Beta-Lactam Allergy: Real Practice in a Regional Hospital

Background/Aims: Beta-lactam (BL) antibiotics are widely prescribed for controlling bacterial infections and relevant culprits of adverse drug reactions (ADRs). BL allergy may vary according to prescription patterns within a given period of time. However, BL allergy in contemporary clinical practice has rarely been a focus of research.Methods: To investigate the clinical characteristics of BL allergy, subjects with ADRs to medicines, including BL antibiotics, were retrospectively reviewed.Results: Among the 175 enrolled subjects, BL antibiotics as culprits were confirmed in 79 (45.1%, female 53.2%, age 49 ± 14 years). Among the patients with confirmed BL allergy, only two (2.5%) were diagnosed via a prescription survey completed as part of multi-drug administration. The others were confirmed by serologic tests in 33 patients (41.8%), skin tests in 29 (36.7%), and drug provocation tests in 15 (19.0%). Regarding the symptoms and signs, onset within an hour of taking medicines was common (61 patients, 77.3%). Itchy skin was most common, followed by hives, rash, breathing difficulty, angioedema, and hypotension. Anaphylaxis occurred in 67%, and one-half (50.6%) of patients visited the emergency room. Cefaclor and amoxicillin were common BL culprits. Among others who did not have BL allergy, nonsteroidal anti-inflammatory drugs were found to be common culprits, followed by quinolones.Conclusions: BL allergy is common among patients who experienced ADRs to medicines including BL antibiotics. For multi-drug administration, a prescription survey hardly helped in confirming BL allergy. Anaphylaxis is common in patients with BL allergy, frequently leading to emergency room visits. Cefaclor and amoxicillin are common culprits.

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Systemic reaction during intradermal skin tests with beta-lactams

BMJ Case Reports ◽

10.1136/bcr-2020-240050 ◽

2021 ◽

Vol 14 (3) ◽

pp. e240050

Author(s):

Joana Carvalho ◽

Georgeta Oliveira

Keyword(s):

Skin Testing ◽

Drug Hypersensitivity ◽

Systemic Reaction ◽

Skin Tests ◽

Beta Lactam ◽

Provocation Tests ◽

Maculopapular Eruption ◽

Intradermal Tests ◽

Amoxicillin Clavulanate ◽

Immediate Reactions

Beta-lactam (BL) antibiotics are the most frequent cause of drug hypersensitivity in children, inducing both immediate and non-immediate reactions. Here we report a case of a 4-year-old child with a disseminated maculopapular exanthema 7 days after the first dose of amoxicillin–clavulanate, referred to our paediatric allergy department. Skin prick tests were negative. Intradermal tests were performed and, after 10 hours, indurated wheals larger than 10×10 mm with progressive erythema and disseminated maculopapular eruption were developed, related to amoxicillin and amoxicillin–clavulanate. Systemic reactions to BL skin tests are rarely reported and the majority are immediate reactions. This case illustrates a rare example of a non-immediate systemic reaction to intradermal tests, underlying the importance of skin testing before drug provocation tests in cases of moderate to severe non-immediate reactions.

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Drug Provocation Tests in Patients with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Acetaminophen Hypersensitivity Reactions

Journal of Allergy and Clinical Immunology ◽

10.1016/j.jaci.2016.12.187 ◽

2017 ◽

Vol 139 (2) ◽

pp. AB40

Author(s):

Wat Mitthamsiri ◽

Panithan Pradubpongsa ◽

Atik Sangasapaviliya ◽

Tadech Boonpiyathad

Keyword(s):

Hypersensitivity Reactions ◽

Provocation Tests ◽

Inflammatory Drugs ◽

Anti Inflammatory ◽

Drug Provocation Tests

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Optimal step doses for drug provocation tests to prove beta-lactam hypersensitivity

Allergy ◽

10.1111/all.13037 ◽

2016 ◽

Vol 72 (4) ◽

pp. 552-561 ◽

Cited By ~ 32

Author(s):

A.-M. Chiriac ◽

T. Rerkpattanapipat ◽

P.-J. Bousquet ◽

N. Molinari ◽

P. Demoly

Keyword(s):

Beta Lactam ◽

Provocation Tests ◽

Drug Provocation Tests

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Delayed positive drug provocation tests to beta‐lactams with flare‐up reactions of skin tests sites

Clinical & Experimental Allergy ◽

10.1111/cea.13810 ◽

2020 ◽

Author(s):

Sabela Pérez‐Codesido ◽

Jean‐Luc Bourrain ◽

Pascal Demoly ◽

Anca‐Mirela Chiriac

Keyword(s):

Skin Tests ◽

Beta Lactams ◽

Provocation Tests ◽

Drug Provocation Tests

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Diagnostic value and safety of penicillin skin tests in children with immediate penicillin allergy

Allergy and Asthma Proceedings ◽

10.2500/aap.2020.41.200082 ◽

2020 ◽

Vol 41 (6) ◽

pp. 442-448 ◽

Cited By ~ 1

Author(s):

Ilknur Kulhas Celik ◽

Irem Turgay Yagmur ◽

Ozge Yilmaz Topal ◽

Muge Toyran ◽

Ersoy Civelek ◽

...

