Flare up to betalactams.

BACKGROUND: The flare up phenomenon has most frequently been described with nickel. Not many cases of flare up to drugs have reported in the literature, however we have reported it with different medications. METHODS AND RESULTS: A 31-year-old woman developed an adverse reaction with an antibiotic during her childhood. Prick test with penicillin (100,000 IU/ml), penicilloyl polylysine (PPL), minor determinant mixture (MDM), amoxicillin (200 mg/ml), ampicillin (200 mg/ml) and cephalotin (200 mg/ml), and intradermal test to the same substances diluted in saline were all negative immediately. We performed an oral challenge test with 500 mg of amoxicillin. Twelve hours later, the intradermal test to PPL and MDM became positive (PPL 10 x 10 mm, MDM 8 x 7 mm). All patch tests were positive after 72 hours with erythema, vesicles and infiltration and the patient also had exanthema with pruritus on her entire body. CONCLUSIONS: We present one patient with delayed allergic reaction caused by amoxicillin and penicillin, that we all know as Flare up. We suggest that this phenomenon of Flare up occurs by a Type IV mechanism mediated by T-cells without participation of IgE antibodies. The betalactam hypersensitivity mechanism which has usually been described is an IgE mediated reaction, but there are other not very well known mechanisms that are responsible for the delayed reactions.

Cross-reactivity of cefotetan and ceftriaxone antibodies, associated with hemolytic anemia, with other: cephalosporins and penicillin.

Most drug-induced immune hemolytic anemias since the late 1980s have been caused by the second- and third-generation cephalosporins, cefotetan and ceftriaxone, respectively. Cross-reactivity of cefotetan and ceftriaxone antibodies with other cephalosporins or penicillin has been studied only minimally. We tested 7 serum samples previously identified to contain cefotetan antibodies and one serum sample previously identified to contain ceftriaxone antibodies against 9 other cephalosporins, penicillin, and 7-aminocephalosporanic acid in the presence of RBCs and also used hapten inhibition to indicate cross-reactivity. Serum samples containing cefotetan antibodies showed some cross-reactivity with cephalothin and cefoxitin (and to a much lesser extent with penicillin and ceftazidime). The ceftriaxone antibodies showed very weak cross-reactivity with cefotaxime, cefamandole, and cefoperazone. There was very little cross-reactivity between cefotetan antibodies and the drugs tested in the present study. We have no data to determine whether the in vitro data relate to in vivo reactivity.

beta-Lactam allergenic determinants: fine structural recognition of a cross-reacting determinant on benzylpenicillin and cephalothin.

BACKGROUND: An appreciation of the structural heterogeneity of allergenic determinants on penicillins and cephalosporins reveals the importance of side-chain groups and their involvement in many allergies to beta-lactam drugs. Although allergenic cross-reactions between penicillins and cephalosporins are known to occur, the precise molecular bases of such recognitions and cross-sensitivities have rarely been studied and identified. OBJECTIVES: The unexpected finding of a high incidence of positive IgE antibody reactions with both benzylpenicillin and cephalothin prompted serological and immunochemical studies to identify the chemical basis of antibody recognition of these drugs from the two different families of beta-lactam antibiotics. METHODS: Adsorption studies were employed to identify whether or not a single population of antibodies was involved in the recognition of benzylpenicillin and cephalothin. Identification of the fine structural features recognized by IgE antibodies was investigated by quantitative hapten inhibition studies employing carefully selected beta-lactam drugs, analogues and some other structurally related chemicals. RESULTS: Adsorption studies with penicilloic acid-solid phase clearly established that a single population of cross-reacting antibodies recognized both benzylpenicillin and cephalothin. Quantitative inhibition findings, especially with phenylacetic acid and 2-thiopheneacetic acid and with cephaloridine and cefoxitin, which have the same (2-thienyl)methyl side-chain as cephalothin, implicated the methylene group as the focus of the allergenic determinant recognized on benzylpenicillin and cephalothin. In addition to the methylene group, recognition graded into neighbouring structures including the amide group and extended weakly to the beta-lactam ring. CONCLUSIONS: Results confirmed that structural features as small as a methylene group may be allergenically important. In the present case, this group, making up only part of the different side-chains on benzylpenicillin and cephalothin, together with neighbouring structures extending toward the beta-lactam ring, accounted for the cross-reactivity seen between structures that, at first sight, appear to be not closely related. Such subtle, small, common structural features are likely to be immunologically recognized and implicated in allergic reactions to other drugs, including beta-lactam antibiotics.

