Update on the evaluation of hypersensitivity reactions to betalactams

Blanca, Miguel; Romano, Antonino; Torres, Marı́a José; Fernández, J.; Mayorga, Cristobalina; Rodríguez, Jorge Rodríguez; Démoly, P.; Bousquet, Philippe‐Jean; Merk, Hans F.; Sánz, M L; Ott, Hagen; Atanasković-Marković, Marina

doi:10.1111/j.1398-9995.2008.01916.x

Cited by 167 publications

(303 citation statements)

References 73 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: 74%

“…The incidence of anaphylaxis to cephalosporin is not known but is at least one order of magnitude lower than to penicillin [28] with an estimated risk range between 0.0001% and 0.1% for each treatment course. In Europe, allergy to benzylpenicillin has been gradually replaced by aminopenicillins and cephalosporins because of changes in prescribing habits [44].…”

Section: Anaphylaxismentioning

confidence: 99%

“…This release is responsible for the broad spectrum of syndromes ranging from morbilliform/maculopapular and urticarial rashes, which are most common to the less common but severe reactions such as AGEP, DRESS and SJS/TEN. The diagnosis of non-immediate reactions can be challenging because clinically, they can mimic autoimmune or infectious diseases and can occur in association with viral infections [44]. A subclassification of Gell and Coombs type IV delayed reactions has been proposed to show a relationship between clinical syndromes and specific cytokine release from distinct T-cell subsets (Table 2) [6].…”

Section: Skin Tests For Non-immediate Hypersensitivity Reactionsmentioning

confidence: 99%

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Management of allergy to penicillins and other beta‐lactams

Mirakian

Leech

Krishna

et al. 2015

Clin Experimental Allergy

225

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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Section: Laboratory Investigationsmentioning

confidence: 74%

Section: Anaphylaxismentioning

confidence: 99%

Section: Skin Tests For Non-immediate Hypersensitivity Reactionsmentioning

confidence: 99%

See 1 more Smart Citation

Management of allergy to penicillins and other beta‐lactams

Mirakian

Leech

Krishna

et al. 2015

Clin Experimental Allergy

225

229

View full text Add to dashboard Cite

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“…6 According to the European Network for Drug Allergy (ENDA), the diagnosis of betalactam antibiotics allergy should be based on the clinical history, skin testing (prick and intradermal tests), in vitro laboratory tests (namely determination of specific IgE to the betalactam) and drug provocation tests. 7,8 Skin prick tests are the safest and easiest tests for immediate drug reactions but are only moderately sensitive. Intradermal tests are more sensitive but carry a higher risk to serious adverse reactions.…”

Section: Introductionmentioning

confidence: 99%

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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“…21 R2 side-chain makes little contribution to cephalosporin hypersensitivity, as it disappears when the BL ring is opened. 22 Human studies have provided insight into the role of similarity in the R1 side-chains in causing BL cross-reactivity. 15 For instance, the 2-amino-2-phenylacetic acid side-chain in ampicillin is also present in first-or second-generation cephalosporins like cephalexin and cefaclor, respectively, but is absent in third-or fourth-generation cephalosporins.…”

Section: Mechanism Of Cross-reactivity and The Side-chain Hypothesismentioning

confidence: 99%

Use of cephalosporins in patients with immediate penicillin hypersensitivity: cross-reactivity revisited

Qu¹

2014

Hong Kong Med J

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A 10% cross-reactivity rate is commonly cited between penicillins and cephalosporins. However, this figure originated from studies in the 1960s and 1970s which included first-generation cephalosporins with similar side-chains to penicillins. Cephalosporins were frequently contaminated by trace amount of penicillins at that time. The sidechain hypothesis for beta-lactam hypersensitivity is supported by abundant scientific evidence. Newer generations of cephalosporins possess side-chains that are dissimilar to those of penicillins, leading to low cross-reactivity. In the assessment of crossreactivity between penicillins and cephalosporins, one has to take into account the background betalactam hypersensitivity, which occurs in up to 10% of patients. Cross-reactivity based on skin testing or in-vitro test occurs in up to 50% and 69% of cases, respectively. Clinical reactivity and drug challenge test suggest an average cross-reactivity rate of only 4.3%. For third-and fourth-generation cephalosporins, the rate is probably less than 1%. Recent international guidelines are in keeping withUse of cephalosporins in patients with immediate penicillin hypersensitivity: cross-reactivity revisited The ten per cent myth about betalactam cross-reactivityPenicillins and cephalosporins are two groups of widely prescribed antibiotics. They belong to the class of beta-lactam (BL) antibiotics because both possess the same BL nucleus. Allergic reactions are common side-effects of BL antibiotics. Studies in the 1960s and 1970s frequently estimated 10% crossreactivity between penicillins and cephalosporins. 1,2 However, at least two recent reviews showed much lower cross-reactivity. 3,4 Notably, cross-reactivity is higher between penicillins and first-and secondgeneration cephalosporins compared with thirdand fourth-generation cephalosporins. 5 The latter two groups are considered safe alternatives for patients with penicillin hypersensitivity. 6 The 10% cross-reactivity rate has recently been questioned as a medical myth. 4,7 Yet until 2005, an influential drug reference such as the British National Formulary (BNF) abided by the "10% rule". 8 Faced with such recommendation, an ordinary physician naturally avoids all BL antibiotics in patients with a history

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Update on the evaluation of hypersensitivity reactions to betalactams

Cited by 167 publications

References 73 publications

Management of allergy to penicillins and other beta‐lactams

Management of allergy to penicillins and other beta‐lactams

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

Use of cephalosporins in patients with immediate penicillin hypersensitivity: cross-reactivity revisited

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