Abstract
This guideline on diagnostic procedures for suspected beta-lactam antibiotic (BLA) hypersensitivity was written by the German and Austrian professional associations for allergology, and the Paul-Ehrlich Society for Chemotherapy in a consensus procedure according to the criteria of the German Association of Scientific Medical Societies. BLA such as penicillins and cephalosporins represent the drug group that most frequently triggers drug allergies. However, the frequency of reports of suspected allergy in patient histories clearly exceeds the number of confirmed cases. The large number of suspected BLA allergies has a significant impact on, e.g., the quality of treatment received by the individual patient and the costs to society as a whole. Allergies to BLA are based on different immunological mechanisms and often manifest as maculopapular exanthema, as well as anaphylaxis; and there are also a number of less frequent special clinical manifestations of drug allergic reactions. All BLA have a beta-lactam ring. BLA are categorized into different classes: penicillins, cephalosporins, carbapenems, monobactams, and beta-lactamase inhibitors with different chemical structures. Knowledge of possible cross-reactivity is of considerable clinical significance. Whereas allergy to the common beta-lactam ring occurs in only a small percentage of all BLA allergic patients, cross-reactivity due to side chain similarities, such as aminopenicillins and aminocephalosporins, and even methoxyimino cephalosporins, are more common. However, the overall picture is complex and its elucidation may require further research. Diagnostic procedures used in BLA allergy are usually made up of four components: patient history, laboratory diagnostics, skin testing (which is particularly important), and drug provocation testing. The diagnostic approach – even in cases where the need to administer a BLA is acute – is guided by patient history and risk – benefit ratio in the individual case. Here again, further studies are required to extend the present state of knowledge. Performing allergy testing for suspected BLA hypersensitivity is urgently recommended not only in the interests of providing the patient with good medical care, but also due to the immense impact of putative BLA allergies on society as a whole.
Highlights
Beta-lactam antibiotics (BLA) are considered the substance group that most frequently triggers immunologically mediated drug hypersensitivity reactions [1].Epidemiology: Approximately 8% of all adults questioned in a southern European survey reported suffering from a drug allergy and 4.5% from an allergy to BLA [2]
In the case of patients with a history of immediate reactions to penicillin in whom the use of another BLA is indicated as part of acute emergency treatment and if skin tests are unavailable, fractionated drug provocation tests with a non-aminocephalosporin, aztreonam, or carbapenem under appropriate supervision should be considered after risk/benefit analysis of the individual case
Drug allergy testing is more complex than usual allergy testing for protein-based allergens due to the potentially irritative diagnostic methods used and the fact that the majority of allergens are only existing as haptens
Summary
Adverse drug reactions can be reproduced independently of their pathomechanism. Patient-specific factors, such as drug metabolization and genetic factors, affect the result. Drug provocation testing is the final step in allergy diagnostics, after the patient history has been taken and in vitro methods as well as skin testing have been performed in line with the indication. Allergy testing for a suspected drug hypersensitivity reaction shall be aimed for pediatric patients of all ages. Allergy diagnosis is based on a consideration of all the available information as well as the findings deemed relevant from the patient history, in vitro diagnostics, skin testing, and DPT; the diagnosing physician should have sound knowledge of the known allergic reactions and allergyrelevant structures. –– Since allergy testing to BLA is currently not cost-effective, adequate reimbursement for these diagnostic methods is required
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