Keyword(s):

Pediatric Patients ◽

Multivariate Logistic Regression Analysis ◽

Diagnostic Value ◽

Penicillin Allergy ◽

Skin Tests ◽

Provocation Tests ◽

Test Kit ◽

History Of ◽

Drug Provocation Tests ◽

Immediate Reactions

Background: The first-line method in the diagnosis of patients who describe an immediate reaction after penicillin intake is a skin test (ST) with penicillin reagents. Objectives: We aimed to determine the safety and diagnostic value of penicillin STs in the diagnosis of immediate reactions to penicillins in pediatric patients. Methods: The study included pediatric patients with suspected immediate reaction to penicillin who were subjected to STs by using a standard penicillin test kit as well as suspected penicillin and the drug provocation tests (DPT) with the suspected penicillin at our clinic. Results: A total of 191 patients (53.9% boys) with a median age of 6.83 years (interquartile range, 4.2‐12 years) were included in the study. The time from drug intake to the onset of reaction was ≤1 hour in 138 patients (72.3%) and 1 to 6 hours in 53 patients (27.7%). Penicillin allergy (PA) was confirmed by diagnostic tests in 36 of the 191 patients (18.8%). In multivariate logistic regression analysis, the history of both urticaria and angioedema (odds ratio [OR] 27.683 [95% confidence interval {CI}, 3.143‐243.837]; p = 0.003) and anaphylaxis (OR 56.246 [95% CI, 6.598‐479.489]; p < 0.001) were the main predictors of a PA diagnosis. Although ST results were positive in 23 patients (63.8%), 13 patients (26.2%) had positive DPT results despite negative ST results. The negative predictive value (NPV) of STs was calculated 92.2% (155/168). None of our patients experienced immediate or delayed systemic and/or local reactions in relation to the STs. Conclusion: A history of urticaria with angioedema and anaphylaxis were the main predictors of true PA in children with suspected immediate reactions. STs with penicillin reagents are safe for use in children. Although STs have a high NPV, DPT is the gold standard for diagnosis. DPTs should be performed as the final step of the diagnostic evaluation of PA in patients with negative ST results.

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Diagnosing and Managing Patients with Reactions to Radiocontrast Media

Current Treatment Options in Allergy ◽

10.1007/s40521-021-00287-x ◽

2021 ◽

Vol 8 (3) ◽

pp. 210-221

Author(s):

Knut Brockow

Keyword(s):

Skin Testing ◽

Drug Hypersensitivity ◽

Skin Tests ◽

Hypersensitivity Reactions ◽

Positive Skin ◽

Provocation Tests ◽

Ring Molecules ◽

Allergic Skin ◽

Drug Hypersensitivity Reactions ◽

Drug Provocation Tests

Abstract Purpose of the review Iodinated radio contrast media (RCM) belong to the most common elicitors of drug hypersensitivity reactions (HR). Urticaria or anaphylaxis may occur ≤ 1(−6) hour(s) (immediate HR) and exanthems (non-immediate HR) develop > 6 h after application of RCM. Evidence for an immunologic mechanism of RCM HR against the different RCM benzene ring molecules and the benefit of allergological testing in patients with previous hypersensitivity reactions is progressively increasing. Recent findings Positive skin tests can confirm allergy in patients with previous reactions to RCM and help to select alternative better tolerated RCMs. Severe hypersensitivity reactions are mainly caused by an allergic mechanism, whereas the majority of non-severe reactions appear to be non-allergic. Skin testing is highly recommended to help identify allergic hypersensitivity reactions and to select alternatives. Using structurally different RCM is more effective than premedication for the prevention of future reactions. Drug provocation tests to RCM have been increasingly used, but are not yet standardized among different centers. Summary In patients with previous severe hypersensitivity reactions to RCM, skin testing is recommended. For future RCM-enhanced examinations in patients with previous reactions, structurally different, skin test-negative preparations should be applied. Drug provocation tests do confirm or exclude RCM hypersensitivity or may demonstrate tolerability of alternative RCMs.

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Macrolide Allergy in Children and the Negative Predictive Value of Drug Provocation Tests in Mild Index Reactions

Asthma Allergy Immunology ◽

10.21911/aai.655 ◽

2021 ◽

Vol 19 (2) ◽

pp. 92-99

Author(s):

Betül Karaatmaca ◽

Şule büyük yaytokgil ◽

İlknur Külhaş Çelik ◽

Özge Yılmaz Topal ◽

Ersoy Civelek ◽

...

