Antibiotic desensitization for the allergic patient: 5 years of experience and practice

doi:10.1016/S1081-1206(10)61778-4

Annals of Allergy, Asthma & Immunology

Volume 92, Issue 4, April 2004, Pages 426-432

https://doi.org/10.1016/S1081-1206(10)61778-4 Get rights and content

Background

Antibiotic desensitization is an option for patients with suspected IgE-mediated antibiotic allergy when no other alternative exists for treating life-threatening bacterial infections. However, there are limited data describing the outcomes of this procedure with newer, commonly used antibiotics.

Objective

To evaluate the safety and utility of antibiotic desensitization.

Methods

We retrospectively reviewed the medical records of all patients undergoing antibiotic desensitization in our institution between November 1996 and November 2001.

Results

There were a total of 57 desensitizations performed in 21 patients. The mean age of the patients was 22.8 years (range, 1.9-44.5 years) and 15 (71%) were female. Nineteen (90%) of the 21 patients had been diagnosed as having cystic fibrosis. In 33 (100%) of 33 desensitizations to unique antibiotics that occurred during the study period, the indication for desensitization was a history suggestive of an IgE-mediated reaction to the antibiotic and/or a positive skin test result to the antibiotic or a known cross-reactive antibiotic. Desensitizations were performed to 12 different antibiotics. Successful outcomes were achieved in 43 desensitizations (75%). Of the 11 cases (19%) that were terminated due to an allergic reaction, there were no fatalities, intubations, or other aggressive interventions besides the use of epinephrine, antihistamines, and corticosteroids. In 7 of 11 unsuccessful desensitizations, a non-IgE mechanism appeared to be responsible for the allergic reaction.

Conclusions

Antibiotic desensitization is a useful option when treating patients with life-threatening infections who must receive antibiotics to which they have an IgE-mediated allergy. These data indicate that in most cases, patients with presumed IgE-mediated antibiotic allergy may safely receive antibiotics after desensitization.

