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American Journal of Health-system... Nov 2023The purpose of this project was to analyze the process of adult inpatient drug desensitization and to create a multidisciplinary standardized procedure with the aim of...
PURPOSE
The purpose of this project was to analyze the process of adult inpatient drug desensitization and to create a multidisciplinary standardized procedure with the aim of improving patient safety, efficiency, length of stay, and patient satisfaction.
SUMMARY
A team consisting of physicians, pharmacists, nurses, critical care specialists, and operational capacity managers was created. The electronic health system was queried to evaluate the frequency of desensitizations, level of care, implicated medications, and length of stay. An electronic desensitization request form was created along with a desensitization team and email listserver for notification of key stakeholders.
CONCLUSION
A standardized, safe, and efficient process for inpatient drug desensitization requires advance planning and participation from all disciplines involved. Operational and logistical aspects of desensitization are crucial components of rapid drug desensitization. A structured, multidisciplinary approach to inpatient desensitization is feasible.
Topics: Adult; Humans; Drug Hypersensitivity; Inpatients; Patient Satisfaction; Desensitization, Immunologic; Pharmacists
PubMed: 37605927
DOI: 10.1093/ajhp/zxad189 -
Current Opinion in Allergy and Clinical... Aug 2024Perioperative hypersensitivity reactions are rare but potentially catastrophic events. This review acts to summarize recent recommendations for both immediate and... (Review)
Review
PURPOSE OF REVIEW
Perioperative hypersensitivity reactions are rare but potentially catastrophic events. This review acts to summarize recent recommendations for both immediate and poststabilization management of suspected reactions, alongside practical advice for anaesthetists who may be faced with these events.
RECENT FINDINGS
Prompt treatment is essential but may be hampered by delay in recognition. This can occur because there are multiple differential diagnoses for the observed clinical signs as well as variations in clinical presentation. Resuscitation is dependent on the use of adrenaline and fluids. Adrenaline should be administered in small, titrated intravenous boluses. Low-dose infusions should be commenced early if the response to boluses is poor. Large volume fluid resuscitation may be required to maintain adequate circulating volume. Chest compressions are recommended when there is evidence of inadequate perfusion, rather than waiting until cardiac arrest is confirmed. Antihistamines and corticosteroids are no longer recommended in the immediate management phase. Once the patient has been stabilized, it is important to obtain serial tryptase concentrations to aid the subsequent clinic investigation. The decision to proceed or abandon surgery will be based on an individual risk-benefit analysis. All cases of suspected perioperative hypersensitivity, including fatal cases, must be referred for formal investigation.
SUMMARY
There have been recent updates to management guidelines in perioperative hypersensitivity. Treatment algorithms, treatment packs and referral packs can all help the anaesthetist manage these complex cases, aid the subsequent investigation and ensure patient safety in the future.
Topics: Humans; Epinephrine; Perioperative Period; Anaphylaxis; Practice Guidelines as Topic; Hypersensitivity; Adrenal Cortex Hormones; Drug Hypersensitivity
PubMed: 38814699
DOI: 10.1097/ACI.0000000000001000 -
The Journal of Allergy and Clinical... Mar 2024Vitamin B (Vit B) deficiency affects approximately 20% of those above the age of 60 years in the United Kingdom and United States. If untreated, it leads to detrimental...
BACKGROUND
Vitamin B (Vit B) deficiency affects approximately 20% of those above the age of 60 years in the United Kingdom and United States. If untreated, it leads to detrimental health outcomes.
OBJECTIVE
To investigate a cohort of patients with Vit B hypersensitivity (VB12H) referred to 3 UK allergy centers and design a pathway for the investigation of VB12H.
METHODS
A total of 29 patients seen between 2014 and 2022 underwent skin prick testing (1 mg/mL) with cyanocobalamin (CC) and hydroxycobalamin (HC) and intradermal testing (0.1 and 0.01 mg/mL). Patients with negative skin tests underwent a Vit B drug provocation test (DPT) with either the index or the alternative drug.
