Allergy associated with ciprofloxacin

Quinolone Allergy

Quinolones are the second most common antibiotic class associated with drug-induced allergic reactions, but data on quinolone allergy are scarce. This review article discusses the available evidence on quinolone allergy, including prevalence, risk factors, diagnosis, clinical manifestations, cross-reactivity, and management of allergic reactions. Although the incidence of quinolone allergy is still lower than beta-lactams, it has been increasingly reported in recent decades, most likely from its expanded use and the introduction of moxifloxacin. Thorough patient history remains essential in the evaluation of quinolone allergy. Many diagnostic tools have been investigated, but skin tests can yield false-positive results and in vitro tests have not been validated. The drug provocation test is considered the test of choice to confirm a quinolone allergy but is not without risk. Evidence regarding cross-reactivity among the quinolones is limited and conflicting. Quinolone allergy can be manifested either as an immediate or delayed reaction, but is not uniform across the class, with moxifloxacin posing the highest risk of anaphylaxis. Quinolone should be discontinued when an allergic reaction occurs and avoided in future scenarios, but desensitization may be warranted if no alternatives are available.

Mass chemoprophylaxis for control of outbreaks of meningococcal disease

Although vaccination is the main strategy used to control meningococcal disease outbreaks, mass chemoprophylaxis has also been used as an immediate response to outbreaks, either to supplement vaccination or when vaccination is not possible. However, public health guidelines regarding the use of mass chemoprophylaxis for outbreak control vary by country, partly because the impact of mass chemoprophylaxis on the course of an individual outbreak is difficult to assess. We have reviewed data for the use of mass chemoprophylaxis during 33 outbreaks that occurred both in military populations and in communities and non-military organisations. In most outbreaks, no additional cases of meningococcal disease occurred after mass chemoprophylaxis, or cases occurred only in individuals who had not received prophylaxis. A delay of several weeks was common before cases occurred among prophylaxis recipients. Overall, the outbreak reports that we reviewed suggest that mass chemoprophylaxis might provide temporary protection to chemoprophylaxis recipients during outbreaks.

Immediate Hypersensitivity to Moxifloxacin with Tolerance to Ciprofloxacin: Report of Three Cases and Review of the Literature

Objective

To report 3 cases of immediate hypersensitivity reactions to moxifloxacin in patients who tolerated ciprofloxacin.

Case summaries

A 71-year-old man, a 44-year-old woman, and a 70-year-old woman with a history of a moxifloxacin reaction developed an immediate hypersensitivity reaction upon oral challenge with moxifloxacin in our Drug Safety Clinic. The reaction was mainly characterized by pruritus and urticaria, although dyspnea and hypotension were noted in the first and second patient, respectively. Two of the patients had negative oral challenge tests with ciprofloxacin and all 3 patients tolerated full treatment courses of oral ciprofloxacin. In all 3 cases, use of the Naranjo probability scale indicated a highly probable adverse drug reaction.

Discussion

Moxiffoxacin, similar to other fluoroquinolones, can cause immediate hypersensitivity reactions. Previous publications have reported both cross-reactivity and a lack of cross-reactivity among various fluoroquinolones. The 3 patients discussed demonstrated a lack of cross-reactivity between moxifloxacin and ciprofloxacin since they tolerated oral challenge tests and full treatment courses of ciprofloxacin. Moxifloxacin has unique side chains at positions 7 and 8 on its bicyclic ring structure. Antigenic specificity to particular side chains at positions 7 and 8 on the bicyclic ring structure of moxifloxacin may explain this lack of cross-reactivity. Higher reporting rates of anaphylaxis to moxifloxacin compared to other fluoroquinolones may also be related to side chain specificity, although definitive evidence for this is lacking.

Conclusions

Based on our experience, patients who develop immediate hypersensitivity reactions to moxifloxacin may receive ciprofloxacin therapy in an appropriately monitored setting if they have previously tolerated full treatment courses of ciprofloxacin. Research into whether there is a specific side chain reaction unique to moxifloxacin is warranted.

Antimicrobial stewardship's new weapon? A review of antibiotic allergy and pathways to 'de-labeling'

PURPOSE OF REVIEW

The continued emergence of multiresistant pathogens and widespread antimicrobial use has led to a greater emphasis on antimicrobial stewardship programs. Concurrently, an increased awareness of the rising number of antibiotic allergy labels and impact on antimicrobial use has surfaced. The integration of antibiotic allergy de-labeling and antimicrobial stewardship programs may be a pathway worthy of further focus and investigation.

RECENT FINDINGS

Recent literature has evaluated the efficacy of antibiotic allergy management (historical de-labeling, in-vitro testing, skin prick testing, intradermal testing, and oral challenges) and impact of antibiotic allergy labels on patient outcome. The importance of true and perceived antibiotic allergy cross-reactivity in the setting of β-lactam allergies has been highlighted. The impact of dedicated antibiotic allergy de-labeling clinics, inpatient antibiotic allergy testing, and integrated antimicrobial stewardship programs has been recently appraised.

SUMMARY

More recent literature supports that appropriate antibiotic allergy in-vitro and in-vivo testing and subsequent antibiotic allergy de-labeling, particularly in regard to β-lactams, can decrease broad-spectrum antibiotic use, costs, patient length of stay, and mortality. Integration of antibiotic allergy management into the decision support systems of inpatient and outpatient antimicrobial stewardship programs represents an important opportunity to further improve measured outcomes from antibiotic utilization.

