Immediate allergic reactions to cephalosporins: Evaluation of cross-reactivity with a panel of penicillins and cephalosporins

Antúnez, C.; Blanca‐López, Natalia; Torres, Marı́a José; Mayorga, Cristobalina; Pérez‐Inestrosa, Ezequiel; Montañez, María Isabel; Fernandez, Tahía D.; Blanca, Miguel

doi:10.1016/j.jaci.2005.10.032

Cited by 182 publications

(145 citation statements)

References 25 publications

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“…Reports from relatively small Spanish cohorts with well-documented histories of immediate beta-lactam allergy showed positive IgE tests but negative skin tests for beta-lactams, indicating that serological IgE detection may have a role in diagnosis [44,86,125,164]. In this Spanish cohort of 290 patients with immediate reaction to a penicillin derivative, 40 patients were skin test negative and RAST positive and 24/40 skin testnegative patients had the RAST diagnosis confirmed by provocation [168].…”

Section: Laboratory Investigationsmentioning

confidence: 75%

Management of allergy to penicillins and other beta‐lactams

Mirakian

Leech

Krishna

et al. 2015

Clin Experimental Allergy

216

220

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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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Section: Laboratory Investigationsmentioning

confidence: 75%

Management of allergy to penicillins and other beta‐lactams

Mirakian

Leech

Krishna

et al. 2015

Clin Experimental Allergy

216

220

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“…The percentage of patients with IgE-mediated allergic reactions to cephalosporins that tolerate penicillin ranges from 50 to 90 %, differences that may be related to the culprit cephalosporin [48][49][50][51]. Tolerance to penicillin is lower with first-generation cephalosporins, probably due to the similarity in the R 1 side chain chemical structure.…”

Section: Penicillin As An Alternative Treatmentmentioning

confidence: 99%

“…The percentage of patients reacting to one cephalosporin ranges from 57.7 to 63.2 % and the percentage of those reacting to more than one from 36.8 to 42.3 % [48,50]. The different percentages are probably due to the cephalosporin generation involved in the reaction (selective responders) and similarities in side chain structures (crossreactors).…”

Section: Cephalosporin As An Alternative Treatmentmentioning

confidence: 99%

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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“…Com o crescente uso de cefalosporinas, houve uma inversão nos fatos. Antunez et al 38 avaliaram 24 pacientes com reação anterior imediata à cefalosporina e RAST positivo para esse antibiótico. Esses autores observaram que dois pacientes também apresentavam testes cutâneos positivos à penicilina, enquanto os demais 22 foram negativos aos determinantes antigênicos da penicilina e toleraram a administração parenteral da penicilina.…”

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

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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Immediate allergic reactions to cephalosporins: Evaluation of cross-reactivity with a panel of penicillins and cephalosporins

Cited by 182 publications

References 25 publications

Management of allergy to penicillins and other beta‐lactams

Management of allergy to penicillins and other beta‐lactams

Cross-Reactivity in Betalactam Allergy: Alternative Treatments

Allergy to beta-lactams in pediatrics: a practical approach

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