Keyword(s):

Negative Predictive Value ◽

Predictive Value ◽

Drug Hypersensitivity ◽

Provocation Test ◽

Skin Tests ◽

Provocation Tests ◽

Patient Reported ◽

Drug Provocation Test ◽

Work Up ◽

Drug Provocation Tests

ABSTRACT Objective: Macrolide allergy is rarely reported, and there is limited knowledge of hypersensitivity reactions (HRs) in children. The negative predictive value (NPV) of drug provocation tests (DPTs) for macrolides is unresolved. We aim to evaluate the clinical features of macrolide allergy in children, and determine the NPV of macrolide DPTs. Materials and Methods: Pediatric patients who were referred to our allergy department with a suspicion of macrolide allergy were evaluated by DPTs with or without prior skin tests between 2011 and 2020. Characteristics of the HRs and patients, the results of skin and DPTs were recorded. At least three months after evaluation of the patients with allergy work up, telephone interviews were performed. Patients were asked whether they had reused the suspected macrolide or not. Patients who reported HR during subsequent drug intake were invited for reevaluation. Results: A total of 160 children (161 reactions) (55.6% male) with a suspicion of macrolide allergy were enrolled for the study, and all children had a mild index reaction. The median age was 48 (18-102) months, and the median time between the suspected allergic reaction and allergy work-up was 3 (2-8) months. The most frequently reported suspected agent was clarithromycin, in 151 patients (94.4%). Macrolide allergy was confirmed in 8 (5%) patients. Only one patient reported skin eruptions upon reuse despite a negative DPT and he was invited to be reevaluated. A second DPT was performed resulting in urticarial lesions. The NPV was found to be 97.4% for negative DPT with macrolides. Conclusion: Confirmed macrolide allergy is rare in children, and DPTs are the gold standard to assess suspected macrolide allergy. The NPV of macrolide provocation tests seems to be high in children. Keywords: Children, drug hypersensitivity, drug provocation test, macrolide, negative predictive value

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Mild to moderate hypersensitivity reactions to beta-lactams in children: a single-centre retrospective review

BMJ Paediatrics Open ◽

10.1136/bmjpo-2019-000435 ◽

2019 ◽

Vol 3 (1) ◽

pp. e000435 ◽

Cited By ~ 5

Author(s):

Leticia Vila ◽

Vanesa Garcia ◽

Oihana Martinez Azcona ◽

Loreley Pineiro ◽

Angela Meijide ◽

...

Keyword(s):

Drug Hypersensitivity ◽

Skin Tests ◽

Penicillin G ◽

Hypersensitivity Reactions ◽

Beta Lactam ◽

Patch Tests ◽

Provocation Tests ◽

Delayed Reactions ◽

Diagnostic Work ◽

Low Sensitivity

ObjectiveBeta-lactam (BL) antibiotics are the most reported drugs in hypersensitivity reactions in children. More than 90% of these children tolerate the suspected drug after diagnostic work-up. Skin tests (STs) show low sensitivity. Our aim was to assess the performance of drug provocation tests (DPTs) without previous ST in mild and moderate delayed reactions and to propose a new DPT protocol.Design of the studyCharts from 213 children under 15 years of age referred for suspected BL allergy from 2011 to 1013 were reviewed. Prick, intradermal and patch tests were performed with major determinant penicilloyl-polylysine, minor determinant mixture, amoxicillin (AMX), cefuroxime, penicillin G and AMX–clavulamate. Children with negative skin tests underwent DPT. After an initial full dose of antibiotic, DPT was carried on for 3 days at home in patients reacting within the first 3 days of treatment. If the reaction took place from day 4 on of treatment, patients took the antibiotic for 5 days.ResultsWe included 108 girls and 105 boys. Mean age at the time of reaction was 3.66±3.06 years. 195 patients (91.5%) reacted to one BL. 154 reactions (67.2%) were non-immediate. Mild to moderate skin manifestations were most frequently reported. AMX–clavulanate was the most frequently involved (63.4%). DPT confirmed the diagnosis of drug hypersensitivity in 17 (7.3%) cases. These 17 patients had negative ST.ConclusionIn mild and moderate cases of BL hypersensitivity, diagnosis can be performed by DPT without previous ST

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Ipersensibilità ai FANS: intolleranza o allergia?

Medico e Bambino ◽

10.53126/meb40037 ◽

2021 ◽

Vol 40 (1) ◽

pp. 37-43

Author(s):

Laura Levantino ◽

Cristiana Corrado ◽

Laura Badina ◽

Sara Lega ◽

Egidio Barbi

Keyword(s):

Drug Hypersensitivity ◽

Clinical Manifestations ◽

Hypersensitivity Reactions ◽

Provocation Tests ◽

Immunological Mechanisms ◽

Drug Hypersensitivity Reactions ◽

Inflammatory Drugs ◽

Anti Inflammatory ◽

Drug Provocation Tests ◽

Cox 1

Non-steroidal anti-inflammatory drugs (NSAIDs) are the main triggers of drug hypersensitivity reactions in children. According to the EAACI latest classification NSAIDs hypersensitivity reactions are differentiated into cross-reactive reactions, with non-immunological mechanisms (based on COX-1 inhibition), and selective reactions, with immunological mechanisms. Paediatric clinical manifestations of NSAID hypersensitivity are typically cutaneous, but sometimes, similarly to anaphylaxis, can involve other systems, especially the respiratory one. Differentiating between NSAID intolerance and NSAID allergy through drug provocation tests is crucial for the patient because the two clinical entities require different management.

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