An overview of penicillin allergies for nurses.

ABSTRACT: Antibiotics are frequently reported as allergies by patients, particularly antibiotics from the penicillin family. Most of these reported allergies are benign, and the consequences of alternative therapies can be significant. This article provides background information on penicillin allergies and serves as a guide to penicillin allergy management.Reprinted with permission from Wrynn, A.F. An overview of penicillin allergies for nurses. Nurse Pract 2022; 47(9): 30-36. Copyright Wolters Kluwer. All rights reserved.

Penicillin allergies: A guide for NPs.

ABSTRACT: Antibiotics are frequently reported as allergies by patients, particularly antibiotics from the penicillin family. Most of these reported allergies are benign, and the consequences of alternative therapies can be significant. This article will deliver background information on penicillin allergies and serve as a guide to penicillin allergy management.

Susceptibility-guided therapy for Helicobacter pylori-infected penicillin-allergic patients: A prospective clinical trial of first-line and rescue therapies.

BACKGROUND: Helicobacter pylori (H pylori) treatment remains a challenge for penicillin-allergic patients. AIM: To evaluate the efficacy and tolerability of susceptibility-guided first-line and rescue treatment in H pylori-infected penicillin-allergic patients. METHODS: Consecutive H pylori-infected patients with penicillin allergy received a 14-day triple or quadruple therapy based on susceptibility to clarithromycin, levofloxacin, and metronidazole. All received esomeprazole 20 mg twice a day. Metronidazole-susceptible infections received metronidazole plus clarithromycin or levofloxacin triple therapy if susceptible. Clarithromycin- and levofloxacin-resistant infections received metronidazole plus tetracycline triple therapy. Metronidazole-resistant infections received a bismuth-high-dose metronidazole plus clarithromycin or levofloxacin quadruple therapy. Triple-resistant infections received classical bismuth quadruple therapy with high-dose metronidazole. Antimicrobial susceptibility was assessed using the E test method. RESULTS: 112 patients were entered (34.8% men, average 47.1 years). Infections in 83.8% (31/37) of treatment-naive subjects and 12.0% (9/75) (P < .001) receiving rescue treatment were susceptible to at least one of the three tested antibiotics. Overall, susceptibility-guided therapy achieved eradication rates of 92.9% (104/112, 95% CI 88.1%-97.7%) by intent-to-treat analysis and 99% (100/101, 95% CI 97.1%-100%) by per-protocol analysis. All regimens achieved eradication rates greater than 90% (P = .327) in the PP populations. Adverse events were relatively frequent; however, compliance remained high. CONCLUSION: Susceptibility-guided therapy proved highly effective for penicillin-allergic patients. When available and proven locally effective, the alternative was empiric classical bismuth quadruple therapy. This trial is registered with ClinicalTrials.gov as NCT03708848.

Controllable vitamin K deficiency under high-dose oral menatetrenone administration - a case report.

Vitamin (V) K deficiency may cause severe bleeding tendencies, which necessitates extreme caution. We report a case of a 30-year-old man diagnosed with VK deficiency of unknown etiology. He was treated with intravenous menatetrenone three times a week in an outpatient setting for about 1 year and 9 months. Eventually, he developed an allergic reaction to intravenous menatetrenone and was under steroid therapy. In order to reduce his hospital visits and discontinue steroid use, the pharmacist proposed to change the method of menatetrenone administration from intravenous to oral (high dose). The change in treatment method has greatly improved the patient's quality of life.

Use of Epinephrine in Patients with Drug-Induced Anaphylaxis: An Analysis of the Beijing Pharmacovigilance Database.

BACKGROUND: Few studies assessing the use of epinephrine in drug-induced anaphylaxis (DIA) in the hospital setting are available. We utilized the Beijing Pharmacovigilance Database (BPD) to evaluate the appropriateness of epinephrine for DIA management. METHODS: DIA cases collected in the BPD from January 2004 to December 2014 were adjudicated and analyzed for demographics, causative drugs, clinical signs, outcomes, initial treatment, route, dosing, and cardiovascular adverse events (CAE) of epinephrine. RESULTS: DIA was primarily caused by antibiotics (38.4%), radiocontrast agents (11.9%), traditional Chinese medicine injections (10.9%), and chemotherapeutic drugs (10.3%). Only 708 (59.5%) patients received epinephrine treatment. Patients who received epinephrine were more likely to experience wheezing (p < 0.001) and respiratory arrest (p < 0.001). Among 518 patients with a complete record of the epinephrine administration route, the percentage of patients receiving it by intramuscular (IM) injection, subcutaneous (SC) injection, intravenous (IV) bolus injection, or IV continuous infusion was 16.9, 31.5, 43.5, and 8.1%, respectively. Among the 427 patients with a record of both the administration route and the dosing, an overdose was more likely with IV bolus (94.1%) in contrast to IM injection (56.6%; p < 0.001) or SC injection (43.7%; p < 0.001). Among the patients analyzed for CAE (n = 349), 17 patients accounted for 19 CAE, and 13 (76.5%) of these patients were overdosed with epinephrine. CONCLUSION: Underuse, inappropriate IV bolus use, and overdosing were the 3 major problems with epinephrine use in DIA in China. Educational training for health care professionals on the appropriate use of epinephrine in managing anaphylactic reactions is suggested.