RESULTS
Of 29 patients, 18 (62%) presented with immediate VB12H. Eight experienced anaphylaxis (4 to HC and 4 to CC) and had positive skin tests to the index drug. One patient reacted to oral and 7 patients to injectable Vit B. Seven patients sensitized to one form of Vit B-tolerated DPT with an alternative Vit B. One patient with immediate VB12H reacted to polyethylene glycol (PEG) in oral cobalamin. Of 29 patients, 8 presented with delayed hypersensitivity reaction; 4 patients tolerated the intramuscular index formulation, whereas 2 patients tolerated the per oral formulation. One patient presented with symptoms consistent with symmetrical drug-related intertriginous and flexural exanthema. Three patients were referred because of cobalt allergy.
CONCLUSION
Confirmed VB12H is rare. We propose a comprehensive evaluation protocol that includes Vit B skin tests and considers PEG allergy in patients presenting with VB12H.
Topics: Humans; Middle Aged; Anaphylaxis; Drug Hypersensitivity; Intradermal Tests; Polyethylene Glycols; Skin Tests; Vitamin B 12; Vitamins; Retrospective Studies
PubMed: 37898177
DOI: 10.1016/j.jaip.2023.10.037 -
The Journal of Allergy and Clinical... May 2024Using the reaction history in logistic regression and machine learning (ML) models to predict penicillin allergy has been reported based on non-US data.
BACKGROUND
Using the reaction history in logistic regression and machine learning (ML) models to predict penicillin allergy has been reported based on non-US data.
OBJECTIVE
We developed ML positive penicillin allergy testing prediction models from multisite US data.
METHODS
Retrospective data from 4 US-based hospitals were grouped into 4 datasets: enriched training (1:3 case-control matched cohort), enriched testing, nonenriched internal testing, and nonenriched external testing. ML algorithms were used for model development. We determined area under the curve (AUC) and applied the Shapley Additive exPlanations (SHAP) framework to interpret risk drivers.
RESULTS
Of 4777 patients (mean age 60 [standard deviation: 17] years; 68% women, 91% White, and 86% non-Hispanic) evaluated for penicillin allergy labels, 513 (11%) had positive penicillin allergy testing. Model input variables were frequently missing: immediate or delayed onset (71%), signs or symptoms (13%), and treatment (31%). The gradient-boosted model was the strongest model with an AUC of 0.67 (95% confidence interval [CI]: 0.57-0.77), which improved to 0.87 (95% CI: 0.73-1) when only cases with complete data were used. Top SHAP drivers for positive testing were reactions within the last year and reactions requiring medical attention; female sex and reaction of hives/urticaria were also positive drivers.
CONCLUSIONS
An ML prediction model for positive penicillin allergy skin testing using US-based retrospective data did not achieve performance strong enough for acceptance and adoption. The optimal ML prediction model for positive penicillin allergy testing was driven by time since reaction, seek medical attention, female sex, and hives/urticaria.
Topics: Humans; Female; Penicillins; Male; Drug Hypersensitivity; Retrospective Studies; Middle Aged; United States; Aged; Machine Learning; Adult; Anti-Bacterial Agents; Case-Control Studies; Skin Tests
PubMed: 38242531
DOI: 10.1016/j.jaip.2024.01.010 -
Delayed hypersensitivity reactions to iodinated contrast media: A diagnostic approach by skin tests.Contact Dermatitis Nov 2023Adverse drug reactions to iodinated contrast media (ICM) have risen due to their increasing use in x-ray-based imaging modalities. Delayed hypersensitivity reactions are...
BACKGROUND
Adverse drug reactions to iodinated contrast media (ICM) have risen due to their increasing use in x-ray-based imaging modalities. Delayed hypersensitivity reactions are mainly caused by nonionic monomeric compounds and represent an issue impacting the diagnostic-therapeutic pathways of cancer, cardiology and surgery patients.
OBJECTIVES
To prospectively evaluate the usefulness of skin tests in delayed hypersensitivity reactions to ICM and to evaluate the tolerability of iobitridol, a monomeric nonionic low osmolality compound, as a possible safe alternative.
METHODS
Patients with delayed hypersensitivity reactions to ICM referred to us from 2020 to 2022 were prospectively enrolled in the study. All patients underwent patch test and, if negative, intradermal test with the culprit ICM and iobitridol as alternative.
