions after penicillin rechallenge. Un-verified penicillin allergy is a significant and growing public health problem. Clinically significant IgE-mediated penicillin allergy can be safely confirmed or refuted using skin testing with penicilloyl-poly-lysine and native penicillin G and, if skin test is negative, an oral amoxicillin challenge. Acute tolerance of an oral therapeutic dose of a penicillin class antibiotic is the current gold standard test for a lack of clinically significant IgE-mediated penicillin allergy. Cephalosporins and other non-penicillin beta-lactams are widely, safely, and appropriately used in individuals, even with confirmed penicillin allergy. There is little, if any, clinically significant immunologic cross-reactivity between penicillins and other beta-lactams. Routine cephalosporin skin testing should be restricted to research settings. It is rarely needed clinically to safely manage patients and has unclear predictive value at this time. The use of alternative cephalosporins, with different side chains, is acceptable in the setting of a specific cephalosporin allergy. Carbapenems and monobactams are also safely used in individuals with confirmed penicillin allergy. A certain predictable, but low, rate of adverse reactions will occur with all beta-lactam antibiotic use both pre- and post-beta-lactam allergy evaluations.
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Affiliation(s)
- Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, 7060 Clairemont Mesa Blvd., San Diego, 92111, CA, USA,
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Macy E, Contreras R. Adverse reactions associated with oral and parenteral use of cephalosporins: A retrospective population-based analysis. J Allergy Clin Immunol 2014; 135:745-52.e5. [PMID: 25262461 DOI: 10.1016/j.jaci.2014.07.062] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 07/07/2014] [Accepted: 07/09/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Few studies have provided population-based, route-specific data on allergy to cephalosporin or incidence of serious adverse drug reactions (ADRs). OBJECTIVE We investigated the incidence of new reports of cephalosporin-associated "allergy" and serious ADRs. METHODS We identified all members of the Kaiser Permanente Southern California health plan given cephalosporins (from January 1, 2010, through December 31, 2012), all new reports of cephalosporin-associated allergy, and all serious ADRs. RESULTS There were 622,456 health plan members exposed to 901,908 courses of oral cephalosporins and 326,867 members exposed to 487,630 courses of parenteral cephalosporins over the 3-year study period. New reports of allergy to cephalosporin were more frequent among women (0.56%; 95% CI, 0.54% to 0.57%) than among men (0.43%; 95% CI, 0.41% to 0.44%) per course (P < .0001). The most frequent serious cephalosporin-associated ADRs were Clostridium difficile infection within 90 days (0.91%), nephropathy within 30 days (0.15%), and all-cause death within 1 day (0.10%). None correlated with history of drug allergy. Physician-documented cephalosporin-associated anaphylaxis occurred with 5 oral exposures (95% CI, 1/1,428,571-1/96,154) and 8 parenteral exposures (95% CI, 1/200,000-1/35,971) (P = .0761). There were 3 documented cephalosporin-associated serious cutaneous adverse reactions (95% CI, 0-1 in 217,291). All were associated with the use of another antibiotic at the same time as cephalosporin. CONCLUSIONS Cephalosporins are widely and safely used, even in individuals with a history of penicillin allergy. Physician-documented cephalosporin-associated anaphylaxis and serious cutaneous adverse reactions are rare compared with C difficile infection within 90 days, nephropathy within 30 days, and all-cause death within 1 day.
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Affiliation(s)
- Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, Calif.
| | - Richard Contreras
- Department of Research and Evaluation, Kaiser Permanente Health Care Program, Pasadena, Calif
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Abstract
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.
