Cross sensitivity between ciprofloxacin and levofloxacin for an immediate hypersensitivity reaction

Ciprofloxacin-Induced Anaphylactic Reaction Followed by Negative Provocation Test in Response to Levofloxacin: A Case Report

Fluoroquinolones are a commonly prescribed class of antibiotics due to their broad spectrum of antimicrobial activity, favorable pharmacokinetic properties, ability to switch from parenteral to oral administration, and global availability. After beta-lactams, they are the second most common antibiotic class associated with drug allergies. The mechanism of fluoroquinolone-induced hypersensitivity reactions has not yet been fully understood, so the true incidence of hypersensitivity reactions remains unknown. Cross-reactivity between fluoroquinolones has been the subject of conflicting and limited clinical research. Due to their similar chemical structure, some argue for close cross-reactivity within the group. However, recent studies have produced contradictory results. We present the case of a young patient who had an anaphylactic reaction to ciprofloxacin but was tolerant to levofloxacin, as determined via a skin prick test followed by a drug provocation test. Our findings support the notion that there is little cross-reactivity between fluoroquinolones. Consequently, exposure to another fluoroquinolone in a hospital setting may be beneficial, particularly for patients who lack adequate antibiotic alternatives. However, additional research on this subject is required.

Immediate hypersensitivity to fluoroquinolones: a cohort assessing cross-reactivity

Background

Fluoroquinolones are the second-most prescribed antimicrobial and are frequently associated with causing hypersensitivity reactions. Existing evidence regarding cross-reactivity of fluoroquinolones is limited, offering clinicians little guidance in understanding the implications of selecting an in-class alternative among patients with histories of allergic reactions to fluoroquinolones. The aim of this study was to compare the frequency of immediate hypersensitivity reactions to either ciprofloxacin, levofloxacin, and/or moxifloxacin among patients with a history of immediate hypersensitivity to a different fluoroquinolone.

Methods

This retrospective chart review included adult patients with a history of an immediate hypersensitivity reaction to ciprofloxacin, levofloxacin, and/or moxifloxacin and a documented prescription for a different fluoroquinolone. The primary outcome was documentation of a hypersensitivity reaction upon second fluoroquinolone exposure.

Results

A total of 321 cases met inclusion criteria. Of these cases, 2.5% experienced an immediate hypersensitivity reaction after second fluoroquinolone exposure to ciprofloxacin, levofloxacin, and/or moxifloxacin. Within the ciprofloxacin, levofloxacin, and moxifloxacin index allergy cohorts, the frequency of cross-reactivity were 2.7%, 2.2%, and 5.3%, respectively.

Conclusion

Our data suggest that patients with a history of immediate hypersensitivity reaction to ciprofloxacin, levofloxacin, and/or moxifloxacin are at low risk of experiencing a cross-reaction when exposed to a different fluoroquinolone. Avoidance of all fluoroquinolones in this patient population may not be warranted.

Trends in the Design of Intensity-Based Optical Fiber Biosensors (2010-2020)

There exists an increasing interest in monitoring low concentrations of biochemical species, as they allow the early-stage detection of illnesses or the monitoring of the environment quality. Thus, both companies and research groups are focused on the development of accurate, fast and highly sensitive biosensors. Optical fiber sensors have been widely employed for these purposes because they provide several advantages for their use in point-of-care and real-time applications. In particular, this review is focused on optical fiber biosensors based on luminescence and absorption. Apart from the key parameters that determine the performance of a sensor (limit of detection, sensibility, cross-sensibility, etc.), other features are analyzed, such as the optical fiber dimensions, the sensing set ups and the fiber functionalization. The aim of this review is to have a comprehensive insight of the different aspects that must be taken into account when working with this kind of sensors.

Probable etoricoxib-induced fixed drug eruption involving the oral mucosa: A case report

Fixed drug eruption (FDE) is a cutaneous adverse drug reaction characterized by recurrence of lesions at the same sites each time a specific drug is taken. Oral mucosal involvement is rare. Nonsteroidal anti-inflammatory drugs are one of the most common offending drug groups in FDE; however, selective cyclooxygenase-2 inhibitors, such as etoricoxib, are rarely implicated. We present a case of oral mucosal and cutaneous FDE induced by etoricoxib that, to the best of our knowledge, is the first reported case of this nature. We describe the diagnostic challenges and review the pertinent literature. The value of drug provocation testing and patch testing in FDE is also discussed.

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.

Immediate type hypersensitivity and late phase reaction occurred consecutively in a patient receiving ethambutol and levofloxacin

Background

We experienced a rare case of immediate type hypersensitivity and late phase reaction to anti-tubercular therapy consisting of ethambutol and levofloxacin, which occurred in close succession, giving the appearance of a single, continuous reaction to one drug.

Case presentation

The patient was a man in his 70's who began therapy consisting of isoniazide, rifampicin, and ethambutol for pulmonary tuberculosis. Since the patient had a drug eruption within several hours after the start of his treatment, his reaction to ethambutol was assessed first among the three suspected drugs using an oral challenge test. Levofloxacin, which was not among the suspected drugs, was administered with ethambutol in order to avoid drug resistance resulting from the administration of a single drug. The patient experienced pruritus within 1 h. We observed a well-defined, edematous erythema with induration, which persisted for several days after the patient received the two drugs. Next, skin tests were performed with ethambutol and levofloxacin. The skin reaction to ethambutol and levofloxacin consisted of two different types of allergic reaction, a immediate type reaction and phase reaction.

