Β-lactam allergy: Difference between revisions

From IDWiki
Β-lactam allergy
(→)
No edit summary
 
(4 intermediate revisions by the same user not shown)
Line 1: Line 1:
 
{{DISPLAYTITLE:β-lactam allergy}}
  
{{DISPLAYTITLE:β-lactam allergy}}
  +
  +
== Background ==
  +
  +
* The rate of IgE-mediated penicillin allergies is decreasing with time
  +
* Most patient reports of penicillin allergy are either unknown or a cutaneous reaction
  +
* Patients with listed allergy often receive second-line, less effective, more expensive, or more harmful treatments
   
 
==Hypersensitivity Reactions==
  
==Hypersensitivity Reactions==
Line 21: Line 27:
 
*Cross-reactivity between [[penicillins]] and [[cephalosporins]] is mediated by homology of the R1 side chains (referring to the C6 side chain in [[penicillins]] or the C7 side chain in [[cephalosporins]])
  
*Cross-reactivity between [[penicillins]] and [[cephalosporins]] is mediated by homology of the R1 side chains (referring to the C6 side chain in [[penicillins]] or the C7 side chain in [[cephalosporins]])
 
*Cross-reactivity within [[cephalosporins]] is mediated both by homology of the R1 side chains and also R2 side chains (referring to the C3 side chain)
  
*Cross-reactivity within [[cephalosporins]] is mediated both by homology of the R1 side chains and also R2 side chains (referring to the C3 side chain)
  +
  +
=== Penicillin ===
 
*There is very low (~2%) cross-reactivity between penicillin allergy and [[carbapenems]][[CiteRef::kula2014a]]
  
*There is very low (~2%) cross-reactivity between penicillin allergy and [[carbapenems]][[CiteRef::kula2014a]]
   
  +
{| class="wikitable"
  +
!Class
  +
!Cross-reactivity
  +
!Notes
  +
|-
  +
|Cephalosporin, 1st generation
  +
|2-8%
  +
|Based on poor studies. Avoid cephalexin and cefaclor in ampicillin allergy.
  +
|-
  +
|Cephalosporin, 2nd generation
  +
|2%
  +
|Avoid cefoxitin in penicillin allergy. Avoid cefadroxil and cefprozil in amoxicillin allergy.
  +
|-
  +
|Cephalosporin, 3rd generation
  +
|<1%
  +
|Generally considered safe.
  +
|-
  +
|Cephalosporin, higher generation
  +
|N/A
  +
|No data available, but generally considered safe.
  +
|-
  +
|Carbapenem
  +
|1%
  +
|Generally considered safe.
  +
|-
  +
|Monobactam
  +
|<1%
  +
|Avoid aztreonam in ceftazidime allergy.
  +
|}
  +
  +
=== All β-Lactams ===
 
{| class="wikitable"
  
{| class="wikitable"
 
! rowspan="2" |Antibiotic
  
! rowspan="2" |Antibiotic
Line 266: Line 305:
 
|}
  
|}
   
−
===R1 Side Chains (C6 and C7)===
 +
====R1 Side Chains (C6 and C7)====
   
 
*'''Group 1:''' [[penicillin]], [[cephalothin]], [[cefoxitin]]; similar to [[ticarcillin]]
  
*'''Group 1:''' [[penicillin]], [[cephalothin]], [[cefoxitin]]; similar to [[ticarcillin]]
Line 273: Line 312:
 
*[[Ceftazidime]] and [[aztreonam]]; similar to group 3
  
*[[Ceftazidime]] and [[aztreonam]]; similar to group 3
   
−
===R2 Side Chains (C3)===
 +
====R2 Side Chains (C3)====
   
 
*'''Group 1:''' [[cefadroxil]], [[cephalexin]]
  
*'''Group 1:''' [[cefadroxil]], [[cephalexin]]
Line 282: Line 321:
 
*'''Group 6:''' [[cefixime]]
  
*'''Group 6:''' [[cefixime]]
 
*'''Group 7:''' [[ceftazidime]]
  