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Affiliation(s)
- Adrienne T. Terico
- Post-Graduate Year 2 Infectious Diseases Pharmacotherapy Resident, Temple University Hospital, Philadelphia, PA, USA
| | - Jason C. Gallagher
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA, USA
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Pichichero ME, Zagursky R. Penicillin and cephalosporin allergy. Ann Allergy Asthma Immunol 2014; 112:404-12. [PMID: 24767695 DOI: 10.1016/j.anai.2014.02.005] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 02/10/2014] [Accepted: 02/11/2014] [Indexed: 12/30/2022]
Affiliation(s)
| | - Robert Zagursky
- Rochester General Hospital Research Institute, Rochester, New York
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Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: A cohort study. J Allergy Clin Immunol 2013; 133:790-6. [PMID: 24188976 DOI: 10.1016/j.jaci.2013.09.021] [Citation(s) in RCA: 543] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 08/15/2013] [Accepted: 09/12/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Penicillin is the most common drug "allergy" noted at hospital admission, although it is often inaccurate. OBJECTIVE We sought to determine total hospital days, antibiotic exposures, and the prevalence rates of Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) in patients with and without penicillin "allergy" at hospital admission. METHODS We performed a retrospective, matched cohort study of subjects admitted to Kaiser Foundation hospitals in Southern California during 2010 through 2012. RESULTS It was possible to match 51,582 (99.6% of all possible cases) unique hospitalized subjects with penicillin "allergy" to 2 unique discharge diagnosis category-matched, sex-matched, age-matched, and date of admission-matched control subjects each. Cases with penicillin "allergy" averaged 0.59 (9.9%; 95% CI, 0.47-0.71) more total hospital days during 20.1 ± 10.5 months of follow-up compared with control subjects. Cases were treated with significantly more fluoroquinolones, clindamycin, and vancomycin (P < .0001) for each antibiotic compared with control subjects. Cases had 23.4% (95% CI, 15.6% to 31.7%) more C difficile, 14.1% (95% CI, 7.1% to 21.6%) more MRSA, and 30.1% (95% CI, 12.5% to 50.4%) more VRE infections than expected compared with control subjects. CONCLUSIONS A penicillin "allergy" history, although often inaccurate, is not a benign finding at hospital admission. Subjects with a penicillin "allergy" history spend significantly more time in the hospital. Subjects with a penicillin "allergy" history are exposed to significantly more antibiotics previously associated with C difficile and VRE. Drug "allergies" in general, but most those notably to penicillin, are associated with increased hospital use and increased C difficile, MRSA, and VRE prevalence.
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Affiliation(s)
- Eric Macy
- Southern California Permanente Medical Group, Department of Allergy, San Diego Medical Center, San Diego, Calif.
| | - Richard Contreras
- Kaiser Permanente Health Care Program, Department of Research and Evaluation, Pasadena, Calif
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Macy E, Ngor EW. Safely diagnosing clinically significant penicillin allergy using only penicilloyl-poly-lysine, penicillin, and oral amoxicillin. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:258-63. [PMID: 24565482 DOI: 10.1016/j.jaip.2013.02.002] [Citation(s) in RCA: 210] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 01/18/2013] [Accepted: 02/12/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Penicillin skin testing is rarely used to undiagnose penicillin "allergy" in the United States, partially because of concern that commercially available materials are inadequate. OBJECTIVE We determined whether skin testing with only commercially available penicilloyl-poly-lysine and penicillin followed by an oral amoxicillin challenge, if skin test-negative, can safely identify clinically significant penicillin allergy. METHODS Five hundred sequential persons with positive history of penicillin "allergy" were evaluated by skin testing with penicilloyl-poly-lysine and penicillin between June 8, 2010, and March 29, 2012. All persons with negative skin tests were given an oral amoxicillin challenge and observed for 1 hour. RESULTS Persons undergoing penicillin allergy testing were representative of all health plan members with penicillin allergy. Only 4 persons (0.8%; 95% CI, 0.32%-2.03%) had a positive skin test result. Only 4 persons (0.8%; 95% CI, 0.32%-2.03%) had an acute objective oral amoxicillin challenge reaction. Fifteen persons (3.0%; 95% CI, 1.83%-4.98%) had subjective oral challenge reactions, either acute transient itching or dizziness. All were women and 11 (73.3%) had multiple drug intolerance syndrome. None had severe reactions or objective signs. These were not considered to be positive challenge reactions. Sixty-eight subjects (13.6%) who were negative on testing were exposed to 88 courses of penicillins during 90 days of follow-up. New reactions were reported after 4 courses (4.5%), 3 (75%) occurring in subjects with multiple drug intolerance syndrome. CONCLUSIONS Penicillin skin testing, using only penicilloyl-poly-lysine and penicillin, followed by oral amoxicillin challenge, if negative, can safely identify clinically significant IgE-mediated penicillin allergy in patients who use health care in the United States at this time.
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Affiliation(s)
- Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, Calif.
| | - Eunis W Ngor
- Department of Research and Evaluation, Kaiser Permanente Health Care Program, Pasadena, Calif
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34
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Macy E. The clinical evaluation of penicillin allergy: what is necessary, sufficient and safe given the materials currently available? Clin Exp Allergy 2011; 41:1498-501. [DOI: 10.1111/j.1365-2222.2011.03837.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- E. Macy
- Southern California Permanente Medical Group; Department of Allergy; San Diego Medical Center; San Diego,; CA; USA
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