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Ang AJS, Lee HY, Naing CS, Chong CJ, Li C, Murthee KG, Hanif IM, Tan V, Chai ZT, Choo KJL. Outcomes of Prolonged Provocation Testing in Penicillin Allergy Evaluation. Clin Exp Allergy 2025; 55:273-275. [PMID: 39909393 DOI: 10.1111/cea.70008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Revised: 01/24/2025] [Accepted: 01/25/2025] [Indexed: 02/07/2025]
Affiliation(s)
| | - Haur Yueh Lee
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore
| | - Chaw Su Naing
- Department of General Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Chiara Jiamin Chong
- Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Chujie Li
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | | | | | - Vivian Tan
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Zi Teng Chai
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore
| | - Karen Jui Lin Choo
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore
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Ng I, James F, Copaescu A, Vogrin S, Mitri E, Rose M, Sullivan R, Lane M, Legg A, Godsell J, Fernando S, Garvey LH, Sabato V, Li P, Peter JG, Trubiano J. Prolonged versus single dose in penicillin oral challenge testing: protocols for a pilot and definitive randomised controlled trial (PROSPECTOR studies). BMJ Open 2025; 15:e094712. [PMID: 39987001 PMCID: PMC11848670 DOI: 10.1136/bmjopen-2024-094712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Accepted: 02/05/2025] [Indexed: 02/24/2025] Open
Abstract
INTRODUCTION Penicillin allergy labels (PALs) are reported in 1 in 10 hospitalised patients globally and associated with inferior patient, hospital and microbiological outcomes; however, the majority are incorrect and should be removed. Direct oral penicillin challenge has been demonstrated to be a safe and effective method for the removal of PALs. However, the question of whether a single dose is sufficient to ascertain true allergy status remains unanswered, with some studies suggesting that extended challenges of 3 or more days are superior for the exclusion of delayed immune reactions. The aim of the PROSPECTOR studies was to determine the feasibility (PROSPECTOR-1) of a definitive trial (PROSPECTOR-2) to evaluate the safety and effectiveness of prolonged oral challenge (ie, 5 days) versus single-dose oral challenge in patients with a delayed or unknown penicillin allergy phenotype (PROSPECTOR-2). METHODS AND ANALYSIS A pair of double-blind two-arm parallel placebo-controlled trials will be undertaken-PROlonged versus Single dose in PEnicillin oral Challenge Testing double-blind parallel group randomised placebo-cOntrolled tRial (PROSPECTOR Studies). Patients with a reported delayed or unknown timing penicillin allergy who have passed a supervised single-dose oral amoxicillin challenge (with or without prior skin testing/single or split dose) will be recruited. Informed patient consent will be granted for sites to recruit patients and collect routine clinical data. PROSPECTOR-1 will assess the safety and feasibility of a placebo-controlled trial for single-dose amoxicillin challenge versus 5-day prolonged oral challenge. PROSPECTOR-2 will assess the superiority of the 5-day prolonged oral challenge compared with single-dose amoxicillin challenge in excluding a delayed immune reaction. PROSPECTOR-2 will commence immediately post completion of PROSPECTOR-1 in a vanguard design, with adjustments to the projected sample size for superiority made following completion of PROSPECTOR-1. PROSPECTOR-2 will commence recruitment immediately following closure of PROSPECTOR-1; however, data from each trial will be analysed separately. ETHICS AND DISSEMINATION These studies were reviewed and approved by the Austin Health Human Research Ethics Committee (PROSPECTOR-1: HREC/99740/Austin-2023 and PROSPECTOR-2: HREC/109785/Austin-2024). The results will be published in peer-reviewed journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER PROSPECTOR-1: ACTRN12623001242617 and PROSPECTOR-2: ACTRN12624001107516.
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Affiliation(s)
- Irvin Ng
- Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
| | - Fiona James
- Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
| | - Ana Copaescu
- Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
| | - Sara Vogrin
- Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
| | - Elise Mitri
- Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
- National Allergy Centre of Excellence, Parkville, Victoria, Australia
| | - Morgan Rose
- Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Richard Sullivan
- Infectious Diseases, St George Hospital, Kogarah, New South Wales, Australia
| | - Michael Lane
- Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Amy Legg
- Pharmacy Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jack Godsell
- Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
- Allergy and Immunology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Suran Fernando
- Clinical Immunology and Allergy, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Lene Heise Garvey
- University of Copenhagen, Kobenhavn, Region Hovedstaden, Denmark
- Allergy Clinic, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Gentofte, Denmark
| | - Vito Sabato
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerpen, Belgium
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, Edegem, Antwerp, Belgium
| | - Philip Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Hong Kong University, Hong Kong, Hong Kong
| | - Jonathan Grant Peter
- Division of Allergy and Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jason Trubiano
- Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
- National Allergy Centre of Excellence, Parkville, Victoria, Australia
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Lendal V, Fransson S, Mosbech H, Boel JB, Kahlhofen N, Blom LH, Poulsen LK, Garvey LH. Clinical Relevance of Specific IgE in Penicillin Allergy Investigation. Int Arch Allergy Immunol 2024; 186:303-310. [PMID: 39462501 PMCID: PMC11939831 DOI: 10.1159/000541243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 08/28/2024] [Indexed: 10/29/2024] Open
Abstract
INTRODUCTION Patients with immediate type allergic reactions to penicillins are at risk of anaphylaxis on reexposure. Diagnostic gold standard is drug provocation test (DPT) if allergy is not diagnosed by other means, such as skin testing or in vitro testing with measurement of specific IgE. Specific IgE testing carries low risk for the patient and blood sampling can be performed in primary care, but it is reported to have low sensitivity. The aim of this study was to evaluate if clinical characteristics of patients with suspected allergic reactions to penicillin and elevated specific IgE to penicillins, differed from patients without specific IgE, to identify predictors for elevated specific IgE to penicillins. METHODS Levels of specific IgE to five penicillins (penicillin G, penicillin V, amoxicillin, ampicillin, and penicillin minor determinants) were available for 9,100 patients. Using multiple logistic regression, clinical data from 430 patients in this group who had elevated specific IgE to one or more penicillins were compared to data from 4,094 patients without specific IgE to penicillins, who had undergone DPT with a penicillin. RESULTS In total 5.2% of patients had elevated specific IgE to one or more penicillins. Significantly more patients with elevated specific IgE had a history of immediate type reactions (<2 h) (OR = 4.34, p < 0.001); circulatory symptoms (OR = 1.63, p = 0.03) or angioedema (OR = 1.46, p = 0.005). Also, significantly more patients with elevated specific IgE had been treated with adrenaline (OR = 2.21, p = 0.005), steroids (OR = 1.76, p < 0.001), or antihistamines (OR = 1.83, p < 0.001). CONCLUSION A history of an immediate type reaction requiring treatment, combined with elevated specific IgE to one or more penicillins is suggestive of an IgE mediated penicillin allergy and further allergy investigations may not be needed. Specific IgE to penicillins may be used early in allergy investigation of patients with severe immediate type reactions to penicillins. INTRODUCTION Patients with immediate type allergic reactions to penicillins are at risk of anaphylaxis on reexposure. Diagnostic gold standard is drug provocation test (DPT) if allergy is not diagnosed by other means, such as skin testing or in vitro testing with measurement of specific IgE. Specific IgE testing carries low risk for the patient and blood sampling can be performed in primary care, but it is reported to have low sensitivity. The aim of this study was to evaluate if clinical characteristics of patients with suspected allergic reactions to penicillin and elevated specific IgE to penicillins, differed from patients without specific IgE, to identify predictors for elevated specific IgE to penicillins. METHODS Levels of specific IgE to five penicillins (penicillin G, penicillin V, amoxicillin, ampicillin, and penicillin minor determinants) were available for 9,100 patients. Using multiple logistic regression, clinical data from 430 patients in this group who had elevated specific IgE to one or more penicillins were compared to data from 4,094 patients without specific IgE to penicillins, who had undergone DPT with a penicillin. RESULTS In total 5.2% of patients had elevated specific IgE to one or more penicillins. Significantly more patients with elevated specific IgE had a history of immediate type reactions (<2 h) (OR = 4.34, p < 0.001); circulatory symptoms (OR = 1.63, p = 0.03) or angioedema (OR = 1.46, p = 0.005). Also, significantly more patients with elevated specific IgE had been treated with adrenaline (OR = 2.21, p = 0.005), steroids (OR = 1.76, p < 0.001), or antihistamines (OR = 1.83, p < 0.001). CONCLUSION A history of an immediate type reaction requiring treatment, combined with elevated specific IgE to one or more penicillins is suggestive of an IgE mediated penicillin allergy and further allergy investigations may not be needed. Specific IgE to penicillins may be used early in allergy investigation of patients with severe immediate type reactions to penicillins.