[Immunological properties of S-1090, cefmatilen hydrochloride hydrate].

S-1090, a cefmatilen hydrochloride hydrate, is being developed as a cephalosporin antibiotic for oral use. Immunogenicity, hypersensitivity-eliciting antigenicity and immunological cross-reactivity with other antibiotics were evaluated by active systemic anaphylaxis (ASA) test, passive cutaneous anaphylaxis (PCA) test and enzyme-linked immunosorbent assay (ELISA) using guinea pigs and mice/rats. In addition, in vitro direct Coombs' test was also performed to examine the possibility of hemolytic anemia in clinical use. Immunogenicity of S-1090 was not observed in guinea pigs after repeated immunization with S-1090 by ASA or PCA tests. Even in ELISA, only weak antibody production against S-1090 was found in some guinea pigs from the intraperitoneal groups showing the antibody titers only 10(1) to 10(2). When the sera collected from C3H/He mice and C57BL/6J mice immunized with S-1090 were tested for immunogenicity, rat PCA was elicited in a C3H/He mouse serum by S-1090 and antibodies against S-1090 were detected in a C57BL/6J mouse serum by ELISA. When adjuvant was used in mice and guinea pigs, the production of antibody against S-1090 was less frequent in comparison with other antibiotics such as cefmetazole (CMZ) and cefotiam (CTM). When hypersensitivity-eliciting antigenicity of S-1090 was examined using S-1090 as an eliciting antigen in ASA and PCA tests, positive ASA and PCA were observed in guinea pigs and positive PCA in a C3H/He mouse. Hypersensitivity-eliciting antigenicity was also observed in other reference antibiotics, i.e. cephalothin (CET), CMZ and CTM. Immunological cross-reactivity among S-1090, penicillin G (PCG), CET, CMZ and CTM was tested by ASA and PCA tests. S-1090 was found to immunologically cross-react only with CET in guinea pigs. In the present study, immunological cross-reactivities were also noted between PCG and CET, PCG and CMZ, PCG and CTM, and between CET and CMZ. In in vitro direct Coombs' test using human red blood cells, S-1090.Na, PCG and CET gave positive reactions at the final concentrations of 40 mg/mL, 20 to 40 mg/mL and 2.5 to 10 mg/mL, respectively.

Sex differences in immune responses to cephalothin in guinea pigs.

Guinea pigs of two strains, outbred Hartley and inbred Strain 2, were immunized subcutaneously with cephalothin (CET, 20 mg/body) alone, without adjuvant. Immune responses to the antibiotic were assessed by guinea-pig passive cutaneous anaphylaxis (GP-PCA) and active systemic anaphylaxis (GP-ASA) reactions. The immune response to CET in the female Hartley guinea pigs was higher than that in the males. In contrast, no difference in response to CET in Strain 2 guinea pigs was observed between males and females. These results suggested that female Hartley guinea pigs possessing a higher response should be employed in antigenicity studies involving the beta-lactam antibiotics.

An assessment of antigenic potential of beta-lactam antibiotics, low molecular weight drugs, using guinea pig models.

Allergic reactions are among the common adverse effects in humans. However, it is widely assumed that there are practically no reliable animal models for preclinical tests of low-molecular weight drugs that are available to predict such reactions. This study was designed to compare the detecting ability of test methods for antigenic potential of eight beta-lactam antibiotics with which allergic outcome has been reported in humans. The tests included active systemic anaphylaxis (ASA), delayed type skin reaction (DSR), maximization test (GPMT) in guinea pigs sensitized with antibiotics emulsified with Freund's complete adjuvant, passive cutaneous anaphylaxis (PCA) and enzyme-linked immunosorbent assay (ELISA) as serological tests. PCA and ELISA though using protein-conjugates as detecting antigens, especially ELISA, showed positive reactions with relatively high incidence. On the other hand, GPMT was the most sensitive method to detect antigenic potential of antibiotics despite the use of antibiotics alone for sensitizing and challenging phases. It is suggested that GPMT can be considered the most reliable method in preclinical testing.

Anti-IL-4 monoclonal antibody prevents antibiotics-induced active fatal anaphylaxis.