RESULTS
A total of 37 patients (females 24, 64.9%) were enrolled in the study. Iodixanol and iomeprol were the most frequently involved ICM (48.5% and 35.2%, respectively); 62.2% of patients presented maculopapular eruption, while 37.8% reported delayed urticaria-like rash. Skin tests resulted positive to the culprit ICM in 19 patients (51.4%), 16 to patch test and 3 to intradermal test. Skin tests with iobitridol, tested as alternative, resulted positive in 3/19 patients (15.8%). All 16 patients with negative results to iobitridol were administered this ICM and tolerated it.
CONCLUSIONS
In at least half of patients, delayed-type hypersensitivity was demonstrated by skin tests, particularly by patch test. This diagnostic approach resulted simple, cost-effective and safe, not only to confirm the culprit ICM but also to identify iobitridol as feasible alternative.
Topics: Female; Humans; Contrast Media; Drug Hypersensitivity; Dermatitis, Allergic Contact; Skin Tests; Iodine Compounds; Exanthema; Hypersensitivity, Delayed
PubMed: 37394777
DOI: 10.1111/cod.14372 -
Journal of Oral and Maxillofacial... Oct 2023Penicillins are a potent antibiotic in managing odontogenic infections, but 10% of the population is labelled as allergic to these drugs. This has limited their use and...
PURPOSE
Penicillins are a potent antibiotic in managing odontogenic infections, but 10% of the population is labelled as allergic to these drugs. This has limited their use and resulted in increased utilization of health care resources as well as complications associated with alternative antibiotics. The purpose of the study was to measure the association between patients labeled as penicillin allergic and treatment outcomes in a sample of patients treated for complicated odontogenic infections. Additionally, we sought to investigate antibiotic resistance patterns in these patients.
MATERIALS AND METHODS
A retrospective cohort study was performed at the Michigan Medicine health care system to include patients who were treated for complicated odontogenic infections by oral and maxillofacial surgery between 2016 and 2020. Complicated odontogenic infection was defined as any odontogenic infection requiring admission and surgical management in the operating room. The primary predictor variable was the penicillin allergy label, which was determined by chart review and not confirmed with formal testing. Outcomes were measures of disease severity. The primary outcome variable was hospital length of stay. Secondary outcome variables were ICU admission (yes/no), repeat computed tomography scan(s), repeat surgery (yes/no), and re-admission (yes/no). Co-variates included were age, sex (male/female), tobacco use status, diabetes, immunocompromised state, number of spaces involved, white blood cell count upon admission and insurance status. For our secondary aim, the primary predictor variable was again penicillin allergy and outcome variable was antibiotic resistance as determined by wound culture results following surgical intervention. Negative binomial regression and logistic regression analyses were performed. P < .05 was considered significant.
RESULTS
A total of 150 patients met the inclusion criteria and of those 17.3% reported as penicillin allergic. Patients labelled as penicillin allergic did not differ significantly from patients without penicillin allergy label in terms of treatment outcomes. Age, diabetes, and immunosuppression were associated with an increased length of stay. Patients labelled as penicillin allergic were at significantly higher risk for antibiotic resistance (relative risk = 2.34; 95% confidence interval, 1.66 to 3.32; P < .001), specifically clindamycin resistance (relative risk = 3.17; 95% confidence interval, 1.93 to 5.18; P < .001).
CONCLUSIONS
Penicillin allergy was significantly associated with clindamycin resistance. There were similar outcomes amongst patients with and without a penicillin allergy label despite antibiotic differences. Delabeling efforts for patients with a reported penicillin allergy must be considered and local nomograms for antibiotic selection should be used by providers when seeking alternative antibiotics.
Topics: Humans; Male; Female; Clindamycin; Retrospective Studies; Anti-Bacterial Agents; Penicillins; Drug Hypersensitivity; Hypersensitivity; Diabetes Mellitus
PubMed: 37507104
DOI: 10.1016/j.joms.2023.07.001 -
Asian Pacific Journal of Allergy and... Dec 2023Allergic reaction to topical drugs varies depending on use and availability of topical drugs and self-medication.
BACKGROUND
Allergic reaction to topical drugs varies depending on use and availability of topical drugs and self-medication.