Conclusion

This is the first report of a late phase reaction and immediate type hypersensitivity occurring in quick succession in the same patient. Subsequent skin tests were able to prove the presence of these two different types of allergic reactions.

Food entries in a large allergy data repository

OBJECTIVE

Accurate food adverse sensitivity documentation in electronic health records (EHRs) is crucial to patient safety. This study examined, encoded, and grouped foods that caused any adverse sensitivity in a large allergy repository using natural language processing and standard terminologies.

METHODS

Using the Medical Text Extraction, Reasoning, and Mapping System (MTERMS), we processed both structured and free-text entries stored in an enterprise-wide allergy repository (Partners' Enterprise-wide Allergy Repository), normalized diverse food allergen terms into concepts, and encoded these concepts using the Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) and Unique Ingredient Identifiers (UNII) terminologies. Concept coverage also was assessed for these two terminologies. We further categorized allergen concepts into groups and calculated the frequencies of these concepts by group. Finally, we conducted an external validation of MTERMS's performance when identifying food allergen terms, using a randomized sample from a different institution.

RESULTS

We identified 158 552 food allergen records (2140 unique terms) in the Partners repository, corresponding to 672 food allergen concepts. High-frequency groups included shellfish (19.3%), fruits or vegetables (18.4%), dairy (9.0%), peanuts (8.5%), tree nuts (8.5%), eggs (6.0%), grains (5.1%), and additives (4.7%). Ambiguous, generic concepts such as "nuts" and "seafood" accounted for 8.8% of the records. SNOMED-CT covered more concepts than UNII in terms of exact (81.7% vs 68.0%) and partial (14.3% vs 9.7%) matches.

DISCUSSION

Adverse sensitivities to food are diverse, and existing standard terminologies have gaps in their coverage of the breadth of allergy concepts.

CONCLUSION

New strategies are needed to represent and standardize food adverse sensitivity concepts, to improve documentation in EHRs.

Cutaneous adverse drug reactions in Indian population: A systematic review

Background:

Epidemiological data is limited for cutaneous adverse drug reactions (CADRs) in India. Most of the Indian studies have small sample size and are of limited duration.

Aims:

The aim of this study is to analyze CADRs with reference to the causative drugs and their clinical characteristics in Indian population.

Materials and Methods:

As per selection criteria, electronic databases were searched for publications describing CADRs from January-1995 to April-2013 by two independent investigators. Data of the causative drugs and clinical characteristics were extracted and summarized by absolute numbers, percentages, ranges, and means as presented by the authors. The subgroup analysis of causative drugs was performed for causality assessment, severe or nonsevere reactions and occurrence of common CADRs. Studies showing “definite” and “probable” categories of causality analysis were labeled as “definite and probable causality (DPC) studies”. The other included studies were labeled as “non-DPC studies”.

Results:

Of 8337 retrieved references, 18 prospective studies were selected for analysis. The pooled incidence was 9.22/1000 total among outpatient and inpatient cases. Commonly observed reactions were maculopapular rash (32.39%), fixed drug eruptions (FDEs) (20.13%), urticaria (17.49%) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) (6.84%). The major causative drug groups were antimicrobials (45.46%), nonsteroidal anti-inflammatory drugs (NSAIDs) (20.87%) and anti-epileptic drugs (14.57%). Commonly implicated drugs were sulfa (13.32%), β-lactams (8.96%) and carbamazepine (6.65%). High frequency of CADRs is observed with anti-epileptic drugs in DPC studies only. Carbamazepine, phenytoin and fluoroquinolones had higher severe to nonsevere cutaneous reaction ratio than other drugs. Antimicrobials were the main causative drugs for maculopapular rash, FDEs and SJS/TEN, and NSAIDs for the urticaria. The mortality for overall CADRs, SJS/TEN, and exfoliative dermatitis were 1.71%, 16.39%, and 3.57%, respectively. “Definitely preventable”, “probably preventable” and “not preventable” categories CADRs were 15.64%, 63.14%, and 34.64%, respectively.

Conclusion:

Antimicrobials, NSAIDs and antiepileptic are common causative agents of CADRs in India. Antiepileptic agents show high rates of severe cutaneous reactions.

Safe medication use based on knowledge of information about contraindications concerning cross allergy and comprehensive clinical intervention

BACKGROUND

An investigation of safety issues regarding information on contraindications related to cross allergy was conducted to promote clinical awareness and prevent medical errors in a 2200-bed tertiary care teaching hospital.

METHODS

Prescribing information on contraindications concerning cross allergy was collected from an information system and package inserts. Data mining and descriptive analysis were performed. A risk register was used for project management and risk assessment. A Plan, Do, Check, Act cycle was used as part of continuous quality improvement. Records of drug counseling and medical errors were collected from an online reporting system. A pharmacist-led multidisciplinary team initiated an intervention program on cross allergy in August 2008.

RESULTS

Four years of risk management at our hospital achieved successful outcomes, ie, the number of medical errors related to cross allergies decreased by 97% (10 cases monthly before August 2008 versus three cases yearly in 2012) and risk rating decreased significantly [initial risk rating: 25(high-risk) before August 2008 versus final risk rating:6 (medium-risk) in December 2012].

CONCLUSION

We conclude that comprehensive clinical interventions are very effective through team cooperation. Medication use has potential for safety risks if sufficient attention is not paid to contraindications concerning cross allergy. The potential for cross allergy involving drugs which belong to completely different pharmacological classes is easily overlooked and can be dangerous. Pharmacists can play an important role in reducing the risk of cross allergy as well as recommending therapeutic alternatives.