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The Journal of Allergy and Clinical... Oct 2020
Topics: Drug Hypersensitivity; Humans; Penicillins; Precision Medicine; Public Health; Quality Improvement
PubMed: 32781047
DOI: 10.1016/j.jaip.2020.07.046 -
Journal of Investigational Allergology... 2020The disease caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), ie, coronavirus disease 2019 (COVID-19), has become a global pandemic since... (Review)
Review
The disease caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), ie, coronavirus disease 2019 (COVID-19), has become a global pandemic since it was first reported in Wuhan, China in December 2019. Its severe clinical manifestations, which often necessitate admission to intensive care units, and high mortality rate represent a therapeutic challenge for the medical community. To date, no drugs have been approved for its treatment, and various therapeutic options are being assayed to address the pathophysiological processes underlying the clinical manifestations experienced by patients. New and old drugs administered as monotherapy or in combination to immunologically compromised patients may favor the development of adverse drug reactions, including drug hypersensitivity reactions, which must be identified and managed accordingly. Given the lack of herd immunity and the high rate of viral contagion, new cases are expected to emerge in the coming months. Thus, the probability of more adverse reactions or even new clinical manifestations may increase in parallel. Allergists must receive updated information on these treatments, as well as on the management of possible drug hypersensitivity reactions.
Topics: Antiviral Agents; COVID-19; Cytokines; Diagnosis, Differential; Drug Hypersensitivity; Humans; Hypersensitivity, Delayed; Hypersensitivity, Immediate; Immunologic Factors; SARS-CoV-2; COVID-19 Drug Treatment
PubMed: 32700681
DOI: 10.18176/jiaci.0588 -
American Journal of TherapeuticsAztreonam is not a preferred empiric antibiotic because of variable susceptibilities compared with alternative agents. In addition, it has no Gram-positive activity,...
BACKGROUND
Aztreonam is not a preferred empiric antibiotic because of variable susceptibilities compared with alternative agents. In addition, it has no Gram-positive activity, necessitating coadministration with vancomycin when used empirically, and is more costly when compared with other Gram-negative active agents. Aztreonam is often given to patients with a reported penicillin allergy without further investigation into the reaction or other relevant allergy information.
STUDY QUESTION
How frequently is aztreonam being used inappropriately?
STUDY DESIGN
We conducted a retrospective chart review at an academic medical center to assess the appropriateness of our aztreonam use.
MEASURES AND OUTCOMES
Our primary outcome was frequency of appropriate aztreonam use, based on a true IgE-mediated allergy reported for each patient. We evaluated whether the patients had tolerated a beta-lactam in the past, and what the reported allergic reaction was.
RESULTS
We included 165 patients and found that 46.7% of our aztreonam use was inappropriate, based on previous use of a beta-lactam, or no documentation of an IgE-mediated response. Of the patients with a documented beta-lactam allergy, 63 (38.2%) patients had no allergy manifestation listed, and 37 (22.4%) patients had a non-IgE-mediated allergy manifestation. Of the total population, 61 (37%) patients had tolerated a beta-lactam in the past.
CONCLUSIONS
Aztreonam should be avoided, except in the case of a true IgE-mediated allergic reaction. Our goal was to reduce the inappropriate use of aztreonam at our institution by one or more of the following: educating providers, reviewing aztreonam orders, requiring answering of order questions, or requiring an indication for use. Penicillin skin testing and desensitization are options as well.
Topics: Anti-Bacterial Agents; Aztreonam; Drug Hypersensitivity; Humans; Penicillins; Retrospective Studies; beta-Lactams
PubMed: 31714256
DOI: 10.1097/MJT.0000000000001058 -
Current Opinion in Allergy and Clinical... Aug 2024Patients with mast cell disorders frequently experience symptoms from excessive mediator release like histamine and tryptase, ranging from mild flushing to severe... (Review)
Review
PURPOSE OF REVIEW
Patients with mast cell disorders frequently experience symptoms from excessive mediator release like histamine and tryptase, ranging from mild flushing to severe anaphylactic responses. Hypersensitivity reactions (HRs) to drugs are a major cause of anaphylaxis in these patients, who often worry about triggering mast cell degranulation when taking medications. The aim of this review is to explore the complex interactions between mast cell disorders and drug HRs, focusing on the clinical challenges of managing these conditions effectively to enhance understanding and guide safer clinical practices.
RECENT FINDINGS
Among the drugs most commonly associated with hypersensitivity reactions in patients with mast cell disorders are non-steroidal anti-inflammatory drugs, antibiotics, and perioperative agents. Recent studies have highlighted the role of Mas-related G-protein coupled receptor member X2 (MRGPRX2) - a receptor involved in non-immunoglobulin E mediated mast cell degranulation - in exacerbating HRs. Investigations reveal varied drug tolerance among patients, underscoring the need for individual risk assessments.
SUMMARY
Tailored diagnostic approaches are crucial for confirming drug allergies and assessing tolerance in patients with mastocytosis, preventing unnecessary medication avoidance and ensuring safety before acute situations arise.
