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Wang CC, Chen IC, Lin GC, Chen YM, Shen CH. Polymorphisms of HLA genes and hypersensitivity to penicillin among patients in a Taiwanese population. Int J Immunogenet 2024. [PMID: 38741273 DOI: 10.1111/iji.12678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/08/2024] [Accepted: 04/28/2024] [Indexed: 05/16/2024]
Abstract
Penicillin allergy is a potentially life-threatening condition that is common among patients. However, the genetic associations with penicillin allergy are not yet recognized for prevention or diagnosis, particularly in East Asian populations. We conducted a retrospective case-control study using data from the Taiwan Precision Medicine Initiative and analysing DNA samples to identify eight major MHC Class I and Class II loci. We employed imputation methods for accurate HLA typing and enrolled 17,827 individuals who received penicillin. Logistic regression analyses were utilized to explore associations between HLA genotypes, comorbidities and allergy risk, while simultaneously conducting a subgroup analysis to explore the association between HLA genotypes, comorbidities and the severity of allergic reactions. Our study assigned 496 cases to the penicillin allergy group and 4960 controls to a matched group. The risk of penicillin allergy was significantly higher with HLA-DPB1*05:01 (OR = 1.36, p = .004) and HLA-DQB1*05:01 (OR = 1.54, p = .03), with adjusted p-values of .032 and .24, respectively. Urticaria was identified as a separate risk factor (OR = 1.73, p < .001). However, neither the HLA alleles nor the comorbidities had a significant relationship with the risk of severe penicillin-induced allergy. HLA-DPB1*05:01 was found to be significantly associated with penicillin allergy reactions among the Taiwanese population.
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Affiliation(s)
- Chih-Chun Wang
- Department of Medical Education, Taichung Veterans General Hospital, Taichung, Taiwan
| | - I-Chieh Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Guan-Cheng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Ming Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Allergy, Immunology and Rheumatology, Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Biomedical Science and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Ching-Hui Shen
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan
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2
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Alqahtani AH, Jagpal P, Kudagammana T, Vedanthan PK, Krishnamurthy K, Hariharan S, El Shabrawy Mohamed Ali RM, Maharaj SB, Marriott JF, Krishna MT. Drug allergy management in Egypt, Sri Lanka and the Caribbean: A qualitative study. Clin Exp Allergy 2024; 54:231-233. [PMID: 38082508 DOI: 10.1111/cea.14437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/24/2023] [Accepted: 11/25/2023] [Indexed: 03/07/2024]
Affiliation(s)
- Abdulaziz H Alqahtani
- The School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
- College of Pharmacy, Taif University, Taif, Kingdom of Saudi Arabia
| | - Parbir Jagpal
- The School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Thushara Kudagammana
- Faculty of Medicine, University of Peradeniya, and Teaching hospital, Peradeniya, Sri Lanka
| | | | - Kandamaran Krishnamurthy
- The Queen Elizabeth Hospital, The University of West Indies, and ARS Medicae, Barbados, West Indies
| | - Seetharaman Hariharan
- Anaesthesia & Critical Care Medicine, The University of the West Indies, St. Augustine, Trinidad, West Indies
| | | | - Sandeep B Maharaj
- The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - John F Marriott
- The School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Mamidipudi Thirumala Krishna
- Institute of Immunology and Immunotherapy, University of Birmingham and Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundations Trust, Birmingham, UK
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3
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Cunha F, Cunha I, Gomes E. Safety of direct oral provocation test to delabel reported mild beta-lactam allergy in infants. Allergol Immunopathol (Madr) 2024; 52:10-15. [PMID: 38459885 DOI: 10.15586/aei.v52i2.887] [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: 04/11/2023] [Accepted: 11/30/2023] [Indexed: 03/11/2024]
Abstract
BACKGROUND Around 10% of people report a drug allergy and avoid some medications because of fear of allergic reactions. However, only after a proper diagnostic workup can some of these reactions be confirmed as allergic or nonallergic hypersensitivities. Beta-lactams (BLs) are the most common medication suspected of being involved in drug hypersensivity reactions (DHRs) in children. Recently, direct oral provocation tests (DPT) with BLs gained popularity within pediatric populations as a tool for delabeling children with suspected BL allergies. This study aimed to evaluate the safety of direct provocation tests in infants with mild cutaneous non-immediate reactions to BLs. METHODS The authors retrospectively analyzed the data of 151 infants between 2015 and 2022, referred for evaluating a suspected allergy to BLs that occurred before age 24 months. RESULTS The mean age of the children, including 55% male kids, at the suspected reaction was 15.9 months and the mean age at the time of the DPT was 39.6 months. In most cases, antibiotics were prescribed to treat common upper respiratory infections, such as acute otitis (54.3%) and acute tonsillitis (27.2%). Amoxicillin was considered the culprit drug in 62.9% of the cases, and the combination of amoxicillin-clavulanic acid in the case of 33.8% of children. The most frequent associated cutaneous clinical manifestations were maculopapular exanthema in 74.8% and delayed urticaria/angioedema in 25.2%. Of the 151 infants evaluated, parents of 149 infants agreed for a direct DPT, and only three had a positive test (2%). Symptoms resulting from the DPT were mild and easily treatable. CONCLUSIONS A direct DPT without prior tests is a safe and effective procedure to delabel BL allergy, even in infants. The authors wish to emphasize the importance of properly validating BL allergy suspicions by promoting appropriate diagnostic procedures in infants as, in most cases, DHRs can be excluded and there is no need for further therapeutic restrictions.
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Affiliation(s)
- Francisca Cunha
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal;
| | - Inês Cunha
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Eva Gomes
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
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4
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Bennett MR, Mathioudakis AG, Wu J, Chu MMH, Tontini C, Thomas I, Simpson A. Performance Characteristics of Basophil Activation Tests for Diagnosing Penicillin Allergy: A Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:714-723.e5. [PMID: 37940090 DOI: 10.1016/j.jaip.2023.11.004] [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: 04/16/2023] [Revised: 09/22/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Approximately 10% of the global population identify themselves as penicillin allergic, yet 90% are not truly allergic and could safely tolerate penicillin. There is no simple way to identify these people. Current in vitro diagnostics include specific immunoglobulin E (with a sensitivity of 19% and specificity of 97%) and a basophil activation test (BAT) with undefined sensitivity and specificity. OBJECTIVE To define the sensitivity and specificity of BAT in the diagnosis of penicillin allergy METHODS: We searched PubMed and EMBASE from inception to April 2, 2023, for original studies evaluating the performance characteristics of BAT for penicillin allergy in adults. Study selection, data extraction, risk of bias, assessment with QUADAS-2 tool, certainty assessment with Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology were performed independently, in duplicate. Meta-analysis was performed using Reitsma methodology. RESULTS Twenty-two studies fulfilled the inclusion criteria. Twelve used the same positive threshold giving a summary point sensitivity 51% (95% confidence interval [95% CI]46%-56%) and specificity 89% (95% CI 85%-93%). Significant risk of bias was identified owing to patient selection. GRADE certainty of evidence rated sensitivity very low due to imprecision and specificity as low. There was great heterogeneity in methods used. Use of 1,000 basophils per test did not improve performance above 500 basophils. CONCLUSIONS BAT sensitivity is highly variable across studies and remains too low to be considered as a routine element of clinical practice. BAT specificity is not as good as specific immunoglobulin E in penicillin allergy diagnosis. Significant further work is required in this field before clinical application of BAT in routine practice.
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Affiliation(s)
- Miriam R Bennett
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK.
| | - Alexander G Mathioudakis
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK; Manchester University NHS Foundation Trust, Respiratory and Allergy, Manchester, UK
| | - Jiakai Wu
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Michael M H Chu
- Manchester University NHS Foundation Trust, Otolaryngology, Manchester, UK
| | - Chiara Tontini
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Iason Thomas
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK; Manchester University NHS Foundation Trust, Respiratory and Allergy, Manchester, UK
| | - Angela Simpson
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK; Manchester University NHS Foundation Trust, Respiratory and Allergy, Manchester, UK
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5
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Pedersen K, van Schalkwyk J, Brewerton M, Jordan A, Cooke P. Penicillin cross-sensitivity in patients with confirmed peri-operative allergic hypersensitivity reactions to cefazolin: a retrospective observational study. Anaesthesia 2024; 79:208-210. [PMID: 37989486 DOI: 10.1111/anae.16185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 11/23/2023]
Affiliation(s)
- K Pedersen
- Te Toka Tumai Auckland, Auckland City Hospital, Auckland, New Zealand
| | - J van Schalkwyk
- Te Toka Tumai Auckland, Auckland City Hospital, Auckland, New Zealand
| | - M Brewerton
- Te Toka Tumai Auckland, Auckland City Hospital, Auckland, New Zealand
| | - A Jordan
- Te Toka Tumai Auckland, Auckland City Hospital, Auckland, New Zealand
| | - P Cooke
- Te Toka Tumai Auckland, Auckland City Hospital, Auckland, New Zealand
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Tuesuwan B, Buranapraditkun S, Arjharn W, Suthumchai N, Chongpison Y, Klaewsongkram J. Immunogenicity of cephalosporin components in non-IgE-mediated cephalosporin allergy. Clin Exp Allergy 2024; 54:156-158. [PMID: 38010885 DOI: 10.1111/cea.14429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/09/2023] [Accepted: 11/12/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Bodin Tuesuwan
- Department of Food and Pharmaceutical Chemistry, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Supranee Buranapraditkun
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Weena Arjharn
- Department of Food and Pharmaceutical Chemistry, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Nithikan Suthumchai
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yuda Chongpison
- Biostatistics Excellence Center, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Jettanong Klaewsongkram
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand
- King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Krishna MT, Liyanage G, Shrestha R, Jordan RE, Christopher DJ. An urgent need for capacity building towards establishment of drug allergy management systems in the Indian sub-continent. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 20:100320. [PMID: 38234704 PMCID: PMC10794096 DOI: 10.1016/j.lansea.2023.100320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/19/2023] [Accepted: 10/30/2023] [Indexed: 01/19/2024]
Affiliation(s)
- Mamidipudi Thirumala Krishna
- Institute of Immunology and Immunotherapy, University of Birmingham and Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Guwani Liyanage
- Department of Paediatrics, University of Sri Jayewardenepura, Colombo, Sri Lanka
| | - Rajeev Shrestha
- Department of Pharmacology, Kathmandu University School of Medical Sciences & Center for Infectious Disease Research and Surveillance, Dhulikhel Hospital, Kathmandu University Hospital, Kavre, Nepal
| | - Rachel E. Jordan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Kanannejad Z, Pourvali A, Esmaeilzadeh H, Shokouhi Shoormasti R, Reza Fazlollahi M, Fallahpour M, Zaremehrjardi F. Diagnosis and selection of alternative antibiotics in beta-lactams hypersensitivity reactions: Current recommendations and challenges. Int Immunopharmacol 2023; 122:110573. [PMID: 37413935 DOI: 10.1016/j.intimp.2023.110573] [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: 05/03/2023] [Revised: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023]
Abstract
Beta-lactam (BLM) antibiotics, including amino-penicillin and cephalosporins, are typically the first-choice treatment for bacterial infections. However, adverse reactions to these antibiotics are frequently reported, causing non-allergist physicians to select alternative broad-spectrum antibiotics that can have harmful consequences. Patients with unclear histories of hypersensitivity reactions to BLMs should undergo an allergy workup to establish a firm diagnosis, particularly when different drugs are prescribed simultaneously. However, finding the safest, most precise, and cost-effective methods for confirming BLMs hypersensitivity and selecting the most appropriate alternative BLM is uncertain, particularly in severe delayed reactions. This review aims to provide data and recommendations on the availability and validity of skin tests (STs), drug provocation test (DPT) protocols, based on the latest published literature and guideline. To make the process more practical, we focused on cross-reactivity between BLMs and diagnostic tests. There are two main novel aspects of this document: 1) For T-cell-mediated reactions, patient stratification into high, moderate, and low-risk groups based on the mortality and morbidity of adverse drug reactions. 2) For IgE-mediated reactions, stratification of individuals with isolated limited urticarial without anaphylaxis in a low-risk group and removal of the extensive limitation.