OBJECTIVE
We aimed to determine the incidence of contact dermatitis to topical medicaments among patients referred for patch testing.
METHODS
All patients with suspected allergic contact dermatitis were patch tested with standard and medicament series. The characterization was performed according to the MOAHLFA index.
RESULTS
59/215 (27.4%) patients had positive reactions to at least 1 medicament but only 13/59 (22.0%) had a relevant history. The 3 most common positive medicaments were framycetin 23/215 (10.7%), miconazole 22/215 (10.2%), and econazole 17/215 (7.9%). Among those positive to medicament, face was the most common location 22/59 (37.3%). 39/215 (18.1%) had more than 2 co-positive standard allergens and showed significant higher rate of topical medicament sensitization. The contributing factors of medicament allergy were the history of suspected allergens in personal care products (OR = 2.09, P = 0.038), topical drugs (OR = 2.93, P = 0.002), topical treatment (OR = 2.47, P = 0.011), and history of drug allergy (OR = 1.78, P = 0.023).
CONCLUSIONS
The study showed a high rate of medicament sensitization especially antibiotic and antifungal drugs. The incidence of positive medicament patch test result was associated with facial dermatitis. Polysensitization and history of previous exposure, either as treatment or overusing of drugs, significantly associated with medicament positive patients. This study supports the inclusion of medicaments within the standard series of patch test.
Topics: Humans; Dermatitis, Allergic Contact; Allergens; Anti-Bacterial Agents; Administration, Topical; Antifungal Agents; Drug Hypersensitivity; Patch Tests; Retrospective Studies
PubMed: 33274954
DOI: 10.12932/AP-180820-0944 -
Clinical Microbiology and Infection :... Oct 2023Penicillin allergy records are common, often incorrect and are associated with broad spectrum antibiotic use. We piloted a pharmacist-led multidisciplinary penicillin...
OBJECTIVES
Penicillin allergy records are common, often incorrect and are associated with broad spectrum antibiotic use. We piloted a pharmacist-led multidisciplinary penicillin allergy de-labelling daily ward round to determine the opportunity for penicillin allergy de-labelling in a UK hospital.
METHODS
A daily ward round, delivered by antibiotic pharmacists or junior doctors, identified adult medical and surgical patients between 7 November 2022 and 31 January 2023 with a penicillin allergy record that was preventing first-line penicillin use. An allergy history was taken before risk stratifying likelihood of future harm from penicillin re-exposure and an allergy testing method was determined (direct de-label on history alone or after direct drug provocation testing). After successful allergy de-label, the antibiotic was switched to a penicillin antibiotic.
RESULTS
Of 7214 inpatients during the study period, 1133 (15.7%) had a penicillin allergy record. Of 285 allergy histories taken, 105 (36.8%) met high-risk criteria, 45 (15.8%) met low-risk criteria eligible for direct de-label and 73 (25.6%) met criteria eligible for direct drug provocation testing. We were unable to obtain a history for 61 (21.4%) patients. Of 45 low-risk patients eligible for direct de-label, 40 (88.9%) were de-labelled of whom 24 (53.3%) were switched to a penicillin antibiotic. Of 73 patients with a low-risk allergy history eligible for direct drug provocation testing, 16 (21.9%) received direct drug provocation testing, of whom 9 were switched to a penicillin antibiotic. Two direct de-label patients experienced harm (thrush within 5 days and delayed skin reaction after day 5); none of the direct drug provocation testing patients had a reaction by day 5. The switches resulted in reduced alternative antibiotic use by 173 Daily Defined Doses (DDDs).
DISCUSSION
Penicillin allergy de-labelling patient pathway delivered by pharmacists and junior doctors was safe and effective and well accepted by patients and the wider clinical teams.
Topics: Adult; Humans; Skin Tests; Penicillins; Anti-Bacterial Agents; Drug Hypersensitivity; Hospitals; Hypersensitivity; United Kingdom
PubMed: 37354996
DOI: 10.1016/j.cmi.2023.06.024 -
ANZ Journal of Surgery Nov 2023Anaphylaxis is a severe, potentially life-threatening generalized or systemic hypersensitivity reaction. Sequential reports have cited anaphylaxis as the most common...