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Affiliation(s)
- Victor Lendal
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Sara Fransson
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Holger Mosbech
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Jonas Bredtoft Boel
- Department of Clinical Microbiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Natasha Kahlhofen
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Lars H. Blom
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Lars K. Poulsen
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Lene H. Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Sobrino-García M, Muñoz-Bellido FJ, Moreno-Rodilla E, Martín-Muñoz R, García-Iglesias A, Dávila I. Delabeling of allergy to beta-lactam antibiotics in hospitalized patients: a prospective study evaluating cost savings. Int J Clin Pharm 2024; 46:1067-1075. [PMID: 38642250 DOI: 10.1007/s11096-024-01737-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/04/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Patients with a penicillin allergy label are at risk of an associated increase in adverse antibiotic events and hospitalization costs. AIM We aimed to study the economic savings derived from the correct diagnosis and delabeling inpatients with suspected beta-lactam allergy, considering the acquisition cost of antimicrobials prescribed during a patient's hospital stay. METHOD We prospectively evaluated patients admitted to the University Hospital of Salamanca who had been labeled as allergic to beta-lactams and performed a delabeling study. Subsequently, cost differences between antibiotics administered before and after the allergy study and those derived from those patients who received alternative antibiotics during admission and those who switched to beta-lactams after the allergy study were calculated. RESULTS One hundred seventy-seven inpatients labeled as allergic to beta-lactams underwent a delabeling study; 34 (19.2%) were confirmed to have allergy to beta-lactams. Of the total number of patients, 136 (76.8%) received antibiotics during their hospitalization, involving a mean (SD) cost of €203.07 (318.42) and a median (IQR) cost of €88.97 (48.86-233.56). After delabeling in 85 (62.5%) patients, the antibiotic treatment was changed to beta-lactams. In this group of patients, the mean cost (SD) decreased from €188.91 (351.09) before the change to 91.31 (136.07) afterward, and the median cost (IQR) decreased from €72.92 (45.82-211.99) to €19.24 (11.66-168). The reduction was significant compared to the median cost of patients whose treatment was not changed to beta-lactams (p<0.001). CONCLUSION Delabeling hospitalized patients represents a cost-saving measure for treating patients labeled as allergic to beta-lactams.
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Affiliation(s)
- Miriam Sobrino-García
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain
| | - Francisco J Muñoz-Bellido
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain.
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain.
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Castilla y León, Spain.
- Red de Enfermedades Inflamatorias - Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain.
- Servicio de Alergología, Hospital Universitario de Salamanca, Paseo de La Transición Española, 37007, Salamanca, Spain.
| | - Esther Moreno-Rodilla
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Castilla y León, Spain
- Red de Enfermedades Inflamatorias - Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain
| | - Rita Martín-Muñoz
- Hospital Pharmacy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
| | - Aránzazu García-Iglesias
- Admission and Clinical Documentation Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
| | - Ignacio Dávila
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Castilla y León, Spain
- Red de Enfermedades Inflamatorias - Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain
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Powell N, Blank M, Luintel A, Elkhalifa S, Bhogal R, Wilcock M, Wakefield M, Sandoe J. Narrative review of recent developments and the future of penicillin allergy de-labelling by non-allergists. NPJ ANTIMICROBIALS AND RESISTANCE 2024; 2:18. [PMID: 39843524 PMCID: PMC11721385 DOI: 10.1038/s44259-024-00035-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/11/2024] [Indexed: 01/24/2025]
Abstract
This article outlines recent developments in non-allergist delivered penicillin allergy de-labelling (PADL), discusses remaining controversies and uncertainties and explores the future for non-allergist delivered PADL. Recent developments include national guidelines for non-allergist delivered PADL and validation of penicillin allergy risk assessment tools. Controversies remain on which penicillin allergy features are low risk of genuine allergy. In the future genetic or immunological tests may facilitate PADL.
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Affiliation(s)
- Neil Powell
- Pharmacy Department, Royal Cornwall Hospital Trust, Truro, Cornwall, UK.
| | | | - Akish Luintel
- Institute of Global Health Innovation, Imperial College London, London, UK
| | - Shuayb Elkhalifa
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Allergy and Immunology Department, Respiratory Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Rashmeet Bhogal
- The School of Pharmacy and Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Michael Wilcock
- Pharmacy Department, Royal Cornwall Hospital Trust, Truro, Cornwall, UK
| | - Michael Wakefield
- Respiratory Department, Harrogate and District NHS Foundation Trust, Harrogate, UK
| | - Jonathan Sandoe
- Healthcare associated infection group, Leeds institute of medical research, university of Leeds, Leeds, UK
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Molina-Molina GJ, Gómez-Duque M, Vidal Guitart X, Agustí Escasany A, Labrador-Horrillo M, Luengo O, Sala-Cunill A, Galvan-Blasco P, Guilarte M, Cardona V. Challenging dogmas: Intravenous versus oral beta-lactam antibiotic provocation tests. World Allergy Organ J 2024; 17:100914. [PMID: 38855082 PMCID: PMC11153252 DOI: 10.1016/j.waojou.2024.100914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 04/26/2024] [Accepted: 04/30/2024] [Indexed: 06/11/2024] Open
Abstract
Background Drug provocation tests (DPT) are considered the gold standard procedure to ascertain the diagnosis of beta-lactam (BL) allergy. Regarding route of administration, current recommendations prioritize oral challenges, considering them safer, and reserving the intravenous route for drugs for which this is the only formulation. Objective To compare in terms of tolerance and safety two protocols of BL DPT, using an oral protocol (OR-DPT) and an intravenous protocol (IV-DPT). Methods A descriptive, retrospective study was performed, including adult patients who underwent IV-DPT or OR-DPT for suspected immediate or delayed hypersensitivity to BL antibiotics, over a period of 4 years (between January 2018 and December 2021). Demographical data, index hypersensivity reactions' characteristics and tolerance to DPT were reviewed. Results A total of 1036 patients underwent DPT, mean age of 56.8 (standard deviation, SD, 17.8) years, 655 were women (63.2%). Immediate drug hypersensitivity reactions (DHR) had occurred in 564 of patients (54.4%). OR-DPT were performed in 439 (42.4%) and IV-DPT in 597 (57.6%). The frequency of reactions during DPT, regardless of the route used, was low (3.6%): only 16 (3.6%) in OR-DPT and 21 (3.5%) in IV-DPT. From IV-DPT, 16 out 21 DHR during DPT were immediate compared with 4 out of 16 in OR-DPT. Adjusted relative risk of developing a hypersensitivity reaction during IV-DPT versus OR-DPT was 1.13 (95% confidence interval (CI)0.57-2.22). Conclusion The results suggest that OR-DPT and IV-DPT are both safe procedures when adequately performed. However, IV-DPT protocols showed a higher rate of immediate DHR during DPT probably due to the selection of basal high-risk patients to undergo IV-DPT. In conclusion, IV-DPT may be considered as an option for challenges in drug-allergy studies, entailing a precise administration.
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Affiliation(s)
| | - Manuel Gómez-Duque
- Paediatric Allergy Section, Respiratory Paediatric Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Xavier Vidal Guitart
- Clinical Pharmacology Service, Fundació Institut Català de Farmacologia, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antònia Agustí Escasany
- Clinical Pharmacology Service, Fundació Institut Català de Farmacologia, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Moisés Labrador-Horrillo
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Olga Luengo
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Anna Sala-Cunill
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Paula Galvan-Blasco
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Mar Guilarte
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Victoria Cardona
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
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Liccioli G, Tomei L, Pessina B, Caubet JC, Barni S, Giovannini M, Sarti L, Mori F. The importance of clinical history in the diagnosis of drug hypersensitivity in children. Pediatr Allergy Immunol 2024; 35:e14091. [PMID: 38444175 DOI: 10.1111/pai.14091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND In case of suspected hypersensitivity reactions (HRs) to drugs, a challenging area for pediatricians is detecting relevant elements in the parent-reported history, in order to reach a definite diagnosis. We analyzed the concordance between the description of the HR and the medical reports documented at the time of the event. Furthermore, we studied any correlation between clinical history variables and the prediction of true allergy. METHODS We retrospectively collected 50 charts of children referred to our Allergy Unit, after a previous access to the Emergency Department. We compared the description of the HR at acute phase to the history told by parents. Type and timing of the HR and culprit drug were classified as "known" or "unknown." The diagnosis was confirmed or excluded at the end of the investigations. Logistic regression analysis was performed to find any significant association. RESULTS The type of the HR was known in 74%, the timing in 28%, and the culprit drug in 98%. We showed that having had a severe HR had an increased odds of remembering the timing; being older >6 years and having had an immediate HR had an increased odds of remembering the type; time to diagnostic was lower in patients whose parents remembered the type of HR. CONCLUSION Our paper underlines the importance of an accurate anamnesis at the time of the event. Providing the physicians with a standardized Case Report Form could be a useful tool to simplify the diagnostic work-up and minimize mistakes due to lack of memory.
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Affiliation(s)
- Giulia Liccioli
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Leonardo Tomei
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Benedetta Pessina
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Women, Children and Adolescents, University Hospital of Geneva, Geneva, Switzerland
| | - Simona Barni
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
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Barbaud A, Garvey LH, Torres M, Laguna JJ, Arcolaci A, Bonadonna P, Scherer Hofmeier K, Chiriac AM, Cernadas J, Caubet JC, Brockow K. EAACI/ENDA position paper on drug provocation testing. Allergy 2024; 79:565-579. [PMID: 38155501 DOI: 10.1111/all.15996] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/30/2023]
Abstract
In drug hypersensitivity, drug provocation testing (DPT), also called drug challenge, is the gold standard for investigation. In recent years, risk stratification has become an important tool for adjusting the diagnostic strategy to the perceived risk, whilst still maintaining a high level of safety for the patient. Skin tests are recommended before DPT but may be omitted in low-risk patients. The task force suggests a strict definition of such low-risk patients in children and adults. Based on experience and evidence from studies of allergy to beta-lactam antibiotics, an algorithm on how to adjust DPT to the risk, and when to omit skin tests before DPT, is presented. For other antibiotics, non-steroidal anti-inflammatory drugs and other drugs, skin tests are poorly validated and DPT is frequently necessary. We recommend performing DPT with chemotherapeutics and biologicals to avoid unnecessary desensitization procedures and DPT with skin tests negative contrast media. We suggest DPT with anesthetics only in highly specialized centers. Specifics of DPT to proton pump inhibitors, anticonvulsants and corticosteroids are discussed. This position paper provides general recommendations and guidance on optimizing use of DPT, whilst balancing benefits with patient safety and optimizing the use of the limited available resources.