*'''Group 7:''' [[ceftazidime]]
  +
  +
== Management ==
  +
  +
=== Penicillin Allergy ===
  +
  +
* Many patients with listed penicillin allergy may be penicillin tolerant due to:
  +
** Benign delayed hypersensitivity rash is the most common reaction
  +
** IgE-mediated penicillin allergy wanes over time (80% are tolerant after a decade)
  +
** Many patients were never allergic
  +
* Consider skin testing for patients with history of severe reaction
  +
  +
=== Massachusetts General Hospital Algorithm (2019) ===
  +
  +
* Developed at MGH[[CiteRef::wolfson2019ac]]<ref>Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. ''JAMA.'' 2019;321(2):188–199. doi:[https://doi.org/10.1001/jama.2018.19283 10.1001/jama.2018.19283]</ref>
  +
  +
==== Allergy History ====
  +
  +
* Intolerance: isolated GI upset, chills, headache, or fatigue
  +
* Low-risk history: family history, itching, unknown and remote (>10 years ago), allergy on record but patient denies
  +
* Moderate-risk: [[anaphylaxis]], [[angioedema]] or swelling, bronchospasm, cough, nasal symptoms, arrhythmia, throat tightness, hypotension, flushing/redness, dyspnea, rash, [[syncope]], wheeze, dizziness/lightheadedness
  +
* High-risk history: [[Stevens-Johnson syndrome]], [[serum sickness]], [[thrombocytopenia]], fever, organ injury (liver or kidney), erythema multiforme, dystonia, anemia, acute generalized exanthematous rash with pustules, [[DRESS]]
  +
* Also assess age at time of reaction, time of onset relative to dose, any treatments received, and any other β-lactams that have been used in the past
  +
* No challenges or testing should be done for patients with a history of penicillin-associated blistering rash, hemolytic anemia, nephritis, [[hepatitis]], fever, or joint pains
  +
  +
==== Low-Risk History ====
  +
  +
* Okay to use [[cephalosporins]] and [[carbapenems]]
  +
* For patients with a low-risk history with cutaneous reaction, IgE-mediated reaction, or hemodynamic instability, do skin testing first
  +
* Otherwise, can follow test dose procedure by given a single dose of [[amoxicillin]] (250 mg or 500 mg) and observing
  +
  +
==== Moderate-Risk History (Type 1 Reaction) ====
  +
  +
* If penicillin skin testing is available, it is preferred; if not available, can consider proceeding with graded challenge
  +
** Give one dose of [[amoxicillin]] 25 or 50 mg and observe for 1 hour; then,
  +
** Given one dose of amoxicillin 250 mg or 500 mg and observe for 1 hour
  +
* Okay to use 3rd generation or higher [[cephalosporin]] by a test dose procedure
  +
* Alternatively, can use [[aztreonam]] or [[carbapenems]]
  +
* Alternatively, can get skin testing if a penicillin or early-generation cephalosporin is preferred
  +
  +
==== High-Risk History (Type 2, 3, or 4 Reaction) ====
  +
  +
* Includes serum sickness, [[Stevens-Johnson syndrome]], [[toxic epidermal necrolysis]], [[acute interstitial nephritis]], [[drug reaction with eosinophilia and systemic symptoms]], [[hemolytic anemia]], and [[drug fever]]
  +
* Avoid all penicillins, cephalosporins, and carbapenems
  +
  +
=== Graded Test Dose Procedure ===
  +
  +
* 10% of the standard dose is given and they are monitored for an hour
  +
* If no reaction is observed in 1 hour, a full dose is given and they are monitored for another hour
   
 
==Further Reading==
  
==Further Reading==

Latest revision as of 18:15, 2 October 2022


Background

  • The rate of IgE-mediated penicillin allergies is decreasing with time
  • Most patient reports of penicillin allergy are either unknown or a cutaneous reaction
  • Patients with listed allergy often receive second-line, less effective, more expensive, or more harmful treatments

Hypersensitivity Reactions

  • Type I (IgE-mediated)
    • Anaphylaxis
    • Itchy rash
    • Penicillins should be avoided
  • Type II (IgG-mediated)
    • Non-itchy rash
    • Rash will improve if treatment continues, no need to avoid penicillins
  • Type IV (cell-mediated)
    • Toxic epidermal necrolysis
    • Stevens-Johnson syndrome
    • Penicillins should be avoided

Cross-Reactivity

  • The following applies to immediate, IgE-mediated hypersensitivity reactions
  • Cross-reactivity within penicillins is mediated by homology of the R1 side chain (referring to the C6 side chain) and by the β-lactam ring itself
  • Cross-reactivity between penicillins and cephalosporins is mediated by homology of the R1 side chains (referring to the C6 side chain in penicillins or the C7 side chain in cephalosporins)
  • Cross-reactivity within cephalosporins is mediated both by homology of the R1 side chains and also R2 side chains (referring to the C3 side chain)

Penicillin

  • There is very low (~2%) cross-reactivity between penicillin allergy and carbapenems1
Class Cross-reactivity Notes
Cephalosporin, 1st generation 2-8% Based on poor studies. Avoid cephalexin and cefaclor in ampicillin allergy.
Cephalosporin, 2nd generation 2% Avoid cefoxitin in penicillin allergy. Avoid cefadroxil and cefprozil in amoxicillin allergy.
Cephalosporin, 3rd generation <1% Generally considered safe.
Cephalosporin, higher generation N/A No data available, but generally considered safe.
Carbapenem 1% Generally considered safe.
Monobactam <1% Avoid aztreonam in ceftazidime allergy.

