Drug Provocation Tests in Patients with a History Suggesting an Immediate Drug Hypersensitivity Reaction

Messaad, D.; Sahla, H.; Benahmed, S.; Godard, P.; Bousquet, Jean; Demoly, Pascal

doi:10.7326/0003-4819-140-12-200406150-00009

Cited by 266 publications

(240 citation statements)

References 12 publications

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“…It is well known that most patients with a suspected drug allergy have negative responses in skin and challenge tests. This is true for adults 21 and for children. In a Portuguese study, only 7% of the children with a self-reported drug allergy had a confirmed diagnosis.…”

Section: Discussionmentioning

confidence: 75%

“…10,24 We should note that the frequency of positive tests to betalactams found in the present study is similar to the results reached in adult studies. 21,25 Despite the lower incidence of all positive DPT in the group skin tested, they have a higher time delay to the diagnosis than the non-skin tested group. That could be due to the fact that skin tests to betalactams are not readily available and a ''waiting strategy'' was taken in skin-tested children in order to achieve an older age.…”

Section: Discussionmentioning

confidence: 94%

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Drug provocation tests to betalactam antibiotics: experience in a paediatric setting

Chambel

Martins

Silva

et al. 2010

Allergologia et Immunopathologia

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Background: Few studies have been performed in children with suspected betalactam allergy. We aimed to assess the role of the drug provocation test (DPT) with betalactams in a paediatric setting and to study the association between allergy to betalactam antibiotics and other allergic diseases. Methods: We included all the patients under 15 years old who were consecutively referred to the Immunoallergy Department, Dona Estefânia Hospital, Portugal (January 2002 to April 2008) for a compatible history of allergic reaction to betalactam. All were submitted to a DPT. Children were proposed to perform skin tests (ST) to betalactam antibiotics followed by DPT. If they decline ST, a DPT with the culprit drug was performed. Results: We studied 161 children, 60% were boys, with a median age of 5 years old at the time of the DPT. Thirty-three patients (20.5%) had an immediate reaction and 33 (20.5%) a non-immediate reaction. The severity of the reported reactions was low in most cases. Skin tests to betalactams were performed in 47 children and were positive in 8. DPT was positive in only one (3.4%) of the patients skin tested and in 11 (13.4%) of those not skin tested. The severity of the DPT reaction was low. Asthma and food allergy were associated with a positive DPT in the later group. Conclusions: DPT seems a safe procedure even in the absence of ST in non-severe cases. This could be a practical option in infants and pre-school children, where ST are painful and difficult to perform. Additional caution should be taken in children with asthma and food allergy.

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Section: Discussionmentioning

confidence: 75%

Section: Discussionmentioning

confidence: 94%

Drug provocation tests to betalactam antibiotics: experience in a paediatric setting

Chambel

Martins

Silva

et al. 2010

Allergologia et Immunopathologia

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“…More recent European studies reported that between 8.4% [154] and 30.7%, skin test-negative patients reacted on drug challenge only. In the study by Messaad and colleagues [154], only 23% were positive for major and minor determinants and 46.3% skin test positive to the specific beta-lactam (but not PPL/MDM), indicating that only 69.3% were diagnosed by skin testing and 30.7% diagnosed following drug provocation [155].…”

Section: Predictive Value Of Skin Tests For Penicillinmentioning

confidence: 99%

Management of allergy to penicillins and other beta‐lactams

Mirakian

Leech

Krishna

et al. 2015

Clin Experimental Allergy

228

229

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SummaryThe Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and an expert panel have prepared this guidance for the management of immediate and non-immediate allergic reactions to penicillins and other beta-lactams. The guideline is intended for UK specialists in both adult and paediatric allergy and for other clinicians practising allergy in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking, the panel reached consensus. During the development of the guideline, all BSACI members were consulted using a Web-based process and all comments carefully considered. Included in the guideline are epidemiology of allergic reactions to beta-lactams, molecular structure, formulations available in the UK and a description of known beta-lactam antigenic determinants. Sections on the value and limitations of clinical history, skin testing and laboratory investigations for both penicillins and cephalosporins are included. Cross-reactivity between penicillins and cephalosporins is discussed in detail. Recommendations on oral provocation and desensitization procedures have been made. Guidance for beta-lactam allergy in children is given in a separate section. An algorithm to help the clinician in the diagnosis of patients with a history of penicillin allergy has also been included.Keywords allergy, anaphylaxis, beta-lactam, BSACI, carbapenem, cephalosporin, children, cross-reactivity, desensitization, drug provocation test, epidemiology, hypersensitivity, monobactam, oral challenges, paediatrics, penicillin, serum-specific IgE, skin tests, Standards of Care Committee • This guideline addresses immediate and non-immediate allergic reactions to beta-lactams.• Up to 20% of drug-related anaphylaxis deaths in • Individuals with a positive skin test to an aminopenicillin but negative skin tests to penicillin determinants are likely to be sensitized to the aminopenicillin side chain. (B) In this situation, a cautious challenge to benzyl or phenoxymethyl penicillin can be considered to ascertain whether the patient has a selective penicillin allergy. (D) • If a cephalosporin is required in a patient with a clinical history of penicillin allergy and positive skin tests -the patient should undergo skin testing using a cephalosporin with a different side chain and, if negative, provocation testing should be undertaken to exclude allergy to the specific cephalosporin. (D)• If penicillin is required in a patient with a clinical history of cephalosporin allergy, skin testing should be undertaken with penicillins and, if negative, provocation testing to exclude allergy to penicillin. (B) If skin tests are positive, then penicillin avoidance or desensitization can be considered. (B)• If a cephalosporin is required by a patient with a previous reaction, skin testing to penicillins and the required cephalosporin should be carried out to establish whether sensitization is to the beta-lactam core or side chain. (B) This should be followed by either provo...