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Affiliation(s)
- Annick Barbaud
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Tenon, Service de dermatologie et allergologie, Paris, France
| | - Lene Heise Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Maria Torres
- Allergy Unit, Regional University Hospital of Malaga-IBIMA-UMA-ARADyAL, Malaga, Spain
| | - Jose Julio Laguna
- Allergy Unit, Allergo-Anaesthesia Unit, Faculty of Medicine, Hospital Central de la Cruz Roja, Alfonso X El Sabio University, ARADyAL, REI, Madrid, Spain
| | - Alessandra Arcolaci
- Immunology Unit, University Hospital of Verona, Policlinico G.B. Rossi, Verona, Italy
| | - Patrizia Bonadonna
- Allergy Unit, University Hospital of Verona, Policlinico G.B. Rossi, Verona, Italy
| | - Kathrin Scherer Hofmeier
- Allergy and Dermatology, Cantonal Hospital Aarau, Cantonal Hospital Aarau, Aarau, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Anca Mirela Chiriac
- Allergy Unit, University Hospital of Montpellier and IDESP, UMR UA11, Univ. Montpellier - INSERM, Montpellier, France
| | - Josefina Cernadas
- Hospital Lusíadas, Porto, Portugal
- Centro Hospitalar Universitário H. S. João, Porto, Portugal
| | - Jean Christoph Caubet
- Department of Women-Children-Teenagers, University Hospital of Geneva, Geneva, Switzerland
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Faculty of Medicine and Health, Munich, Germany
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Kulalert P, Phinyo P, Chiriac AM, Demoly P, Saokaew S, Kanchanaphoomi K, Srisuwatchari W. Is a Prolonged Drug Provocation Test Better Than a Single-Day Drug Provocation Test? A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:431-448. [PMID: 38000713 DOI: 10.1016/j.jaip.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND There is currently no standardized duration of drug provocation test (DPT) for confirming/delabeling beta-lactam hypersensitivity reaction (BL-HSR). OBJECTIVES This meta-analysis and systematic review aimed to investigate the added diagnostic value of extended-day over single-day DPT for confirming/delabeling BL-HSR in adults and children. METHODS The MEDLINE, EMBASE, Web of Science, and CINAHL online databases were searched from inception to March 15, 2023, for studies that performed extended-day DPT to confirm/delabel BL-HSR. Risk difference and risk ratio were used to compare the proportions of patients with confirmed BL-HSR by single-day or extended-day DPT. RESULTS A total of 10,371 DPTs from 42 studies were included. Extended-day DPTs ranged from 2 to 7 days, or as long as index reactions were reported (maximum 10 days). The overall prevalence of confirmed BL-HSR was 6.96% (3.31% during the first-day DPT, and 3.65% during extended-day DPT). Approximately half of the positive reactions during extended-day DPT occurred during the second/third day. The increased detected pool prevalence of confirmed BL-HSR yielded by extended-day DPT was 0.03 (95% CI, 0.02%-0.04%; I2 = 57.69%; P < .001), and the risk ratio of positive reactions between extended-day and single-day DPT was 1.94 (95% CI, 1.62-2.33; I2 = 36.26%; P < .001). The risk difference increased per 1% increase in prevalence of BL-HSR by 0.6% (95% CI, 0.4%-0.7%; P < .001). Twenty-three severe reactions occurred during DPT, and only 2 severe reactions (0.02%) occurred during extended-day DPT. An additional 28 extended-day DPTs were needed to identify 1 mild reaction. CONCLUSIONS The increased prevalence of confirmed BL-HSR observed during extended-day DPT could be attributed to the first-day DPT. As a result, our findings do not conclusively support the use of extended-day DPT over single-day DPT. Further studies, incorporating a washout period, are required to comprehensively compare these 2 approaches.
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Affiliation(s)
- Prapasri Kulalert
- Department of Clinical Epidemiology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand; Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Musculoskeletal Science and Translational Research Center (MSTR), Chiang Mai University, Chiang Mai, Thailand
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; UMR UA11 Univ Montpellier - INSERM IDESP, Montpellier, France
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; UMR UA11 Univ Montpellier - INSERM IDESP, Montpellier, France
| | - Surasak Saokaew
- UNIt of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Kantima Kanchanaphoomi
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Witchaya Srisuwatchari
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Alnæs MB, Oppegaard O, Kittang BR, Lygre SHL, Langeland AB, Skodvin B, Bjånes T, Storaas T. A new pathway for penicillin delabeling in Norway. World Allergy Organ J 2023; 16:100829. [PMID: 37868111 PMCID: PMC10587752 DOI: 10.1016/j.waojou.2023.100829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/24/2023] Open
Abstract
Background Penicillin allergy is self-reported by 3-10% of patients admitted to hospital. The label is wrong in 90% of the cases and has severe health implications. Penicillin-delabeling can reverse the negative effects of the label, and pathways adapted to local practice are needed. No tools are available in Norway for penicillin delabeling outside an allergy clinic. Objective To create and validate the first penicillin delabeling pathway applicable outside an allergy clinic in Norway. Methods An interdisciplinary taskforce created a penicillin allergy delabeling program (PAD) adapted to the Norwegian health care system. This was validated in a prospective, single-center study. Very low-risk and low-risk patients underwent a direct oral penicillin challenge and high-risk patients were referred for allergologic evaluation. Results One-hundred forty-nine patients declaring penicillin allergy were included. Seventy-four (50%) were very-low- and low risk patients suitable for a direct oral penicillin challenge resulting in only 1 mild reaction. Sixty high-risk patients were eligible for an oral penicillin challenge after allergologic evaluation; 3 patients reacted non-severely. Conclusion We have created and demonstrated feasibility of the first penicillin delabeling program (PAD) applicable in a hospital setting outside an allergy clinic in Norway. Our data suggest this is safe and beneficial, with 49% patients delabeled through a direct oral penicillin challenge, performed without any serious adverse events, and an overall 87% delabeling rate.
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Affiliation(s)
- Marie Bjørbak Alnæs
- Section of Clinical Allergy, Department of Occupational Medicine, Haukeland University Hospital, 5020 Bergen, Norway
- Department of Clinical Medicine, University of Bergen, 5021 Bergen, Norway
| | - Oddvar Oppegaard
- Department of Clinical Medicine, University of Bergen, 5021 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, 5020 Bergen, Norway
| | - Bård Reiakvam Kittang
- Department of Clinical Medicine, University of Bergen, 5021 Bergen, Norway
- Haraldsplass Deaconess Hospital 5009 Bergen, Norway
- Department of Nursing Home Medicine, 5145 Fyllingsdalen, Norway
| | - Stein Håkon Låstad Lygre
- Section of Clinical Allergy, Department of Occupational Medicine, Haukeland University Hospital, 5020 Bergen, Norway
| | | | - Brita Skodvin
- The Norwegian Advisory Unit for Antibiotic Use in Hospitals, 5020 Bergen, Norway
| | - Tormod Bjånes
- Department of Medical Biochemistry and Pharmacology (MBF) Haukeland University Hospital, 5020 Bergen, Norway
| | - Torgeir Storaas
- Section of Clinical Allergy, Department of Occupational Medicine, Haukeland University Hospital, 5020 Bergen, Norway
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11
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Palacios Cañas AA, Meneses Sotomayor JV, Clar Castelló M, Gómez Torrijos E, Borja Segade JM, García Rodríguez R. [Reproducibilidad clínica de reacciones de hipersensibilidad a fármacos en pruebas de exposición controlada]. REVISTA ALERGIA MÉXICO 2023; 70:113-120. [PMID: 37933921 DOI: 10.29262/ram.v70i3.1199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/19/2023] [Indexed: 11/08/2023] Open
Abstract
Objective To assess the reproducibility of symptoms in drug challenge tests. Methods The study included patients with positive cutaneous or challenge test throughout 2019. For each patient, clinical suspicion according to Karch-Lasagna algorithm was registered. Primary outcome was the reproducibility of symptoms in the provocation tests using a paired analysis of data with McNemar test. Results Eighty-nine patients were included, 16 of them presented more than one positive test. Thirty were skin tests positive and 75 reacted to provocation tests. Eighty nine percent of patients who reacted in challenge test were probably or possibly reactors according to Karch-Lasagna scale. Symptoms of initial reaction did not differ from those triggered in challenge tests. Conclusions Karch-Lasagna scale is useful in predicting the response to drug provocation tests. In most of the positive studies, results were suggested by clinical history and no differences were found between symptoms triggered in challenge test and that referred to in the previous reaction.