We previously reported that anti-IL-4 mAb (11B11) failed to prevent protein-induced fatal murine anaphylaxis. To investigate the effect of anti-IL-4 on hapten-induced anaphylaxis, a model of murine anaphylaxis induced by antibiotics, penicillin V (Pen V) and cephalothin (CET), was developed, and the effect of anti-IL-4 on the anaphylaxis was observed. Pen V and CET induced 100 and 70 to 90% fatal reactions, respectively, when C57BL/6 mice were sensitized i.p. with 500 microg of antibiotic-OVA conjugate with 2 x 10(9) Bordetella pertussis and 1.0 mg of alum and challenged i.v. with 100 microg of antibiotic-BSA conjugate 14 days later. Serum taken from mice sensitized to Pen V passively sensitized normal mice to develop systemic anaphylaxis, and this ability of the serum was abrogated by heating at 56 degrees C for 2 h or depletion of IgE, but not IgG, Abs. Thus, the antibiotic-induced fatal reaction was an IgE-dependent anaphylactic reaction. Administration of anti-IL-4 at the beginning of sensitization completely prevented the fatal anaphylactic reactions to both Pen V and CET. This effect of anti-IL-4 was associated with its suppressive activity on antibiotic-specific serum IgE, but not IgG, levels. More importantly, anti-IL-4 therapy in previously sensitized mice was also effective in preventing the fatal reactions and rapidly reduced the established IgE levels. This study provides a new animal model of hapten-induced anaphylaxis and indicates that blocking of IL-4 activity may be beneficial in allergic diseases caused by a variety of haptens in which IgE Abs play a major role.

Differences in immune responses to antibiotics in three guinea-pig strains.

The present experiments were undertaken to clarify the differences in humoral immune response to two beta-lactam antibiotics, benzylpenicillin potassium (PcG) and cephalothin sodium (CET), in guinea-pig strains. Guinea pigs of three different strains, Hartley, Strain 2 and Strain 13, were immunized subcutaneously with PcG (10 mg/body) 1 or 3 times a week, 10 times in total, or with CET (20 mg/body) 3 times a week, 12 times in total. Humoral immune responses to the two antibiotics were assessed by passive cutaneous anaphylaxis (PCA) and active systemic anaphylaxis (ASA) reactions. The relative intensities of the responses to PcG and CET detected by PCA reaction were Hartley > Strain 2 > Strain 13. On the other hand, Hartley and Strain 13 guinea pigs displayed high responses to the two antibiotics by ASA reaction, and Strain 2 exhibited a relatively low response. Based on these results, it was clarified that the Hartley strain, which is the most common strain used in ordinary allergenicity tests, showed the highest response to the two antibiotics tested in PCA and ASA reactions.

Serovars and multiple drug resistant Salmonella sp. isolated from children in Rio de Janeiro-Brazil

Foram caracterizadas sorologicamente e testadas para a susceptibilidade e antimicrobianos, 116 amostras de Salmonella isoladas de coproculturas e hemoculturas efetuadas de crianças durante o período de maio de 1987-junho 1992 no Instituto Fernando Figueira, Brasil. Detectou-se seis sorogrupos (04; 07; 08; 09; 03; 10 e 035) representados por 18 serovares, sendo a S. typhimurium (62,93 por cento) a mais frequente, seguida da S. agona (7,75 por cento). Os antimicrobianos utilizados foram a ampicilina (Ap), cefalotina (Cf), cefoxitina (Cx), ceftriaxona (Cro), pefloxacin (Pf), gentamicina (Ge), amicacina (Am), sulfametoxazoletrimetropim (SxT), cloranfenicol (CL) e tetraciclina (Te). 94.52 por cento das cepas de S. typhimurium representaram determinantes de resistência. Foram encontrados 29 padröes de resistência diferentes, sendo o mais frequente para S. typhimurium o Ap, Cf, Ge, Am, Sxt, Cl, Te, Pf (40,47 por cento) e para os outros serovares o Te (20.83 por cento). A determinaçäo da concentraçäo mínima inibitória realizada para cinco dos antimicrobianos citados evidenciou altos níveis de resistência para Ap e Cl, contrapondo-se a níveis mais baixos obtidos para Ge, Sxt e Cro

Evaluation of delayed type hypersensitivity to beta-lactam antibiotics in mice.