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Affiliation(s)
- Zahra Kanannejad
- Allergy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Pourvali
- Department of Pediatrics, School of Medicine, Arak University of Medical Sciences, Arak, Iran
| | - Hossein Esmaeilzadeh
- Allergy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Allergy and Clinical Immunology, Namazi Hospital, Shiraz, Iran.
| | - Raheleh Shokouhi Shoormasti
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical, Sciences, Tehran, Iran
| | - Mohammad Reza Fazlollahi
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical, Sciences, Tehran, Iran
| | - Morteza Fallahpour
- Department of Allergy and Clinical Immunology, Rasoole- Akaram Medical Research Development Center (RCRDC), School of Medicine, Iran University of Medical Science, Tehran, Iran
| | - Fatemeh Zaremehrjardi
- Allergist and Clinical Immunologist, Clinical Research Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Iran
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9
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Gao C, Ma B, Liu W, Zhu L. The state and consideration for skin test of β-lactam antibiotics in pediatrics. Front Cell Infect Microbiol 2023; 13:1147976. [PMID: 37396306 PMCID: PMC10308085 DOI: 10.3389/fcimb.2023.1147976] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/23/2023] [Indexed: 07/04/2023] Open
Abstract
β-lactam antibiotics are the most frequently used drugs and the most common drugs that cause allergic reactions in pediatrics. The occurrence of some allergic reactions can be predicted by skin testing, especially severe adverse reactions such as anaphylactic shock. Thus, penicillin and cephalosporin skin tests are widely used to predict allergic reactions before medication in pediatrics. However, false-positive results from skin tests were more often encountered in pediatrics than in adults. In fact, many children labeled as allergic to β-lactam are not allergic to the antibiotic, leading to the use of alternative antibiotics, which are less effective and more toxic, and the increase of antibiotic resistance. There has been controversy over whether β-lactam antibiotics should be tested for skin allergies before application in children. Based on the great controversy in the implementation of β-lactam antibiotic skin tests, especially the controversial cephalosporin skin tests in pediatrics, the mechanism and reasons of anaphylaxis to β-lactam antibiotics, the significance of β-lactam antibiotic skin tests, the current state of β-lactam antibiotic skin tests at home and abroad, and the problems of domestic and international skin tests were analyzed to determine a unified standard of β-lactam antibiotic skin tests in pediatrics to prevent and decrease adverse drug reactions, avoid waste of drugs, and a large amount of manpower and material resource consumption.
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Affiliation(s)
- Chunhui Gao
- Department of Pharmacy, Tianjin Children's Hospital (Children's Hospital of Tianjin University), Tianjin, China
| | - Bowen Ma
- Department of Pharmacy, Cangzhou People's Hospital, Cangzhou, Hebei, China
| | - Wei Liu
- Tianjin Children's Hospital (Children's Hospital of Tianjin University), Tianjin, China
| | - Liqin Zhu
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, China
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Powell N, Stephens J, Kohl D, Owens R, Ahmed S, Musicha C, Upton M, Kent B, Tonkin-Crine S, Sandoe J. The effectiveness of interventions that support penicillin allergy assessment and delabeling of adult and pediatric patients by nonallergy specialists: a systematic review and meta-analysis. Int J Infect Dis 2023; 129:152-161. [PMID: 36450321 PMCID: PMC10017351 DOI: 10.1016/j.ijid.2022.11.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Penicillin allergy records are often incorrect and may result in harm. We aimed to systematically review the effectiveness and safety of nonallergist health care worker delivery of penicillin allergy delabeling. METHODS We searched EMBASE/MEDLINE/CINAHL (Ovid), PsycInfo, Web of Science, and Cochrane CENTRAL from inception to January 21, 2022 and unpublished studies and gray literature. The proportion of patients allergic to penicillin delabeled and harmed was calculated using random-effects models. RESULTS Overall, 5019 patients were delabeled. Using allergy history alone, 14% (95% confidence interval [CI], 9-21%) of 4350 assessed patients were delabeled without reported harm. Direct drug provocation testing resulted in delabeling in 27% (95% CI, 18-37%) of 4207 assessed patients. Of the 1373 patients tested, 98% were delabeled (95% CI, 97-99%), and nonserious harm was reported in 1% (95% CI, 0-2%). Using skin testing, followed by drug provocation testing, 41% (95% CI, 24-59%) of 2890 assessed patients were delabeled. Of the 1294 tested patients, 95.0% (95% CI, 90-99%) were delabeled, and the reported harm was low (0%; (95% CI 0-1%). CONCLUSION Penicillin allergy delabeling by nonallergists is efficacious and safe. The proportion of assessed patients who can be delabeled increases with the complexity of testing method, but substantial numbers can be delabeled without skin testing.
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Affiliation(s)
- Neil Powell
- Pharmacy Department, Royal Cornwall Hospital, Truro, United Kingdom TR1 3LJ / School of Biomedical Sciences, University of Plymouth, Plymouth, United Kingdom.
| | - Jennie Stephens
- Intensive Care Department, Royal Cornwall Hospital, Truro, United Kingdom
| | - Declan Kohl
- School of Biomedical Sciences, University of Leeds, Leeds, United Kingdom
| | - Rhys Owens
- Core Medical Trainee, Royal Cornwall Hospital, Truro, United Kingdom
| | - Shadia Ahmed
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Crispin Musicha
- Medical Statistics, Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - Mathew Upton
- School of Biomedical Sciences, University of Plymouth, Plymouth, United Kingdom
| | - Bridie Kent
- School of Nursing and Midwifery, University of Plymouth, Plymouth, United Kingdom
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jonathan Sandoe
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
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Marietti R, Bianchi L, Hansel K, Casciola G, Biondi F, Tramontana M, Stingeni L. Multiple allergy to cephalosporins confirmed by patch test: From the first to the fifth generation. Contact Dermatitis 2023; 88:487-490. [PMID: 36855909 DOI: 10.1111/cod.14301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/15/2023] [Accepted: 02/25/2023] [Indexed: 03/02/2023]
Affiliation(s)
- Rossella Marietti
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Leonardo Bianchi
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Katharina Hansel
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Gabriele Casciola
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Filippo Biondi
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Marta Tramontana
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Luca Stingeni
- Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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12
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Bennett M, Tsoumani M, Thomas I, Liau JL, Azmi S, Marinho S. Towards a safe and efficient de-labelling penicillin allergy service by non-allergists. Clin Exp Allergy 2023; 53:378-379. [PMID: 36629095 DOI: 10.1111/cea.14271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 12/10/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Miriam Bennett
- Allergy Centre, Wythenshawe Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Marina Tsoumani
- Allergy Centre, Wythenshawe Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Iason Thomas
- Allergy Centre, Wythenshawe Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Jia Li Liau
- Allergy Centre, Wythenshawe Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Samia Azmi
- Allergy Centre, Wythenshawe Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Susana Marinho
- Allergy Centre, Wythenshawe Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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13
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Addressing the Challenges of Penicillin Allergy Delabeling With Electronic Health Records and Mobile Applications. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:414-421. [PMID: 36356924 DOI: 10.1016/j.jaip.2022.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/29/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022]
Abstract
Allergy labels are common, often incorrect, and potentially harmful. There are many opportunities for clinical decision support (CDS) tools integrated in the electronic health record (EHR) and mobile apps to address the challenges with drug allergy management, including penicillin allergy delabeling (PADL). Effective delabeling solutions must consider multidisciplinary clinical workflow and multistep processes, including documentation, assessment, plan (eg, allergy testing and referral), record update, drug allergy alert management, and allergy reconciliation over time. Developing a systematic infrastructure to manage allergies across the EHR is critical to improve the accuracy and completeness of a patient's allergy and avoid inadvertently relabeling. Improving the appropriateness and relevancy of drug allergy alerts is important to reduce alert fatigue. Using alerts to guide clinicians on appropriate antibiotic use may reduce unnecessary β-lactam avoidance. To date, EHR CDS tools have facilitated non-allergists to provide PADL at the point of care. A mobile app was shown to support PADL and provide specialist support and education. Future research is needed to standardize, integrate, and evaluate innovative CDS tools in the EHR to demonstrate patient safety and clinical utility and facilitate wider adoption.
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Kan AKC, Hui HKS, Li TS, Chiang V, Wong JCY, Chan TS, Kwan IYK, Shum WZ, Yeung MSC, Au EYL, Ho CTK, Lau CS, Li PH. Comparative Effectiveness, Safety, and Real-World Outcomes of a Nurse-Led, Protocol-Driven Penicillin Allergy Evaluation From the Hong Kong Drug Allergy Delabelling Initiative (HK-DADI). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:474-480.e2. [PMID: 36126867 DOI: 10.1016/j.jaip.2022.08.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/13/2022] [Accepted: 08/31/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a high prevalence of unconfirmed penicillin allergy, which is associated with a multitude of adverse clinical outcomes. With the overwhelming burden of currently incorrect labels and the lack of allergy specialist services, new delabeling strategies are urgently needed. OBJECTIVE To assess the effectiveness, safety, and real-world outcomes of a nurse-led, protocol-driven evaluation of penicillin allergy, the Hong Kong Drug Allergy Delabelling Initiative (HK-DADI). METHODS Adult patients with suspected penicillin allergy were recruited into HK-DADI. Allergy and postdelabeling outcomes were retrospectively compared between patients evaluated via HK-DADI or traditional allergist evaluation. RESULTS A total of 312 completed penicillin allergy evaluation: 84 (27%) and 228 (73%) via HK-DADI and traditional pathways, respectively. Overall, 280 penicillin allergies were delabeled (90%). The delabeling rate between HK-DADI and traditional pathways was similar (90% vs 89%; P = .796). Among patients of the HK-DADI pathway, the delabeling rate was significantly higher among low-risk (LR) compared with non-LR patients (97% vs 77%; P = .010). Skin tests did not add diagnostic value among LR patients. No patients developed severe or systemic reactions during the evaluation. Upon 6- to 12-month follow-up (median, 10 months), 123 patients experienced infective episodes (44%) and 63 used penicillins again after delabeling (23%). This proportion was significantly higher in patients who were delabeled via HK-DADI compared with the traditional pathway (32% vs 19%; P = .026). CONCLUSIONS The Hong Kong Drug Allergy Delabelling Initiative, a nurse-led, protocol-driven evaluation, was safe and effective in penicillin allergy delabeling. It led to an even higher rate of future penicillin use after delabeling and mitigated the need for unnecessary skin testing among LR patients.
