Antimicrobial anaphylaxis: the changing face of severe antimicrobial allergy

Abstract

Objectives The epidemiology, clinical characteristics and outcomes of antimicrobial-associated anaphylaxis remain ill-defined. We sought to examine antimicrobial anaphylaxis with regard to: (i) the frequency of implicated antimicrobials; (ii) attributable mortality; and (iii) referral for definitive allergy assessment. Methods This was conducted through a national retrospective multicentre cohort study at five Australian tertiary hospitals (January 2010 to December 2015). Cases of antimicrobial anaphylaxis were identified from ICD-10 coding and adverse drug reaction committee databases. Results There were 293 participants meeting the case definition of antimicrobial anaphylaxis and 310 antimicrobial anaphylaxis episodes. Of 336 implicated antimicrobials, aminopenicillins (62/336, 18.5%) and aminocephalosporins (57/336, 17%) were implicated most frequently. ICU admission occurred in 43/310 (13.9%) episodes; however, attributable mortality was low (3/310, 1%). The rate of anaphylaxis to IV antibiotics was 3.5 (95% CI = 2.9–4.3) per 100 000 DDDs and the rate of hospital-acquired anaphylaxis was 1.9 (95% CI = 2.1–3.3) per 100 000 occupied bed-days. We observed overall low rates of hospital discharge documentation (222/310, 71.6%) and follow-up by specialist allergy services (73/310, 23.5%), which may compromise medication safety and antimicrobial prescribing in future. Conclusions This study demonstrated that a high proportion of severe immediate hypersensitivity reactions presenting or acquired in Australian hospitals are secondary to aminopenicillins and aminocephalosporins. Overall rates of hospital-acquired anaphylaxis, predominantly secondary to cephalosporins, are low, and also associated with low inpatient mortality.

Delabeling Delayed Drug Hypersensitivity: How Far Can You Safely Go?

“…This has primarily been due to an absence of high sensitivity diagnostics and availability of trained specialists (38)(39)(40). Compounding this are concerns of disease-relapse related to both performing skin testing and oral challenge in the setting of disease phenotypes with associated high mortality (41)(42)(43)(44) Many patients with non-specific delayed reactions such as a mild exanthem associated with antibiotics in the face of a viral infection, have been labeled in childhood and an increasing evidence base supports ingestion challenge in this setting. (45)(46)(47) For more severe delayed and likely T-cell mediated reactions (Table 1) including DRESS, AGEP, FDE and SJS/TEN in particular, specialized testing may have an important role to provide supportive information for a causative drug and potential for cross-reactivity (1).…”

Drug-Related Hypersensitivity Reactions Leading to Emergency Department: Original Data and Systematic Review

“…After full-text review, 37 manuscripts were included in the systematic review ( Table 4 ). Most of the primary studies (57%) were performed in USA and/or Canada [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ], followed by 10 (27%) studies performed in Asia [ 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ], 5 (13%) studies in Europe [ 52 , 53 , 54 , 55 , 56 ], and 1 (3%) study in Australia [ 57 ]. Overall, 17 (46%) were multicentre studies, either retrospective or retrospective/prospective [ 23 , 24 , 25 , 26 , 28 , 29 , 30 , 31 , 33 , 34 , 35 , 40 , 41 , 42 , 44 , 48 …”

Adverse drug reaction management in hospital settings: review on practice variations, quality indicators and education focus

“…Moreover, 26.3% had a mismatch of knowledge regarding what they believed was the implicated medication and what was documented in hospital records [26]. Another multicentre Australian study found that nearly 30% of the anaphylaxis episodes to antimicrobials were not documented in hospital records [28]. A study in the UK showed that, of 127 general practitioners who followed up patients with ADRs after discharge, 89% had no record of patients' ADRs, having to rely on the patients themselves to provide this information [47].…”

“…Amongst 80 patients with anaphylaxis reactions to non-antimicrobial medications, a large proportion of which were due to neuromuscular blocking agents in the perioperative setting; less than half (47.5%) of the cases were reported for further evaluation [ 27 ]. Similarly, in a multicentre Australian study concerning antimicrobial-related anaphylaxis episodes, only 43.7% of 222 episodes were reported to ADR management systems within respective hospitals [ 28 ].…”