Cephalosporin Allergy Research Articles

Reduction of Vancomycin Use in Orthopedic Patients With a History of Antibiotic Allergy

To reduce prophylactic vancomycin use in patients with a history of penicillin or cephalosporin allergy undergoing elective orthopedic surgery by using a targeted allergy consultation and penicillin allergy skin testing. The participants in this practice improvement study were patients with a history of penicillin or cephalosporin allergy who were scheduled for elective orthopedic surgery and referred by orthopedic surgeons for allergy consultation and penicillin allergy skin testing between September 22, 1998, and April 15, 1999. The primary outcome measure was the percentage of participants who received prophylactic cefazolin during the study period compared with historical controls. Of the 60 study patients, 59 received a penicillin allergy skin test, 58 underwent orthopedic surgery, and 55 received antibiotic prophylaxis. Fifty-five patients had a history of allergy to penicillin, a cephalosporin, or both, and 5 had a history of nonspecific antibiotic allergy. Of the 59 patients, 55 (93%) had negative penicillin allergy skin test results. Fifty-four (90%) of the 60 patients were given clearance by the allergist to receive cefazolin. Of the 55 study patients who received antibiotic prophylaxis, 6 (11%) received vancomycin compared with 38 (30%) of 127 historical controls (P < or = .05). None of the study patients had an immediate reaction to cefazolin or to vancomycin. Prophylactic vancomycin use in patients with a history of penicillin or cephalosporin allergy undergoing elective orthopedic surgery can be reduced by a targeted allergy consultation and penicillin allergy skin testing.

Diagnosis of Penicillin, Amoxicillin, and Cephalosporin Allergy:Reliability of Examination Assessed by Skin Testing and Oral Challenge

Pichichero ME, Pichichero DMJ Pediatr.1321998137143The major aims were to 1) assess the reliability of pediatrician-diagnosed allergic reactions to commonly used β-lactam antibiotics based on the examination at the time of reaction followed by elective skin testing and oral challenge, and 2) monitor prospectively the predictive value of negative skin testing for subsequent reactions to antibiotics administered.Children and adolescents (n = 247) experiencing an adverse reaction to penicillin, amoxicillin, and/or an oral cephalosporin sufficient to lead to the recommendation to avoid further use of the drug.Skin testing with penicillin G, commercial benzylpenicilloyl phosphate (Pre-pen), penicillin minor determinant mixture (MDM), ampicillin, cefazolin, cefuroxime, and/or ceftriaxone was performed according to the suspected cause of the reaction. This was followed by an oral challenge, repeat testing, and prospective follow-up if no reactions were observed.Overall, 84 (34%) of 247 patients had an immunoglobulin E (IgE)-type reaction on skin testing or oral challenge. Twenty-seven (32%) of 85 suspected penicillin reactions, 53 (34%) of 156 suspected amoxicillin reactions, and 13 (50%) of 26 suspected cephalosporin reactions were felt to be IgE-mediated. Positive skin tests were observed in 20 patients with non-IgE-type adverse reactions, including 15 patients with only a pruritic polymorphous rash. No reactions to oral challenge were severe after negative skin testing. One hundred sixty-three patients received multiple treatment courses with β-lactam antibiotics after a negative skin test and oral challenge and 3 (1.8%) had adverse IgE-type reactions, all of which were mild.Physician-diagnosed allergic reactions to β-lactam antibiotics based on the examination at the time of the reaction is more accurate than patient history alone, but still overestimates the rate of true allergy in 66% of patients. Elective penicillin, amoxicillin, and cephalosporin skin testing and oral challenge protocols are necessary to identify patients at risk.How often (ie, monthly, weekly, or even daily) do you encounter a patient with a history of a β-lactam allergy? In our current era of emerging antibiotic resistance, this clinical issue has reached an even greater degree of importance. This article addressing the diagnosis of β-lactam allergy should strike a cord with both pediatricians and allergy/immunology specialists. There are several useful “take home” messages. First, examination of the patient at the time of the adverse antibiotic reaction accurately diagnosed an IgE-mediated reaction only 30% of the time. Second, young and middle-aged adults (ages 20–49) seemed to have the greatest risk of acute allergic reactions to antibiotics. Third, this investigation confirms the safety of testing for penicillin allergy with penicillin G, Pre-pen, and MDM, as well as with cephalosporin skin testing reagents. Fourth, after negative skin testing, use of an oral challenge is the safest method of confirming the negative result. Fifth, while a potential for increased hypersensitivity to first-generation cephalosporins exists in those patients who have histories of penicillin, second- and third-generation cephalosporins have a lower incidence of allergic reactions. Finally, patients observed during subsequent, multiple treatment courses with β-lactams after negative testing and oral challenge rarely had mild IgE-mediated reactions.