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12
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Mertes PM, Tacquard C. Perioperative anaphylaxis: when the allergological work-up goes negative. Curr Opin Allergy Clin Immunol 2023; 23:287-293. [PMID: 37357801 DOI: 10.1097/aci.0000000000000912] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
PURPOSE OF REVIEW Perioperative anaphylaxis (POA) is rare but is associated with significant morbidity and mortality. Patients are referred to the allergist to identify the mechanism of the reaction, the causative agent and make recommendations regarding subsequent anaesthesia. Despite a well conducted allergological evaluation, the causative agent is not found in 30-60% of these reactions, leaving patients without a well established diagnosis. RECENT FINDINGS Several mechanisms can induce POA. In addition to the well known IgE-mediated reactions, IgG-mediated reaction, MRGPR-X2-related reaction or nonspecific histamine release may be involved. These situations are not easily assessed by the allergological workup. SUMMARY When the allergological workup is negative, the situation should be reassessed with the team present at the time of the reaction to confirm the reality of the hypersensitivity reaction and to search for a possible differential diagnosis. If POA is confirmed, the allergological evaluation should be repeated, ensuring proper execution according to current guidelines and including the search for hidden allergens. Specific IgE assays or basophil activation tests may be of interest. In case of negative results, a closely monitored drug challenge test, in coordination with the anaesthesia teams, may be useful to avoid the exclusion of any drug injected during the reaction.
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Affiliation(s)
- Paul-Michel Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Team EFS-INSERM U1255, EFS Grand-Est, Strasbourg, France
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13
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Srisuwatchari W, Phinyo P, Chiriac AM, Saokaew S, Kulalert P. The Safety of the Direct Drug Provocation Test in Beta-Lactam Hypersensitivity in Children: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:506-518. [PMID: 36528293 DOI: 10.1016/j.jaip.2022.11.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Direct drug provocation test (DPT) without prior skin testing (ST) has been investigated in children suspected of being at risk for beta-lactam (BL) hypersensitivity reaction (HSR). However, no systematic review and meta-analysis has investigated the efficacy and safety of direct DPT for BL-HSR in children. OBJECTIVE To investigate the prevalence of BL-HSR by direct DPT and the safety of direct DPT in children. METHODS We searched MEDLINE, EMBASE, Web of Science, and CINAHL from their inception to July 23, 2022, for studies that performed direct DPT in children with suspected BL-HSR, or for studies that performed DPT in all cases with ST results, but they ignored the ST results. The true prevalence was defined as the proportion of children who experienced an HSR during direct DPT. Safety was determined according to the proportion of children who developed a dangerous reaction following DPT. RESULTS Twenty-eight studies with 8,334 direct challenges were included. Fifteen studies included patients who presented with either immediate or nonimmediate HSR, and the majority of the index reactions were nonsevere. Amoxicillin/amoxicillin-clavulanic acid was the most commonly used during the DPT. The pooled prevalence of confirmed BL-HSR was 5.23% (95% CI 4.17-6.39; I2 = 72%). Immediate and nonimmediate HSR were reported in 0.8% (95% CI 0.43-1.25; I2 = 55.1%) and 3.69% (95% CI 2.66-4.87; I2 = 79.77%), respectively. Severe reactions were found in 3 cases with the frequency of 0.036% (95% CI 0.012-0.112; I2 = 0%). CONCLUSIONS The prevalence of BL-HSR by direct DPT was 5.23%, and the frequency of severe reactions from direct DPT was very low (0.036%). Our findings support direct DPT as a safe and effective delabeling tool in children with suspected nonsevere BL-HSR.
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Affiliation(s)
- Witchaya Srisuwatchari
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Musculoskeletal Science and Translational Research (MSTR), Chiang Mai University, Chiang Mai, Thailand
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; IDESP, UMR UA11, University of Montpellier, INSERM, Montpellier, France
| | - Surasak Saokaew
- UNIt of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Prapasri Kulalert
- Department of Clinical Epidemiology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand; Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
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14
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Daghfous H, Moussa C, Ben Mansour A, Slim A, Ben Saad S, Tritar F. Drug reintroduction testing and beta-lactam hypersensitivity in children: Protocols and results, a 12-year experience. Int J Immunopathol Pharmacol 2023; 37:3946320231204220. [PMID: 37789550 PMCID: PMC10552452 DOI: 10.1177/03946320231204220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/12/2023] [Indexed: 10/05/2023] Open
Abstract
Introduction: Oral provocation test (OPT) to beta-lactam antibiotics (BL) is a gold standard in allergology investigation. We aimed to demonstrate the contribution of OPT in BL hypersensitivity (HS) indicated as a first step in diagnosis. Methods: We conducted a retrospective study from 2007 to 2019, in a single Tunisian tertiary care academic center. It concerned children with presumed non-severe allergic manifestations to BL, with a reaction that has occurred at least 6 months before the OPT. Results: We identified 35 children for inclusion. After the first OPT, a second OPT with a different BL was performed in case of a positive result of the first one. In 12 cases (34.2%), the OPT elicited a reaction. In eight cases the allergy was to penicillin and in two cases to cephalosporins (cefixim). Cross-reactivity was noted in two cases. Conclusion: An OPT to BL indicated in the first instance in non-severe reaction in children will allow a rapid diagnosis in case of suspicion of HS to BL.
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Affiliation(s)
- Hafaoua Daghfous
- Pneumology Department, Abderrahmen Mami Hospital, Ariana, Tunisia
- Faculty of Medicine, El Manar University, Tunis, Tunisia
| | - Chirine Moussa
- Pneumology Department, Abderrahmen Mami Hospital, Ariana, Tunisia
- Faculty of Medicine, El Manar University, Tunis, Tunisia
| | - Amani Ben Mansour
- Pneumology Department, Abderrahmen Mami Hospital, Ariana, Tunisia
- Faculty of Medicine, El Manar University, Tunis, Tunisia
| | - Azza Slim
- Pneumology Department, Abderrahmen Mami Hospital, Ariana, Tunisia
- Faculty of Medicine, El Manar University, Tunis, Tunisia
| | - Soumaya Ben Saad
- Pneumology Department, Abderrahmen Mami Hospital, Ariana, Tunisia
- Faculty of Medicine, El Manar University, Tunis, Tunisia
| | - Fatma Tritar
- Pneumology Department, Abderrahmen Mami Hospital, Ariana, Tunisia
- Faculty of Medicine, El Manar University, Tunis, Tunisia
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Macy E, Trautmann A, Chiriac AM, Demoly P, Phillips EJ. Advances in the Understanding of Drug Hypersensitivity: 2012 Through 2022. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:80-91. [PMID: 36384652 DOI: 10.1016/j.jaip.2022.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/09/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022]
Abstract
Over the last decade there have been key advances in understanding mechanisms, risk, and consequences of both true immunological drug hypersensitivity and unverified drug allergy labels that have changed clinical practice. This has been facilitated by the widespread adoption of electronic health records (EHRs). The vast majority of EHR drug allergy labels are unverified and cause significant morbidity from unnecessary avoidance of optimal drug therapy. There has also been significant movement in our understanding of mechanisms of drug hypersensitivity that, in addition to advancing our understanding of the pathogenesis of immediate and delayed reactions, have guided preventive efforts, diagnostic procedures, and clinical management. More widespread adoption, including scale-up of "allergy" delabeling and appropriate management, specifically for antibiotics, opiates, radiocontrast, chemotherapeutics, biologics, and nonsteroidal anti-inflammatory medications, will be necessary to improve patient outcomes over the next decade. This will require further engagement and collaboration between primary care health care providers, allergists, and other specialists.
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Affiliation(s)
- Eric Macy
- Allergy Department, Kaiser Permanente Southern California, San Diego, Calif.
| | - Axel Trautmann
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - Anca M Chiriac
- Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; Sorbonne Universités, Paris, France; IDESP, UMR UA11, Univ. Montpellier-INSERM, Montpellier, France
| | - Pascal Demoly
- Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; Sorbonne Universités, Paris, France; IDESP, UMR UA11, Univ. Montpellier-INSERM, Montpellier, France
| | - Elizabeth J Phillips
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
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Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J, Khan DA, Golden DBK, Shaker M, Stukus DR, Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333-1393. [PMID: 36122788 DOI: 10.1016/j.jaci.2022.08.028] [Citation(s) in RCA: 246] [Impact Index Per Article: 82.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Aleena Banerji
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Roland Solensky
- Corvallis Clinic, Oregon State University/Oregon Health Science University College of Pharmacy, Corvallis, Ore
| | - Andrew A White
- Department of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St Joe's Hamilton, Hamilton, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew J Greenhawt
- Food Challenge and Research Unit Section of Allergy and Immunology, Children's Hospital Colorado University of Colorado School of Medicine, Aurora, Colo
| | - Caroline C Horner
- Department of Pediatrics, Division of Allergy Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla; James A. Haley Veterans Affairs Hospital, Tampa, Fla
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | - John Oppenheimer
- Division of Allergy, Rutgers New Jersey Medical School, Rutgers, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Chong CJ, Choo KJL, Ong KY, Tan V, Khoo JBN, Murthee KG, Hanif IM, Naing CS, Lee HY. Improving drug allergy label accuracy by supervised safety- and protocol-driven evaluation. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022. [DOI: 10.47102/annals-acadmedsg.2022118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction: Drug allergies are often self-reported but of unknown accuracy. We carried out a prospective study to examine the utility and safety of formal allergology evaluation, and to identify factors associated with accurate drug allergy labels.