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Affiliation(s)
- Andy K C Kan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Harris K S Hui
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Tin Sum Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Jane C Y Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Tik Suet Chan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Ian Y K Kwan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wing Zi Shum
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Matthew S C Yeung
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Elaine Y L Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Carmen T K Ho
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
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15
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Hofmeier KS, Bircher AJ. [Isolated Tongue Swelling after Penicillin and Negative Allergy Workup - All Done and Dusted?]. Laryngorhinootologie 2023. [PMID: 36693385 DOI: 10.1055/a-1949-2916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
| | - Andreas J Bircher
- Allergologie, Dermatologie, Universitätsspital Basel, Schweiz.,Facoltà di scienze biomediche, Università della Svizzera italiana, Lugano, Schweiz
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16
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Beta-lactam allergy and drug challenge test in children: a systematic review and meta-analysis. Pediatr Res 2023; 93:22-30. [PMID: 35449396 DOI: 10.1038/s41390-022-02076-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Most cases of beta-lactam allergy in children are likely to be mislabeled. This study aimed to assess the prevalence of true positives, as determined by drug challenge tests, and the rate of false negatives in children with suspected allergies and confirm the safety of the drug challenge test. METHODS We conducted a systematic review and meta-analysis according to established procedures. Study participants were children with suspected beta-lactam allergy who underwent a drug challenge. PubMed MEDLINE, Dialog EMBASE, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform, and clinicaltrials.gov were searched from inception until March 5, 2021. RESULTS The pooled prevalence of (a) positive results in the first challenge was 0.049 (95% CI, 0.041-0.057; I2 = 71%) from 78 studies; (b) serious adverse events was 0.00 (95% CI, 0.00-0.00; I2 = 0.0%) from 62 studies; and (c) positive results in the second challenge after the first negative result was 0.028 (95% CI, 0.016-0.043; I2 = 38%) from 18 studies. CONCLUSIONS The prevalence of children with suspected beta-lactam allergy with true-positive results and false-negative results from the drug challenge test was very low. Serious adverse events resulting from drug challenge tests were also very rare. IMPACT Most children with suspected beta-lactam allergy were likely to be mislabeled. Serious adverse events caused by the drug challenge test were rare. Few false-negative results were obtained from the drug challenge test.
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17
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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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18
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Powell N, Upton M, Kent B, Tonkin-Crine S, Sandoe J. Is penicillin allergy de-labelling about to find its place in UK antimicrobial stewardship strategy? Clin Med (Lond) 2023; 23:76-77. [PMID: 36650063 PMCID: PMC11046535 DOI: 10.7861/clinmed.2022-0518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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19
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Maduemem K, Clark H, Sohal I, Dawson T, Makwana N. Barriers to paediatric penicillin allergy de-labelling in UK secondary care: a regional survey. Arch Dis Child 2022; 108:363-366. [PMID: 36535750 DOI: 10.1136/archdischild-2022-324564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Incorrect penicillin allergy labels result in the use of inappropriately broad-spectrum antibiotics. De-labelling inaccurate penicillin allergy promotes antimicrobial stewardship and optimises prescribing practices. The objectives were to evaluate paediatric clinicians' knowledge and understanding of penicillin allergy and to identify barriers in tackling incorrect penicillin allergy labels. METHODS Paediatric clinicians from across the West Midlands of the UK were surveyed using an online, anonymised questionnaire between 1 August and 30 September 2021. Domains explored were (1) approach to penicillin allergy clinical vignettes, (2) knowledge of the impact of penicillin allergy labels, (3) frequency of allergy-focused history questions and (4) barriers in tackling incorrect penicillin allergy. RESULTS Responses were received from 307 paediatric clinicians across 12 hospitals. Sixty-one per cent would not prescribe a penicillin-based antibiotic if a family history of penicillin allergy was reported. There was an overall deficit in taking an allergy-focused history with only 36.5% inquiring about diagnostic confirmation. Absence, or lack of awareness of a referral pathway for antibiotic allergy evaluation (58.6%) and unfamiliarity of the indications for oral provocation testing (55%) were the most common reported barriers to penicillin allergy de-labelling. Fifty-one per cent would rather 'play it safe' than explore penicillin allergy confirmation as it is felt that alternative treatments were readily available. CONCLUSIONS The deficiency in antibiotic allergy-focused history among paediatric clinicians highlights the need for better allergy education across all clinical grades. Pragmatic algorithms and clear referral pathways could address barriers faced by non-allergists in de-labelling incorrect penicillin allergy.
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Affiliation(s)
- Kene Maduemem
- Emergency department, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Hannah Clark
- Paediatrics, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Iseult Sohal
- Paediatrics, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Tom Dawson
- Paediatrics, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Niten Makwana
- Department of Paediatrics, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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20
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Romano A, Valluzzi RL, Gaeta F, Caruso C, Zaffiro A, Quaratino D, Ebo D, Sabato V. The Combined Use of Chronological and Morphological Criteria in the Evaluation of Immediate Penicillin Reactions: Evidence From a Large Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3238-3248.e2. [PMID: 36108927 DOI: 10.1016/j.jaip.2022.08.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 08/10/2022] [Accepted: 08/26/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Immediate hypersensitivity reactions to penicillins are often labeled on the basis of a similar set of symptoms, but a key feature of these reactions that can be reproduced in diagnostic testing may be the timing of a reaction in relation to the dose administration. OBJECTIVE To determine whether the timing of a reaction in response to the last dose of a penicillin would predict the results of diagnostic testing. METHODS We evaluated 1074 patients by performing skin tests, serum specific IgE assays (ImmunoCAP), and challenges. Patients who were evaluated by us more than 6 months after their reactions and found negative were reevaluated within 2 to 4 weeks. RESULTS Patients who had reacted within 1 hour after the first dose, within 1 hour after subsequent doses, more than 1 hour to within 6 hours after the first dose, or more than 1 hour to within 6 hours after subsequent doses were classified as group A (758 individuals), B (92), C (67), or D (157), respectively. Penicillin hypersensitivity was diagnosed in 707 patients (65.8%) by skin tests (407 patients, 57.6%), ImmunoCAP (47, 6.6%), both tests (232, 32.8%), or challenges (21, 3%). A conversion to allergy-test positivity occurred in 7 of 10 patients with anaphylactic reactions and in 1 of 28 patients with other reactions who were reevaluated after negative challenges. The rate of penicillin-allergic patients in groups A, B, C, and D was 85%, 35.9%, 35.8%, and 3.8%, respectively. Only 1 of 107 patients reporting cutaneous reactions lasting more than 1 day had positive results to allergy tests. CONCLUSIONS IgE-mediated hypersensitivity can be diagnosed by skin tests in about 70% of subjects who react within 1 hour (eg, patients from groups A and B). This hypersensitivity can be lost over time, as demonstrated by the negativization of allergy tests in follow-up studies. In subjects with anaphylactic reactions, however, it is advisable to not consider this phenomenon definitive. In fact, a conversion to allergy test positivity can be observed in up to 20% of such subjects retested after negative challenges.
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Affiliation(s)
| | - Rocco Luigi Valluzzi
- Department of Pediatrics, Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Vatican City, Italy
| | - Francesco Gaeta
- Allergy Unit, Columbus Hospital, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Cristiano Caruso
- Allergy Unit, Columbus Hospital, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | | | - Didier Ebo
- Immunology-Allergology-Rheumatology, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Vito Sabato
- Immunology-Allergology-Rheumatology, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
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21
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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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22
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Mabilat C, Gros MF, Van Belkum A, Trubiano JA, Blumenthal KG, Romano A, Timbrook TT. Improving antimicrobial stewardship with penicillin allergy testing: a review of current practices and unmet needs. JAC Antimicrob Resist 2022; 4:dlac116. [PMID: 36415507 PMCID: PMC9675589 DOI: 10.1093/jacamr/dlac116] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Penicillin allergy, the most frequently reported drug allergy, has been associated with suboptimal antibiotic therapy, increased antimicrobial resistance, increased rates of Clostridioides difficile colonization and infection, as well as extended hospital length of stay and increased cost. Although up to 10% of all patients may report penicillin allergy, most penicillin allergies are not confirmed. As such, most patients with a penicillin allergy can still safely use penicillin and related drugs following a more precise assessment. Herein, we review the current practices and unmet needs in penicillin allergy testing. The diagnostic algorithm is mostly based on a clinical history assessment followed by in vivo testing, i.e. skin test and/or drug challenge. As these tests are labour and resource intensive, there is increased interest in point-of-care penicillin allergy de-labelling solutions incorporated into Antimicrobial Stewardship Programmes including digital assessment tools. These can be locally parameterized on the basis of characteristics of target populations, incidence of specific allergies and local antibiotic usage to perform clinical risk stratification. Safely ruling out any residual risk remains essential and in vivo drug challenge and/or skin testing should be systematically encouraged. Gradual understanding and convergence of the risk stratification of the clinical presentation of penicillin allergy is enabling a wider implementation of this essential aspect of antimicrobial stewardship through digitalized decision tools and in vivo testing. More research is needed to deliver point of care in vitro diagnostic tools to democratize this de-labelling practice, which would be highly beneficial to patient care. This progress, together with better education of patients and clinicians about the availability, efficacy and safety of penicillin allergy testing, will increase the dissemination of penicillin allergy assessment as an important component of Antimicrobial Stewardship Programmes.
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Affiliation(s)
| | - Marie-Françoise Gros
- bioMérieux, Medical Affairs, 100 Rue Louis Pasteur, F-69280 Marcy l'Etoile, France
| | - Alex Van Belkum
- Current address:BaseClear, Sylviusweg 74, 2333 BE Leiden, The Netherlands
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, 145 Studley Road, Heidelberg, Victoria, 3084Australia
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | | | - Tristan T Timbrook
- bioMérieux, BioFire Diagnostics, Global Medical Affairs, 515 Colorow Drive, Salt Lake City, UT 84108, USA
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23
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Copaescu AM, Ben-Shoshan M, Trubiano JA. Tools to improve the diagnosis and management of T-cell mediated adverse drug reactions. Front Med (Lausanne) 2022; 9:923991. [PMID: 36313986 PMCID: PMC9606226 DOI: 10.3389/fmed.2022.923991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/26/2022] [Indexed: 11/25/2022] Open
Abstract
Delayed drug T-cell immune-mediated hypersensitivity reactions have a large clinical heterogeneity varying from mild maculopapular exanthema (MPE) to severe cutaneous adverse reactions (SCARs) such as acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS) and severe skin necrosis and blistering as seen in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Given the knowledge gaps related to the immunopathogenesis of these conditions, the absence of validated diagnostic tools and the significant associated morbidity and mortality, patients with SCARs often have limited drug choices. We performed a comprehensive review aiming to evaluate in vivo diagnostic tools such as delayed intradermal skin and patch testing and ex vivo/in vitro research assays such as the lymphocyte transformation test (LTT) and the enzyme-linked ImmunoSpot (ELISpot) assay. We searched through PubMed using the terms “drug allergy,” “in vivo” and “ex vivo” for original papers in the last 10 years. A detailed meticulous approach adapted to the various clinical phenotypes is recommended for the diagnostic and management of delayed drug hypersensitivity reactions. This review highlights the current diagnostic tools for the delayed drug hypersensitivity phenotypes.
