Impact of an extended challenge on the effectiveness of β-lactam hypersensitivity investigation

Ratzon, Roy; Reshef, Avner; Efrati, Ori; Deutch, Michal; Forschmidt, Rinat; Kenett, Ron S.; Kidon, Mona

doi:10.1016/j.anai.2016.01.018

Cited by 34 publications

(47 citation statements)

References 19 publications

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“…Immediate clinical use of a penicillin following de‐labeling is beneficial to future patient confidence for use. Multi‐day challenges also have the potential to decrease patient anxiety and penicillin avoidance, but this will need to be weighed against the downside of increased antimicrobial exposure …”

Section: Specific Challenges To Allergy De‐labelingmentioning

confidence: 99%

The challenge of de‐labeling penicillin allergy

Stone

Trubiano

Coleman

et al. 2019

Allergy

186

160

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Background Even though 8%‐25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de‐labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. Methods We performed an evidence‐based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de‐labeling. Over the period 1928‐2018 in Pubmed and Medline, search terms used included “penicillin allergy” or “penicillin hypersensitivity” alone or in combination with “adverse events,” “testing,” “evaluation,” “effects,” “label,” “de‐labeling,” “prick or epicutaneous,” and “intradermal” skin testing, “oral challenge or provocation,” “cross‐reactivity,” and “antimicrobial stewardship”. Results Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. Conclusions Operationalizing penicillin allergy de‐labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de‐labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.

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Section: Specific Challenges To Allergy De‐labelingmentioning

confidence: 99%

The challenge of de‐labeling penicillin allergy

Stone

Trubiano

Coleman

et al. 2019

Allergy

186

160

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“…The ubiquitous use of beta‐lactam antibiotics has led to an increase in antibiotic allergy labelling, while the rate of true allergy has been shown to be low …”

mentioning

confidence: 99%

The role of skin testing and extended antibiotic courses in assessment of children with penicillin allergy: An Australian experience

Arnold

Sommerfield

Ramgolam

et al. 2018

J Paediatrics Child Health

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A direct OPC with the culprit drug in Australian children can be safely performed, avoiding resource-intensive and painful ST. Our data demonstrate that a prior history of anaphylaxis does not necessarily predict IgE-mediated allergy, as detected by positive immediate ST or reactions to oral challenge. Such history should not detract from efforts to assess these children for antibiotic allergy. We suggest that extended courses of at least 5 days are important in paediatric antibiotic de-labelling as six children (4.5% of those who were prescribed the extended course) reacted in our study and even developed symptoms late in the extended course, from days 2 to 6.

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“…23 In a recent study, it was found that amoxicillin was the culprit drug in 50%, followed by 12% each for penicillin and cephalosporins. 24 Variations in occurrence of allergy in the form of immediate reactions to β lactams were observed. In this study total, allergic patients were 13% and non-allergic were 87%.…”

Section: Discussionmentioning

confidence: 99%

“…In a similar study by Ratzon et al, 25 out of 49 patients (51%) were tested positive for immediate reactions to β lactam group of antibiotics. 24 In another study by Doña I et al, the immediate allergic reactions to β lactams ranges from 21.19% in 2005 to 16.07% in 2010. 23 Skin tests include two steps: skin prick test followed by intradermal test.…”

Section: Discussionmentioning

confidence: 99%

“…In a similar study by Ratzon et al, 23 (88%) of the patients showed skin manifestations following a short drug provocation test. 24 In this study, the diagnostic algorithm was applied to the most commonly prescribed drugs. It has also been suggested that in case of a negative skin test, confirmation of drug allergy can be successfully achieved by challenges via oral or any other route.…”

Section: Discussionmentioning

confidence: 99%

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Evaluation of immediate reactions to β lactam antibiotics using a comprehensive diagnostic protocol

Bhagwat

Anuradha

2017

Int J Basic Clin Pharmacol

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Background: β lactam antibiotics are commonly prescribed groups of antibacterial drugs for various infections however the prevalence of its allergic effects is not clear in our country, hence the need for an effective diagnostic protocol to determine immediate hypersensitivity reactions. The objective was to formulate a diagnostic protocol for evaluating immediate drug hypersensitivity to β lactam antibiotics.Methods: A prospective study was conducted at a tertiary care hospital. Adults who were prescribed any class of β lactam antibiotic were included. Non irritating concentrations of the antibiotic as per The European Network on drug Allergy were used. A strict three step diagnostic algorithm with skin prick test followed by intradermal test and drug provocation test, with 20 minutes observation period between each step, to determine cutaneous allergic reactions was followed.Results: The most commonly prescribed drug was cefazolin, followed by ceftriaxone, and cefoperazone + sulbactam combination. The culprit drugs were ceftriaxone in 4 (4.7%) patients, followed by piperacillin + tazobactam combination in 3 (3.5%), amoxicillin + clavulanic acid in 2 (2.3%) and 1 (1.1%) each for cefotaxime and cefepime + tazobactam combination. No patients were positive for skin prick test; 2.4% were positive for intradermal test and 10.6% were positive for drug provocation test.Conclusions: This diagnostic protocol is apt to adequately diagnose immediate reactions to β lactam antibiotics and henceforth can be used effectively in India. However, the skin prick test may be excluded but the intradermal test and drug provocation test is crucial to identify these immediate reactions.

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Impact of an extended challenge on the effectiveness of β-lactam hypersensitivity investigation

Cited by 34 publications

References 19 publications

The challenge of de‐labeling penicillin allergy

The challenge of de‐labeling penicillin allergy

The role of skin testing and extended antibiotic courses in assessment of children with penicillin allergy: An Australian experience

Evaluation of immediate reactions to β lactam antibiotics using a comprehensive diagnostic protocol

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