Method: All patients who underwent drug allergy evaluation in our clinic during the study period were recruited. Baseline demographics, characteristics of index hypersensitivity reaction and outcomes of evaluation were recorded.
Results: A total of 331 patients from March 2019 to June 2021 completed drug allergy evaluation to index drugs of concern. There were 123 (37%) male patients, and the mean age was 49 years (standard deviation 17). There were 170 beta-lactam antibiotics, 53 peri-operative drugs, 43 others, 38 non-steroidal anti-inflammatory drugs, and 27 non-beta-lactam antibiotic evaluations. Index reaction occurred within 5 years in 165 (50%) patients, with latency of less than 4 hours in 125 (38%) patients. The most common index reactions were rash, angioedema and urticaria. There were 57 (17%) evaluations stratified as low risk, 222 (67%) moderate risk, and 52 (16%) high risk based on multidisciplinary consensus. Allergy label was found to be false (negative drug evaluation) in 248 (75%) patients, while 16/237 (7%) skin tests, 44/331 (13%) in-clinic graded challenge, and 23/134 (17%) home prolonged challenges were positive (true drug allergy). The most common evaluation reactions were rash and urticaria. No cases of anaphylaxis were elicited.
Conclusion: Seventy-five percent of drug allergy labels are inaccurate. Risk-stratified, protocolised allergy evaluation is safe. Prolonged drug challenge increases the sensitivity of drug allergy evaluation and should therefore be performed when indicated.
Keywords: Drug allergy, drug hypersensitivity, graded challenge, prolonged drug provocation, skin testing
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Liccioli G, Giovannini M, Caubet JC, Barni S, Sarti L, Parronchi P, Capone M, Tomei L, Mori F. Simplifying the drug provocation test in non-immediate hypersensitivity reactions to amoxicillin in children: The experience of a tertiary care allergy unit. Pediatr Allergy Immunol 2022; 33:e13809. [PMID: 35754120 PMCID: PMC9328376 DOI: 10.1111/pai.13809] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/29/2022] [Accepted: 05/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mild non-immediate reactions (NIR) to beta-lactams (βLs) are the most common manifestation of adverse drug reactions in children, and the drug provocation test (DPT) remains the gold standard for diagnosis. However, there are still controversies about the protocol that should be used, especially regarding the administration of doses and the DPT length. OBJECTIVE This study aimed to evaluate a pediatric population with a history of mild NIR to amoxicillin (AMX) or to amoxicillin-clavulanic acid (AMX/CL) who underwent a diagnostic workup including a DPT with the culprit drug, to understand if a graded DPT or, instead, a single full dose could be the most appropriate way of administration in clinical practice. METHODS The data of children were retrospectively analyzed for a 5-year period, with demographic and clinical characteristics collected. We reported the allergy workup and the results of the DPT performed with the administration of incremental doses and a prolonged DPT at home for a total of 5 days. RESULTS Three hundred fifty-four patients were included. Overall, 23/354 (6.5%) DPTs were positive: 11/23 patients showed a reaction after 2-8 h after the last dose on the 1st or 2nd day (1 reacted 30 min after the last dose), 1/23 reacted with urticaria 30 min after the first dose, 11/23 reacted at home on the 5th day of the DPT. CONCLUSION This paper indirectly suggests that a single therapeutic dose administered on the 1st day of a DPT could be safe in the diagnostic workup of mild NIR to AMX/CL. Moreover, this could be less time-consuming as patients would spend less time in the hospital, also considering the public health restrictions imposed during the COVID-19 pandemic.
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Affiliation(s)
- Giulia Liccioli
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Paola Parronchi
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Manuela Capone
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Leonardo Tomei
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
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19
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Arıkoğlu T, Kuyucu S, Caubet JC. New diagnostıc perspectives in the management of pediatrıc beta-lactam allergy. Pediatr Allergy Immunol 2022; 33:e13745. [PMID: 35338725 DOI: 10.1111/pai.13745] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 12/15/2022]
Abstract
Since overdiagnosis of beta-lactam (BL) allergy is common in the pediatric population, delabeling is a critical part of antimicrobial stewardship. Undesirable consequences of inaccurate BL allergy labeling can be handled by incorporating traditional delabeling or newer risk-based strategies into antibiotic stewardship programs. Conventional assessment of BL allergy relies upon a stepwise algorithm including a clinical history with skin testing followed by drug provocation tests (DPTs). However, a growing number of studies highlighted the suboptimal diagnostic value of skin testing in children. Recently, there has been a paradigm shift in the practice of BL allergy assessment due to recent challenging data which emphasize the safety and accuracy of direct DPTs in children with a suspicion of non-immediate mild cutaneous reactions such as maculopapular eruption, delayed urticaria, and possibly also for benign immediate reactions such as urticaria/angioedema. Identifying low-risk BL allergy patients, in whom skin tests can be skipped and proceeding directly to DPTs could be safe, has become a hot topic in recent years. New risk stratification and predictive modeling studies that have the potential to better predict BL allergy risk status have recently been introduced into the field of drug allergy, particularly in adults. However, in contrast to adults, risk assessment studies in children are rare, and optimal risk definitions are controversial. In the coming years, promising potential methods to elucidate the predictors of BL allergy in children will require multidimensional approaches that may include predictive analytics, artificial intelligence techniques, and point-of-care clinical decision tools.
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Affiliation(s)
- Tuğba Arıkoğlu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
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20
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Bhogal R, Hussain A, Savic L, Misbah SA, Balaji A, Hullur C, Marriott JF, Krishna MT. Heterogeneity in direct oral penicillin challenge protocols in penicillin allergy de-labelling. Infect Prev Pract 2021; 4:100185. [PMID: 36090525 PMCID: PMC9452040 DOI: 10.1016/j.infpip.2021.100185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/09/2021] [Indexed: 10/28/2022] Open
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21
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Blanca-Lopez N, Atanaskovic-Markovic M, Gomes ER, Kidon M, Kuyucu S, Mori F, Soyer O, Caubet JC. An EAACI Task Force report on allergy to beta-lactams in children: Clinical entities and diagnostic procedures. Pediatr Allergy Immunol 2021; 32:1426-1436. [PMID: 33931922 DOI: 10.1111/pai.13529] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/24/2021] [Indexed: 12/14/2022]
Abstract
Beta-lactam (BL) allergy suspicion is common in children and constitutes a major public health problem, with an impact on patient's health and on medical costs. However, it has been found that most of these reactions are not confirmed by a complete allergic workup. The diagnostic value of the currently available allergy tests has been investigated intensively recently by different groups throughout the world. This has led to major changes in the management of children with a suspected BL allergy. Particularly, it is now well accepted that skin tests can be skipped before the drug provocation test in children with a benign non-immediate reaction to BL. However, there is still a debate on the optimal allergic workup to perform in children with a benign immediate reaction. In addition, management of children with severe cutaneous adverse drug reactions remains difficult. In this review, based on a selection of the most relevant studies found in the literature, we will review and discuss the diagnosis of different forms of BL allergy in children.
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Affiliation(s)
| | | | - Eva R Gomes
- Allergy Unit, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Mona Kidon
- Safra Children's Hospital and the Clinical Immunology, Angioedema and Allergy Unit, Chaim Sheba Medical Center, Tel Hashomer, Faculty of Pediatric Medicine, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Francesca Mori
- Allergy Unit, Department of Pediatric, Meyer Children's Hospital, Florence, Italy
| | - Ozge Soyer
- Department of Pediatric Allergy, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
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22
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Delabeling Delayed Drug Hypersensitivity: How Far Can You Safely Go? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2878-2895.e6. [PMID: 33039012 DOI: 10.1016/j.jaip.2020.07.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/01/2020] [Accepted: 07/08/2020] [Indexed: 12/17/2022]
Abstract
Delayed immune-mediated adverse drug reactions (IM-ADRs) are defined as reactions occurring more than 6 hours after dosing. They include heterogeneous clinical phenotypes that are typically T-cell-mediated reactions with distinct mechanisms across a wide spectrum of severity from benign exanthems through to life-threatening cutaneous or organ-specific diseases. For mild reactions such as benign exanthem, considerations for delabeling are similar to immediate reactions and may include a graded or single-dose drug challenge with or without preceding skin or patch testing. Evaluation of challenging cases such as the patient who is on multiple drugs at the time a severe delayed IM-ADR occurs should prioritize clinical ascertainment of the most likely phenotype and implicated drug(s). Although not widely available and validated, procedures such as patch testing, delayed intradermal skin testing, and laboratory-based functional drug assays or genetic (human leukocyte antigen) testing may provide valuable information to further help risk stratify patients and identify the likely implicated and/or cross-reactive drug(s). The decision to use a drug challenge as a diagnostic or delabeling tool in a patient with a severe delayed IM-ADR should weigh the risk-benefit ratio, balancing the severity and priority for the treatment of the underlying, and the availability of alternative efficacious and safe treatments.