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Affiliation(s)
- Ana Maria Copaescu
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia,Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre (MUHC), Montreal, QC, Canada,The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), Montreal, QC, Canada,*Correspondence: Ana Maria Copaescu,
| | - Moshe Ben-Shoshan
- The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), Montreal, QC, Canada,Division of Allergy, Immunology and Dermatology, Montreal Children’s Hospital, McGill University Health Centre (MUHC), Montreal, QC, Canada
| | - Jason A. Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia,Department of Oncology, Sir Peter MacCallum Cancer Centre, The University of Melbourne, Parkville, VIC, Australia,Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, VIC, Australia,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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24
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Savic L, Ardern-Jones M, Avery A, Cook T, Denman S, Farooque S, Garcez T, Gold R, Jay N, Krishna MT, Leech S, McKibben S, Nasser S, Premchand N, Sandoe J, Sneddon J, Warner A. BSACI guideline for the set-up of penicillin allergy de-labelling services by non-allergists working in a hospital setting. Clin Exp Allergy 2022; 52:1135-1141. [PMID: 36128691 DOI: 10.1111/cea.14217] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/13/2022] [Accepted: 06/30/2022] [Indexed: 01/26/2023]
Abstract
The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and a committee of experts and key stakeholders have developed this guideline for the evaluation and testing of patients with an unsubstantiated label of penicillin allergy. The guideline is intended for UK clinicians who are not trained in allergy or immunology, but who wish to develop a penicillin allergy de-labelling service for their patients. It is intended to supplement the BSACI 2015 guideline "Management of allergy to penicillin and other beta-lactams" and therefore does not detail the epidemiology or aetiology of penicillin allergy, as this is covered extensively in the 2015 guideline (1). The guideline is intended for use only in patients with a label of penicillin allergy and does not apply to other beta-lactam allergies. The recommendations include a checklist to identify patients at low risk of allergy and a framework for the conduct of drug provocation testing by non-allergists. There are separate sections for adults and paediatrics within the guideline, in recognition of the common differences in reported allergy history and likelihood of true allergy.
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Affiliation(s)
- Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Michael Ardern-Jones
- Faculty of Medicine, University of Southampton, Southamptom, UK.,Department of Dermatology, University Hospitals Southampton NHS Foundation Trust, Southamptom, UK
| | - Anthony Avery
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tim Cook
- Department of Anaesthesia and Intensive Care, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Sarah Denman
- Medicines Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sophie Farooque
- Department of Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Tomaz Garcez
- Dept of Immunology, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Nicola Jay
- Department of Paediatric Allergy, Sheffield Childrens NHS Foundation Trust, Sheffield, UK
| | - Mamidipudi Thirumala Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Sue Leech
- Department of Paedaitric Allergy, Kings College Hospital NHS Foundation Trust, London, UK
| | - Shauna McKibben
- Department of Asthma and Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Nikhil Premchand
- Department of Clinical Infection, Northumbria Healthcare NHS Foundation Trust, Newcastle, UK
| | - Jonathan Sandoe
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK.,Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline Sneddon
- British Society for Antimicrobial Chemotherapy, Birmingham, UK.,Health Improvement Scotland, Glasgow, UK
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25
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Atakul G, Köse SŞ, Atay O, Boyacıoglu OK, Al S, Asilsoy S, Uzuner N, Karaman O. Oral Challenge without Penicillin Skin Tests in Children with Suspected Beta-Lactam Hypersensitivity. JOURNAL OF CHILD SCIENCE 2022. [DOI: 10.1055/s-0042-1757151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Abstract
Objective A misdiagnosed “penicillin allergy” is a common problem in childhood. Recently, skipping skin tests (STs) and performing a direct oral challenge test (OCT) have become an increasingly common approach in children with suspected β-lactam (BL) allergy. In our study, we aimed to evaluate the safety and efficacy of OCT without using ST in children who had a history of hypersensitivity reactions with BL antibiotics.
Materials and Methods We retrospectively evaluated direct OCT outcomes in children with both nonimmediate and immediate-type reaction history with BL antibiotics. STs were not performed before the challenge test. The patients were monitored for 4 hours after the challenge and continued using the drug in two divided doses for 3 days at home.
Results In this study, 72 patients were included, with median age of 7 years (interquartile range: 4; min: 1 year to max: 16 years), and of these, 56% were male. Forty-five subjects (63%) reported immediate-type adverse reactions. The most common clinical manifestation was urticaria/angioedema (51%, n: 37) and maculopapular exanthema in 46% (n: 33) of patients, respectively. The most commonly suspected drug was 71% amoxicillin-clavulanate. A 3-day OCT without preceding ST was performed in all patients. Only three patients (4.2%) showed a positive response to the oral drug challenge test. None of these reactions observed was more severe than index reactions.
Conclusion Performing OCT without STs is a safe and convenient method to exclude BL hypersensitivity in the pediatric age group.
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Affiliation(s)
- Gizem Atakul
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Seda Şirin Köse
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Ozge Atay
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Ozge Kangallı Boyacıoglu
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Serdar Al
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Suna Asilsoy
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Nevin Uzuner
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Ozkan Karaman
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
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Li PH, Wong JCY, Chan JMC, Chik TSH, Chu MY, Ho GCH, Leung WS, Li TCM, Ng YY, Shum R, Sin WWY, Tso EYK, Wu AKL, Au EYL. Hong Kong Drug Allergy Delabelling Initiative (HK-DADI) consensus statements for penicillin allergy testing by nonallergists. FRONTIERS IN ALLERGY 2022; 3:974138. [PMID: 36133403 PMCID: PMC9483020 DOI: 10.3389/falgy.2022.974138] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Penicillin allergy testing has been traditionally performed by allergists, but there remains a huge deficit of specialists. A multidisciplinary effort with nonallergists would be invaluable to overcome the magnitude of penicillin allergy labels via the Hong Kong Drug Allergy Delabelling Initiative (HK-DADI). These consensus statements (CSs) offer recommendations and guidance to enable nonallergists to screen for low-risk (LR) patients and perform penicillin allergy testing. Methods CSs were formulated by the HK-DADI Group using the Delphi method. An agreement was defined as greater than or equal to 80% consensus. Results A total of 26 CSs reached consensus after multiple rounds of Delphi. CSs were categorized into risk assessment, skin testing, drug provocation testing (DPT), and post-testing management. For risk assessment, the essentials of allergy history and exclusion criteria were detailed. Patients with only LR features can proceed with testing by nonallergists. Skin tests should be performed prior to DPT. Details regarding the timing, preparation, and interpretation of skin tests were elaborated. DPT remains the gold standard to diagnose genuine allergy or tolerance and should be performed when there is a low pretest probability following negative skin testing. Details of DPT preparations, dosing protocols, and interpretation were elaborated. For post-testing management, inaccurate allergy labels should be delabeled following negative DPT with proper patient counseling. Conclusion CSs support penicillin allergy testing by nonallergists in Hong Kong. LR cases can be managed by nonallergists at Spoke Clinics, with training and support of an allergist-led Hub.
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Affiliation(s)
- Philip H. Li
- Division of Rheumatology & Clinical Immunology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
- Correspondence: Philip H. Li
| | - Jane C. Y. Wong
- Division of Rheumatology & Clinical Immunology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Jacky M. C. Chan
- Division of Infectious Diseases, Department of Medicine & Geriatrics, Kwong Wah Hospital, Hong Kong SAR, China
| | - Thomas S. H. Chik
- Division of Infectious Diseases, Department of Medicine & Geriatrics, Kwong Wah Hospital, Hong Kong SAR, China
| | - M. Y. Chu
- Division of Infectious Diseases, Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Grace C. H. Ho
- Division of Rheumatology, Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - W. S. Leung
- Division of Infectious Diseases, Department of Medicine & Geriatrics, Kwong Wah Hospital, Hong Kong SAR, China
| | - Timothy C. M. Li
- Division of Infectious Diseases, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Y. Y. Ng
- Division of Infectious Diseases, Department of Medicine & Geriatrics, Tuen Mun Hospital, Hong Kong SAR, China
| | - Rocky Shum
- Division of Microbiology, Department of Clinical Pathology, Tuen Mun Hospital, Hong Kong SAR, China
| | - Winnie W. Y. Sin
- Division of Infectious Diseases, Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR, China
| | - Eugene Y. K. Tso
- Division of Infectious Diseases, Department of Medicine & Geriatrics, United Christian Hospital, Hong Kong SAR, China
| | - Alan K. L. Wu
- Division of Microbiology, Department of Clinical Pathology, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Elaine Y. L. Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China
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McLaughlin DJ, Grayson M, Toth C. Quality Improvement to Engage General Pediatrics in Reducing Inaccurate Penicillin Allergy Labels. Acad Pediatr 2022; 22:1175-1183. [PMID: 35644367 DOI: 10.1016/j.acap.2022.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/21/2022] [Accepted: 05/23/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To remove inaccurate penicillin allergy labels in the general pediatric clinic setting. METHODS From October 2017 through December 2021, this collaborative, quality improvement project used education, feedback, electronic health record alerts, and the introduction of oral amoxicillin challenges in a general pediatric clinic setting with the primary aim of decreasing the proportion of penicillin allergy labeled patients. Control charts were used to track the relationship between interventions and improvements in referral rates to allergy clinic, removal of the allergy label at clinic visits and the overall proportion of clinic patients labeled as PCN allergic. RESULTS Referral rates to allergy clinic for penicillin allergy labeled patients increased from a baseline mean of 1.9% to 20.4%. The proportion of PCN allergy labeled patients who had the label removed during a pediatric clinic visit increased from a baseline of 1.1% to 6.6%. The overall proportion of penicillin allergy labeled clinic patients decreased from a baseline of 3.4% to 2.2%. CONCLUSION With adequate education and collaboration with allergists, general pediatric practitioners can play a significant role in removing inaccurate penicillin allergy labels. Pediatricians can remove some of the burden placed on allergists by evaluating low risk patients in the primary care setting while referring higher risk patients to the specialist.
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Affiliation(s)
- Douglas J McLaughlin
- Division of Primary Care Pediatrics Nationwide Children's Hospital and The Ohio State University School of Medicine (DJ McLaughlin), Columbus, Ohio.
| | - Mitchell Grayson
- Division of Allergy and Immunology Nationwide Children's Hospital and The Ohio State University School of Medicine (M Grayson), Columbus, Ohio
| | - Christina Toth
- Center for Clinical Excellence Nationwide Children's Hospital (C Toth), Columbus, Ohio
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Tang W, Tan J. Cephalexin-Induced Leukocytoclastic Vasculitis. Cureus 2022; 14:e26545. [PMID: 35936130 PMCID: PMC9347303 DOI: 10.7759/cureus.26545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 11/05/2022] Open
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Knibb RC, Huissoon AP, Baretto R, Ekbote A, Onyango-Odera S, Screti C, Newman KL, Krishna MT. Development and Validation of the Anaphylaxis Quality of Life Scale for Adults. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1527-1533.e3. [PMID: 35259537 DOI: 10.1016/j.jaip.2022.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/17/2022] [Accepted: 02/09/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Anaphylaxis is a severe and potentially life-threatening allergic reaction that can have a detrimental impact on quality of life (QoL). There are no validated scales to measure the impact of anaphylaxis on QoL of adults. OBJECTIVE The aim of this study was to develop and assess the reliability and validity of a QoL scale for adults with anaphylaxis (Anaphylaxis Quality of Life Scale for Adults [A-QoL-Adults]). METHODS All participants were recruited from a specialist allergy clinic and had a confirmed diagnosis of anaphylaxis (as per the World Allergy Organization diagnostic criteria) to food, drugs, venom, or latex or had spontaneous anaphylaxis. Interviews were conducted with 13 adults; data were analyzed using thematic analysis to extract items for a QoL scale. A prototype QoL scale was then completed by 115 participants alongside validated scales to measure generic QoL (World Health Organization Quality of Life Scale [Brief Version] [WHOQoL BREF]), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), and stress (Perceived Stress Scale [PSS]). RESULTS The A-QoL-Adults scale has 21 items demonstrating excellent internal reliability (Cronbach α = 0.96). Factor analysis produced 3 subscales: Emotional Impact; Social Impact; and Limitations on Life. Each has excellent internal reliability (0.92, 0.92, and 0.91, respectively). Poorer anaphylaxis-related QoL (total A-QoL-Adults score and subscale scores) correlated significantly with poorer general QoL and greater anxiety, depression, and stress (all P < .01 with medium-to-large effect sizes). CONCLUSIONS The A-QoL-Adults scale is a reliable measure of QoL in adults with anaphylaxis and shows good construct validity. It will offer health care professionals a means to further understand the impact of anaphylaxis on adult patients and could help direct and monitor allergy management and the need for further psychological intervention.
