Tolerability of Aztreonam in Patients with Cell-Mediated Allergy to β-Lactams

Buonomo, Alessandro; Nucera, Eleonora; Pasquale, Tiziana De; Pecora, Valentina; Lombardo, Carla; Sabato, Vito; Colagiovanni, Amira; Rizzi, Angela; Aruanno, Arianna; Pascolini, Lucilla; Patriarca, Giampiero; Schiavino, Domenico

doi:10.1159/000318844

Cited by 36 publications

(31 citation statements)

References 29 publications

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“…The most recent study found that all penicillin-allergic patients with negative skin tests to aztreonam tolerated their administration with escalating doses [70]. Similar results have been published in patients with delayed reactions to penicillins [83].…”

Section: Aztreonam As An Alternative Treatmentsupporting

confidence: 56%

Cross-Reactivity in Betalactam Allergy: Alternative Treatments

Montañez

Ariza

Mayorga

et al. 2015

Curr Treat Options Allergy

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Opinion statementIt was originally thought that, as all betalactams share a four-member ring, they would cross-react, and so the classical recommendation was for allergic patients to avoid all betalactams. However, later studies found that some individuals selectively responded to one betalactam only and tolerated others. This was shown to be more frequent than initially thought, and this finding has led to a change from the initial recommendations of complete avoidance. Selective responses to amoxicillin are mainly due to recognition of the side chain structure, making benzylpenicillin a safe alternative. These amoxicillin-selective responders comprise up to 55 and 90 % of patients with immediate allergic reactions to amoxicillin and amoxicillin-clavulanic, respectively. Additionally, more than 85 % of penicillin-allergic patients can tolerate cephalosporins with different R 1 side chains, decreasing to 65 % if the side chain is identical. It is known that third and fourth generation cephalosporins are well tolerated by penicillin-allergic patients, probably because their chemical structures differ more from penicillins that those from the first generation. In patients with IgE-mediated allergic reactions to cephalosporins, penicillins can be an alternative treatment in up to 75 % of cases. Moreover, 40 % of patients primarily sensitized to a given cephalosporin also react to others, which might be because some cephaloporins have the same (ceftriaxone and cefotaxime) or very similar (ceftriaxone and cefuroxime) side chain structures. Finally, carbapenems and monobactams are good alternative for patients with penicillin and/or cephalosporin allergy because cross-reactivity occurs in G1 % of these cases. For all betalactams, tolerance is higher in T-cell-mediated reactions than IgE-mediated. These results show that alternative treatments for infectious disease are available to patients with allergic reactions to betalactams, from within the same group of antibiotics. Nevertheless, this general rules need to be analyzed patient by patient, and skin tests and graded challenge with the betalactam that is going to be administered are recommended. Keypoints• Patients with IgE-or T-cell-mediated allergy to betalactams can have selective reactions, specific to one betalactam with good tolerance to others, or be crossreactive, recognizing several different chemically related betalactams.• The percentage of selective reactions to the different betalactam compounds is higher than previously reported and patients should be studied in order to increase the treatment options available.

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Section: Aztreonam As An Alternative Treatmentsupporting

confidence: 56%

Cross-Reactivity in Betalactam Allergy: Alternative Treatments

Montañez

Ariza

Mayorga

et al. 2015

Curr Treat Options Allergy

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“…It is less immunogenic than penicillins or cephalosporins. Patients with proven immediate and delayed sensitivity to beta-lactams have been shown to tolerate challenge with aztreonam [177][178][179] including two patients with evidence of specific IgE to aztreonam [180]. Of 45 patients with a clinical history of immediate beta-lactam, mainly penicillin allergy and positive skin or IgE tests, none had a positive intradermal test for aztreonam and all tolerated a graded intramuscular challenge [178].…”

Section: Cross-reactivity With Monobactamsmentioning

confidence: 99%

“…In a cohort of 78 patients with non-immediate allergy to beta-lactams, again mainly penicillins, and positive patch and/or delayed intradermal tests for at least one beta-lactam, none tested positive to aztreonam, and all 65 patients who underwent challenge tolerated intramuscular aztreonam [179]. However, a single case of cross-reactivity between penicillins and aztreonam has been reported in which a patient with confirmed anaphylaxis to penicillin developed anaphylaxis immediately following the administration of aztreonam [181].…”

Section: Cross-reactivity With Monobactamsmentioning

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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“…14,16,18,23 Specifically, the largest of these studies 18 evaluated 97 subjects with such hypersensitivity by performing both patch tests and delayed-reading skin tests with aztreonam. None of these participants had positive responses to aztreonam allergologic tests; 72 of them underwent aztreonam challenges and tolerated them.…”

Section: Reacted To Cefuroximementioning

confidence: 99%

Cross-reactivity and tolerability of aztreonam and cephalosporins in subjects with a T cell–mediated hypersensitivity to penicillins

Romano

Gaeta²,

Valluzzi³

et al. 2016

Journal of Allergy and Clinical Immunology

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These data demonstrate a rate of cross-reactivity between aminopenicillins and aminocephalosporins (ie, cephalexin, cefaclor, and cefadroxil) of around 20%, as well as the absence of cross-reactivity between penicillins and cefuroxime, ceftriaxone, and aztreonam in all subjects with T cell-mediated hypersensitivity to penicillins, almost exclusively aminopenicillins. Therefore these subjects could be treated with cefuroxime, ceftriaxone, and aztreonam. In those who especially require cephalosporin or aztreonam treatment, however, we recommend pretreatment skin tests because negative responses indicate tolerability.

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Tolerability of Aztreonam in Patients with Cell-Mediated Allergy to β-Lactams

Cited by 36 publications

References 29 publications

Cross-Reactivity in Betalactam Allergy: Alternative Treatments

Cross-Reactivity in Betalactam Allergy: Alternative Treatments

Management of allergy to penicillins and other beta‐lactams

Cross-reactivity and tolerability of aztreonam and cephalosporins in subjects with a T cell–mediated hypersensitivity to penicillins

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