BACKGROUND
Anaphylaxis is a severe, potentially life-threatening generalized or systemic hypersensitivity reaction. Sequential reports have cited anaphylaxis as the most common cause of anaesthesia-related deaths. We undertook an audit at a quaternary centre, examining the management of perioperative anaphylaxis and quality of referrals made to our anaesthesia allergy testing service.
METHODS
The data of 41 patients consulted at St Vincent's Hospital Melbourne for perioperative anaphylaxis between 17th of January 2020 and 20th of January 2022 were analysed. Intervention outcomes included total intravenous fluid administered, adrenaline administration, instigation of CPR and the collection and the timing of serum tryptase samples. We also assessed referral quality, provision of institutional allergy alert and time elapsed from the anaphylaxis event to allergy testing. Contemporaneous Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) guidelines were used as the reference standard for most outcomes.
RESULTS
Our data reveals compliance of <80% with respect to intravenous fluid administration, referral quality and tryptase sampling, particularly at the 4-h timepoint.
CONCLUSION
Surgical leadership and patient advocacy in the post-acute phase would likely facilitate requisite testing and improve the quality of counselling. We recommend institutions adopt a case-by-case review of management compliance with recommendations. Additionally, we advocate for the inclusion of a prompt to the ANZAAG referral form, that encourages the operator to update their patient's institutional allergy alert while awaiting allergy testing.
Topics: Humans; Anaphylaxis; Drug Hypersensitivity; Tryptases; Australia; Epinephrine
PubMed: 37138508
DOI: 10.1111/ans.18499 -
JAMA Dermatology Aug 2023Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a severe hypersensitivity reaction. Identifying a culprit drug is critical for patient care, yet...
IMPORTANCE
Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a severe hypersensitivity reaction. Identifying a culprit drug is critical for patient care, yet identification is based on clinical judgment. Data are limited on the accuracy in or approach to identifying a culprit drug.
OBJECTIVE
To evaluate patient allergy list outcomes, current approaches in identifying culprit drugs, and potential methods of improving culprit drug identification.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study spanned 18 years (January 2000 to July 2018), was conducted at Brigham and Women's Hospital and Massachusetts General Hospital (Boston), and included patients with clinically and histologically confirmed cases of SJS/TEN overlap and TEN.
MAIN OUTCOMES AND MEASURES
This study descriptively analyzed potential culprits to SJS/TEN, patients' allergy lists, and currently used approaches that led to those lists. It then tested the theoretical contribution of incorporating various parameters to allergy list outcomes.
RESULTS
Of 48 patients (29 women [60.4%]; 4 Asian [8.3%], 6 Black [12.5%], 5 Hispanic [10.4%], and 25 White [52.1%] individuals; median age, 40 years [range, 1-82 years]), the mean (SD) number of drugs taken per patient at disease onset was 6.5 (4.7). Physicians labeled 17 patients as allergic to a single culprit drug. Comparatively, 104 drugs were added to allergy lists across all patients. Physicians' approaches relied largely on heuristic identification of high-notoriety drugs and the timing of drug exposure. Use of a vetted database for drug risk improved sensitivity. Algorithm for Drug Causality for Epidermal Necrolysis scoring was discordant in 28 cases, labeling an additional 9 drugs missed by physicians and clearing 43 drugs labeled as allergens by physicians. Human leukocyte antigen testing could have potentially affected 20 cases. Consideration of infection as a culprit was limited.
CONCLUSIONS AND RELEVANCE
The results of this cohort study suggest that currently used approaches to identify culprit drugs in SJS/TEN are associated with overlabeling patients allergic to likely nonculprit drugs and less commonly missed possible culprit drugs. Incorporation of a systematized unbiased approach could potentially improve culprit drug identification, although ultimately a diagnostic test is necessary.
Topics: Adult; Female; Humans; HLA Antigens; Retrospective Studies; Stevens-Johnson Syndrome; Male; Infant; Child, Preschool; Child; Adolescent; Young Adult; Middle Aged; Aged; Aged, 80 and over
PubMed: 37342052
DOI: 10.1001/jamadermatol.2023.1693