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Affiliation(s)
- Rebecca C Knibb
- School of Psychology, College of Health and Life Sciences, Aston University, Birmingham, UK.
| | - Aarnoud P Huissoon
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Richard Baretto
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Anjali Ekbote
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Sham Onyango-Odera
- Research and Development, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Cassandra Screti
- School of Psychology, College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Kristina L Newman
- School of Psychology, Nottingham Trent University, Nottingham, United Kingdom
| | - Mamidipudi T Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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Alvarez-Cuesta E, Madrigal-Burgaleta R, Broyles AD, Cuesta-Herranz J, Guzman-Melendez MA, Maciag MC, Phillips EJ, Trubiano JA, Wong JT, Ansotegui I. Standards for practical intravenous rapid drug desensitization & delabeling: A WAO committee statement. World Allergy Organ J 2022; 15:100640. [PMID: 35694005 PMCID: PMC9163606 DOI: 10.1016/j.waojou.2022.100640] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/27/2022] [Accepted: 03/03/2022] [Indexed: 12/16/2022] Open
Abstract
Drug hypersensitivity reactions (DHRs) to intravenous drugs can be severe and might leave patients and doctors in a difficult position where an essential treatment or intervention has to be suspended. Even if virtually any intravenous medication can potentially trigger a life-threatening DHR, chemotherapeutics, biologics, and antibiotics are amongst the intravenous drugs most frequently involved in these reactions. Admittedly, suspending such treatments may negatively impact the survival outcomes or the quality of life of affected patients. Delabeling pathways and rapid drug desensitization (RDD) can help reactive patients stay on first-choice therapies instead of turning to less efficacious, less cost-effective, or more toxic alternatives. However, these are high-complexity and high-risk techniques, which usually need expert teams and allergy-specific techniques (skin testing, in vitro testing, drug provocation testing) to ensure safety, an accurate diagnosis, and personalized management. Unfortunately, there are significant inequalities within and among countries in access to allergy departments with the necessary expertise and resources to offer these techniques and tackle these DHRs optimally. The main objective of this consensus document is to create a great benefit for patients worldwide by aiding allergists to expand the scope of their practice and support them with evidence, data, and experience from leading groups from around the globe. This statement of the Drug Hypersensitivity Committee of the World Allergy Organization (WAO) aims to be a comprehensive practical guide on the technical aspects of implementing acute-onset intravenous hypersensitivity delabeling and RDD for a wide range of drugs. Thus, the manuscript does not only focus on clinical pathways. Instead, it also provides guidance on topics usually left unaddressed, namely, internal validation, continuous quality improvement, creating a healthy multidisciplinary environment, and redesigning care (including a specific supplemental section on a real-life example of how to design a dedicated space that can combine basic and complex diagnostic and therapeutic techniques in allergy).
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Affiliation(s)
| | - Ricardo Madrigal-Burgaleta
- Allergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
- Drug Desensitisation Centre, Catalan Institute of Oncology (ICO), Barcelona, Spain
- Corresponding author. Allergy & Severe Asthma Service, Respiratory Department, 4th Floor, King George V Building, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Ana D. Broyles
- Division of Allergy & Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Javier Cuesta-Herranz
- Department of Allergy and Immunology, FIIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
- RETIC ARADyAL, Instituto de Salud Carlos III, Spain
| | | | - Michelle C. Maciag
- Division of Allergy & Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth J. Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason A. Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Johnson T. Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Steering Committee AuthorsAliF. RunaMBBS, PhD, FRCPaxAngel-PereiraDenisseMDlBanerjiAleenaMDayBerges-GimenoMaria PilarMD, PhDmBernal-RubioLorenaMDmBrockowKnutMDnCardona VillaRicardoMDoCastellsMariana C.MD, PhDpCaubetJean-ChristophMDqChangYoon-SeokMD, PhDrEnsinaLuis FelipeMD, MSc, PhDsChikhladzeMananaPhDtChiriacAnca MirelaMD, PhDuChungWeng-HungMD, PhDvEbisawaMotohiroMD, PhDwFernandesBryanMBBS, MRCPaxGarveyLene HeiseMD, PhDxawGomezMaximilianoMD, PhDyGomez VeraJavierMDzGonzalez DiazSandraMD, PhDaaHongDavid I.MDpIvancevichJuan CarlosMDabKangHye-RyunMD, PhDacKhanDavid A.MDadKuruvillaMerinMDaeLarco SousaJose IgnacioMDafLatour-StaffeldPatriciaMDagLiuAnne Y.MDahMacyEricMDaiMallingHans JorgenMDajMasperoJorgeMDakMaySara M.MDalMayorgaCristobalinaPhDamParkMiguel A.MDanPeterJonathanMBChB, PhDaoPicardMatthieuMD, FRCPCapRodriguez-BouzaTitoMD, PhDaq2RomanoAntoninoMDarSanchez-BorgesMarioMDazbaTannoLuciana KaseMD, PhDuTorresMaria JoseMD, PhDamUreña-TaveraAliciaMDasValluzziRocco L.MDatVolcheckGerald W.MDauYamaguchiMasaoMD, PhDavHospital Universitario de Canarias, Tenerife, SpainAllergy Division, Ramon y Cajal University Hospital, Madrid, SpainDepartment of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, GermanyUniversidad de Antioquia, Medellín, ColombiaDivision of Allergy and Clinical Immunology, Department of Medicine, Brigham & Women's Hospital, Boston, MA, USAPediatric Allergy Unit, Geneva University Hospitals, Geneva, SwitzerlandDivision of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of KoreaDivision of Allergy, Clinical Immunology and Rheumatology, Department of Pediatrics, Federal University of Sao Paulo, BrazilMedical Faculty at Akaki Tsereteli State University, KuTaisi, Tskaltubo, GeorgiaDivision of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, FranceDepartment of Dermatology, Chang Gung Memorial Hospital, Taipei, Linko and Keelung, TaiwanClinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Kanagawa, JapanAllergy Clinic, Copenhagen University Hospital Gentofte, Copenhagen, DenmarkSchool of Health Sciences, Catholic University of Salta, ArgentinaInstitute of Security and Social Services of State Workers, López Mateos Regional Hospital, Mexico City, MexicoRegional Center of Allergy and Clinical Immunology, University Hospital “Dr. José Eleuterio González”, Gonzalitos y Madero s/n Colonia Mitras Centro, Monterrey, MexicoServicio de Alergia e Immunologia, Clinica Santa Isabel, Buenos Aires, ArgentinaInstitute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of KoreaDepartment of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USADivision of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USAAllergy Department, Clinica San Felipe, Lima, PeruCentro Avanzado de Alergia y Asma de Santo Domingo, Santo Domingo, Dominican RepublicStanford University School of Medicine, Palo Alto, CA, USASouthern California Permanente Medical Group, Kaiser Permanente Southern California, San Diego Medical Center, San Diego, CA, USADanish Allergy Centre, University of Copenhagen, Copenhagen, DenmarkAllergy and Respiratory Research Unit, Fundación CIDEA, Buenos Aires, ArgentinaDivision of Pulmonary, Critical Care, Sleep & Allergy, University of Nebraska Medical Center, Omaha, NE, USAAllergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, SpainDivision of Allergic Diseases, Mayo Clinic, Rochester, MN, USADivision of Allergology and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South AfricaDepartment of Medicine, Division of Allergy and Immunology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, CanadaCentro de Patología Alérgica, Hospital Quirón Palmaplanas, Palma, SpainOasi Research Institute – IRCCS, Troina, ItalyClinica Union Medica del Norte, Santiago, Dominican RepublicMultifactorial and Systemic Diseases Research Area, Predictive and Preventive Medicine Research Unit, Division of Allergy, Bambino Gesù Children's Hospital IRCCS, Rome, ItalyDivision of Allergic Diseases, Mayo Clinic, Rochester, MN, USADivision of Respiratory Medicine, Third Department of Medicine, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, JapanDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, DenmarkAllergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UKDivision of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USAAllergy and Clinical Immunology Department, Centro Médico Docente La Trinidad, Caracas, VenezuelaAllergy and Clinical Immunology Department, Clínica El Avila, Caracas, Venezuela
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Miceli LM, Chang OH, Zhang S, Yao M, Propst K. Antimicrobial Stewardship in Patients with Penicillin Allergy Undergoing Hysterectomy for Benign Indications. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2021.0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lia M. Miceli
- Department of Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Olivia H. Chang
- Department of Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Salina Zhang
- Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Katie Propst
- Department of Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Iuliano S, Senn L, Moi L, Muller YD, Ribi C, Buss G, Comte D. Management of Beta-Lactam Antibiotics Allergy: A Real-Life Study. FRONTIERS IN ALLERGY 2022; 3:853587. [PMID: 35769578 PMCID: PMC9234877 DOI: 10.3389/falgy.2022.853587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
Beta-lactam allergy is a common problem in everyday medical practice and is recognized as a major public health issue. Carrying this label frequently leads to the avoidance of all beta-lactam antibiotics, favoring the use of other less preferred classes of antibiotics, that are more expensive and associated with more side effects and increased antimicrobial resistance. Therefore, delabeling a beta-lactam allergy is part of antimicrobial stewardship programs. Herein, we retrospectively examined the clinical records of 576 patients who were referred to our center for a label of allergy to beta-lactam antibiotics and were systematically investigated following a standardized algorithm. Our main aim was to evaluate the frequency of confirmed immediate- and delayed-type allergy to commonly prescribed subclasses of beta-lactam antibiotics (penicillin and cephalosporin), as well as the negative predictive value (NPV) and the sensitivity of skin tests. Our secondary aims were to examine the safety of beta-lactam skin testing and drug challenge. We identified that 260 patients reported a history of immediate reactions, 131 of delayed reactions, and 114 of unknown timing or mechanism of reactions. Following assessment and testing, 86 (18.3%) patients had a confirmed allergy to any beta-lactam antibiotics; 63 (13.4%) with an immediate- and 23 (4.9%) with a delayed-type reaction. Most frequently identified confirmed allergy was to penicillins (65 patients), followed by cephalosporins (21 patients). When immediate-type reactions were examined, NPV of skin tests were 96.3% and 100% for penicillins and cephalosporins, respectively. When delayed reactions were considered, NPV were 91.9 and 87.5% for penicillins and cephalosporins, respectively. Evaluation of the safety of skin tests according to the standardized procedure showed that systemic allergic reactions occurred in only 0.7% of skin tests and in 3.1% of drug challenges. Overall, our data indicate that only 18.3% of patients with a beta-lactam allergy label have a confirmed allergy and non-allergic patients can be safely delabeled through allergic workup based on skin tests and drug challenge. This approach supports the policy of saving second-line antibiotics through a standardized allergy workup.