Lesiones purpúricas en manos / Purpura in hands

Presentamos el caso de un varón institucionalizado de 57 años, afectado por síndrome de Down, que presentó lesiones purpúricas en manos y extremidades inferiores tras administración de una dosis de amoxicilina-ácido clavulánico. Se sospechó una reacción de hipersensibilidad por fármacos, pero la reacción cutánea persistió tras la suspensión del antibiótico. Tras descartar otras etiologías, fue diagnosticado de escorbuto. El paciente fue tratado con suplementos de vitamina C, mostrando clara mejoría de las lesiones. El escorbuto no es un diagnóstico frecuente en la actualidad, sin embargo esta patología de otras épocas no ha desaparecido del todo. Se trata de una enfermedad que resulta fácil olvidar al plantearnos un diagnóstico diferencial y cuyo tratamiento con la suplementación vitamínica es simple y efectivo (AU)

We report the case of an institutionalized 57-year-old man affected by Down syndrome, with purpura in hands and lower extremities after the administration of a dose of amoxicillin-clavulanic acid. We suspected a drug hypersensitivity reaction but the skin reaction persisted after discontinuation of the antibiotic. After ruling out any other etiology, scurvy was diagnosed. The patient was treated with vitamin C supplements, showing a clear improvement. Scurvy is not a common diagnosis at the present time, but this disease from the past has not disappeared entirely. It can be easily overlooked in differential diagnosis, but vitamin supplementation is a simple and effective treatment (AU)

Potential cutaneous hypersensitivity reaction to an inactive ingredient of thyroid hormone supplements in a dog.

BACKGROUND: Although discussions about allergic reactions to thyroid supplements abound on professional forums, there is almost no information in the literature on these specific idiosyncratic drug reactions. ANIMAL: A dog with a history of hypothyroidism-associated weight gain and mild lethargy was prescribed levothyroxine tablets (0.018 mg/kg twice daily). After 19 days the dog developed a severe skin condition that was responsive to levothyroxine withdrawal, and antibiotic and glucocorticoid therapy. Three weeks later a different levothyroxine tablet was prescribed. Within 48 h the dog developed a more severe cutaneous reaction that resolved with drug discontinuation and appropriate topical care. OBJECTIVES: To confirm a possible hypersensitivity reaction and identify its chemical target. METHODS AND RESULTS: The two prescribed levothyroxine formulations shared two inactive ingredients: magnesium stearate and polyvinylpyrrolidone. Nine months after discontinuation of thyroid supplement, a formulation without either of these two compounds was used for a second re-challenge. There was no recurrence of the drug reaction and after 1.5 years of treatment the dog remains normal. CONCLUSIONS AND CLINICAL IMPORTANCE: These elements strongly suggest that this dog had an idiosyncratic reaction (likely immune-mediated) against one or both inactive ingredients in the first two formulations of levothyroxine. We are not aware of any previous confirmed delayed hypersensitivity to a thyroid supplement in a dog with the likely chemical trigger being an inactive ingredient rather than the therapeutic agent itself. We hope that this case will raise awareness about allergic reactions to thyroid supplements and allergic reactions to inactive formulation components.

Vitiligo induced by specific immunotherapy with grass pollen: the Koebner phenomenon

No disponible

Inhibition of Toll-like receptor-mediated inflammation in vitro and in vivo by a novel benzoxaborole.