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du Plessis T, Walls G, Jordan A, Holland DJ. Implementation of a pharmacist-led penicillin allergy de-labelling service in a public hospital. J Antimicrob Chemother 2020; 74:1438-1446. [PMID: 30753497 DOI: 10.1093/jac/dky575] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/13/2018] [Accepted: 12/23/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Inaccurate allergy labelling results in inappropriate antimicrobial management of the patient, which may affect clinical outcome, increase the risk of adverse events and increase costs. Inappropriate use of alternative antibiotics has implications for antimicrobial stewardship programmes and microbial resistance. METHODS All adult inpatients labelled as penicillin allergic were identified and screened for eligibility by the study pharmacist. An accurate allergy and medication history was taken. Patients were 'de-labelled', underwent oral challenge or were referred to an immunology clinic, if study criteria were met. All patients included in the study were followed-up 1 year after intervention. RESULTS Two hundred and fifty eligible patients with a label of 'penicillin allergy' were identified. The prevalence of reported penicillin allergy at Middlemore Hospital was 11%. We found that 80% of study patients could be 'de-labelled'. Of those, 80% were 'de-labelled' after an interview with the pharmacist alone, 16% had an uneventful oral challenge and 4% were deemed to be inappropriately labelled after referral to an immunology clinic. Appropriately labelled patients accounted for 20% of the study population. Changes to inpatient antibiotic therapy were recommended in 61% of 'de-labelled' patients, of which no patients had adverse events after commencing on penicillin antibiotics. At the 1 year follow-up, 98% of patients who were 'de-labelled' had no adverse events to repeated administration of penicillin antibiotics. CONCLUSIONS This study showed that a pharmacist-led allergy management service is a safe option to promote antimicrobial stewardship and appropriate allergy labelling.
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Affiliation(s)
| | - Genevieve Walls
- Infection Services, Middlemore Hospital, Auckland, New Zealand
| | - Anthony Jordan
- Department of Immunology, Auckland City Hospital, Auckland, New Zealand
| | - David J Holland
- Infection Services, Middlemore Hospital, Auckland, New Zealand
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24
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Romano A, Atanaskovic‐Markovic M, Barbaud A, Bircher AJ, Brockow K, Caubet J, Celik G, Cernadas J, Chiriac A, Demoly P, Garvey LH, Mayorga C, Nakonechna A, Whitaker P, Torres MJ. Towards a more precise diagnosis of hypersensitivity to beta-lactams - an EAACI position paper. Allergy 2020; 75:1300-1315. [PMID: 31749148 DOI: 10.1111/all.14122] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/08/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023]
Abstract
A recent survey of the European Academy of Allergy and Clinical Immunology (EAACI) Drug Allergy Interest Group (DAIG) on how European allergy specialists deal with beta-lactam (BL) hypersensitivity demonstrated a significant heterogeneity in current practice, suggesting the need to review and update existing EAACI guidelines in order to make the diagnostic procedures as safe and accurate, but also as cost-effective, as possible. For this purpose, a bibliographic search on large studies regarding BL hypersensitivity diagnosis was performed by an EAACI task force, which reviewed and evaluated the literature data using the GRADE system for quality of evidence and strength of recommendation. The updated guidelines provide a risk stratification in BL hypersensitivity according to index reaction(s), as well as an algorithmic approach, based on cross-reactivity studies, in patients with a suspicion of BL hypersensitivity and an immediate need for antibiotic therapy, when referral to an allergist is not feasible. Furthermore, the update addresses availability and concentrations of skin test (ST) reagents, ST and drug provocation test (DPT) protocols, and diagnostic algorithms and administration of alternative BL in allergic subjects. Specifically, distinct diagnostic algorithms are suggested depending on risk stratification of the patient into high and low risk based on the morphology and chronology of the reaction, immediate (ie, occurring within 1-6 hours after the last administered dose) or nonimmediate (ie, occurring more than 1 hour after the initial drug administration), and the reaction severity. Regarding the allergy workup, the main novelty of this document is the fact that in some low-risk nonimmediate reactions ST are not mandatory, especially in children. For DPT, further studies are necessary to provide data supporting the standardization of protocols, especially of those regarding nonimmediate reactions, for which there is currently no consensus.
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Affiliation(s)
- Antonino Romano
- Casa di Cura Quisisana Rome & Fondazione Mediterranea G.B. Catania Italy
| | | | - Annick Barbaud
- Departement of Dermatology and Allergology Institut Pierre Louis d'Epidemiologie et de Sante Publique INSERM Tenon Hospital Sorbonne Université Paris France
| | | | - Knut Brockow
- Department of Dermatology and Allergy Biederstein Technische Universität München Munich Germany
| | | | - Gulfem Celik
- Department of Immunology and Allergy Ankara University School of Medicine Ankara Turkey
| | - Josefina Cernadas
- Department of Allergy and Immunology Centro Hospitalar Universitário de S João Porto Portugal
| | - Anca‐Mirela Chiriac
- Division of Allergy Department of Pulmonology Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- UMRS 1136 Equipe ‐ EPAR ‐ IPLESP UPMC Univ Sorbonne Universités Paris France
| | - Pascal Demoly
- Division of Allergy Department of Pulmonology Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- UMRS 1136 Equipe ‐ EPAR ‐ IPLESP UPMC Univ Sorbonne Universités Paris France
| | - Lene H. Garvey
- Allergy Clinic Department of Dermatology and Allergy Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga-IBIMA Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga-UMA-ARADyAL Malaga Spain
| | - Alla Nakonechna
- Clinical Immunology and Allergy Unit Sheffield Teaching Hospital Sheffield UK
- University of Liverpool Liverpool UK
| | - Paul Whitaker
- Regional Adult Cystic Fibrosis Unit St James's Hospital Leeds UK
| | - María José Torres
- Allergy Unit Hospital Regional Universitario de Málaga-UMA-ARADyAL Malaga Spain
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25
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Petersen BT, Gradman J. Prospective study of 5-day challenge with penicillins in children. BMJ Paediatr Open 2020; 4:e000734. [PMID: 32818157 PMCID: PMC7406022 DOI: 10.1136/bmjpo-2020-000734] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/02/2020] [Accepted: 07/06/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To examine if a 5-day challenge with penicillin improves the diagnostic sensitivity compared with a single full dose in children with mild skin reactions. DESIGN Subjects referred with suspected allergy to penicillin were consecutively included. Irrespectively of the morphology of the index reaction and the result of specific IgE, all subjects underwent a two-step titrated drug provocation test (DPT) with the culprit drug followed by a 5-day challenge at home. PARTICIPANTS Children and adolescents aged 0-18 years referred to allergic workup for penicillin hypersensitivity at two paediatric Danish centres. Only subjects with non-severe skin reactions were included. RESULTS A total of 305 subjects were included and 22 (7%) of the DPTs were positive. Three subjects reacted within 1 hour of the first full dose and nine reacted 1-8 hours after the first full dose. Additional 10 positive reactions were observed during the prolonged provocation. Seven subjects reacted after the second full dose and three reacted after 3-6 days. Only mild skin rashes were observed. Eighteen subjects had a specific IgE to a penicillin >0.1 kU/L. Only one of these had a positive DPT. CONCLUSION In children, a DPT with penicillins should include at least two full doses. In children with mild hypersensitivity reactions it may be safe to perform DPTs despite a low specific IgE. TRIAL REGISTRATION NUMBER NCT04331522.
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Affiliation(s)
| | - Josefine Gradman
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
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26
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Mayorga C, Fernandez TD, Montañez MI, Moreno E, Torres MJ. Recent developments and highlights in drug hypersensitivity. Allergy 2019; 74:2368-2381. [PMID: 31557314 DOI: 10.1111/all.14061] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 12/12/2022]
Abstract
Drug hypersensitivity reactions (DHRs) are nowadays the third cause of allergy after rhinitis and asthma with a significant increase in prevalence in both adults and paediatric population with new drugs included as culprit. For this, DHRs represent not only a health problem but also a significant financial burden for affected individuals and health systems. Mislabelling DHRs is showing to be a relevant problem for both, false label of drug allergic and false label of nonallergic. All this reinforces the need to improve accurate diagnostic approaches that allow an appropriate management. Moreover, there is a need for training both, nonallergist stakeholders and patients to improve the reaction identification and therefore decrease the mislabelling. The use of allergy cards has shown to be relevant to avoid the induction of DHRs due to the prescription of wrong medication. Recent developments over the last 2 years and highlights about risk factors, diagnostic approaches, mechanisms involved as well as prevention actions, and management have been reviewed. In these papers, it has been outlined the need for correct diagnosis and de-labelling of patients previously false-reported as allergic, which will improve the management and treatment of patients with DHRs.
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Affiliation(s)
- Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
| | - Tahia D. Fernandez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Maria Isabel Montañez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
| | - Esther Moreno
- Allergy Unit Hospital Universitario de Salamanca‐ARADyAL IBSAL Salamanca Spain
| | - María José Torres
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
- Universidad de Málaga Málaga Spain
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27
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Regateiro F, Rezende I, Pinto N, Abreu C, Carreiro-Martins P, Gomes E. Short and extended provocation tests have similar negative predictive value in non-immediate hypersensitivity to beta-lactams in children. Allergol Immunopathol (Madr) 2019; 47:477-483. [PMID: 30910271 DOI: 10.1016/j.aller.2019.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Drug provocation tests (DPTs) are the gold-standard method to diagnose non-immediate hypersensitivity reactions (NIHSR) to beta-lactam antibiotics (BL) in children. Our aim was to compare the negative predictive value (NPV) of one-day (short) DPT versus 3-7 days (extended) DPT for the diagnosis of NIHSR to BL in paediatric age. A secondary aim was to compare confidence on drug re-exposure after short and extended negative DPTs. METHODS The occurrence of HSR on drug re-exposure and drug refusal after negative diagnostic DPTs were evaluated in children/adolescents with a history of NIHSR to BL using a questionnaire performed six months to ten years after DPT. Patients were divided into two groups according to the protocol performed: short DPT vs. extended DPT. RESULTS We enrolled 212 children and adolescents (86 females, 126 males, mean age at DPT 5.52 years, p25=3 years, p75=7.25 years): 69 tested with short DPT, and 143 with extended DPT. The NPV of both types of DPT together was 95.2%. The NPV of short DPT was 97.5% and the NPV of extended DPT was 93.8% (p=0.419). After negative DPT, beta-lactams were refused by carers in 14.75% of the children requiring subsequent treatment, 6.98% in the short DPT group and 18.99% in the extended DPT group (p=0.074). CONCLUSIONS In our paediatric sample, prolonging drug administration did not increase the NPV of diagnostic DPT for NIHSR to BL or reduce drug refusal. Altogether, the data here reported suggest that, however intuitive, prolonging DPT is not beneficial in the parameters analysed.