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Affiliation(s)
- Sarah Iuliano
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Laurence Senn
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Service of Hospital Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Laura Moi
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Yannick D. Muller
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Camillo Ribi
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Guillaume Buss
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Denis Comte
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- *Correspondence: Denis Comte
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Lee JH, Park CS, Pyo MJ, Ryang Lee A, Shin E, Yoo YS, Song WJ, Kim TB, Cho YS, Kwon HS. Intradermal testing increases the accuracy of an immediate-type cefaclor hypersensitivity diagnosis. World Allergy Organ J 2022; 15:100643. [PMID: 35432713 PMCID: PMC8983408 DOI: 10.1016/j.waojou.2022.100643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/18/2022] [Accepted: 03/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background Hypersensitivity reactions to cefaclor have increased in accordance with its frequent use. However, only limited data are available on the diagnostic value of skin tests for these conditions, particularly intradermal tests (IDTs). Objective To evaluate the clinical usefulness of IDT compared to the ImmunoCAP test in patients with cefaclor-induced immediate-type hypersensitivity. Methods We conducted a retrospective chart review from January 2010 to June 2020 of adult subjects from 2 tertiary hospitals in Korea with a history of suspected immediate-type hypersensitivity to cefaclor, and who had undergone ImmunoCAP and IDT. Results Overall, 131 subjects diagnosed with cefaclor hypersensitivity were included in the analysis. Fifty-nine patients (59/131, 45.04%) were positive in both IDT and ImmunoCAP. Fifty-four (54/131, 41.22%) and 6 (6/131, 4.58%) subjects showed positive results only with IDT or the ImmunoCAP test, respectively. Twelve subjects (12/131, 9.16%) were negative by both tests but reacted positively in a drug provocation test. The frequency of IDT positivity was similar regardless of the severity of reactions. However, positivity of ImmunoCAP was lower in subjects with mild reactions compared to those with anaphylaxis. Regarding the diagnosis of cefaclor hypersensitivity, the overall sensitivity of IDT and ImmunoCAP was 0.863 and 0.496, respectively while the specificity was 1. The combination of IDT and ImmunoCAP further increased this sensitivity to 0.908. Conclusion IDT was more sensitive than ImmunoCAP for the diagnosis of cefaclor allergy, regardless of the severity of the hypersensitivity reaction. Therefore, we recommend a combination of IDT and ImmunoCAP for the diagnosis of cefaclor hypersensitivity.
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Affiliation(s)
- Ji-Hyang Lee
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chan Sun Park
- Department of Allergy and Clinical Immunology, Inje University of College of Medicine, Haeundae Paik Hospital, Busan, South Korea
| | - Min Ju Pyo
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - A. Ryang Lee
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eunyong Shin
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young-Sang Yoo
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Tae-Bum Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - You-Sook Cho
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyouk-Soo Kwon
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
- Corresponding author. Hyouk-Soo Kwon, M.D., Ph.D.; Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
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Schrüfer P, Stoevesandt J, Trautmann A. Outcome of a de-labelling algorithm compared with results of penicillin (β-lactam) allergy testing. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:26. [PMID: 35317861 PMCID: PMC8941741 DOI: 10.1186/s13223-022-00659-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
Background Penicillin allergy labels frequently impede guideline-directed treatment with a penicillin or other β-lactam antibiotics. Despite presumed allergy, targeted questioning may indicate a low probability of sensitization and permit reasonably safe administration of the antibiotic in question. In this study, we evaluated a standardized algorithm aiming to differentiate non-allergic patients from those with true allergic β-lactam hypersensitivity. Methods We retrospectively applied a de-labelling algorithm in 800 consecutive patients with suspected β-lactam hypersensitivity. All had undergone complete allergy work-up permitting to definitely exclude or diagnose β-lactam allergy between 2009 and 2019. Results In 595 (74.4%) out of 800 cases evaluated, β-lactam allergy could be excluded by negative challenge testing. IgE-mediated anaphylaxis was diagnosed in 70 (8.7%) patients, delayed-type hypersensitivity in 135 (16.9%). In 62 (88.6%) anaphylaxis cases, the algorithm correctly advised to use an alternative antibiotic. Accuracy was higher in patients with moderate to severe anaphylaxis (97.7%) compared to those with a history of mild reactions (73.1%). The algorithm correctly identified 122 (90.4%) patients with proven delayed-type hypersensitivity. It permitted de-labelling in 330 (55.5%) out of 595 patients with diagnostic exclusion of penicillin hypersensitivity, but failed to identify the remaining 265 (44.5%) as low-risk cases. Conclusions The algorithm detected 89.8% of cases with penicillin (β-lactam) allergy, sensitivity was optimal for moderate to severe anaphylaxis. Study data justify the implementation of a standardized de-labelling algorithm under close supervision in order to permit guideline-directed treatment and reduce the use of broad-spectrum antibiotics as part of an antibiotic stewardship program. Supplementary Information The online version contains supplementary material available at 10.1186/s13223-022-00659-1.
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Affiliation(s)
- Philipp Schrüfer
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Johanna Stoevesandt
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Axel Trautmann
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany.
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Prosty C, Copaescu AM, Gabrielli S, Mule P, Ben-Shoshan M. Pediatric Drug Allergy. Immunol Allergy Clin North Am 2022; 42:433-452. [DOI: 10.1016/j.iac.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Scherer Hofmeier K, Bircher AJ. Isolierte Zungenschwellung nach Penizillin und negative Allergieabklärung – alles in Butter? AKTUELLE DERMATOLOGIE 2022. [DOI: 10.1055/a-1543-0663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
ZusammenfassungPenizilline können alle Arten spezifischer Immunreaktionen nach der erweiterten Coombs- und Gell-Klassifikation auslösen und zählen zu den häufigsten Ursachen unerwünschter Arzneimittelreaktionen. Das diagnostische Armamentarium umfasst neben den verschiedenen Hauttesten den Nachweis spezifischer IgE gegen allergene Determinanten am Betalaktam-Molekül und ggf. zelluläre Aktivierungsteste. Im Fall negativer Ergebnisse bei den genannten Testen kann ggf. noch die Toleranz im Rahmen eines Provokationstestes nachgewiesen werden. Die Sensitivität der diagnostischen Teste ist – mit Ausnahme des Provokationstests – aber limitiert, und falsch negative Teste sind möglich. Wir präsentieren zwei Fälle mit einer isolierten Zungenschwellung nach Gabe von Amoxicillin bei vollständig negativem, wiederholtem allergologischen Work-up. Bei beiden Patienten konnte die Überempfindlichkeit nur mit einer Reexposition nachgewiesen werden.
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Affiliation(s)
| | - Andreas J. Bircher
- Allergologie, Dermatologie, Universitätsspital Basel, Schweiz
- Facoltà di scienze biomediche, Università della Svizzera italiana, Lugano, Schweiz
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Andreev SS, Ryazantseva E, Maltseva N, Mutovina Z, Fomina D, Lysenko M. Corynebacterium amycolatum infective endocarditis in a patient with severe COVID-19: a case report. CLINICAL MICROBIOLOGY AND ANTIMICROBIAL CHEMOTHERAPY 2022. [DOI: 10.36488/cmac.2022.3.261-266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective.
To present a case of successful treatment of a secondary bacterial infection caused by nondiphtheritic corynebacterium in a patient with severe COVID-19 and known beta-lactam intolerance.
Materials and Methods.
A clinical case of infective endocarditis (IE) caused by Corynebacterium amycolatum in a 74-year-old patient hospitalized with severe COVID-19 is presented. Comorbidity (secondary immune deficiency due to active malignancy, chemotherapy courses; previous heart disease) and the need for immunosuppressive therapy were triggers for infection caused by a rare Gram-positive bacterium which is usually considered as clinically non-significant. The choice of empiric antimicrobial treatment was limited by the patient’s history of beta-lactam intolerance.
Results.
A multidisciplinary approach to medical care of the patient and alertness to secondary infections helped to diagnose IE in a timely manner and to choose effective antimicrobial therapy. Combination therapy with vancomycin and amikacin helped to make blood flow free from infection. The further switch to oral doxycycline in outpatient settings resulted in the patient recovery from the infection.
Conclusions.
Under conditions of limited choice of drug therapy, it is critical to have access to modern microbiological diagnostics which make it possible to diagnose rare pathogens. A dialogue between treating physician and clinical pharmacologist helps to choose an empirical and targeted antimicrobial therapy with the best efficacy-safety ratio. There is a need to be alert to secondary infections, including those of atypical locations and courses and caused by rare or opportunistic pathogens.
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Affiliation(s)
| | | | | | - Z.Yu. Mutovina
- City Clinical Hospital No. 52; Central State Medical Academy (Moscow, Russia)
| | - D.S. Fomina
- City Clinical Hospital No. 52; I.M. Sechenov First Moscow State Medical University (Moscow, Russia)
| | - M.A. Lysenko
- City Clinical Hospital No. 52; Pirogov Russian National Research Medical University (Moscow, Russia)
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Jouffroy R, Gilbert B, Hassan A, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. Adequacy of probabilistic prehospital antibiotic therapy for septic shock. Am J Emerg Med 2021; 53:80-85. [PMID: 34995860 DOI: 10.1016/j.ajem.2021.12.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Guidelines on sepsis management recommend early recognition, diagnosis and treatment, especially early antibiotic therapy (ABT) administration in order to reduce septic shock (SS) mortality. However, the adequacy of probabilistic prehospital ABT remains unknown. METHODS From May 2016 to March 2021, all consecutive patients with SS cared for by a prehospital mICU intervention were retrospectively analyzed. RESULTS Among 386 patients retrospectively analyzed, 119 (33%) received probabilistic prehospital ABT, among which 74% received a 3rd generation cephalosporin: 31% cefotaxime and 42% ceftriaxone. No patient had a serious adverse effect related to ABT administration. Overall mortality rate on day-30 was 29%. Among the 119 patients with prehospital ABT, bacteriological identification was obtained for 81 (68%) patients with adequate prehospital ABT for 65 patients (80%) of which 10 (15%) deceased on day-30. Conversely, among the 16 (20%) patients with inadequate prehospital ABT, 9 patients (56%) were deceased on day-30. Prehospital adequate ABT was significantly different between alive and deceased patients on day-30 (p = 4.10-3). After propensity score matching, a significant association between adequate prehospital ABT administration and day-30 mortality was observed (aOR = 0.09 [0.01-0.47]). Inverse probability treatment weighting with multivariable logistic regression reported a day-30 mortality decrease in the adequate prehospital ABT group: aOR = 0.70 [0.53-0.93]. CONCLUSIONS Among SS cared for by a mICU, probabilistic prehospital ABT is adequate most of the time and associated with a day-30 mortality decrease. Further prospective studies are needed to confirm these results and the weight of prehospital ABT in the prehospital bundle of care for SS.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, University Hospital Ambroise Paré, Boulogne Billancourt, France; Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France; Centre de recherche en Epidémiologie et Santé des Populations, U1018 INSERM, Université Paris Saclay, France; Institut de Recherche bioMédicale et d'Epidémiologie du Sport - EA7329, INSEP, Université de Paris, France; EA 7525 Université des Antilles, France.