Pro-inflammatory cytokines play a critical role in the development of autoimmune and inflammatory diseases. Targeting the cytokine environment has proven efficient for averting inflammation. In this study, we reported that 6-[4-(aminomethyl)-2-chlorophenoxyl]benzo[c][1,2]oxaborol-1(3H)-ol (AN3485), a benzoxaborole analog, inhibited TLR2-, TLR3-, TLR4-, and TLR5-mediated TNF-α, IL-1ß, and IL-6 release from human PBMCs and isolated monocytes with IC(50) values ranging from 18 to 580 nM, and the inhibition was mediated at the transcriptional level. Topical administration of AN3485 significantly reduced PMA-induced contact dermatitis and oxazolone-induced delayed-type hypersensitivity in mice, indicating its capability of penetrating skin and potential topical application in skin inflammation. Oral administration of AN3485 showed dose-dependent suppression of LPS-induced TNF-α and IL-6 production in mice with an ED(90) of 30 mg/kg. Oral AN3485, 35 mg/kg, twice a day, suppressed collagen-induced arthritis in mice over a 20-day period. The potent anti-inflammatory activity in in vitro and in vivo disease models makes AN3485 an attractive therapeutic lead for a variety of cutaneous and systemic inflammatory diseases.

Iron oxide particles modulate the ovalbumin-induced Th2 immune response in mice.

This study was designed to investigate the modulatory effects of submicron and nanosized iron oxide (Fe(2)O(3)) particles on the ovalbumin (OVA)-induced immune Th2 response in BALB/c mice. Particles were intratracheally administered four times to mice before and during the OVA sensitization period. For each particle type, three different doses, namely 4×100, 4×250 or 4×500 µg/mouse, were used and for each dose, four groups of mice, i.e. group saline solution (1), OVA (2), particles (3), and OVA plus particles (4), were constituted. Mice exposed to OVA alone exhibited an allergic Th2-dominated response with a consistent increase in inflammatory scores, eosinophil numbers, specific IgE levels and IL-4 production. When the mice were exposed to OVA and to high and intermediate doses of iron oxide submicron- or nanoparticles, the OVA-induced allergic response was significantly inhibited, as evidenced by the decrease in eosinophil cell influx and specific IgE levels. However, the low dose (4×100 µg) of submicron particles had no significant effect on the OVA allergic response while the same dose of nanoparticles had an adjuvant effect on the Th2 response to OVA. In conclusion, these data demonstrate that the pulmonary immune response to OVA is a sensitive target for intratracheally instilled particles. Depending on the particle dose and size, the allergic response was suppressed or enhanced.

Treatment of DIHS/DRESS syndrome with combined N-acetylcysteine, prednisone and valganciclovir--a hypothesis.

BACKGROUND: Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS) is a rare and severe adverse drug reaction with an associated mortality of 10-20%. Clinical worsening despite discontinuation of the culprit drug is considered a characteristic feature of DIHS/DRESS. Besides the early recognition of the syndrome and discontinuation of its causative drug, the mainstay of treatment is systemic corticosteroids. Nevertheless, treatment of severe DIHS/DRESS is not well defined, as corticosteroids may sometimes not be effective, and decreasing the dose may be associated with flaring of the disease. CASE REPORT: A 38-year-old woman with high fever, malaise, abdominal pain, rash, and elevated liver enzymes received immediate high-dose N-acetylcysteine, because acetaminophen hepatotoxicity was suspected. N-acetylcysteine administration was associated with a significant clinical improvement. However, within the next week DIHS/DRESS syndrome was diagnosed, which explained all the symptoms, and which was subsequently treated with prednisone and valganciclovir. CONCLUSIONS: New options necessary to improve treatment of severe DIHD/DRESS have to consider its sequential pathogenetic mechanisms. N-acetylcysteine might neutralize the drug-derived reactive metabolites, which are responsible for protein adduct formation and specific T cell stimulation, and replete the glutathione stores that counterbalance oxidative stress. Prednisone might inhibit lymphoproliferation and valganciclovir might prevent complications related to HHV-6 reactivation. We therefore propose the unprecedented combination of N-acetylcysteine, prednisone and valganciclovir as a treatment option for DIHS/DRESS.

High-dose dexamethasone plus antihistamine prevents colorectal cancer patients treated with modified FOLFOX6 from hypersensitivity reactions induced by oxaliplatin.