Topics: Humans; Mast Cells; Drug Hypersensitivity; Receptors, G-Protein-Coupled; Anaphylaxis; Receptors, Neuropeptide; Cell Degranulation; Mastocytosis; Anti-Inflammatory Agents, Non-Steroidal; Animals; Anti-Bacterial Agents; Nerve Tissue Proteins
PubMed: 38814742
DOI: 10.1097/ACI.0000000000001001 -
Annals of Allergy, Asthma & Immunology... Jun 2020An epidemic of antibiotic allergy is occurring. (Review)
Review
OBJECTIVE
An epidemic of antibiotic allergy is occurring.
DATA SOURCES
Articles published since 2008.
STUDY SELECTIONS
Articles on antibiotic allergy and stewardship.
RESULTS
A number of overlapping factors contribute. The most important factor is antibiotic overuse. Antibiotics are commonly used in situations in which no antibiotics are indicated. Thirty percent to 50% of ambulatory antibiotic use may be inappropriate. The duration of indicated antibiotic use is often excessive, which leads to more side effects. All antibiotic use can result in adverse reactions, and a fraction of these will be dutifully recorded as an allergy in the electronic health record (EHR). Most EHRs are not well structured to accurately convey information on expected side effects that have occurred, metabolic or other contraindications, dose-related or situational toxicities, personal preferences, clinically significant immunologically mediated hypersensitivity, and other reasons a particular patient may not want or should not be given a specific drug or type of drug in the future. As populations age, their accumulated baggage of reported antibiotic allergies increase. Suspected antibiotic allergy is rarely confirmed with appropriate testing or rechallenge. Patients then receive suboptimal antibiotic therapy and experience more side effects, treatment failures, and serious antibiotic-resistant infections. Reporting an antibiotic allergy in the EHR is nominally done to improve patient safety, but unfortunately, this is often not the actual result.
CONCLUSION
Audit and feedback, to help ensure adherence to Choosing Wisely recommendations and good antibiotic stewardship practices, can help reduce inappropriate antibiotic use. Restructuring EHRs to facilitate correct drug intolerance reporting, along with active antibiotic allergy delabeling programs, can help stem this epidemic.
Topics: Anti-Bacterial Agents; Clinical Decision-Making; Comorbidity; Drug Hypersensitivity; Electronic Health Records; Female; Humans; Male; Medical Overuse; Public Health Surveillance; Skin Tests
PubMed: 31881269
DOI: 10.1016/j.anai.2019.12.016 -
Current Opinion in Allergy and Clinical... Aug 2020The purpose of this review is to provide an update on how best to manage the investigation of suspected perioperative hypersensitivity reactions based on recent... (Review)
Review
PURPOSE OF REVIEW
The purpose of this review is to provide an update on how best to manage the investigation of suspected perioperative hypersensitivity reactions based on recent literature and key publications.
RECENT FINDINGS
In the past two years, several very important initiatives have been taken in the field of perioperative hypersensitivity. The 6th national audit project in the United Kingdom has provided new knowledge through a series of studies, including a nationwide prospective study, and the European Academy of Allergy and Clinical Immunology has commissioned a position paper with updated recommendations for investigations. Lastly, a large international working group comprising experts in anesthesiology, allergology, and immunology, the International Suspected Perioperative Allergic Reactions group, has published a series of articles providing updates and new insights into several different key areas of perioperative hypersensitivity.
SUMMARY
The investigation of perioperative hypersensitivity reactions is highly complex and aims to identify the correct culprit to ensure future avoidance but also to disprove allergy to other suspected culprits, making them available for subsequent anesthesia. To achieve this, close collaboration between anesthesiologists and allergists is called upon to ensure the best possible outcome for the patient.
Topics: Allergy and Immunology; Anaphylaxis; Anesthesiology; Diagnosis, Differential; Drug Hypersensitivity; Heart Arrest; Humans; Patient Care Team; Perioperative Period; Practice Guidelines as Topic; Severity of Illness Index
PubMed: 32590501
DOI: 10.1097/ACI.0000000000000654 -
The Journal of Allergy and Clinical... Feb 2021Polyethylene glycols (PEGs) or macrogols are hydrophilic polymers found in everyday products such as foods, cosmetics, and medications. We present 5 cases of confirmed...
Polyethylene glycols (PEGs) or macrogols are hydrophilic polymers found in everyday products such as foods, cosmetics, and medications. We present 5 cases of confirmed PEG allergy, which to our knowledge is the largest case series to date. Four of the 5 cases developed anaphylaxis to medications containing PEGs, with 1 near-fatal case resulting in cardiac arrest. Skin tests were undertaken to the index medications and to PEGs of different molecular weights. Three were confirmed with positive skin prick test result to PEG, 1 confirmed with a positive intradermal test result, and 1 confirmed after positive oral challenge. Two patients developed anaphylaxis following intradermal test to PEG and 1 a systemic allergic reaction (without hypotension or respiratory distress) following PEG skin prick tests. Before diagnosis, all 5 patients were mislabeled as allergic to multiple medications and their clinical management had become increasingly challenging. An algorithm is proposed to safely investigate suspected PEG allergy, with guidance on PEG molecular weights and skin test dilutions to minimize the risk of systemic allergic reaction. Investigation carries considerable risk without knowledge and informed planning so should only be conducted in a specialist drug allergy center.
