Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations.

Unsubstantiated penicillin-allergy labels are common in surgical patients, and can lead to significant harm through avoidance of best first-line prophylaxis of surgical site infections and increased infection with resistant bacterial strains. Up to 98% of penicillin-allergy labels are incorrect when tested. Because of the scarcity of trained allergists in all healthcare systems, only a minority of surgical patients have the opportunity to undergo testing and de-labelling before surgery. Testing pathways can be modified and shortened in selected patients. A variety of healthcare professionals can, with appropriate training and in collaboration with allergists, provide testing for selected patients. We review how patients might be assessed, the appropriate testing strategies that can be used, and the minimum standards of safe testing.

Consensus clinical scoring for suspected perioperative immediate hypersensitivity reactions.

BACKGROUND: Grading schemes for severity of suspected allergic reactions have been applied to the perioperative setting, but there is no scoring system that estimates the likelihood that the reaction is an immediate hypersensitivity reaction. Such a score would be useful in evaluating current and proposed tests for the diagnosis of suspected perioperative immediate hypersensitivity reactions and culprit agents. METHODS: We conducted a Delphi consensus process involving a panel of 25 international multidisciplinary experts in suspected perioperative allergy. Items were ranked according to appropriateness (on a scale of 1-9) and consensus, which informed development of a clinical scoring system. The scoring system was assessed by comparing scores generated for a series of clinical scenarios against ratings of panel members. Supplementary scores for mast cell tryptase were generated. RESULTS: Two rounds of the Delphi process achieved stopping criteria for all statements. From an initial 60 statements, 43 were rated appropriate (median score 7 or more) and met agreement criteria (disagreement index <0.5); these were used in the clinical scoring system. The rating of clinical scenarios supported the validity of the scoring system. Although there was variability in the interpretation of changes in mast cell tryptase by the panel, we were able to include supplementary scores for mast cell tryptase. CONCLUSION: We used a robust consensus development process to devise a clinical scoring system for suspected perioperative immediate hypersensitivity reactions. This will enable objectivity and uniformity in the assessment of the sensitivity of diagnostic tests.

Consequences of proceeding with surgery after resuscitation from intra-operative anaphylaxis.

Intra-operative acute hypersensitivity reactions require a decision to be made regarding whether to proceed with or abandon the planned surgical procedure once the patient has stabilised. Using retrospective case controls, we examined all cases (223) of proven acute hypersensitivity reactions from 2005 to 2014 in Western Australia, in which the syndrome was recognised by the treating clinician before or during surgery, to determine whether recovery outcomes were adversely affected by proceeding with the planned procedure. Surgery proceeded in 104 patients (47%) and was abandoned in 119 (53%). The severity of acute hypersensitivity reactions was Société Française d'Anesthésie et de Réanimation grade 1 or 2 in 56 patients (25%), grade 3 in 128 (56%) and grade 4 in 39 (17%). Abandoning surgery was more common in patients with increasing severity of hypersensitivity. The rate of major hypersensitivity-related complications for all patients was zero for grade 1 and 2 reactions, 4.7% for grade 3 and 12.8% for grade 4. There were no deaths. Patients in whom surgery was completed were not observed to have a higher frequency of major hypersensitivity-related complications when compared with cases of similar severity in whom surgery was abandoned. For patients admitted to the intensive care unit, proceeding with surgery was not associated with an increased duration of mechanical ventilation of the lungs. Our results suggest that, once initial resuscitation has been achieved and if resuscitative efforts can be re-instituted if required, continuing with planned surgery in grade 1, 2 and 3 immediate hypersensitivity was not associated with poorer outcomes. After grade 3 reactions, there was a significant incidence of complications attributable to acute hypersensitivity regardless of whether surgery proceeded or was abandoned. Surgery was frequently abandoned in grade 4 immediate hypersensitivity and was associated with a high rate of complications.

Cefalotin as antimicrobial prophylaxis in patients with known intraoperative anaphylaxis to cefazolin.