All β-Lactams

Antibiotic R1 R2
G1 G2 G3 G1 G2 G3 G4 G5 G6 G7
Penicillins
Penicillin X
Ampicillin X
Amoxicillin X
First-Generation Cephalosporins
Cefazolin
Cephalexin X X
Cefadroxil X X
Cephalothin X X
Second-Generation Cephalosporins
Cefotetan X
Cefoxitin X X
Cefuroxime X
Cefaclor X
Third-Generation Cephalosporins
Cefotaxime X X
Ceftriaxone X
Ceftazidime X
Cefixime X
Cefdinir
Fourth-Generation Cephalosporins and Higher
Cefipime X
Ceftaroline

R1 Side Chains (C6 and C7)

R2 Side Chains (C3)

Management

Penicillin Allergy

  • Many patients with listed penicillin allergy may be penicillin tolerant due to:
    • Benign delayed hypersensitivity rash is the most common reaction
    • IgE-mediated penicillin allergy wanes over time (80% are tolerant after a decade)
    • Many patients were never allergic
  • Consider skin testing for patients with history of severe reaction

Massachusetts General Hospital Algorithm (2019)

  • Developed at MGH2[1]

Allergy History

  • Intolerance: isolated GI upset, chills, headache, or fatigue
  • Low-risk history: family history, itching, unknown and remote (>10 years ago), allergy on record but patient denies
  • Moderate-risk: anaphylaxis, angioedema or swelling, bronchospasm, cough, nasal symptoms, arrhythmia, throat tightness, hypotension, flushing/redness, dyspnea, rash, syncope, wheeze, dizziness/lightheadedness
  • High-risk history: Stevens-Johnson syndrome, serum sickness, thrombocytopenia, fever, organ injury (liver or kidney), erythema multiforme, dystonia, anemia, acute generalized exanthematous rash with pustules, DRESS
  • Also assess age at time of reaction, time of onset relative to dose, any treatments received, and any other β-lactams that have been used in the past
  • No challenges or testing should be done for patients with a history of penicillin-associated blistering rash, hemolytic anemia, nephritis, hepatitis, fever, or joint pains

Low-Risk History

  • Okay to use cephalosporins and carbapenems
  • For patients with a low-risk history with cutaneous reaction, IgE-mediated reaction, or hemodynamic instability, do skin testing first
  • Otherwise, can follow test dose procedure by given a single dose of amoxicillin (250 mg or 500 mg) and observing

Moderate-Risk History (Type 1 Reaction)

  • If penicillin skin testing is available, it is preferred; if not available, can consider proceeding with graded challenge
    • Give one dose of amoxicillin 25 or 50 mg and observe for 1 hour; then,
    • Given one dose of amoxicillin 250 mg or 500 mg and observe for 1 hour
  • Okay to use 3rd generation or higher cephalosporin by a test dose procedure
  • Alternatively, can use aztreonam or carbapenems
  • Alternatively, can get skin testing if a penicillin or early-generation cephalosporin is preferred

High-Risk History (Type 2, 3, or 4 Reaction)

Graded Test Dose Procedure

  • 10% of the standard dose is given and they are monitored for an hour
  • If no reaction is observed in 1 hour, a full dose is given and they are monitored for another hour

Further Reading

  • Cross-reactivity in β-Lactam Allergy. J Allergy Clin Immunol Pract. 2018;6(1):72-81.e1. doi: 10.1016/j.jaip.2017.08.027
  • Cross-Reactivity to Cephalosporins and Carbapenems in Penicillin-Allergic Patients: Two Systematic Reviews and Meta-Analyses. J Allergy Clin Immunol Pract. 2019;7(8):2722-2738.e5. doi: 10.1016/j.jaip.2019.05.038
  1. ↑ Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019;321(2):188–199. doi:10.1001/jama.2018.19283

References

  1. ^  Brittany Kula, Gordana Djordjevic, Joan L. Robinson. A Systematic Review: Can One Prescribe Carbapenems to Patients With IgE-Mediated Allergy to Penicillins or Cephalosporins?. Clinical Infectious Diseases. 2014;59(8):1113-1122. doi:10.1093/cid/ciu587.
  2. ^  Anna R. Wolfson, Emily M. Huebner, Kimberly G. Blumenthal. Acute care beta-lactam allergy pathways: approaches and outcomes. Annals of Allergy, Asthma & Immunology. 2019;123(1):16-34. doi:10.1016/j.anai.2019.04.009.

Retrieved from "https://idwiki.org/index.php?title=Β-lactam_allergy&oldid=9508"
Powered by MediaWiki
Powered by Semantic MediaWiki