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France; Paris Fire Brigade, Paris, France
| | - Anna Hassan
- Intensive Care Unit, University Hospital Ambroise Paré, Boulogne Billancourt, France
| | - Jean-Pierre Tourtier
- Emergency Department, Cochin Hospital, Paris, France; Emergency Department, SMUR, Hôtel Dieu Hospital, Paris, France
| | - Emmanuel Bloch-Laine
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, 75013 Paris, France
| | | | - Josiane Boularan
- SAMU 972 University Hospital of Martinique, Fort-de-France, Martinique, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France; Paris Fire Brigade, Paris, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France
| | - Papa Gueye
- EA 7525 Université des Antilles, France; SAMU 972 University Hospital of Martinique, Fort-de-France, Martinique, France
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Minaldi E, Phillips EJ, Norton A. Immediate and Delayed Hypersensitivity Reactions to Beta-Lactam Antibiotics. Clin Rev Allergy Immunol 2021; 62:449-462. [PMID: 34767158 DOI: 10.1007/s12016-021-08903-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 12/16/2022]
Abstract
Beta-lactam antibiotics are the most commonly reported drug allergy in adults and children. More than 95% of those with reported allergy labels to beta lactams are not confirmed when subjected to allergy testing. Beta lactam antibiotics are associated with a wide spectrum of immediate and delayed drug hypersensitivity reactions. The latency period to symptoms and clinical presentation aids in the causality assessment. Risk stratification based on diagnosis and timing then allows for appropriate management and evaluation. Skin prick testing, intradermal testing and oral challenge are well established for evaluation of immediate reactions. Delayed intradermal testing, patch testing and oral challenge can also be considered for evaluation of mild to moderate delayed reactions. Cross-reactivity between beta-lactams appears to be driven most commonly by a shared R1 side-chain. Standardized algorithms, protocols and pathways are needed for widespread implementation of a pragmatic and effective approach to patients reporting beta lactam allergy.
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Affiliation(s)
- Ellen Minaldi
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Allison Norton
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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Lányi K, Darnay L, László N, Lehel J, Friedrich L, Győri R, Laczay P. Transfer of certain beta-lactam antibiotics from cow's milk to fresh cheese and whey. Food Addit Contam Part A Chem Anal Control Expo Risk Assess 2021; 39:52-60. [PMID: 34506720 DOI: 10.1080/19440049.2021.1973114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The aim of this study was to investigate the transfer of cephalexin, penicillin-G, and ampicillin & cloxacillin from cow's milk to cheese and whey. For this purpose, raw milk was artificially contaminated to different antibiotic levels and then heat-treated to prepare fresh cheese from it. Antibiotic levels of the milk, whey and cheese were measured with LC-MS/MS. The extent of heat degradation was not sufficient to remove the antibiotic residues from milk. Antibiotic concentrations in whey and fresh cheese were in good accordance with the concentration of the same compound in milk suggesting that contamination of the milk will result in contamination of the product. The investigated antibiotics were transferred less into the cheese curd (1.6-12.5% of the original amount), than into the whey (33.2-74.1%). For penicillin-G even 100% (complete removal) was experienced.
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Affiliation(s)
- Katalin Lányi
- Department of Food Hygiene, University of Veterinary Medicine, Budapest, Hungary
| | - Lívia Darnay
- Department of Food Hygiene, University of Veterinary Medicine, Budapest, Hungary
| | - Noémi László
- Department of Food Hygiene, University of Veterinary Medicine, Budapest, Hungary
| | - József Lehel
- Department of Food Hygiene, University of Veterinary Medicine, Budapest, Hungary
| | - László Friedrich
- Faculty of Food Science, Department of Refrigeration and Livestock Products Technology, Szent István University, Budapest, Hungary
| | - Rebeka Győri
- Department of Food Hygiene, University of Veterinary Medicine, Budapest, Hungary
| | - Péter Laczay
- Department of Food Hygiene, University of Veterinary Medicine, Budapest, Hungary
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Bogas G, Doña I, Dionicio J, Fernández TD, Mayorga C, Boteanu C, Montañez MI, Al-Ahmad M, Rondón C, Moreno E, Laguna JJ, Torres MJ. Diagnostic Approach of Hypersensitivity Reactions to Cefazolin in a Large Prospective Cohort. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4421-4430.e4. [PMID: 34464750 DOI: 10.1016/j.jaip.2021.08.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/29/2021] [Accepted: 08/11/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Cefazolin is a common trigger of perioperative anaphylaxis. The diagnostic approach is controversial because the optimal concentration for skin testing is uncertain, drug provocation tests (DPTs) are contraindicated in severe reactions, and in vitro tests are not thoroughly validated. OBJECTIVE We aimed to characterize a large number of patients reporting cefazolin allergic reactions and to analyze the diagnostic role of in vivo and in vitro tests. METHODS We prospectively evaluated patients with suspicion for allergic reactions to cefazolin by clinical history, skin tests (STs), and, if negative, DPT. In a subgroup of patients, basophil activation test (BAT) and radioallergosorbent test were done before allergologic workup was performed and the final diagnosis was achieved. RESULTS We evaluated 184 patients, 76 of whom were confirmed as allergic (41.3%), 90 were nonallergic (48.9%), and 18 were nonconfirmed (9.8%). All patients reporting anaphylactic shock and most reporting anaphylaxis were confirmed to be allergic (P < .001). Forty allergic patients (52.6%) were confirmed by STs, 22 by DPT (28.9%), and 14 by clinical history (18.4%). All subjects manifesting exanthemas and pruritus were nonallergic. The BAT sensitivity was 66.7% when CD63 and CD203c were combined as activation markers. Six of 8 patients with negative STs and positive DPT had a positive BAT. CONCLUSIONS Patients allergic to cefazolin often reported severe immediate-type reactions. Skin tests enabled a diagnosis in half of patients when using cefazolin at 20 mg/mL. Unfortunately, DPT could not be performed in all patients owing to reaction severity, which makes BAT a promising diagnostic tool. Further research is needed to clarify the underlying mechanisms, especially in severe reactions.
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Affiliation(s)
- Gador Bogas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Inmaculada Doña
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | | | - Tahia D Fernández
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Department of Cell Biology, Genetics, and Physiology, Universidad de Málaga, Málaga, Spain
| | - 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
| | - Cosmin Boteanu
- Allergy Section, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - María I Montañez
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain
| | - Mona Al-Ahmad
- Al Rashed Allergy Centre, Ministry of Health, Kuwait; Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait
| | - Carmen Rondón
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Esther Moreno
- Allergy Service, University Hospital of Salamanca., Salamanca, Spain
| | - Jose J Laguna
- Allergy Unit, Hospital de la Cruz Roja, Madrid, Spain; Faculty of Medicine, Universidad Alfonso X El Sabio, Madrid, Spain
| | - Maria J Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital de la Cruz Roja, Madrid, Spain; Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain; Department of Medicine, Universidad de Málaga, Málaga, Spain.
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Prieto A, Muñoz C, Bogas G, Fernández‐Santamaría R, Palomares F, Mayorga C, Salas M, Doña I, Torres MJ. Single-dose prolonged drug provocation test, without previous skin testing, is safe for diagnosing children with mild non-immediate reactions to beta-lactams. Allergy 2021; 76:2544-2554. [PMID: 33650109 DOI: 10.1111/all.14800] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 02/02/2021] [Accepted: 02/09/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Mild non-immediate reactions (NIRs) to beta-lactams (BLs) are the most frequent manifestation of drug allergy in children. The diagnostic approach is complex as the utility of skin tests (STs) and lymphocyte transformation tests (LTTs) is controversial. Drug provocation test (DPT) is the gold standard, although no standardized protocols exist. We aimed to investigate the utility of DPT in a unique dose without previous STs, and LTTs in the diagnosis of NIRs to BLs in children. METHODS We prospectively evaluated children 0-14 years old referred to the Regional University Hospital of Málaga during 2017-2020 reporting NIRs to BLs. We performed a DPT with a unique dose followed by regular treatment at home. If positive, STs and LTTs were done after the reaction had disappeared. RESULTS We included 194 children, having 24 (12.4%) a positive DPT. The main culprit was AX (70.1%) followed by AX-clavulanic acid (CLV) (26.8%) and the main symptoms maculopapular exanthema (MPE) (49.5%) and delayed-urticaria (48.5%). A decrease (p = 0.013) in the interval of days between drug administration and onset of symptoms was observed in positive DPT compared with the original reaction (3.5 vs 6 days), with no differences in the overall percentage of MPE and delayed-appearing urticaria (p = 0.551). No severe reactions occurred during DPT. Moreover, STs were positive in 13.33% and LTTs in 52.9%. CONCLUSIONS Single-dose DPT without previous STs is a safe and useful way to assess NIRs to BLs in children. LTT has shown to be useful, confirming a T-cell mechanism involved in these reactions.
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Affiliation(s)
- Ana Prieto
- Paediatrics Unit Hospital Regional Universitario de Malaga Málaga Spain
| | - Candelaria Muñoz
- Paediatrics Unit Hospital Regional Universitario de Malaga Málaga Spain
| | - Gádor Bogas
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy UnitHospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
| | | | - Francisca Palomares
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Maria Salas
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy UnitHospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
| | - Inmaculada Doña
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy UnitHospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
| | - María José Torres
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy UnitHospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
- Medicine Department Universidad de Málaga Málaga Spain
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Abstract
PURPOSE OF REVIEW Understand how the clinical history has been used to risk stratify patients reporting a beta-lactam allergy, both in clinical care pathways and predictive models. RECENT FINDINGS Drug allergy clinical care pathways have emerged as a safe and effective method of stratifying patients with a reported beta-lactam allergy into risk categories, with 'low-risk' patients able to proceed straight to direct challenges or test doses. These methods have streamlined antibiotic stewardship policies and penicillin allergy de-labeling. However, how to define 'low-risk' has been subject to much debate. New research has developed predictive models that utilize the clinical history to assess a patient's true risk of beta-lactam allergy. SUMMARY The clinical history has long been an essential part of drug allergy evaluation and has proven invaluable within the past decade in the development of drug allergy clinical pathways. Evidence-based predictive models that use the clinical history to assess a patient's true risk of beta-lactam allergy offer tremendous promise, but differ in crucial areas such as the populations they study, the predictor variables they use, and the ultimate accuracy they attain. These models highlight key aspects of the drug allergy history and pave the way for future large-scale research.
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Affiliation(s)
| | - Allen Judd
- Division of Rheumatology, Allergy and Immunology, Department of Medicine
| | - Kimberly Blumenthal
- Medical Practice Evaluation Center
- The Mongan Institute, Massachusetts General Hospital
- Harvard Medical School, Boston, Massachusetts, USA
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Piotin A, Godet J, Trubiano JA, Grandbastien M, Guénard-Bilbault L, de Blay F, Metz-Favre C. Predictive factors of amoxicillin immediate hypersensitivity and validation of PEN-FAST clinical decision rule. Ann Allergy Asthma Immunol 2021; 128:27-32. [PMID: 34271183 DOI: 10.1016/j.anai.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/12/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The challenge of delabeling amoxicillin allergy is an important issue for patients and clinicians, especially when anaphylaxis is reported. A recent study has proposed a clinical decision rule, PEN-FAST, to identify low-risk penicillin allergies. OBJECTIVE To validate the PEN-FAST clinical decision rule in a population with high risk of suspected immediate amoxicillin allergy and to identify clinical predictive factors of amoxicillin immediate hypersensitivity. METHODS We retrospectively analyzed medical records of patients with a suspected immediate amoxicillin allergy who carried out an allergologic evaluation by a specialist in the Allergy Unit of Strasbourg University Hospital from 2015 to 2020. RESULTS A total of 142 adult patients (88 women [62.0%]; median age, 52 [interquartile range, 40.3-62.0] years) were analyzed. Most of them reported anaphylaxis (68.8%). Internal validation of PEN-FAST score revealed a good discrimination with area under the curve of 0.86 (95% confidence interval, 0.79-0.92). A cutoff of less than 3 points for PEN-FAST was used to classify 29 from 142 patients at low risk of allergy, of whom only 2 (6.9%) received positive results of allergy testing. The negative predictive value for successful delabeling was 0.93 (95% confidence interval, 0.77-0.99). Predictive clinical features for immediate amoxicillin hypersensitivity were time since reaction (P < .001), time elapsed between drug intake and first symptom (P < .001), severity grade reaction (P < .001), and treatment or hospitalization required (P < .001). CONCLUSION PEN-FAST has been validated to identify low-risk penicillin allergies in our European cohort of patients mainly reporting anaphylaxis. This is the first reported external validation of a penicillin allergy clinical decision rule internationally.