BACKGROUND: The most common trigger for intraoperative anaphylaxis in Western Australia for the period 2014-5 was an antibiotic used for surgical prophylaxis, cefazolin. In these patients who subsequently present for surgery, alternative cephalosporins are forbidden by current guidelines because of concerns regarding an increased risk of anaphylaxis. However, consideration of the structure-activity relationships relevant to anaphylaxis suggests that cefalotin is a safe alternative because of structural dissimilarities, although there are no pubished clinical data relevant to the perioperative setting. METHODS: Patients diagnosed with intraoperative anaphylaxis to cefazolin at the Western Australian Anaesthetic Allergy Clinic were tested with intradermal cefalotin and, if negative, subsequently challenged i.v. If tolerated, cefalotin was recommended for subsequent surgery, and subjects were followed up to determine the safety of subsequent intraoperative doses. RESULTS: Twenty-one subjects diagnosed with immediate hypersensitivity to cephazolin, including 19 subjects with confirmed anaphylaxis, participated. None tested positive to intradermal cefalotin, and all received a graded i.v. challenge to cefalotin without developing signs or symptoms of anaphylaxis. Three subjects subsequently received intraoperative cefalotin 12-139 days later without adverse events. CONCLUSIONS: A negative intradermal cefalotin skin test has a good negative predictive value in patients who have previously suffered anaphylaxis to cefazolin, allowing the rational and desirable use of this alternative cephalosporin for future surgery and the avoidance of less desirable antimicrobial agents.

The association of PTPN22 rs2476601 with juvenile idiopathic arthritis is specific to females.

A preponderance of females develop autoimmune disease, including juvenile idiopathic arthritis (JIA), yet the reason for this bias remains elusive. Evidence suggests that genetic risk of disease may be influenced by sex. PTPN22 rs2476601 is associated with JIA and numerous other autoimmune diseases, and has been reported to show female-specific association with type 1 diabetes. We performed main effect and sex-stratified association analyses to determine whether a sex-specific association exists in JIA. As expected, rs2476601 was associated with JIA in our discovery (413 cases and 690 controls) and replication (1008 cases and 9284 controls) samples. Discovery sample sex-stratified analyses demonstrated an association specifically in females (odds ratio (OR)=2.35, 95% confidence interval (CI)=1.52-3.63, P=0.00011) but not males (OR=0.91, 95% CI=0.52-1.60, P=0.75). This was similarly observed in the replication sample. There was evidence for genotype-by-sex interaction (Pinteraction=0.009). The association between rs2476601 and JIA appears restricted to females, partly accounting for the predominance of females with this disease.

Efficacy of sugammadex in rocuronium-induced or antibiotic-induced anaphylaxis. A case-control study.

We report 13 cases of presumed rocuronium-induced anaphylaxis in which sugammadex was administered with the intention of reversing the immunological reaction. Of these 13 cases, eight (62%) were later confirmed to be type-1 hypersensitivity reactions to rocuronium, three (23%) were triggered by an antibiotic and two (15%) were non-immunologically mediated. Response to treatment was scored by the treating anaesthetist, and compared with haemodynamic and inotrope measurements from the resuscitation and anaesthetic records. Haemodynamic improvement was seen in only six (46%) cases, three of which were associated with a non-rocuronium trigger. Of the three cases in which the treating anaesthetist thought that sugammadex had been beneficial, one was not caused by rocuronium, one had no improvement in blood pressure and one required 8.5 times as much adrenaline in boluses after, compared with the period before, sugammadex administration. These data suggest that sugammadex does not modify the clinical course of a suspected hypersensitivity reaction.

Survival from perioperative anaphylaxis in Western Australia 2000-2009.

BACKGROUND: The mortality from perioperative anaphylaxis has recently been quoted in a range between 3 and 9%. However, it was our impression in Western Australia that we had had no deaths from perioperative anaphylaxis for over a decade. As we have comprehensive processes in place to investigate both perioperative anaphylaxis and anaesthesia-related deaths, we undertook this study to determine our actual perioperative anaphylaxis mortality rate. METHODS: We obtained the number of deaths related to perioperative anaphylaxis for the decade 2000-2009 from the database of the West Australian Anaesthetic Mortality Committee; in Western Australia it is a legal requirement to report all deaths that occur within 48 h of an anaesthetic, and all deaths due to a complication of an anaesthetic. We obtained the number of cases of perioperative anaphylaxis for the same period from the database of the West Australian Anaesthetic Drug Reaction Clinic. RESULTS: From 2000 to 2009, there were 45 anaesthesia-related deaths in Western Australia, but none of these involved anaphylaxis. Over this period, there were 264 cases classified by the West Australian Anaesthetic Drug Reaction Clinic as anaphylaxis. The 95% confidence interval for the observed 0/264 mortality rate is 0-1.4%. There were about three million anaesthetics administered in Western Australia over the decade, giving a perioperative anaphylaxis rate of ~1:11,000. CONCLUSIONS: Our incidence of perioperative anaphylaxis was within expectations, but our mortality rate was lower than recently quoted figures. It is likely that the current true perioperative anaphylaxis mortality rate is within the range 0-1.4%.

Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011.