BACKGROUND: Oxaliplatin is a third-generation platinum compound and a key agent for the management of colorectal cancer. Patients treated with oxaliplatin are at risk for hypersensitivity reactions. We designed a modified premedication regimen to prevent oxaliplatin-related hypersensitivity reactions and assessed if this approach is effective. METHODS: A retrospective cohort study of patients with advanced colorectal cancer who received modified FOLFOX6 (mFOLFOX6) was performed. Patients received routine premedication with dexamethasone 8 mg and granisetron 3 mg for the first five cycles of mFOLFOX6. From the sixth cycle onward, cohort 1 received the same premedication, and cohort 2 received modified premedication (diphenhydramine 50 mg orally, followed by dexamethasone 20 mg, granisetron 3 mg, and famotidine 20 mg). We compared the incidence of hypersensitivity reactions, duration of treatment, and reasons for treatment withdrawal between the two cohorts. RESULTS: A total of 181 patients were studied (cohort 1, 81; cohort 2, 100). Hypersensitivity reactions developed in 16 patients (20%) in cohort 1 and 7 (7.0%) in cohort 2 (P = 0.0153). The median number of cycles increased from 9 in cohort 1 to 12 in cohort 2. Apart from progressive disease, neurotoxicity was the reason for discontinuing treatment in 20% of the patients in cohort 1, as compared with 53% in cohort 2. CONCLUSION: Increased doses of dexamethasone and antihistamine significantly reduced oxaliplatin-related hypersensitivity reactions. This effective approach should be considered for all patients who receive FOLFOX, allowing treatment to be completed as planned.

Anaphylactic reactions to local anesthetics.

Local anesthetics (LA) are common elicitors of adverse reactions and the clinical symptoms often correspond to anaphylaxis with tachycardia, hypotension and subjective feelings of weakness, heat or vertigo. The pathomechanism of immediate hypersensitivity reactions to LA is largely unknown -they are commonly regarded as 'pseudo-allergic' or 'non-immune type' anaphylaxis. Immunologically mediated reactions have rarely been observed with positive skin prick tests. Other ingredients in LA preparations have to be considered as elicitors, e.g. preservatives like benzoates or sulfites or latex contaminants in injection bottles. Practical management of patients with a history of LA reaction includes a careful allergy history, skin-prick and intradermal tests. Undiluted LA solutions may elicit false-positive intradermal test reactions. If prick and intradermal tests are negative, the procedure of subcutaneous provocation testing is applied in a placebo-controlled manner. When patients are constantly reacting to placebo, a regimen of 'reverse placebo provocation' with injection of a LA (verum) is applied while the patient is informed about receiving placebo in order to 'rule out psychosomatic involvement'. With this regimen it is possible to eliminate anxiousness and fear, and the patient has proof that he has tolerated the respective LA substance.

Manejo analgésico y anestésico en la mastocitosis sistémica: a propósito de un caso / Analgesic and anesthetic management in systemic mastocytosis: a case report

Las mastocitosis son un grupo heterogéneo de enfermedades que se caracterizan por la proliferación de mastocitos en uno o más órganos o tejidos. Se denomina mastocitosis sistémica (MS) cuando hay afectación de un tejido distinto a la piel. La MS es una enfermedad poco frecuente, cuya incidencia y prevalencia se desconocen. El manejo anestésico de estos pacientes debe considerar que muchos de los fármacos empleados pueden causar una liberación masiva de mediadores químicos mastocitarios. Se presenta el caso de una mujer con MS programada para una histerectomía total, valorando la importancia del correcto estudio preoperatorio así como la técnica anestésica y el tipo de analgesia elegida en este caso. Se presenta nuestro protocolo de actuación de cara a la cirugía en estos pacientes(AU)

Mastocytoses are a heterogeneous group of entities characterized by mast cell proliferation in one or more organs or tissues. When tissues other than the skin are involved, the disease is called systemic mastocytosis (SM). SM is a highly infrequent disease, whose incidence and prevalence are unknown. The anesthetic management of these patients must consider the fact that many drugs can trigger massive release of chemical mediators of mast cells. We report the case of a patient diagnosed with SM who underwent total hysterectomy and discuss the importance of thorough preoperative study, as well as the anesthetic technique and type of analgesia chosen. We also report our protocol for anesthetic management in this disease(AU)

Oxaliplatin-induced allergic reaction in patients with colorectal cancer in Japan.

BACKGROUND: Oxaliplatin is a platinum compound that is clinically effective for colorectal cancer (CRC), in combination with 5-fluorouracil (5-FU) and leucovorin (LV), and it is widely used for metastatic disease and for the adjuvant treatment of stage III CRC. With the increasing use of oxaliplatin in Japan, serious adverse events have been experienced other than hematologic and neurologic toxicities. METHODS: In order to clarify the clinical features of allergic reactions to oxaliplatin, we retrospectively investigated CRC patients who had received oxaliplatin-based chemotherapies. RESULTS: One hundred and twenty-five CRC patients who had been treated with FOLFOX regimens (containing oxaliplatin, 5-FU, and LV) were examined, and 21 patients (17%) were found to have developed allergic reactions. Sixteen patients (13%) had grade 1/2 adverse events, classified according to the common terminology criteria for adverse events (CTC-AE) version 3.0 and 5 (4%) had grade 3/4 adverse events. The allergic reaction appeared after a median number of nine cycles (range, 2-15 cycles). Previous chemotherapy included 5-FU/LV, CPT-11, and S-1. All of the patients with allergic reactions recovered completely when treated with antiallergy drugs. Oxaliplatin was reintroduced in 11 patients, with the use of prophylactic agents; allergic reaction to the reintroduction was not observed in 8 patients and grade 1/2 allergic reactions developed in 3 patients. No correlation was identified between allergic reaction and patients' background characteristics such as sex, history of allergy, and profile of other adverse events. CONCLUSION: Allergic reactions to oxaliplatin remain an important issue for patients being able to safely continue effective chemotherapies; further analysis will be needed to establish methods for the prediction and prophylaxis of such reactions.