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Garvey LH, Ebo DG, Krøigaard M, Savic S, Clarke R, Cooke P, Dewachter P, Garcez T, Guttormsen AB, Hopkins PM, Hepner DL, Khan DA, Kolawole H, Kopac P, Marshall S, Mertes PM, Platt P, Rose M, Sabato V, Sadleir P, Savic L, Scherer K, Takazawa T, Volcheck GW, Voltolini S, Laguna JJ. The use of drug provocation testing in the investigation of suspected immediate perioperative allergic reactions: current status. Br J Anaesth 2019; 123:e126-e134. [DOI: 10.1016/j.bja.2019.03.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/09/2019] [Accepted: 03/12/2019] [Indexed: 01/23/2023] Open
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30
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Torres MJ, Celik GE, Whitaker P, Atanaskovic-Markovic M, Barbaud A, Bircher A, Blanca M, Brockow K, Caubet JC, Cernadas JR, Chiriac A, Demoly P, Garvey LH, Merk HF, Mosbech H, Nakonechna A, Romano A. A EAACI drug allergy interest group survey on how European allergy specialists deal with β-lactam allergy. Allergy 2019; 74:1052-1062. [PMID: 30637768 DOI: 10.1111/all.13721] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/09/2018] [Accepted: 08/22/2018] [Indexed: 12/18/2022]
Abstract
An accurate diagnosis of β-lactam (BL) allergy can reduce patient morbidity and mortality. Our aim was to investigate the availability of BL reagents, their use and test procedures in different parts of Europe, as well as any differences in the diagnostic workups for evaluating subjects with BL hypersensitivity. A survey was emailed to all members of the EAACI Drug Allergy Interest Group (DAIG) between February and April 2016, and the questionnaire was meant to study the management of suspected BL hypersensitivity. The questionnaire was emailed to 82 DAIG centres and answered by 57. Amoxicillin alone or combined to clavulanic acid were the most commonly involved BL except in the Danish centre, where penicillin V was the most frequently suspected BL. All centres performed an allergy workup in subjects with histories of hypersensitivity to BL: 53 centres (93%) followed DAIG guidelines, two national guidelines and two local guidelines. However, there were deviations from DAIG recommendations concerning allergy tests, especially drug provocation tests. A significant heterogeneity exists in current practice not only among countries, but also among centres within the same country. This suggests the need to re-evaluate, update and standardize protocols on the management of patients with suspected BL allergy.
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Affiliation(s)
- Maria Jose Torres
- Allergy Unit; Regional University Hospital of Malaga-IBIMA-UMA; Malaga Spain
| | - Gulfem Elif Celik
- Department of Immunology and Allergy; Ankara University School of Medicine; Ankara Turkey
| | - Paul Whitaker
- Regional Adult Cystic Fibrosis Unit; St James's Hospital; Leeds UK
| | | | - Annick Barbaud
- Dermatology and Allergology Department; Tenon Hospital (AP-HP); Sorbonne Universities; UPMC University Paris 06; Paris France
| | | | - Miguel Blanca
- Allergy Service; Infanta Leonor University Hospital; Madrid Spain
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Munich Germany
| | | | | | - Anca Chiriac
- Division of Allergy; Department of Pulmonology; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- UMRS 1136; Equipe - EPAR - IPLESP; Sorbonne Universités; UPMC Univ Paris 06; Paris France
| | - Pascal Demoly
- Division of Allergy; Department of Pulmonology; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
| | - Lene Heise Garvey
- Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - Hans F. Merk
- Department of Dermatology and Allergology; RWTH Aachen University; Aachen Germany
| | - Holger Mosbech
- Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - Alla Nakonechna
- Allergy and Immunology Clinic; Royal Liverpool and Broadgreen University Hospitals; Liverpool UK
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31
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Van Gasse AL, Ebo DG, Chiriac AM, Hagendorens MM, Faber MA, Coenen S, Bridts CH, Mertens CM, De Clerck LS, Sabato V. The Limited Value of Prolonged Drug Challenges in Nonimmediate Amoxicillin (Clavulanic Acid) Hypersensitivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2225-2229.e1. [PMID: 31034997 DOI: 10.1016/j.jaip.2019.04.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/12/2019] [Accepted: 04/04/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Misdiagnosis of amoxicillin (clavulanic acid) (AX(/CL)) hypersensitivity has serious consequences. A drug challenge (DC) is the final diagnostic to affirm or infirm AX(/CL) hypersensitivity. However, uncertainties remain whether a prolonged drug challenge (pDC) should benefit the diagnosis of a nonimmediate AX(/CL) hypersensitivity. OBJECTIVE To assess the added value of a standardized 7-day pDC in the diagnosis of nonimmediate or unclear penicillin hypersensitivity. METHODS A total of 132 patients with a history of a nonimmediate hypersensitivity reaction or an unclear reaction to AX(/CL) or an undefined penicillin with a negative diagnostic workup including a single-day DC (DC) with AX(/CL) were selected. In all these patients, an additional pDC with AX(/CL) was planned. Thirteen patients started the pDC immediately after the DC. To ensure that hypersensitivity symptoms manifesting during the pDC course do not result from the DC, in the remaining 119 patients, the pDC was scheduled after a washout of 1 week. RESULTS A total of 128 patients (12 without washout, 116 with washout) completed the pDC. Three patients reacted with a mild maculopapular exanthema. However, the value of a pDC was evidenced in only 1 patient who reacted during her pDC after an uneventful washout. In 2 patients pDC was cancelled because they reacted during the washout. CONCLUSIONS A pDC is of limited added value to the diagnostic algorithms of nonimmediate hypersensitivity reaction or unclear hypersensitivity reactions to AX(/CL). In our hands, the traditionally recommended diagnostic algorithm that offers a 1-day DC as a final diagnostic in patients with negative workup for AX(/CL) is appropriate.
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Affiliation(s)
- Athina L Van Gasse
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Didier G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium.
| | - Anca M Chiriac
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; UMR-S 1136 INSERM-Sorbonne Université, Equipe EPAR - IPLESP, Paris, France
| | - Margo M Hagendorens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Margaretha A Faber
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Samuel Coenen
- Faculty of Medicine and Health Sciences, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Chris H Bridts
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Christel M Mertens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Luc S De Clerck
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
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Kennard L, Rutkowski K, Siew LQC, Nakonechna A, Sargur R, Egner W, Shrimpton A, Mirakian R, Wagner A. Flucloxacillin Hypersensitivity: Patient Outcomes in a Multicenter Retrospective Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2212-2217.e1. [PMID: 30922988 DOI: 10.1016/j.jaip.2019.03.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 02/27/2019] [Accepted: 03/10/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Flucloxacillin is a narrow-spectrum, beta-lactamase-resistant penicillin. Type I (IgE-mediated) and type IV (T-cell-mediated) reactions are less frequently reported than with other penicillins. OBJECTIVE To undertake a detailed clinical characterization of a cohort of patients referred with suspected flucloxacillin hypersensitivity. METHODS We retrospectively analyzed demographic characteristics, presentation, investigation, and management of 108 patients presenting to 4 UK centers. Patients underwent skin prick and intradermal testing with flucloxacillin, major (benzylpenicilloyl poly-l-lysine) and minor determinants, amoxicillin, and benzylpenicillin with immediate and, where appropriate, delayed reading of the test. In the immediate group, a further 14 patients were tested to ampicillin and 16 to Augmentin (co-amoxiclav-combination of clavulanic acid and amoxicillin). Skin test-negative patients underwent oral drug provocation. A multistep protocol was used, depending on risk assessment. RESULTS Forty of 108 (37%) patients were diagnosed with hypersensitivity to flucloxacillin, of whom 33 (82.5%) showed immediate and 7 (17.5%) nonimmediate hypersensitivity, respectively. In the immediate group, most reactions were severe: 19 of 33 (58%). Intradermal testing had a higher negative predictive value (86%) in the immediate group than in the nonimmediate group (67%). Only a minority of patients (6 of 17 [35%]) with IgE-mediated allergy were cross-sensitized on intradermal testing with other penicillins, compared with 3 of 4 (75%) in the delayed group. CONCLUSIONS Immediate hypersensitivity reactions to flucloxacillin are more common than delayed. Cross-sensitization to other penicillins appears higher in delayed reactions than in immediate. The negative predictive value of intradermal testing is higher in the immediate group than in the nonimmediate group. Drug provocation testing remains the diagnostic criterion standard.
