Type-I hypersensitivity to ceftriaxone and cross-reactivity with cefalexin and ampicillin

Cephalosporins' Cross-Reactivity and the High Degree of Required Knowledge. Case Report and Review of the Literature

Antibiotic cross-reactivity represents a phenomenon of considerable interest as well as antibiotic resistance. Immediate reactions to cephalosporins are reported in the literature with a prevalence of only 1%-3% of the population, while anaphylactic reactions are rarely described (approximately 0.0001%-0.1%) as well as fatalities. Allergic reaction to cephalosporins may occur because of sensitization to unique cephalosporin haptens or to determinants shared with penicillins. Cross-reactivity between cephalosporins represents, in fact, a well-known threatening event involving cephalosporins with similar or identical R1- or R2-side chains. The present report describes the case of a 79-year-old man who suddenly died after intramuscular administration of ceftriaxone. Serum dosage of mast cell tryptase from a femoral blood sample at 3 and 24 hours detected values of 87.7μg/L and 93.5μg/L, respectively (cut-off value 44.3 μg/L); the serum-specific IgE for penicillins, amoxicillin, cephaclor and also for the most common allergens were also determined. A complete post-mortem examination was performed, including gross, histological and immunohistochemical examination, with an anti-tryptase antibody. The cause of death was identified as anaphylactic shock: past administrations of cefepime sensitized the subject to cephalosporins and a fatal cross-reactivity of ceftriaxone with cefepime occurred due to the identical seven-position side chain structure in both molecules. The reported case offers food for thought regarding the study of cross-reactivity and the need to clarify the predictability and preventability of the phenomenon in fatal events.

Immunologic evaluation of immediate hypersensitivity to cefaclor

PURPOSE

Cefaclor is widely prescribed for various infectious diseases. As its consumption increases, the number of hypersensitivity reactions to cefaclor has increased. This study aimed to evaluate the immunologic findings of immediate hypersensitivity to cefaclor.

MATERIALS AND METHODS

We enrolled 47 patients with immediate hypersensitivity to cefaclor from Ajou University Hospital and Asan Medical Center. Serum specific IgE, IgG1, and IgG4 antibodies to cefaclor-human serum albumin (HSA) conjugate were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

The most common phenotype was anaphylaxis (Group I, 78.7%), followed by urticaria (Group II, 21.3%). The detection of specific IgE, IgG1, and IgG4 to cefaclor-HSA conjugate by ELISA tended to be higher in Group I (40.5%, 41.7%, 21.6%) than in Group II (20.0%, 20.0%, 0%) with no statistical significance. Significant associations were found between specific IgE and IgG1 or IgG4 (p<0.001, p=0.019). ELISA inhibition tests showed significant inhibitions by both free cefaclor and cefaclor-HSA conjugate. For basophil activation tests in patients having no specific IgE antibody, the CD63 expression level on basophils increased with incubations of free cefaclor.

CONCLUSION

The most common manifestation of immediate hypersensitivity to cefaclor was anaphylaxis, most of which was mediated by IgE; however, a non-IgE mediated direct basophil activation mechanism was suggested in a subset of anaphylaxis patients.

Immediate allergic reactions to cephalosporins: evaluation of cross-reactivity with a panel of penicillins and cephalosporins

BACKGROUND

Allergy to cephalosporins has mainly been evaluated in the context of patients with confirmed penicillin allergy. The problem of studying cross-reactivity in subjects primarily sensitized to cephalosporins and potentially allergic to penicillins has not been sufficiently addressed.

OBJECTIVE

To evaluate the in vitro IgE response and cross-reactivity to betalactams in patients with immediate allergic reactions to cephalosporins.

METHODS

The study included 24 patients with immediate allergic reactions to cephalosporins and RAST-positive to at least 1 cephalosporin. Skin testing and RAST were performed with a panel of penicillins and cephalosporins. RAST inhibition assay with different monomeric conjugates of penicillin and cephalosporin was performed to establish cross-reactivity.