Biotin status affects nickel allergy via regulation of interleukin-1beta production in mice.

Biotin, a water-soluble B complex vitamin, is possibly involved in chronic inflammatory diseases, although the detailed mechanisms are unclear. In this study, we investigated the effects of biotin status on nickel (Ni) allergy in mice. Mice were fed a basal or biotin-deficient (BD) diet for 8 wk and sensitized with an intraperitoneal injection of NiCl(2) and lipopolysaccharide. Ten days after sensitization, NiCl(2) was intradermally injected into pinnas and ear swelling was measured. For in vitro analysis, we cultured a murine macrophage cell line, J774.1, under a biotin-sufficient (C, meaning control) or BD condition for 4 wk and analyzed interleukin (IL)-1 production. Significantly higher ear swelling was induced in BD mice than C mice. Adaptive transfer of splenocytes from both C and BD mice induced Ni allergy in unsensitized mice. Regardless of donor mice, ear swelling was significantly higher in BD recipient mice than C recipient mice. Ni allergy was not induced in either C or BD IL-1(-/-) mice. Splenocytes from BD mice produced a significantly higher amount of IL-1beta than those from C mice. Production and mRNA expression of IL-1beta were significantly higher in BD J774.1 cells than in C cells. Biotin supplementation inhibited the augmentation of IL-1beta production in vitro. In vivo supplementation of biotin in drinking water dose-dependently decreased ear swelling in C and BD mice. These results indicate that biotin status affects Ni allergy in the elicitation phase via the upregulation of IL-1beta production in mice, suggesting that biotin supplementation may have therapeutic effects on human metal allergy.

Control of salicylate intolerance with fish oils.

We report three patients with disabling salicylate-induced intolerance who experienced abrogation of symptoms following dietary supplementation with omega-3 polyunsaturated fatty acids (PUFAs). All three patients experienced severe urticaria, asthma requiring systemic steroid therapy and anaphylactic reactions. After dietary supplementation with 10 g daily of fish oils rich in omega-3 PUFAs for 6-8 weeks all three experienced complete or virtually complete resolution of symptoms allowing discontinuation of systemic corticosteroid therapy. Symptoms relapsed after dose reduction. Fish oil appears a safe and effective treatment for this difficult and often serious condition.

Estrategias para optimizar el tratamiento con efalizumab / Strategies to improve treatment with efalizumab

Con el objetivo de optimizar los resultados clínicos de efalizumab y garantizar su empleo bajo criterios de seguridad resulta fundamental adquirir una cierta sistemática en su manejo. De forma previa a proponer y prescribir el tratamiento, el dermatólogo deberá cerciorarse de que el paciente cumple los requisitos para poder iniciarlo y de que, por otro lado, no presenta ninguna contraindicación grave que pueda comprometer su seguridad a corto o largo plazo. Durante el curso del tratamiento deberán establecerse unas pautas de seguimiento que permitan tanto contrastarla evolución del paciente con respecto a las perspectivas generales de efalizumab como monitorizar y manejarlos efectos adversos más habituales asociados a su empleo. Finalmente, será adecuado familiarizarse con la evolución natural de la enfermedad una vez suspendido el tratamiento en aquellos casos en los que esta actuación decida o deba tomarse (AU)

It is essential to improve the clinical results of efalizumab and to assure that it is used under safety criteria in order to obtain a systemic management of the treatment. Prior to proposing and prescribing the treatment, the dermatologist should make sure that the patient fulfills pills the requirements to be able to initiate it and that, on the other hand, there is no serious contraindication that may affect its short-to-long term safety. During the course of the treatment, some follow-up guidelines should be established that will make it possible to compare the evolution of the patient with the general perspectives of efalizumab as well as to monitor and manage the most common adverse effects associated to its use. Finally, it would be convenient to become familiar with the natural course of the disease once the treatment is discontinued in those cases in which this action is decided or should be carried out (AU)