This study was designed to determine whether delayed type hypersensitivity could be evoked by protein-unconjugated beta-lactam antibiotics emulsified with Freund's complete adjuvant (FCA) in mice. The method providing the strongest sensitization was assessed by measuring footpad swelling induced by several biweekly intervals of subcutaneous injections of 0.8 mg/mouse cephalothin with FCA, followed by intradermal challenge with 1.0 mg/site cephalothin into the footpad in four different strains of female mice. A total of three and four injections, once every two weeks, in BDF1 and DBA/2 mice, respectively, produced the greatest potential for swelling. This swelling could be reinduced by the local passive transfer of cephalothin-primed splenocytes into the footpad of naive recipient mice. Moreover, the reaction was diminished by the addition of anti-Thy-1.2 monoclonal antibody with low-toxicity rabbit complement to cephalothin-primed splenocytes. Swelling in the footpad was therefore induced via the delayed type hypersensitivity reaction, indicating T-lymphocyte dependence. When the potential for beta-lactam antibiotics to elicit delayed type hypersensitivity was investigated in BDF1 mice, eight of the nine agents employed showed a 10-90% positive incidence. This result had a significant correlation (r = 0.76) with the data for skin reaction in guinea pigs, the method generally used for estimating allergenicity. These results suggest that this procedure may be a useful tool for evaluating delayed type hypersensitivity induction during the early development of novel antibiotics, since not only can sensitization be induced with protein-unconjugated antibiotic, but also because assessment can be made using a small amount of sample.

Identification of penicillin allergenic determinants that bind IgE antibodies in the sera of subjects with penicillin allergy.

Much of the literature on penicillin hypersensitivity is devoted to the identification of penicillin antigens rather than allergens. Human IgE-binding determinants on different penicillins have rarely been closely investigated with the view of defining fine structural allergenic features and differences. We have developed radioimmunoassays employing ampicillin, amoxicillin and ticarcillin solid phases for the detection of penicillin-reactive IgE antibodies. Quantitative hapten inhibition studies employed to identify IgE-binding regions on the penicillin molecules revealed a heterogeneous group of allergenic determinants consisting exclusively, or in part, of the alpha-aminobenzyl and benzyl side chain groups and the beta-lactam and thiazolidine rings of the penicillin nucleus.

[Comparative studies on delayed type hypersensitivity of low-molecular compounds and compound-protein conjugates in rabbits].

Comparative studies on immunogenicity for compounds (TNBS, CET and 4-AAP) and compound-protein conjugates (TNBS-OA, CET-OA and 4-AAP-OA) were undertaken by the assay systems of humoral reaction (HA) and cellular reaction (DTH) in rabbits. The immunogenicity of TNBS-OA was substantially different from either that of CET-OA or 4-AAP-OA in the assay system of DTH. That is, rabbits immunized with TNBS-OA plus FCA displayed positive DTH reactions to the eliciting antigen (TNBS), while such reactions were never recognized in the rabbits immunized with CET-OA plus FCA or 4-AAP-OA plus FCA to the eliciting antigen of CET or 4-AAP, respectively. The above negative reactions observed in both groups, CET-OA and 4-AAP-OA, can be explained by the ordinary interpretation that the specificity of cellular immunoreaction (DTH) is directed toward the binding part of hapten-protein conjugate. By contrast, TNBS, spread on the skin to evoke DTH, may react with epidermal proteins in vivo to form 2,4,6-trinitrophenyl (TNP)-coupled protein. Consequently, it was suggested that this TNP-coupled protein evoked the positive DTH reaction in the TNBS-OA group.

Cross-antigenicity between penams and cephems by intradermal skin test and leucocyte migration test in guinea pigs.

The delayed-type hypersensitivity (DTH) reactions for penams or cephems of beta-lactam antibiotics were investigated by intradermal skin test and leucocyte migration test (LMT) in guinea pigs. The animals were immunized with ampicillin (ABPC) or cephalexin (CEX) using Freund's complete adjuvant. The cross-reactivities among ABPC, penicillin G (PCG) and cloxacillin as penam and CEX, cephalothin (CET) and cephalosporin C (CEPC) as cephem and phenylglycine (PhGly), which is the amino acyl side chain of ABPC and CEX, were examined. By intradermal reaction, ABPC-sensitized animals showed a cross-reaction with CEX, PCG and CET, but CEX-sensitized animals did not cause cross-reaction with ABPC. The CEX-sensitized group exhibited slight cross-reactions to CET and PhGly. PhGly exhibited low immunogenicity only in maximization test of guinea pig. The above results indicate that there is the difference in cross-reactivity between penams and cephems in skin test. In LMT, all the ABPC-sensitized animals reacted with ABPC and showed cross-reactions with all drugs tested. The CEX-sensitized group reacted with 4 out of 7 animals with CEX and exhibited cross-reactivities to ABPC, PCG, CET, CEPC and PhGly. The cross-reactivity between intradermal skin reaction and LMT elicited some different results.