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Drug hypersensitivity reactions (DHRs) to intravenous drugs can be severe and might leave patients and doctors in a difficult position where an essential treatment or intervention has to be suspended. Even if virtually any intravenous medication can potentially trigger a life-threatening DHR, chemotherapeutics, biologics, and antibiotics are amongst the intravenous drugs most frequently involved in these reactions. Admittedly, suspending such treatments may negatively impact the survival outcomes or the quality of life of affected patients.
Delabeling pathways and rapid drug desensitization (RDD) can help reactive patients stay on first-choice therapies instead of turning to less efficacious, less cost-effective, or more toxic alternatives. However, these are high-complexity and high-risk techniques, which usually need expert teams and allergy-specific techniques (skin testing, in vitro testing, drug provocation testing) to ensure safety, an accurate diagnosis, and personalized management. Unfortunately, there are significant inequalities within and among countries in access to allergy departments with the necessary expertise and resources to offer these techniques and tackle these DHRs optimally.
The main objective of this consensus document is to create a great benefit for patients worldwide by aiding allergists to expand the scope of their practice and support them with evidence, data, and experience from leading groups from around the globe.
This statement of the Drug Hypersensitivity Committee of the World Allergy Organization (WAO) aims to be a comprehensive practical guide on the technical aspects of implementing acute-onset intravenous hypersensitivity delabeling and RDD for a wide range of drugs. Thus, the manuscript does not only focus on clinical pathways. Instead, it also provides guidance on topics usually left unaddressed, namely, internal validation, continuous quality improvement, creating a healthy multidisciplinary environment, and redesigning care (including a specific supplemental section on a real-life example of how to design a dedicated space that can combine basic and complex diagnostic and therapeutic techniques in allergy).
Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: General Concepts
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In addition, desensitization to coagulation factors requires more prolonged protocols, likely due to the presence of inhibitor antibodies in these patients.90,91 A variety of other protocols have been described not only for intravenous desensitization but also for oral, subcutaneous, and intraperitoneal routes in both outpatient and inpatient contexts.8,9,73,80 The main risk during a desensitization procedure is that of a recurrent immediate reaction and anaphylaxis when the patient is re-exposed to the culprit drug, but current data suggest that most breakthrough reactions are mild and less severe than the patient's initial hypersensitivity reaction.
Hypersensitivity to tetracyclines: Skin testing, graded challenge, and desensitization regimens
2020, Annals of Allergy, Asthma and Immunology
Hypersensitivity reactions (HSRs) to tetracyclines and the related compound, tigecycline, can limit the use of these medications and compromise optimal patient care. Despite this, there is little discussion in the literature describing the presentation of these reactions or guiding clinicians on the management of these reactions in adult and pediatric patients.
To describe the clinical features, optimal diagnostic approach, and management of HSRs to tetracyclines.
Patients with reactions to tetracyclines at our institution from 2011 to 2019 were identified by retrospective chart review. Skin testing protocols were designed for each antibiotic. Graded challenge and desensitization procedures were devised based on medical history, skin testing results when available, and need for readministration.
The HSRs to tetracyclines, their workup, and management are described for 10 patients, aged 7 to 68 years. Our skin testing protocols for doxycycline, minocycline, and tigecycline described herein had good negative predictive value. When skin testing was negative and the initial reaction was not severe, graded challenge to the culprit drug was performed. Using the included procedures, 3 patients were desensitized to oral doxycycline, 3 to oral minocycline, and 2 to intravenous tigecycline. All the desensitizations were successful.
Once identified, HSRs to tetracyclines can be further evaluated with skin testing and graded challenge and managed in appropriate cases with desensitization. These procedures can facilitate first-line therapy for patients who require tetracyclines but developed hypersensitivity reactions.
Antibiotics allergy in cystic fibrosis: A retrospective cohort of adult patients followed at the resource and skills centre for cystic fibrosis in Angers with a literature review
2018, Revue Francaise d'Allergologie
La mucoviscidose est une maladie héréditaire, dont le pronostic est lié à l’atteinte respiratoire et aux complications infectieuses. Les réactions d’hypersensibilité allergique aux antibiotiques, notamment aux β-lactamines, concerneraient 6 à 30 % des patients. Notre objectif était de décrire (fréquence, nature, chronologie) les réactions présumées allergiques aux antibiotiques chez les patients adultes suivis au CRCM d’Angers adressés en consultation d’allergologie au CHU d’Angers et celle des réactions d’hypersensibilité prouvée à ces médicaments sur la base du bilan allergologique (tests cutanés et tests de provocation), et, enfin, d’évaluer la fiabilité des accoutumances médicamenteuse chez ces patients. Douze des 64 patients suivis au CRCM d’Angers entre 2004 et 2017 ont été adressés en allergologie, dont 5 pour une suspicion d’allergie à un antibiotique et 7 à plusieurs antibiotiques. Vingt-trois réactions cliniques étaient rapportées, dont 9 de chronologie immédiate, 12 de chronologie retardée et 2 de chronologie indéterminée. Les symptômes les plus fréquents étaient les exanthèmes maculopapuleux et les réactions d’angiœdème. Aucune réaction sévère n’a été rapportée. Une allergie a été diagnostiquée chez 8 patients rapportant 10 réactions, sur la positivité des tests cutanés dans 6 cas, sur la positivité des tests de provocation/réintroduction dans 2 cas et sur l’imputabilité forte de l’histoire clinique malgré des TC négatifs pour 2 patients ayant présenté un érythème pigmenté fixe. L’antibiotique le plus pourvoyeur d’allergie (suspectée et prouvée) était le ceftazidime suivi du sulfaméthoxazole–triméthoprime et de la pipéracilline–tazobactam. Quatre protocoles d’accoutumance ont été effectués avec une bonne tolérance dans 3 cas. La prévalence de l’hypersensibilité aux antibiotiques dans notre population de patients mucoviscidosiques était de 12,5 %. Nos résultats confirment que la réalisation d’un bilan allergologique complet est essentielle pour confirmer ou exclure la nature allergique de la réaction, ce qui amène soit à proposer une alternative thérapeutique, soit une accoutumance.
Cystic fibrosis is a hereditary disease of which the prognosis is related to respiratory and infectious complications. Allergic hypersensitivity reactions to antibiotics, particularly β-lactams, appear to affect between 6 and 30% of patients. Our objective was to describe (frequency, nature, chronology) suspected antibiotic hypersensitivity reactions in adults followed up at the resource and competence centre for cystic fibrosis in Angers and sent to allergology consultations and to evaluate the results of the allergology assessment (skin and drug challenge tests) and drug desensitization. Twelve of the 64 patients followed up in Angers between 2004 and 2017 were referred in allergology: 5 patients for suspected allergy to 1 antibiotic and 7 patients for suspected allergy to several antibiotics. Twenty-three reactions were reported, 9 of which were immediate, 12 non-immediate and 2 of indeterminate chronology. The most common symptoms were maculopapular exanthema and angioedema; there was no severe reaction. Antibiotic hypersensitivity was diagnosed in 8 patients based on positive responses in skin tests and challenge tests in 60 and 20% of patients respectively, and on strong accountability of drug causality and case history despite negative skin tests for 2 patients with fixed drug eruption. The most commonly incriminated antibiotic (suspected and proven) was ceftazidime followed by trimethoprim–sulfamethoxazole and piperacillin–tazobactam. Four desensitisations were performed with good safety in 3 cases. Thus, the prevalence of proven antibiotic hypersensitivity was 12.5% in our population. Our results confirm that a complete allergological assessment is essential to confirm or exclude the allergic nature of the reaction, resulting proposal of either a therapeutic alternative or drug desensitization.
Management of Children with Hypersensitivity to Antibiotics and Monoclonal Antibodies
2017, Immunology and Allergy Clinics of North America
Continuous intravenous β-lactam antibiotics in cystic fibrosis patients with severe drug hypersensitivity
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ORIGINAL ARTICLESAntibiotic desensitization for the allergic patient: 5 years of experience and practice

Background

Objective

Methods

Results

Conclusions

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

J Allergy Clin Immunol

J Pediatr

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Antibiotic hypersensitivity in patients with CF

Clin Rev Allergy Immunol

Drug allergy

Management of the patient with allergic reactions to antibiotics

Pediatr Pulmonol

Acute drug desensitization

Clin Exp Allergy

Drug allergy

ORIGINAL ARTICLES
Antibiotic desensitization for the allergic patient: 5 years of experience and practice