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Affiliation(s)
- Lucinda Kennard
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
| | - Krzysztof Rutkowski
- Department of Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Leonard Q C Siew
- Department of Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Alla Nakonechna
- Clinical Immunology & Allergy Unit, Sheffield Teaching Hospital, Royal Hallamshire Hospital, Sheffield, United Kingdom; Liverpool Hope University, Liverpool, United Kingdom
| | - Ravishankar Sargur
- Clinical Immunology & Allergy Unit, Sheffield Teaching Hospital, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - William Egner
- Clinical Immunology & Allergy Unit, Sheffield Teaching Hospital, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Anna Shrimpton
- Clinical Immunology & Allergy Unit, Sheffield Teaching Hospital, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Rita Mirakian
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Annette Wagner
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Savic LC, Khan DA, Kopac P, Clarke RC, Cooke PJ, Dewachter P, Ebo DG, Garcez T, Garvey LH, Guttormsen AB, Hopkins PM, Hepner DL, Kolawole H, Krøigaard M, Laguna JJ, Marshall SD, Mertes PM, Platt PR, Rose MA, Sabato V, Sadleir PHM, Savic S, Takazawa T, Voltolini S, Volcheck GW. Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations. Br J Anaesth 2019; 123:e82-e94. [PMID: 30916014 DOI: 10.1016/j.bja.2019.01.026] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/21/2018] [Accepted: 01/09/2019] [Indexed: 11/30/2022] Open
Abstract
Unsubstantiated penicillin-allergy labels are common in surgical patients, and can lead to significant harm through avoidance of best first-line prophylaxis of surgical site infections and increased infection with resistant bacterial strains. Up to 98% of penicillin-allergy labels are incorrect when tested. Because of the scarcity of trained allergists in all healthcare systems, only a minority of surgical patients have the opportunity to undergo testing and de-labelling before surgery. Testing pathways can be modified and shortened in selected patients. A variety of healthcare professionals can, with appropriate training and in collaboration with allergists, provide testing for selected patients. We review how patients might be assessed, the appropriate testing strategies that can be used, and the minimum standards of safe testing.
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Affiliation(s)
- L C Savic
- Anaesthetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - D A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - P Kopac
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - R C Clarke
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Nedlands, Western Australia, Australia
| | - P J Cooke
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - P Dewachter
- Service d'Anesthésie-Réanimation, Groupe Hospitalier de Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris 13, Sorbonne-Paris-Cité, Paris, France
| | - D G Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - T Garcez
- Department of Immunology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - L H Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - A B Guttormsen
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - P M Hopkins
- Anaesthetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - D L Hepner
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA, USA
| | - H Kolawole
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia; Department of Anaesthesia, Peninsula Health, Melbourne, Australia
| | - M Krøigaard
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital, Gentofte, Denmark
| | - J J Laguna
- Allergy Unit, Allergo-Anaesthesia Unit, Hospital Central de la Cruz Roja, Faculty of Medicine, Alfonso X El Sabio University, ARADyAL, Madrid, Spain
| | - S D Marshall
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia; Department of Anaesthesia, Peninsula Health, Melbourne, Australia
| | - P M Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France
| | - P R Platt
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Nedlands, Western Australia, Australia
| | - M A Rose
- Department of Anaesthesia, Royal North Shore Hospital, and University of Sydney, Sydney, NSW, Australia
| | - V Sabato
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - P H M Sadleir
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Nedlands, Western Australia, Australia; Department of Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - S Savic
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - T Takazawa
- Intensive Care Unit, Gunma University Hospital, Maebashi, Gunma, Japan
| | - S Voltolini
- Allergy Unit, Policlinic Hospital San Martino, Genoa, Italy
| | - G W Volcheck
- Division of Allergic Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
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Nohra D, Schrijvers R, Touati N, Nahas O, Ben Fadhel N, Ferrando L, Demoly P, Chiriac AM. Risk factors for positive paracetamol drug provocation testing and procedure optimization. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2045-2048.e2. [PMID: 30708142 DOI: 10.1016/j.jaip.2019.01.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/31/2018] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Dunya Nohra
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France; Equipe EPAR - IPLESP, UMR 1136 INSERM - Sorbonne Université, Paris, France
| | - Rik Schrijvers
- KU Leuven Department of Microbiology and Clinical Immunology, Laboratory of Clinical Immunology, Leuven, Belgium
| | - Nidhal Touati
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France
| | - Olga Nahas
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France
| | - Najah Ben Fadhel
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France; Department of Clinical Pharmacology, University Hospital of Fattouma Bourguiba, Monastir, Tunisia
| | - Laetitia Ferrando
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France
| | - Pascal Demoly
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France; Equipe EPAR - IPLESP, UMR 1136 INSERM - Sorbonne Université, Paris, France
| | - Anca-Mirela Chiriac
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University, Hospital of Montpellier, Montpellier, France; Equipe EPAR - IPLESP, UMR 1136 INSERM - Sorbonne Université, Paris, France.
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Schatz M, Sicherer SH, Zeiger RS. The Journal of Allergy and Clinical Immunology: In Practice 2017 Year in Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:328-352. [PMID: 29397373 DOI: 10.1016/j.jaip.2017.12.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/19/2017] [Indexed: 12/29/2022]
Abstract
An impressive number of clinically impactful studies and reviews were published in The Journal of Allergy and Clinical Immunology: In Practice in 2017. As a service to our readers, the editors provide this Year in Review article to highlight and contextualize the advances published over the past year. We include information from articles on asthma, allergic rhinitis, rhinosinusitis, immunotherapy, atopic dermatitis, contact dermatitis, food allergy, anaphylaxis, drug hypersensitivity, urticarial/angioedema, eosinophilic disorders, and immunodeficiency. Within each topic, epidemiologic findings are presented, relevant aspects of prevention are described, and diagnostic and therapeutic advances are enumerated. Treatments discussed include behavioral therapy, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We hope this review will help readers consolidate and use this extensive and practical knowledge for the benefit of patients.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif.
| | - Scott H Sicherer
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif
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36
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Kvisselgaard AD, Mosbech HF, Fransson S, Garvey LH. Risk of Immediate-Type Allergy to Local Anesthetics Is Overestimated-Results from 5 Years of Provocation Testing in a Danish Allergy Clinic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:1217-1223. [PMID: 28988784 DOI: 10.1016/j.jaip.2017.08.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/14/2017] [Accepted: 08/15/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Local anesthetics (LAs) are used in many health care settings and exposure during a lifetime is almost inevitable. Immediate-type allergy to LAs is considered rare among allergy experts but is commonly suspected by health care workers from other specialties, and by patients. OBJECTIVE The main aim of this study was to investigate the incidence of immediate-type allergy to LAs in our regional allergy clinic over the 5-year period 2010 to 2014. METHODS This was a retrospective single-center study of patients referred to a regional allergy clinic (excluding patients with perioperative reactions) with suspected immediate allergy to LAs, who had undergone subcutaneous provocation with 1 or more LAs. Patients were identified in the hospital clinical coding system and clinical information about the reaction and investigation results was obtained from their medical records. RESULTS A total of 164 patients (123 women/41 men; median age, 56 years; range, 7-89 years) who had 189 provocations with LAs were included over the 5-year period 2010 to 2014. All 164 patients had negative subcutaneous provocations to all 189 tests with LAs (95% CI, 0%-1.83%). Another allergen was identified in 10% (n = 17) of the patients. CONCLUSIONS None of the 164 patients with suspected immediate-type allergy to LAs reacted on provocation. Thus, no patients have been diagnosed with an immediate allergy to LAs in our regional allergy clinic in the 5-year period studied, and allergy to LAs must be considered very rare. Alternative mechanisms should be considered, but if symptoms are consistent with allergy, other potential allergens should be investigated.
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Affiliation(s)
- Ask D Kvisselgaard
- Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Holger F Mosbech
- Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Sara Fransson
- Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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37
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Soyer O, Sahiner UM, Sekerel BE. Pro and Contra: Provocation Tests in Drug Hypersensitivity. Int J Mol Sci 2017; 18:ijms18071437. [PMID: 28677662 PMCID: PMC5535928 DOI: 10.3390/ijms18071437] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 06/24/2017] [Accepted: 06/27/2017] [Indexed: 02/06/2023] Open
Abstract
Drug provocation test (DPT) is the controlled administration of a drug to diagnose immune- or non-immune-mediated drug hypersensitivity and the last step for accurate recognition of drug hypersensitivity reactions when the previous diagnostic evaluations are negative or unavailable. A DPT is performed only if other conventional tests fail to yield conclusive results. In each clinical presentation, "to provoke or not to provoke" a patient should be decided after careful assessment of the risk-benefit ratio. Well-defined benefits of DPT include confirmative exclusion of diagnoses of drug hypersensitivity and provision of safe alternatives. However, disadvantages such as safety, difficulty in interpretations of results, lack of objective biomarkers, risks of resensitization, efficiency in daily practice, and lack of standardized protocols, are poorly debated. This review summarizes the current published research concerning DPT, with particular emphasis on the advantages and disadvantages of DPT in an evidence-based manner.
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Affiliation(s)
- Ozge Soyer
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
| | - Umit Murat Sahiner
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
| | - Bulent Enis Sekerel
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
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