DRUG CHALLENGE AND DESENSITIZATION PROTOCOLS

Drug challenges and desensitization protocols can be of great value to patients who require medications that have previously caused allergic reactions. In the case of penicillin or cephalosporin allergy, it is possible to identify patients at high risk of an immediate hypersensitivity reaction because of the presence of anti-penicillin IgE antibodies that are directed to the β-lactam ring structure. 26,30 Conversely, if IgE antibodies to penicillin major and minor determinants are absent, the incidence of an immediate hypersensitivity reaction on administration of β-lactam antibiotics approaches 1% or less. 30 Desensitization protocols can be separated into true immunologic desensitization, in which IgE antibodies are bound to the medication, and test-dosing regimens, in which risk of a repeated allergic reaction is high, but no in vitro or in vivo tests are available to verify or monitor the presumed immunologic sensitivity. 26 In the case of radiographic contrast material idiosyncrasy, pretreatment medications combined with the use of lower osmolality radiographic contrast media have helped to reduce the risk of repeated immediate generalized reactions. 19

Diagnosis of penicillin, amoxicillin, and cephalosporin allergy: Reliability of examination assessed by skin testing and oral challenge

The specificity of pediatrician-diagnosed allergy reactions to penicillin, amoxicillin, and oral cephalosporins, which was based on contemporaneous examination of the patient, was evaluated by an elective skin testing program. Children and adolescents ( n = 247) experiencing an adverse reaction to penicillin, amoxicillin, and/or an oral cephalosporin sufficient to lead to the recommendation to avoid further use were enrolled. Skin testing with penicillin G, commercial benzylpenicilloyl phosphate, penicillin minor determinate mixture, ampicillin, cefazolin, cefuroxime, and ceftriaxone was performed according to the suspected drug allergy followed by an oral challenge, repeat testing, and prospective follow-up if no reactions were observed. Overall, 84 (34.0%) of 247 patients had an IgE-type reaction on skin testing or oral challenge. Twenty-seven (32%) of 85 suspected penicillin reactions, 53 (34%) of 156 suspected amoxicillin reactions, and 13 (50%) of 26 suspected cephalosporin reactions were shown to be IgE mediated. Positive skin tests were observed in 20 patients with non-IgE-type clinical adverse reactions, including 15 patients with only a pruritic polymorphous rash. No reactions to oral challenge were severe after negative skin testing. One hundred sixty-three patients received multiple treatment courses with beta-lactam antibiotics after a negative skin testing procedure and three (1.8%) had adverse IgE reactions, all of which were mild. Physician-diagnosed allergic reactions to beta-lactam antibiotics based on patient examination at the time of the reaction is more accurate than patient history alone but still overestimates the rate of possible true allergy in 66% of patients. Elective penicillin, amoxicillin, and cephalosporin skin testing and oral challenge protocols are necessary to identify patients not at risk. (J Pediatr 1998;132:137-43)

Analysis of Therapeutic Options in Patients Reporting a Penicillin or Cephalosporin Allergy