Antibiotic allergies in children and adults: from clinical symptoms to skin testing diagnosis

Hypersensitivity reactions to β-lactam and non-β-lactam antibiotics are commonly reported. They can be classified as immediate or nonimmediate according to the time interval between the last drug administration and their onset. Immediate reactions occur within 1 hour after the last drug administration and are manifested clinically by urticaria and/or angioedema, rhinitis, bronchospasm, and anaphylactic shock; they may be mediated by specific IgE-antibodies. Nonimmediate reactions occur more than 1 hour after the last drug administration. The most common manifestations are maculopapular exanthems; specific T lymphocytes may be involved in this type of manifestation. The diagnostic evaluation of hypersensitivity reactions to antibiotics is usually complex. The patient's history is fundamental; the allergic examination is based mainly on in vivo tests selected on the basis of the clinical features and the type of reaction, immediate or nonimmediate. Immediate reactions can be assessed by immediate-reading skin tests and, in selected cases, drug provocation tests. Nonimmediate reactions can be assessed by delayed-reading skin tests, patch tests, and drug provocation tests. However, skin tests have been well validated mainly for β-lactams but less for other classes of antibiotics.

What is the evidence for giving chemoprophylaxis to children or students attending the same preschool, school or college as a case of meningococcal disease?

We performed a systematic literature review to assess the effectiveness of chemoprophylaxis for contacts of sporadic cases of invasive meningococcal disease (IMD) in educational settings. No studies directly compared IMD risk in contacts with/without chemoprophylaxis. However, compared to the background incidence, an elevated IMD risk was identified in settings without a general recommendation for chemoprophylaxis in pre-schools [pooled risk difference (RD) 58·2/10⁵, 95% confidence interval (CI) 27·3-89·0] and primary schools (pooled RD 4·9/10⁵, 95% CI 2·9-6·9) in the ~30 days after contact with a sporadic IMD case, but not in other educational settings. Thus, limited but consistent evidence suggests the risk of IMD in pre-school contacts of sporadic IMD cases is significantly increased above the background risk, but lower than in household contacts (pooled RD for household contacts with no chemoprophylaxis vs. background incidence: 480·1/10⁵, 95% CI 321·5-639·9). We recommend chemoprophylaxis for pre-school contacts depending on an assessment of duration and closeness of contact.

Drug allergy: an updated practice parameter

Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient

Epidemiology of hypersensitivity drug reactions

PURPOSE OF REVIEW

Hypersensitivity drug reactions are but one of the many different types of adverse drug reactions. They may be potentially life-threatening, prolong hospitalization, affect drug prescribing patterns of physicians and result in socioeconomic costs. This review summarizes current knowledge on the incidence, prevalence, mortality and risk factors for these reactions in different populations.

RECENT FINDINGS

Hypersensitivity reactions represent about one third of all adverse drug reactions. Adverse drug reactions affect 10-20% of hospitalized patients and more than 7% of the general population. Severe reactions including anaphylaxis, drug hypersensitivity syndromes, Stevens Johnson syndrome and toxic epidermal necrolysis are also associated with significant morbidity and mortality. Although several risk factors have been identified, their clinical importance has not been fully understood. Future progress in immunogenetics and pharmacogenetics may help identify populations at risk for specific types of reactions.

SUMMARY

Well designed epidemiological studies on hypersensitivity drug reactions are lacking as most studies have been on adverse drug reactions. Such studies will be helpful in identifying patients at risk of developing such reactions, in particular severe reactions, and implementing early preventive measures.

Classification and epidemiology of hypersensitivity drug reactions

Nonimmune hypersensitivity reactions are unpredictable adverse drug reactions that are clinically similar to allergic reactions for which no drug-specific antibodies or T lymphocytes are identified. Few tools allow a definite diagnosis, and most of the available ones need to be validated. True epidemiologic data are limited, and most of the available information on the incidence, mortality, and socioeconomic impact should be discussed with caution.

[Identifying and understanding drug allergies]

Drug hypersensitivity reactions frequently occur in hospitalized and out-patients. Clinical presentations are numerous and heterogeneous, from a mild urticaria to a dramatic anaphylactic shock and an extensive bullous skin disease. Allergic reactions are unpredictable reactions, related to immunologic mechanisms. Some reactions mimic allergic reactions but no drug specific antibody or T cell proliferation can be demonstrated. A true diagnosis is rarely set up and the tools for it are lacking. In this review, we will focus on the available epidemiological data concerning these reactions, including data on incidence and mortality and on the most recent advances in the pathophysiology and allergy diagnosis of drug hypersensitivity reactions.

Modeling the public health response to bioterrorism: using discrete event simulation to design antibiotic distribution centers

BACKGROUND

Post-exposure prophylaxis is a critical component of the public health response to bioterrorism. Computer simulation modeling may assist in designing antibiotic distribution centers for this task.

METHODS

The authors used discrete event simulation modeling to determine staffing levels for entry screening, triage, medical evaluation, and drug dispensing stations in a hypothetical antibiotic distribution center operating in low, medium, and high disease prevalence bioterrorism response scenarios. Patient arrival rates and processing times were based on prior mass prophylaxis campaigns. Multiple sensitivity analyses examined the relationship between average staff utilization rate (UR) (i.e., percentage of time occupied in patient contact) and capacity of the model to handle surge arrivals.

RESULTS

Distribution center operation required from 93 staff for the low-prevalence scenario to 111 staff for the high-prevalence scenario to process approximately 1000 people per hour within the baseline model assumptions. Excess capacity to process surge arrivals approximated (1-UR) for triage staffing.

CONCLUSIONS

Discrete event simulation modeling is a useful tool in developing the public health infrastructure for bioterrorism response. Live exercises to validate the assumptions and outcomes presented here may improve preparedness to respond to bioterrorism.