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“…Entretanto, todos os esquemas são definidos com base no aumento progressivo das concentrações do medicamento a ser administrado, iniciandose por amostras muito diluídas e concluindo-se o processo com preparados em diluições similares às que serão utilizadas (Tabela 4). No caso da penicilina, a dessensibilização é indicada quando não houver possibilidade de substituição do medicamento 20,21,31 .…”

Section: O Diagnóstico De Alergia Foi Confirmado E a Dessensibilização?unclassified

“…Portanto, ao se optar pela realização de um teste alérgico, deve-se utilizar o produto adequado. Deve-se salientar que os testes são úteis somente para as reações que envolvem anticorpos da classe IgE, não tendo valor preditivo para as reações do tipo exantema tardio, febre, anemia hemolítica, dermatite exfoliativa, síndrome de Stevens-Johnson, dermatite de contato, nefrite intersticial ou doença do soro 8,20 .…”

Section: S181 Introduçãounclassified

Allergy to beta-lactams in pediatrics: a practical approach

Grumach

2006

J Pediatr (Rio J)

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Objective: To present a practical approach to the diagnosis and management of allergy to beta-lactam antibiotics.Sources: Allergy journals indexed in MEDLINE and LILACS, as well as seminal studies and texts.Summary of the findings: Allergy to penicillin is commonly reported. In many cases, this results in the decision not to use this drug. About 10% of drug allergy reports are confirmed. The clinical manifestations due to allergic reaction to penicillin vary widely, with emphasis on skin disorders. Gell & Coombs four hypersensitivity mechanisms are involved in allergic reactions. Penicillin is degraded to a major (95%) and minor determinants (5%). Immediate IgE-mediated reactions causing anaphylaxis are associated with minor determinants in 95% of the cases. Hypersensitivity to these products can be assessed using cutaneous tests performed with major and minor determinants, thus avoiding anaphylactic shock in allergic individuals. The present article underscores the basic body of knowledge on allergy to penicillin, providing support for a more accurate diagnosis of this event and for the choice of management in cases of suspected beta-lactam allergy. Conclusions:The incorrect diagnosis of penicillin allergy frequently leads to the exclusion of this drug as a therapeutic option. A better recognition of these situations will enable the use of penicillin and reduce the risks associated with hypersensitivity.J Pediatr (Rio J). 2006;82(5 Suppl):S181-8: Beta-lactam, penicillin, cephalosporin, allergy, hypersensitivity reaction. ResumoObjetivo: Apresentar uma abordagem prática ao diagnóstico e conduta na alergia a antibióticos beta-lactâmicos.Fontes dos dados: Periódicos da área de alergia indexados nas bases MEDLINE e LILACS, além de estudos e textos clássicos que tratam do tema. Síntese dos dados:A alergia à penicilina é relatada com freqüên-cia, em muitos casos resultando na exclusão desse medicamento do arsenal terapêutico. Cerca de 10% dos relatos de alergia a drogas são confirmados. As manifestações clínicas decorrentes da reação alérgica à penicilina são bastante amplas, destacando-se os quadros cutâneos. Os quatro mecanismos de hipersensibilidade de Gell & Coombs estão envolvidos nas reações alérgicas. A penicilina é degradada em determinante maior (95% dos produtos) e em determinantes menores (5% dos produtos). As reações imediatas, mediadas por IgE, e que determinam quadros de anafilaxia, estão relacionadas aos determinantes menores em 95% dos casos. A hipersensibilidade a esses produtos pode ser avaliada através de testes cutâneos realizados com os determinantes maior e menores, permitindo, assim, evitar o choque anafilático em indivíduos alérgicos. O texto ressalta conhecimentos básicos sobre a alergia à penicilina, propiciando um diagnóstico mais adequado desse evento e a conduta em casos de suspeita de alergia a beta-lactâmicos.Conclusões: O diagnóstico de alergia à penicilina tem sido feito de forma inadequada, resultando em sua exclusão do arsenal terapêutico. O melhor reconhecimento dessas cond...

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Drug Provocation Tests in Patients with a History Suggesting an Immediate Drug Hypersensitivity Reaction

Abstract: Drug provocation tests in individuals with suspected drug allergy performed in carefully controlled settings can confirm drug hypersensitivity.

Cited by 266 publications

References 12 publications

Drug provocation tests to betalactam antibiotics: experience in a paediatric setting

Drug provocation tests to betalactam antibiotics: experience in a paediatric setting

Management of allergy to penicillins and other beta‐lactams

Allergy to beta-lactams in pediatrics: a practical approach

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