BACKGROUND: Neuromuscular blocking drugs (NMBDs) are the most common cause of intraoperative anaphylaxis in Western Australia. Differences in the rates of anaphylaxis between individual agents have been surmised in the past, but not proven, and are an important consideration if agents are otherwise equivalent. METHODS: We estimated a rate of anaphylaxis to NMBDs by analysing cases of NMBD anaphylaxis referred to the only specialized diagnostic centre in Western Australia over a 10 yr period. Exposure was approximated by analysing a 5 yr period of NMBD ampoule sales data. Agents were also ranked according to the prevalence of cross-reactivity in patients with previous NMBD anaphylaxis. RESULTS: Rocuronium was responsible for 56% of cases of NMBD anaphylaxis, succinylcholine 21%, and vecuronium 11%. There was no difference in the severity of reactions for different NMBDs. Rocuronium had a higher rate of IgE-mediated anaphylaxis compared with vecuronium (8.0 vs 2.8 per 100,000 exposures; P=0.0013). The prevalence of cross-reactivity after NMBD anaphylaxis suggested that succinylcholine also has a high risk of triggering anaphylaxis. Cisatracurium had the lowest prevalence of cross-reactivity in patients with known anaphylaxis to rocuronium or vecuronium. CONCLUSIONS: Rocuronium has a higher rate of IgE-mediated anaphylaxis compared with vecuronium, a result that is statistically significant and clinically important. Cisatracurium had the lowest rate of cross-reactivity in patients who had previously suffered anaphylaxis to rocuronium or vecuronium.

The role of sugammadex in the development and modification of an allergic response to rocuronium: evidence from a cutaneous model.

The availability of sugammadex as a selective encapsulating agent for rocuronium has led to speculation that it may be useful in mitigating rocuronium-induced anaphylaxis. Off-label use of sugammadex for this indication has already been documented in case reports although there are theoretical objections to the likelihood of an allergen-binding agent's being able to attenuate the immunological cascade of anaphylaxis. Using a cutaneous model of anaphylaxis in rocuronium-sensitised patients, we were unable to demonstrate that sugammadex was effective in attenuating the type-1 hypersensitivity reaction after it has been triggered by rocuronium, but we were able to demonstrate that these patients are anergic to sugammadex-bound rocuronium. These findings demonstrate that a cyclodextrin can bind an allergen and exclude it from interacting with the immune system, and may potentially lead to novel applications in other allergic diseases. However, there is no evidence that sugammadex should be used for the treatment of rocuronium-induced anaphylaxis, and clinical management should follow established protocols.

Epinephrine (adrenaline) preventing recovery from intraoperative anaphylactic shock complicated by systolic anterior motion of the mitral valve with left ventricular outflow tract obstruction on transoesophageal echocardiography.

We describe a case of severe left ventricular outflow tract obstruction (LVOTO) with severe mitral incompetence due to systolic anterior motion of the anterior mitral leaflet (SAM) that was recognised thanks to the immediate availability of transoesophageal echocardiography during the resuscitation of anaphylactic shock. The patient rapidly responded to cessation of the epinephrine (adrenaline) infusion and intravascular volume expansion with intravenous crystalloid. The absence of risk factors for developing SAM/LVOTO serve as a warning to clinicians to consider this diagnosis in all cases of epinephrine non-responsive anaphylactic shock.

Association of juvenile idiopathic arthritis with PTPN22 rs2476601 is specific to females in a Greek population.

BACKGROUND: Juvenile idiopathic arthritis (JIA) is an autoimmune disease characterized by persistent chronic arthritis. Disease risk is believed to be influenced by both genetic and environmental factors. It is well established that the PTPN22 single nucleotide polymorphism (SNP) rs2476601 is associated with JIA susceptibility. It was recently reported in an Australian study that this association is restricted to females and is not observed in males. A significant source of inconsistency amongst the literature on autoimmune disease susceptibility genes stems from an inability to replicate genetic findings across different racial or ethnic groups. We therefore attempted to generate further evidence of the female-specific association of rs2476601 in a homogeneous Greek population. FINDINGS: We genotyped rs2476601 in 128 Caucasian JIA patients (70.3 % female) and 221 healthy controls (28.1 % female) from Northern Greece. Overall, PTPN22 was associated with increased risk of JIA in this Greek sample (OR = 2.3, 95 % CI 1.1 - 5.1, p = 0.038). Sex-stratified analyses showed that, once again, the risk association was restricted to females (Female: OR = 19.9, 95 % CI 1.2 - 342, p = 0.0016; Male: OR = 1.1, 95 % CI 0.3 - 3.1, p = 0.94) supporting the prior findings. CONCLUSIONS: Our data demonstrates that this sex-specific pattern of association is broadly applicable to different populations, and provides further impetus to undertake mechanistic studies to understand the impact of sex on PTPN22 in JIA.