ABSTRACT The majority of patients with a purported β-lactam allergy tolerate β-lactam therapy without incident. The objective of this study was to determine the potential for direct drug cost-avoidance by comparing therapies predicted by a decision analysis model (DAM) using routine allergy consults versus actual therapies received. Based on history, 100 patients were categorized as either probably allergic (Group A; 29%), possibly allergic and requiring an allergy consult (Group B; 53%), or unlikely to be allergic (Group C; 18%). These probabilities were incorporated into a DAM to predict the potential for β-lactam allergy. Patients in Group C and 84% of Group B were considered likely able to tolerate β-lactam therapy based on history and/or probability of a negative skin test as reported in the literature. Direct drug cost-avoidance was calculated as the difference between actual therapy received and therapy indicated by the model. The actual cost of therapy was $156/patient while the potential cost according to the model was $165/patient. A direct drug cost-avoidance of -$25/course (i.e., increased cost) for prophylactic therapy and $31/course for active treatment was calculated. This study suggested no direct drug cost-avoidance when routine allergy consults were used as part of the DAM, although cost-avoidance may be achieved in select subsets of patients. RESUME La majorite des patients qui ont une presumee allergie aux beta-lactames tolerent les traitements aux beta-lactames sans incidents. L'objectif de cette etude etait de determiner la possibilite d'eviter les couts directs en medicaments en comparant les traitements theoriques determines par un modele d'analyse de decision (MAD) qui utilise une methode de consultation, habituelles pour les allergies versus les traitements actuellement recus. Selon les antecedents, 100 patients ont ete categorises soit comme etant probablement allergiques, Groupe A (29 %) soit possiblement allergiques et necessitant une consultation pour leur allergie, Groupe B (53 %), soit encore peu probablement allergiques, Groupe C (18 %). Ces probabilites ont ete incorporees au MAD pour predire la probabilite d'allergie au beta-lactame. Les chercheurs ont estime que les patients du Groupe C et 84 % de ceux du Groupe B etaient vraisemblablement capables de tolerer un traitement aux beta-lactames, en se fondant sur les antecedents et (ou) la probabilite d'un resultat negatif a l'epreuve cutanee, comme on le rapporte dans la documentation. L'evitement des couts directs en medicaments a ete calcule comme la difference entre le traitement actuellement recu et le traitement indique selon le modele d'analyse de decision, Le cotit actuel du traitement etait de 156 $ par patient, alors que le cout potentiel du traitement selon le MAD etait de 165 $ par patient. Les couts directs evites qui ont ete calcules etaient de -25 $ par traitement (c.-a-d, un cout superieur) pour le traitement prophylactique et de 31 $ par traitement pour le traitement actif. Cette etude porte a croire qu'il n'y a eu aucun evitement des couts directs en medicaments avec la methode de consultation habituelle pour les allergies utilisee avec le MAD, bien qu'il soit possible d'eviter des couts chez certains sous-groupes de patients choisis.

Selecting Skin Testing Reagents to Predict Amoxicillin and Cephalosporin Allergy

Objectives This study assessed the accuracy of a panel of skin testing reagents to detect immunoglobulin E sensitivity to amoxicillin and oral cephalosporins. Methods One hundred and eighty-seven children and adolescents experiencing adverse reactions to amoxicillin (or amoxicillin/clavulanate), and/or an oral cephalosporin, that were considered sufficient to preclude further use were studied. Skin testing with penicillin G, commercial benzylpenicilloyl phosphate, penicillin minor determinant mixture (MDM), ampicillin, cefazolin, cefuroxime, and ceftriaxone was performed according to the suspected drug allergy, followed by an oral challenge, repeat skin testing, and prospective follow-up if no reactions were observed. Results Fifty-four (33.5%) of 161 patients with suspected amoxicillin reactions and 13 (50%) of 26 suspected cephalosporin reactions had positive skin tests or oral challenges. Positive reactions to only the MDM reagent occurred in 9 amoxicillin- or cephalosporin-allergic patients, to only the ampicillin reagent in 4 amoxicillin-allergic patients, and to only a cephalosporin reagent in 3 cephalosporin-allergic patients. No reactions to oral challenge were severe after negative skin testing. During prospective follow-up, one (0.9%) of 107 patients suspected of amoxicillin allergy who completed our skin testing—oral challenge repeat skin test protocol without a reaction and two (1.8%) patients with borderline reactions subsequently developed urticaria 8-16 months later while taking a course of amoxicillin. Reactions were mild. No test negative patients suspected of cephalosporin allergy developed a reaction with a subsequent course of a cephalosporin. Amoxicillin reactors with positive skin tests or oral challenges (N = 54) received 83 treatment courses of cephalosporins uneventfully in prospective follow-up. Conclusions Elective amoxicillin and cephalosporin skin testing and oral challenge protocols are helpful in identifying patients at very low risk for developing subsequent hypersensitivity reactions.

Production workers develop cephalosporin allergy

Production workers develop cephalosporin allergy