Food, drug, insect sting allergy, and anaphylaxis
IgE-mediated hypersensitivity to cephalosporins: Cross-reactivity and tolerability of penicillins, monobactams, and carbapenems

https://doi.org/10.1016/j.jaci.2010.06.052Get rights and content

Background

There have been few studies regarding the cross-reactivity and tolerability of penicillins, aztreonam, and carbapenems in large samples of subjects with cephalosporin allergy.

Objective

We sought to evaluate the possibility of using penicillins, monobactams, and carbapenems in subjects with cephalosporin allergy who especially require them.

Methods

We conducted a prospective study of 98 consecutive subjects who had 106 immediate reactions (mostly anaphylactic shock) to cephalosporins and had positive skin test results for these drugs. To assess the cross-reactivity with penicillins, monobactams, and carbapenems and the tolerability of such alternative β-lactams, all subjects underwent skin tests and serum-specific IgE assays with penicillin reagents, as well as skin tests with aztreonam, imipenem/cilastatin, and meropenem. Subjects with negative test results were challenged with meropenem, imipenem/cilastatin, aztreonam, and amoxicillin.

Results

Positive allergologic test results to penicillins were displayed by 25 (25.5%) subjects, including 1 with positive results to all reagents tested and another with a positive result to aztreonam. Another subject had positive results to both ceftazidime and aztreonam. A reaction to cephalosporins with side-chain structures similar or identical to those of penicillins was a significant predictor of cross-reactivity because of an increased 3-fold risk of positive results on allergologic tests with penicillin determinants. Challenges with alternative β-lactams were tolerated, with the exception of 1 urticarial reaction to imipenem/cilastatin.

Conclusions

About 25% of subjects with cephalosporin allergy had positive results to penicillins, 3.1% to aztreonam, 2% to imipenem/cilastatin, and 1% to meropenem. In those who especially require alternative β-lactams, pretreatment skin tests are advisable because negative results indicate tolerability of the β-lactam concerned.

Section snippets

Patient selection

Subjects were recruited from a large outpatient population with a history of immediate reactions to at least 1 cephalosporin. To be included in the study, a subject must have experienced a positive skin test result to the responsible cephalosporin. An indication for treatment with β-lactams other than cephalosporins was not a criterion of inclusion. We used skin tests to evaluate sensitization to aztreonam and carbapenems (imipenem/cilastatin and meropenem). In the event of negative results to

Results

We examined 98 subjects (68 female and 30 male subjects) who ranged in age from 13 to 90 years (mean age, 44.5 ± 21 years) and had a well-demonstrated, IgE-mediated hypersensitivity to cephalosporins. These subjects constituted 71% of an outpatient population of 138 adults recruited prospectively between January 2000 and December 2008 in the Allergy Units of C.I. Columbus and Oasi Maria S.S. because they had a history of immediate reactions to cephalosporins. None of the 98 subjects had a

Discussion

IgE-mediated reactions to cephalosporins occur because of sensitization to determinants shared with other β-lactams or to unique cephalosporin haptens.32, 33, 34 Therefore in subjects with hypersensitivity reactions to cephalosporins, physicians should use responsible cephalosporins in allergologic tests in addition to the classic penicillin reagents.8, 29, 35 The rate of positive responses to the penicillin reagents observed in the present study (25.5% [25/98] of subjects) falls within the

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    Supported by MURST (Italian Ministry for University, Scientific and Technological Research).

    Disclosure of potential conflict of interest: The authors have declared that they have no conflict of interest.

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