Meningococcal septicaemia: treatment with protein C concentrate.

Meningococcal septicaemia is a devastating disease with the potential to develop severe vascular complications. The incidence in Northern Ireland has risen from 27 cases notified in 1992 to 56 notified in 1997. We describe the first use of protein C concentrate in addition to antithrombin III infusion in the management of a life-threatening case of meningococcal septicaemia in the Regional Intensive Care Unit, Royal Group of Hospitals, Belfast, UK. The rationale and the evidence to support the use of protein C concentrate are discussed. Despite the apparent efficacy and safety of this treatment, subsequent cases of meningococcal septicaemia have not received protein C concentrate due to a lack of availability.

Comparative cytotoxicity of purified Shiga-like toxin-IIe on porcine and bovine aortic endothelial and human colonic adenocarcinoma cells.

Porcine and bovine aortic endothelial cells and human colonic adenocarcinoma cells were compared for their susceptibility to the toxic effect of purified Shiga-like toxin IIe (SLT-IIe), measured by the neutral red cytotoxicity assay. Cytotoxicity correlated with toxin binding as indicated by fluorescence activated cell sorter analysis and with the globotriosylceramide (Gb3) and globotetraosylceramide (Gb4) content of cells determined by high pressure liquid chromatography. One line of porcine aortic endothelial cells was 1400-fold more susceptible than the line of bovine aortic endothelial cells that was tested, but a second line of porcine aortic endothelial cells was highly refractory to SLT-IIe. Human colonic adenocarcinoma cells lacked detectable levels of Gb4 and were least susceptible to SLT-IIe.

Individual and group antimicrobial usage rates on 34 farrow-to-finish swine farms in Ontario, Canada.

Antimicrobial drug-use was assessed on 34 farrow-to-finish operations that marketed at least 500 hogs/yr. These operations either did not use any antimicrobials or used narrow-spectrum or broad-spectrum antimicrobials in rations of post-weaning pigs. Total antimicrobial use was measured for two months after obtaining inventories and records of all antimicrobials used. The collection of empty medication bottles and inventories of drugs on hand was convenient for producers and useful for estimating or validating recorded treatment rates, particularly for antimicrobials that were used only in one class of pig. Treatment records, however, underestimated by approximately 35% the amounts used for 27/29 farm-antimicrobial combinations. Rates of individual-pig treatment varied from 0-24.1 pigs treated/1000 pig-days, with a median of 5.29. Most individual animal treatments were given to piglets and sows at parturition and penicillin was the most commonly used antimicrobial. Gentamicin was administered to suckling piglets on 19 of the farms.

Prevalences of resistance to seven antimicrobials among fecal Escherichia coli of swine on thirty-four farrow-to-finish farms in Ontario, Canada.

Fecal specimens were composited and a hydrophobic-grid membrane-filter method was used to measure antimicrobial resistance to ampicillin 16 micrograms/ml, carbadox 30 micrograms/ml, gentamicin 4 mu/ml, nitrofurantoin 32 micrograms/ml, spectinomycin 16 micrograms/ml, sulfisoxazole 32 micrograms/ml and tetracycline 8 micrograms/ml among 8119 Escherichia coli isolates from 68 fecal samples collected on 34 farrow-to-finish swine farms marketing over 500 hogs/yr. The overall prevalences of resistance to antimicrobials among these isolates were: ampicillin 29%, carbadox 3.5%, gentamicin 0.6%, nitrofurantoin 27%, spectinomycin 28%, sulfasoxizole 38% and tetracycline 71%. Thirty to seventy-six per cent of the variations in prevalences were explained by between-farm differences.

Associations among antimicrobial drug treatments and antimicrobial resistance of fecal Escherichia coli of swine on 34 farrow-to-finish farms in Ontario, Canada.

Logistic regression was used to model associations between antimicrobial treatment and resistance among fecal Escherichia coli of finisher pigs at the farm level. Four sets of potential risk factors representing different levels of refinement of antimicrobial use on farms were modelled on resistance to antimicrobials. Final models for each antimicrobial were constructed from treatment and management variables significant on initial screening, and corrections for overdispersion were made. In general, in-feed antimicrobial treatment of pigs was more consistently associated with an increased risk of resistance than individual-animal treatment. Antimicrobial treatment in starter rations was significant in final models of resistance to ampicillin, carbadox, nitrofurantoin, sulfisoxizole, and tetracycline. Treatment in grower-finisher rations was significantly associated with resistance to ampicillin, spectinomycin, sulfisoxizole, and tetracycline. There was little evidence that in-feed antimicrobials increased the risk of resistance to gentamicin, which is a drug used only for individual-pig treatment in this study population. These results suggest that antimicrobial medication of rations of post-weaning pigs selects for and maintains antimicrobial resistance among E. coli of finisher pigs. Although resistance was common on farms that did not medicate rations of post-weaning pigs, the results indicate that antimicrobial use does increase the risk of resistance to the antimicrobials studied.

