Antibiotic allergy

Abstract

Antibiotics are the commonest cause of life-threatening immune-mediated drug reactions that are considered off-target, including anaphylaxis, and organ-specific and severe cutaneous adverse reactions. However, many antibiotic reactions documented as allergies were unknown or not remembered by the patient, cutaneous reactions unrelated to drug hypersensitivity, drug-infection interactions, or drug intolerances. Although such reactions pose negligible risk to patients, they currently represent a global threat to public health. Antibiotic allergy labels result in displacement of first-line therapies for antibiotic prophylaxis and treatment. A penicillin allergy label, in particular, is associated with increased use of broad-spectrum and non-β-lactam antibiotics, which results in increased adverse events and antibiotic resistance. Most patients labelled as allergic to penicillins are not allergic when appropriately stratified for risk, tested, and re-challenged. Given the public health importance of penicillin allergy, this Review provides a global update on antibiotic allergy epidemiology, classification, mechanisms, and management.

Sustaining and spreading penicillin allergy delabelling: A narrative review of the challenges for service delivery and patient safety

“…Clinical algorithms adapted from expert opinion, published studies and guidelines, have been proposed to aid structured risk stratification by nonspecialists. 5,9,33 Paper and computer-based stratification tools have been developed and employed at various stages of the patient's journey by clinicians and pharmacists in hospitalised patients and for preoperative testing. 5,[34][35][36][37] Application of these tools results in 1 of 3 possible outcomes: removal of spurious PenA label; referral to specialist allergy assessment services for those deemed to be high risk; or confirmation of PenA status.…”

“…Focus on antimicrobial stewardship (AMS) and concerns of inappropriate use of antimicrobials has led to greater interest in the impact of spurious PenA labels on clinical and operational outcomes, and a call for global action . Inaccurate PenA labels are a major barrier to AMS and a patient safety concern .…”

“…The first stage of direct PenA delabelling involves a comprehensive, structured assessment of the clinical history to establish a level of certainty and likelihood of the reported allergy. Clinical algorithms adapted from expert opinion, published studies and guidelines, have been proposed to aid structured risk stratification by nonspecialists . Paper and computer‐based stratification tools have been developed and employed at various stages of the patient's journey by clinicians and pharmacists in hospitalised patients and for preoperative testing .…”

“…Focus on antimicrobial stewardship (AMS) and concerns of inappropriate use of antimicrobials has led to greater interest in the impact of spurious PenA labels on clinical and operational outcomes, and a call for global action. 8,9 Inaccurate PenA labels are a major barrier to AMS and a patient safety concern. 2,4,10 Large cohort studies from UK and USA show that PenA labels enhance the risk of serious hospital acquired infections such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci and Clostridioides difficile infections.…”

Cross‐reactivity in beta‐lactams after a non‐immediate cutaneous adverse reaction: experience of a reference centre for toxic bullous diseases and severe cutaneous adverse reactions

“…Beta-lactam (BL) antibiotics are a first-line treatment for many common infections but are often implicated in cutaneous adverse drug reactions (CADRs), even severe ones [epidermal necrolysis, including Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN), acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS) and generalized fixed drug eruption (FDE)]. [1][2][3][4][5][6] Without a proper allergologic exploration, empiric stopping of all BL antibiotics is suggested, which may lead to prescribing less effective, more expensive, poorly tolerated or with wider antibacterial spectrum molecules 7 with potentially increased adverse events. [8][9][10] Many studies have been published on cross-reactivity in patients with IgE-mediated immediate hypersensitivity to BL, for which intradermal tests (IDRs) have high sensitivity and specificity.…”