EVIDENCE-BASED PRACTICEG adolinium-based contrast agents (GBCAs) have been used clinically for decades and have an excellent safety record (1-3). Immediate hypersensitivity reactions to GB-CAs remain uncommon, estimated by meta-analysis to be approximately nine per 10 000 administrations, with severe reactions occurring in approximately five per 100 000 administrations (4). Limited studies have evaluated repeat GBCA administration in patients with a prior hypersensitivity reaction to a GBCA. The efficacy of corticosteroid premedication with or without antihistamines prior to repeat GBCA exposure remains unproven. Although commonly performed in clinical practice, the rationale for premedication prior to repeat GBCA administration is extrapolated from studies evaluating iodinated contrast media (5). Breakthrough reactions are immediate hypersensitivity reactions occurring despite appropriately dosed corticosteroid premedication. These reactions occur in up to one-third of patients in individual series that have studied GBCAs (6-8). Breakthrough reactions to GBCAs usually occur with the same severity as the original or index reaction, but escalation of breakthrough reaction severity to a GBCA has been reported (6-8). In patients with a prior severe hypersensitivity reaction to a GBCA, re-exposure to a GBCA (even with corticosteroid premedication) is contraindicated by the American College of Radiology (ACR) (9).
Background β-Lactam antibiotics are first-line therapy for perioperative prophylaxis; however, patient-reported allergies often lead to increased prescribing of alternative antibiotics that may increase the incidence of surgical site infections. The R-group side chain of the β-lactam ring is responsible for allergic cross-reactivity and experts recommend the use of β-lactams that are structurally dissimilar. Methods An internally developed, antibiotic side-chain–based cross-reactivity chart was developed and implemented alongside enhanced allergy assessment processes. This single-center, quasi-experimental study analyzed antibiotic prescribing in all adult patients with a documented β-lactam allergy undergoing an inpatient surgical procedure between quartile (Q) 1 (2012)–Q3 (2014) (historical group) and Q3 (2016)–Q3 (2018) (intervention group). Propensity-weighted scoring analyses compared categorical and continuous outcomes. Interrupted time-series analysis further analyzed key outcomes. Results A total of 1119 and 1089 patients were included in the historical and intervention cohorts, respectively. There was a significant difference in patients receiving a β-lactam alternative antibiotic between cohorts (84.9% vs 15.1%; P < .001). There was a decrease in 30-day readmissions in the intervention cohort (7.9% vs 6.3%; P = .035); however, there was no difference in the incidence of SSIs in patients readmitted (14.8% vs 13%; P = .765). No significant differences were observed in allergic reactions (0.5% vs 0.3%; P = .323), surgical site infections, in-hospital and 30-day mortality, healthcare facility–onset Clostridiodes difficile infection, acute kidney injury, or hospital costs. Conclusions Implementation of an antibiotic cross-reactivity chart combined with enhanced allergy assessment processes significantly improved the prescribing of β-lactam antibiotics for surgical prophylaxis.
The available studies indicate that omalizumab is effective and well tolerated in decreasing hypersensitivity reactions associated with allergen immunotherapy in patients with allergic rhinitis and mild-to-moderate asthma. Additionally, omalizumab may represent a promising therapy of anaphylaxis with or without known trigger, which should be further investigated with randomized studies. Moreover, additional research is needed to elucidate the mechanism of anaphylaxis with the medication itself.
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