Risk factors for infection with verocytotoxigenic Escherichia coli in cattle on Ontario dairy farms.

Risk factors for prevalent infection with verocytotoxigenic Escherichia coli (VTEC) were studied in a random sample of 886 cows and 592 calves under 3 months of age on 80 randomly selected dairy farms in southern Ontario. Fecal-culture supernatants from each animal were screened for verocytotoxicity using a Vero cell assay (VCA) and for verocytotoxin (VT) genes by a polymerase chain reaction (PCR) procedure. Up to 20 F. colt isolates from positive samples were tested for VT production using VCA and PCR. VTEC isolates were serotyped. Farm managers were interviewed using a standardized questionnaire to obtain information on farm- and individual animal-level management practices and characteristics. There was a significant (P < 0.001) positive association between age of calves and their VTEC infection status, and calves were significantly more likely to be infected than cows. The proportion of calves infected on the farm was positively associated with both the use of regular pails for feeding calves (as opposed to nipple bottles or nipple pails) and bringing new animals into the herd in the previous year.

Hemolysin phenotypes and genotypes of eaeA-positive and eaeA-negative bovine verotoxigenic Escherichia coli.

Intimin or EaeA protein has been implicated in the attaching/effacing lesion caused by entero-hemorrhagic Escherichia coli (EHEC) in the intestine but it is not produced by all EHEC and is therefore not adequate as a marker for EHEC. Hemolysins are produced by a high percentage of verotoxigenic E. coli (VTEC) and could be a marker for EHEC, but their distribution and relation to virulence are not known. We used PCR amplification to determine the presence or absence of eaeA sequences in 281 VTEC isolates from the feces of healthy cattle. There were 101 eaeA-positive isolates, which belonged to O groups 5, 26, 69, 80, 84, 98, 103, 111, 119, 145, 157 and 108 eaeA-negative isolates, which belonged to O groups 8, 22, 38, 113, 119, 116, 132, 153, 156 or untypable. All isolates were tested for hemolysis on horse blood agar and on washed sheep blood agar. PCR amplification was used to test for EHEC hemolysin, Ehly1, Ehly2 and alpha-hemolysin D sequences. Among eaeA-positive isolates 98% were positive for EHEC hemolysin sequences and were hemolytic on washed sheep red blood cell agar; the corresponding percentage for eaeA-negative isolates was 36%. Ehly1 and Ehly2 sequences were present in only 11 isolates (O groups 26, 84, 119 and 132). None of the eaeA-positive and 13 of the eaeA-negative isolates (including all 11 isolates of O group 132) were positive for alpha-hemolysin D gene sequences by PCR and alpha-hemolysin production on horse blood agar. We conclude that since Ehly1, Ehly2 and alpha-hemolysin occur at low frequency among bovine VTEC and serotypes implicated in human disease they are unlikely to be significant virulence factors. In contrast, EHEC hemolysin was present in almost all eaeA-positive VTEC isolates and in approximately one-third the eaeA-negative ones; it may be both a virulence marker and virulence factor but further testing is required. The study identified isolates with all combinations of eaeA and EHEC hly, which may be useful for further testing.

A descriptive study of verocytotoxigenic Escherichia coli (VTEC) cases reported in Ontario, 1990-1994.

Characteristics of VTEC cases identified through routine surveillance in Ontario between 1990 and 1994 are described. Information was extracted from the Reportable Disease Information System (RDIS) of Ontario and was evaluated for its completeness and internal validity. A total of 2,441 VTEC cases were identified for the five-year study period corresponding to an average annual rate of 4.8 cases per 100,000. Sixteen deaths were recorded. Bloody diarrhea was reported for 546 patients (40%) and was the most frequently reported symptom. For most cases, the home was recorded as the likely risk setting (36%). Food was incriminated as the source of infection for more than 36% of cases. Nine (69%) of the thirteen data fields compulsory for transmission to the Ontario Ministry of Health had less than 10% of combined missing and unspecified values. Fields describing risk factors had greater than 56% of entries missing or unspecified.