Acute generalized exanthematous pustulosis: a rare clinical entity with use of piperacillin/tazobactam

Piperacillin-Tazobactam Hypersensitivity: A Large, Multicenter Analysis

BACKGROUND

Piperacillin/tazobactam is a broad-spectrum penicillin. Hypersensitivity reactions are less commonly reported than with other penicillins except in patients with cystic fibrosis.

OBJECTIVE

Detailed clinical characterization of a patient cohort referred with suspected piperacillin-tazobactam hypersensitivity.

METHODS

Retrospective analysis of the demographic characteristics, clinical presentation, investigation, and management of 87 patients presenting to 5 European allergy centers. Patients underwent skin prick and intradermal testing with piperacillin/tazobactam, major (penicilloyl-polylysine) and minor (sodium penilloate) determinants, amoxicillin, benzylpenicillin, flucloxacillin, co-amoxiclav, clavulanic acid, and meropenem with immediate and, where appropriate, delayed reading of tests. Skin test-negative patients underwent drug provocation to piperacillin/tazobactam and/or other penicillins. A multistep protocol was used, depending on risk assessment.

RESULTS

Forty-eight of 87 (55%) patients were diagnosed with hypersensitivity to piperacillin/tazobactam with either positive skin or drug provocation test results, of whom 10 (21%) had a diagnosis of cystic fibrosis. Twenty-six (54%) patients presented with immediate and 22 (45%) with nonimmediate hypersensitivity. Patients with cystic fibrosis predominantly presented with nonimmediate hypersensitivity (70%). Reactions were severe in 52% of immediate reactors (Brown's anaphylaxis grade 3) and moderately severe (systemic involvement) in 75% of nonimmediate reactors. The number of patients with negative skin test results tolerating reintroduction was comparable in immediate (80%) and nonimmediate (88%) hypersensitivity. One-third of patients were cross-sensitized to other penicillins. The cross-sensitization pattern raised the possibility of tazobactam allergy in 3 patients. In 21 patients selectively sensitized to piperacillin/tazobactam (12 immediate, 9 nonimmediate), tolerance to other beta-lactams was demonstrated by drug provocation testing.

CONCLUSIONS

Piperacillin-tazobactam caused immediate and nonimmediate hypersensitivity with similar frequency. Most patients were selectively sensitized and tolerated other penicillins. Some patients may be allergic to the beta-lactamase inhibitor only.

Piperacillin/Tazobactam as Cause of Acute Generalized Exanthematous Pustulosis

Acute generalized exanthematous pustulosis (AGEP) is a rare cutaneous adverse reaction mainly attributed to antibiotics. It is characterized by numerous, nonfollicular, sterile pustules, arising on an exanthematous and edematous base. It is a serious adverse reaction accompanied by fever and leukocytosis. Piperacillin/tazobactam is indicated for the treatment of patients with moderate to severe infections. Herein is reported a case of AGEP caused by piperacillin/tazobactam. A 78-year-old woman with metastatic breast cancer was presented to the emergency department reporting fever and groin pain. The laboratory analysis and more specifically urine cultivation showed a urinary tract infection by E. coli with sensitivity to piperacillin/tazobactam. She had no known allergies. She was started on intravenous piperacillin/tazobactam; she improved clinically on the second day, but on the fourth day of intravenous therapy, she developed extensive pustular rash on the folds and anterior proximal thighs, accompanied by fever and neutrophilia. Piperacillin/tazobactam administration was interrupted and she was given prednisolone for ten days. The patient improved clinically and her laboratory tests returned to normal after two weeks. AGEP is an uncommon side effect of piperacillin/tazobactam treatment and there are few cases reported.

Delayed Cutaneous Hypersensitivity Reactions to Antibiotics: Management with Desensitization

Successful desensitization to mild to moderate delayed cutaneous adverse reaction to antibiotics has been described in a limited number of antibiotics and found to be safe. However, there are ample opportunities to standardize protocols for delayed cutaneous adverse reactions to antibiotics.

Piperacillin/Tazobactam-Associated Hypersensitivity Syndrome with Overlapping Features of Acute Generalized Exanthematous Pustulosis and Drug-Related Rash with Eosinophilia and Systemic Symptoms Syndrome

Acute generalized exanthematous pustulosis (AGEP) is a rare disorder characterized by acute onset of erythematous and edematous eruptions with sterile pustules, accompanied by fever, and a self-limiting condition thought to be caused by drugs, in particular, antibiotics. Drug-related rash with eosinophilia and systemic symptoms (DRESS) syndrome is a severe adverse drug-induced reaction, characterized by a generalized skin rash associated with hypereosinophilia, lymphocytosis, and internal organ involvement. These reactions differ in causative agents, as well as clinical presentation, prognosis, and treatment. Therefore, appropriate diagnostic measures should be rapidly undertaken. Herein, we described a patient who developed overlapping features of hypersensitivity syndromes, AGEP and DRESS, with the use of piperacillin and the beta-lactamase inhibitor sodium tazobactam. Coexistence of AGEP and DRESS in the same patient is quite rare. To the best of our knowledge, there have been no previous reports on the coexistence of AGEP and DRESS associated with piperacillin/tazobactam.