Topics: Anaphylaxis; Drug Hypersensitivity; Humans; Intradermal Tests; Polyethylene Glycols; Skin Tests
PubMed: 33011299
DOI: 10.1016/j.jaip.2020.09.029 -
Immunology and Allergy Clinics of North... Nov 2020Biologic and other therapies used for the treatment of immune-mediated hypersensitivity conditions, and in people with immune-mediated hypersensitivity, can trigger a... (Review)
Review
Biologic and other therapies used for the treatment of immune-mediated hypersensitivity conditions, and in people with immune-mediated hypersensitivity, can trigger a wide variety of immune-related adverse drug reactions and immunologically mediated drug hypersensitivities. These range from acute-onset immunoglobulin E-mediated allergies to delayed-onset T-cell-mediated hypersensitivities. Certain therapeutic and diagnostic agents can directly activate mast cells. Biologic agents used to treat immune-mediated hypersensitivity can also globally upregulate or downregulate the immune system leading to pathologic reactions, including cytokine storm and hypogammaglobulinemia.
Topics: B-Lymphocytes; Biological Products; Clinical Decision-Making; Desensitization, Immunologic; Drug Hypersensitivity; Drug Therapy, Combination; Humans; Immunoglobulin E; Immunosuppressive Agents; Lymphocyte Depletion; Mast Cells; Prevalence; Recombinant Proteins; Risk Factors; Severity of Illness Index; Skin Tests; T-Lymphocytes; Treatment Outcome
PubMed: 33012325
DOI: 10.1016/j.iac.2020.06.003 -
Clinical and Experimental Allergy :... Aug 2019Amoxicillin is the most common antibiotic prescribed in children with increasing use over time. While up to 10% of children are labelled as amoxicillin allergic, most... (Review)
Review
Amoxicillin is the most common antibiotic prescribed in children with increasing use over time. While up to 10% of children are labelled as amoxicillin allergic, most children can tolerate amoxicillin after allergy evaluation. It is well documented that the label of amoxicillin allergy in children is associated with adverse health outcomes such as antibiotic-resistant infections. However, it remains controversial how best to assess children for amoxicillin allergy. While in general it is recommended that skin testing be done prior to drug provocation test in the evaluation of amoxicillin allergy, there is increasing evidence that drug provocation testing could be done in lower risk children without skin testing prior. The goal of this article as a narrative review is to review the strengths and limitations of skin testing prior to drug provocation test in children who have a history of either immediate or non-immediate, reactions to amoxicillin.
Topics: Amoxicillin; Anti-Bacterial Agents; Child; Child, Preschool; Drug Hypersensitivity; Female; Humans; Male; Skin Tests
PubMed: 31141238
DOI: 10.1111/cea.13443 -
Allergy and Asthma Proceedings Mar 2020Antibiotic allergies, especially penicillin, are the most frequent drug allergy listed in the medical record. Proactive evaluations of antibiotic allergies,... (Review)
Review
Antibiotic allergies, especially penicillin, are the most frequent drug allergy listed in the medical record. Proactive evaluations of antibiotic allergies, particularly penicillin allergies, have been recommended by various specialty societies. To review the history of the discovery of penicillin, implications of the penicillin allergy label, various delabeling strategies as well as a brief overview of the approach to cephalosporin, fluoroquinolone, and macrolide allergy. Recent studies on penicillin allergy delabeling and on cephalosporin and fluoroquinolone allergies were reviewed. Although Alexander Fleming is often solely credited with the discovery of penicillin, other scientists were critical to the development of penicillin as a life-saving antibiotic. The vast majority of patients with a penicillin allergy label are not allergic; however, this label results in increased morbidities and mortality. A variety of penicillin delabeling strategies can be used in both the outpatient and the inpatient settings. The role of direct penicillin challenge in patients at low risk is emerging and is the method of choice for children. Patients with an unconfirmed penicillin allergy have a low risk of reacting to cephalosporins. The R1 side chain largely dictates cephalosporin allergy and cross-reactivity. Drug challenge is the preferred method for evaluation of both fluoroquinolone and macrolide allergy. Multiple effective methods are available to delabel patients of common antibiotic allergies. Delabeling patients in a proactive manner can reduce patient morbidity.
Topics: Allergens; Animals; Anti-Bacterial Agents; Cephalosporins; Child; Cross Reactions; Drug Hypersensitivity; Drug Labeling; Drug-Related Side Effects and Adverse Reactions; Humans; Penicillins; Risk; United States
PubMed: 32122444
DOI: 10.2500/aap.2020.41.190024