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Affiliation(s)
- Anays Piotin
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France.
| | - Julien Godet
- Public Health Department, Strasbourg University Hospital, Strasbourg, France
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Australia; Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Manon Grandbastien
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France
| | | | - Frédéric de Blay
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France; EA 3070 Federation of Translational Medicine, FHU Homicare, University of Strasbourg, Strasbourg, France
| | - Carine Metz-Favre
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France
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Bian LF, Zheng C, Shi XL. Atezolizumab-induced anaphylactic shock in a patient with hepatocellular carcinoma undergoing immunotherapy: A case report. World J Clin Cases 2021; 9:4110-4115. [PMID: 34141773 PMCID: PMC8180205 DOI: 10.12998/wjcc.v9.i16.4110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/16/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Atezolizumab is a programmed death ligand 1 (PD-L1) inhibitor, and its combination with bevacizumab has been proven an effective immunotherapy for unresectable hepatocellular carcinoma (HCC). Treatment with immune checkpoint inhibitors (ICIs) can lead to hypersensitivity reactions; however, anaphylactic shock is rare. We present a case of life-threatening anaphylactic shock during atezolizumab infusion and performed a relevant literature review.
CASE SUMMARY A 75-year-old man was diagnosed with HCC recurrence after hepatectomy. He was administered immunotherapy with atezolizumab plus bevacizumab after an allergy to a programmed death-1 (PD-1) inhibitor. The patient showed a sudden onset of dizziness, numbness, and lack of consciousness with severe hypotension during atezolizumab infusion. The treatment was stopped immediately. The patient’s symptoms resolved after 5 mg dexamethasone was administered. Because of repeated hypersensitivity reactions to ICIs, treatment was changed to oral targeted regorafenib therapy.
CONCLUSION Further research is necessary for elucidating the hypersensitivity mechanisms and establishing standardized skin test and desensitization protocols associated with PD-1 and PD-L1 to ensure effective treatment with ICIs.
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Affiliation(s)
- Li-Fang Bian
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Chao Zheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Xiao-Lan Shi
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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47
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Broyles AD, Banerji A, Barmettler S, Biggs CM, Blumenthal K, Brennan PJ, Breslow RG, Brockow K, Buchheit KM, Cahill KN, Cernadas J, Chiriac AM, Crestani E, Demoly P, Dewachter P, Dilley M, Farmer JR, Foer D, Fried AJ, Garon SL, Giannetti MP, Hepner DL, Hong DI, Hsu JT, Kothari PH, Kyin T, Lax T, Lee MJ, Lee-Sarwar K, Liu A, Logsdon S, Louisias M, MacGinnitie A, Maciag M, Minnicozzi S, Norton AE, Otani IM, Park M, Patil S, Phillips EJ, Picard M, Platt CD, Rachid R, Rodriguez T, Romano A, Stone CA, Torres MJ, Verdú M, Wang AL, Wickner P, Wolfson AR, Wong JT, Yee C, Zhou J, Castells M. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:S16-S116. [PMID: 33039007 DOI: 10.1016/j.jaip.2020.08.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ana Dioun Broyles
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Sara Barmettler
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Catherine M Biggs
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kimberly Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Patrick J Brennan
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca G Breslow
- Division of Sports Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Josefina Cernadas
- Allergology and Immunology Service, Centro Hospitalar Universitário de S.João Hospital, Porto, Portugal
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Elena Crestani
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Pascale Dewachter
- Department of Anesthesiology and Intensive Care Medicine, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Meredith Dilley
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Ari J Fried
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Sarah L Garon
- Associated Allergists and Asthma Specialists, Chicago, Ill
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass
| | - David I Hong
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Joyce T Hsu
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Parul H Kothari
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Timothy Kyin
- Division of Asthma, Allergy & Immunology, University of Virginia, Charlottesville, Va
| | - Timothy Lax
- Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Min Jung Lee
- Allergy and Immunology at Hoag Medical Group, Newport Beach, Calif
| | - Kathleen Lee-Sarwar
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Anne Liu
- Division of Allergy / Immunology, Stanford University School of Medicine, Palo Alto, Calif
| | - Stephanie Logsdon
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Andrew MacGinnitie
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Michelle Maciag
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Samantha Minnicozzi
- Division of Allergy and Clinical Immunology, Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Sarita Patil
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Division of Allergy and Clinical Immunology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Rima Rachid
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Tito Rodriguez
- Drug Allergy Department, Al-Rashed Allergy Center, Sulaibikhat, Al-Kuwait, Kuwait
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Miriam Verdú
- Allergy Unit, Hospital Universitario de Ceuta, Ceuta, Spain
| | - Alberta L Wang
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Paige Wickner
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Johnson T Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Christina Yee
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Joseph Zhou
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Mariana Castells
- Drug hypersensitivity and Desensitization Center, Brigham and Women's Hospital, Boston, Mass
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Elzagallaai AA, Rieder MJ. Model Based Evaluation of Hypersensitivity Adverse Drug Reactions to Antimicrobial Agents in Children. Front Pharmacol 2021; 12:638881. [PMID: 33995043 PMCID: PMC8120305 DOI: 10.3389/fphar.2021.638881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/26/2021] [Indexed: 12/25/2022] Open
Abstract
Drug use in children is-in most cases-supported by extrapolation of data generated from clinical trials in adult populations. This puts children at higher risk of developing adverse drug reactions (ADRs) due to "off-label" use of drugs and dosing issues. Major types of ADRs are drug hypersensitivity reactions, an idiosyncratic type of ADRs that are largely unpredictable and can cause high morbidity and mortality in a hard-to-identify specific population of patients. Lack of a complete understanding of the pathophysiology of DHRs and their unpredictive nature make them problematic in clinical practice and in drug development. In addition, ethical and legal obstacles hinder conducting large clinical trials in children, which in turn make children a "therapeutic orphan" where clear clinical guidelines are lacking, and practice is based largely on the personal experience of the clinician, hence making modeling desirable. This brief review summarizes the current knowledge of model-based evaluation of diagnosis and management of drug hypersensitivity reactions (DHRs) to antimicrobial drugs in the pediatric population. Ethical and legal aspects of drug research in children and the effect of different stages of child development and other factors on the risk of DHRs are discussed. The role of animal models, in vitro models and oral provocation test in management of DHRs are examined in the context of the current understanding of the pathophysiology of DHRs. Finally, recent changes in drug development legislations have been put forward to encourage drug developers to conduct trials in children clearly indicate the urgent need for evidence to support drug safety in children and for modeling to guide these clinical trials.
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Affiliation(s)
- Abdelbaset A Elzagallaai
- Department of Paediatrics, London, ON, Canada.,Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Michael J Rieder
- Department of Paediatrics, London, ON, Canada.,Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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49
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Hall V, Wong M, Munsif M, Stevenson BR, Elliott K, Lucas M, Baird AJ, Athan E, Young M, Pickles R, Cheng AC, Stewardson AJ, Aung AK, Trubiano JA. Antimicrobial anaphylaxis: the changing face of severe antimicrobial allergy. J Antimicrob Chemother 2021; 75:229-235. [PMID: 31637446 DOI: 10.1093/jac/dkz422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/25/2019] [Accepted: 09/10/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES The epidemiology, clinical characteristics and outcomes of antimicrobial-associated anaphylaxis remain ill-defined. We sought to examine antimicrobial anaphylaxis with regard to: (i) the frequency of implicated antimicrobials; (ii) attributable mortality; and (iii) referral for definitive allergy assessment. METHODS This was conducted through a national retrospective multicentre cohort study at five Australian tertiary hospitals (January 2010 to December 2015). Cases of antimicrobial anaphylaxis were identified from ICD-10 coding and adverse drug reaction committee databases. RESULTS There were 293 participants meeting the case definition of antimicrobial anaphylaxis and 310 antimicrobial anaphylaxis episodes. Of 336 implicated antimicrobials, aminopenicillins (62/336, 18.5%) and aminocephalosporins (57/336, 17%) were implicated most frequently. ICU admission occurred in 43/310 (13.9%) episodes; however, attributable mortality was low (3/310, 1%). The rate of anaphylaxis to IV antibiotics was 3.5 (95% CI=2.9-4.3) per 100 000 DDDs and the rate of hospital-acquired anaphylaxis was 1.9 (95% CI=2.1-3.3) per 100 000 occupied bed-days. We observed overall low rates of hospital discharge documentation (222/310, 71.6%) and follow-up by specialist allergy services (73/310, 23.5%), which may compromise medication safety and antimicrobial prescribing in future. CONCLUSIONS This study demonstrated that a high proportion of severe immediate hypersensitivity reactions presenting or acquired in Australian hospitals are secondary to aminopenicillins and aminocephalosporins. Overall rates of hospital-acquired anaphylaxis, predominantly secondary to cephalosporins, are low, and also associated with low inpatient mortality.
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Affiliation(s)
- Victoria Hall
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Hospital, VIC, Australia.,Department of Infectious Diseases, Alfred Health, VIC, Australia
| | - Micah Wong
- School of Medicine, University of Melbourne, VIC, Australia
| | - Maitri Munsif
- Department of General Medicine, Alfred Hospital, Monash University, VIC, Australia
| | - Brittany R Stevenson
- Department of Immunology, Sir Charles Gairdner Hospital, WA, Australia.,PathWest Immunology, Nedlands, WA, Australia
| | - Katie Elliott
- School of Medicine, University of Western Australia, WA, Australia
| | - Michaela Lucas
- Department of Immunology, Sir Charles Gairdner Hospital, WA, Australia.,PathWest Immunology, Nedlands, WA, Australia
| | - Ashleigh J Baird
- University Hospital Geelong Barwon Health, Geelong, VIC, Australia
| | - Eugene Athan
- University Hospital Geelong Barwon Health, Geelong, VIC, Australia.,Deakin University, School of Medicine, Geelong, VIC, Australia
| | - Melissa Young
- Hunter New England Local Health District, John Hunter Hospital, NSW, Australia
| | - Robert Pickles
- Departments of Infectious Diseases and General Medicine, John Hunter Hospital, Hunter New England Local Health District, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, NSW, Australia
| | - Allen C Cheng
- Department of Infectious Diseases, Alfred Health, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, VIC, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, Alfred Health, VIC, Australia.,ASID Clinical Research Network, Sydney, NSW, Australia
| | - Ar K Aung
- Department of Infectious Diseases, Alfred Health, VIC, Australia.,Department of General Medicine, Alfred Hospital, Monash University, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Hospital, VIC, Australia.,Department of Medicine, University of Melbourne, VIC, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, VIC, Australia
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50
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Evaluating Immediate Reactions to Cephalosporins: Time Is of the Essence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1648-1657.e1. [DOI: 10.1016/j.jaip.2020.11.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/11/2020] [Accepted: 11/13/2020] [Indexed: 12/26/2022]
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