Experimental drug-induced allergic nephritis mediated by antihapten antibody.

Experimental drug-induced allergic nephritis (DIAN) was mediated by an antihapten antibody. It has been postulated that DIAN is induced by cellular and humoral mechanisms. We tried to induce DIAN in mice, where the mechanism depends on humoral immunity. The first attempt was made in mice actively producing antibodies against cephem antibiotics, i.e. cephalothin (CET). Acute interstitial nephritis (AIN), morphologically similar to human disease, was obtained by injection of a CET-protein conjugate into the renal cortex in mice producing anti-CET-IgE and IgG antibodies. AIN could also be induced when normal mice, passively given anti-CET IgG antibody, received a subsequent intrarenal challenge with CET-protein conjugate. These preliminary results indicate that IgG antibody has an important role in the genesis of DIAN. Further experiments were performed with monoclonal antibodies directed against haptens instead of antibiotics in order to clarify the Ig isotype concerned. In mice passively given anti-Dansyl-IgG2a or anti-NP-IgG2a monoclonal antibodies, a challenge with an appropriate hapten-protein conjugate into the renal cortex resulted in AIN. However, transfer of anti-Dansyl-IgE or anti-DNP-IgE monoclonal antibodies, followed by challenge, did not induce AIN. In the experimental systems described, the involvement of a cellular immune mechanism is excluded. The results suggest that IgG, but not IgE antibody, is essential for the induction of DIAN by humoral immune mechanism.

Disulphide bonds are a requirement for adsorption of cephalosporins on the red cell membrane.

The authors studied the behavior of red cells (RBCs), treated with 2-aminoethylisothiouronium bromide (AET), against 100 serums containing cephalothin antibodies and 27 serums with cephapirin antibodies. None of the serums reacted with cephalosporin-coated RBCs that had been exposed previously to AET. The possibility of the Kell system acting as a receptor for cephalosporins was excluded. The authors discuss the significance of cysteine disulphide bonds and the tertiary or quaternary structure of red cell membrane proteins in the binding of cephalosporins to RBCs.

Heterogeneity of cross-reactivity of mouse anti-benzylpenicilloyl antibodies against cephalothin haptens or polymers.

The cross-reactivity of mouse anti-benzylpenicilloyl antibodies against cephalothin-haptens and cephalothin-polymers was divergent depending on the source and isotype of antibodies and the methods to raise them. High cross-reactivity nearly equal to the reactivity to homologous haptens and polymers was obtained only with the IgE antibody of C57BL/6J mouse raised shortly after an immunizing injection of the emulsion containing Freund's complete adjuvant and benzylpenicilloyl-bovine gamma-globulin conjugate. With the other antibody preparations, cross-reactivity was moderate to negligible.

Cross-allergenicity and immunogenicity of aztreonam.

The immunochemistry of aztreonam, the prototype of the new monobactam class of beta-lactam antibiotics, was studied in a series of experimental and clinical investigations. Rabbit antibodies to aztreonam and naturally occurring human antibodies that recognize aztreonam were found to have negligible cross-reactivity with benzylpenicillin, cephalothin, and cefotaxime. Aztreonam likewise displayed negligible cross-reactivity (less than or equal to 0.001%) with antibodies to penicillin (including human IgE antibodies to major and minor penicillin determinants) and to cephalothin. These studies suggest that aztreonam may be well tolerated by penicillin-allergic individuals, and this possibly is now being evaluated in clinical trials. Seven (6.25%) of 112 healthy persons tested had preexisting IgG antibodies to aztreonam in low titer, presumably as a result of exposure to naturally occurring cross-reacting moieties. Only two of seven patients with preexisting IgG antibodies to aztreonam had a rise in titer following aztreonam treatment. No IgE antibody to aztreonam was detected in serum specimens obtained on day 10 during any of the 112 courses of therapy. These clinical observations suggest but do not prove that aztreonam has only weak potential to elicit a drug-specific immunologic response.