RESULTS

The culprit cephalosporins were cefaclor (N = 7), cefonicid (N = 1), cefotaxime (N = 2), ceftazidime (N = 2), ceftriaxone (N = 3), and cefuroxime (N = 9). Two patients had a positive skin test result to penicillin determinants, and 22 patients had a negative result to penicillin determinants and tolerated benzylpenicillin administration. Of these 22, 19 had a positive skin test result to cephalosporins and divided into patients reacting only to the culprit cephalosporin (63.2%) and those reacting to more than 1 cephalosporin (36.8%). RAST and RAST inhibition studies confirmed that the side chain at the R1 position is crucial for recognition.

CONCLUSION

The R1 side chain rather than the betalactam structure, shared by penicillins and cephalosporins, seems to play a dominant role in determining the specificity of immunologic reactions to cephalosporins. Thus, penicillin can be administered safely to patients allergic to cephalosporins and with a negative skin test result to penicillin determinants.

Immediate allergic reactions to cephalosporins and penicillins and their cross-reactivity in children

Penicillins and cephalosporins are the most important betalactams inducing IgE-mediated reactions. The safety of administering cephalosporins to penicillin-allergic children is a particular problem, because cephalosporin allergenic determinants have not been properly identified. A study was undertaken to evaluate the frequency of anaphylactic reactions to cephalosporins and penicillins and their cross-reactivity in a pediatric population. A prospective survey was conducted in a group of 1170 children with suspected immediate allergic reactions to cephalosporins and/or penicillins, which were examined during a period of 8 yr. In vivo (skin tests and challenges) and in vitro tests (for specific IgE) were performed with standard concentration of penicillins and cephalosporins. When 1170 children with a clinical history of allergy to penicillins and/or cephalosporins were tested in vivo for immediate hypersensitivity to betalactams, 58.3% cases overall were found to be skin or challenge test positive. Among them, 94.4% patients were positive to penicillins and 35.3% to cephalosporins. The frequency of positive reactions in the in vivo testing was in the range from 36.4% to 88.1% for penicillins and from 0.3% to 29.2% for cephalosporins. However, 31.5% of the penicillin allergic children cross-reacted to some cephalosporin. If a child was allergic to a cephalosporin, the frequency of positive reactions to penicillin was 84.2%. The cross-reactivity between cephalosporins and penicillins varied between 0.3% and 23.9%. The cross-reactivity among different generations of cephalosporins varied between 0% and 68.8%, being the highest for first and second-generation cephalosporins and 0% for third generation cephalosporins. The frequency of immediate allergic reactions to cephalosporins is considerably lower compared to penicillins, and the degree of cross-reactivity between cephalosporins and penicillins depends on the generation of cephalosporins, being higher with earlier generation cephalosporins. The cross-reactivity among cephalosporins is lower compared to cross-reactivity between penicillins and cephalosporins.

Cefazolin Tolerance Does Not Predict Ceftriaxone Hypersensitivity: Unique Side Chains Precipitate Anaphylaxis

A 48-year-old woman with a questionable history of an unspecified ceftriaxone allergy was treated with cefazolin for surgical antibiotic prophylaxis. After she tolerated cefazolin therapy for 4 days, the medical staff concluded that her allergy history was inaccurate, and she was treated with intravenous ceftriaxone for suspected nosocomial pneumonia. Approximately 10 minutes after the start of the infusion, the patient experienced anaphylaxis. Initial symptoms of oral angioedema and laryngopharyngeal constriction progressed to dyspnea, tachypnea, hypotension, and tachycardia, all of which quickly resolved after immediate treatment with hydrocortisone, diphenhydramine, and epinephrine. Skin testing with cefazolin, cefepime, and ceftriaxone revealed that the likely allergic determinant mediating the patient's hypersensitivity reaction was the unique ceftriaxone R2 side chain and not the beta-lactam ring, which initially was suspected by the physician. Immunoglobulin E-mediated hypersensitivity reactions to cephalosporins may occur due to antibody complexes with the beta-lactam ring or various cephalosporin side chains. Misconceptions regarding the nature of cephalosporin allergies complicate antibiotic selection for patients with questionable allergy histories and may lead to inappropriate drug reexposure and anaphylaxis. Detailed understanding of the antigenic determinants that mediate hypersensitivity reactions is essential for clinicians to avoid type 1 reactions in patients with a suspected allergy to cephalosporins.