Management of Patients with Suspected or Confirmed Antibiotic Allergy: Executive Summary of Guidelines from the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Allergy and Clinical Immunology (SEAIC), the Spanish Society of Hospital Pharmacy (SEFH) and the Spanish Society of Intensive Medicine and Coronary Care Units (SEMICYUC).

Suspected or confirmed antibiotic allergy is a frequent clinical circumstance that influences antimicrobial prescription and often leads to the avoidable use of less efficacious and/or more toxic or costly drugs than first-line antimicrobials. Optimizing antimicrobial therapy in patients with antibiotic allergy labels has become one of the priorities of antimicrobial stewardship programs in several countries. These guidelines aim to make recommendations for the systematic approach to patients with suspected or confirmed antibiotic allergy based on current evidence. An expert panel (11 members of various scientific societies) formulated questions about the management of patients with suspected or confirmed antibiotic allergy. A systematic literature review was performed by a medical librarian. The questions were distributed among panel members who selected the most relevant references, summarized the evidence, and formulated graded recommendations when possible. The answers to all the questions were finally reviewed by all panel members. A systematic approach to patients with suspected or confirmed antibiotic allergy was recommended to improve antibiotic selection and, consequently, clinical outcomes. A clinically oriented, 3-category risk-stratification strategy was recommended for patients with suspected antibiotic allergy. Complementary assessments should consider both clinical risk category and preferred antibiotic agent. Empirical therapy recommendations for the most relevant clinical syndromes in patients with suspected or confirmed ß-lactam allergy were formulated, as were recommendations on the implementation and monitoring of the impact of the guidelines. Antimicrobial stewardship programs and allergists should design and implement activities that facilitate the most appropriate use of antibiotics in these patients.

Management of Patients with Suspected or Confirmed Antibiotic Allergy: Executive Summary of Guidelines from the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Allergy and Clinical Immunology (SEAIC), the Spanish Society of Hospital Pharmacy (SEFH) and the Spanish Society of Intensive Medicine and Coronary Care Units (SEMICYUC)

Suspected or confirmed antibiotic allergy is a frequent clinical circumstance that influences antimicrobial prescription and often leads to the avoidable use of less efficacious and/or more toxic or costly drugs than first-line antimicrobials. Optimizing antimicrobial therapy in patients with antibiotic allergy labels has become one of the priorities of antimicrobial stewardship programs in several countries. These guidelines aim to make recommendations for the systematic approach to patients with suspected or confirmed antibiotic allergy based on current evidence. An expert panel (11 members of various scientific societies) formulated questions about the management of patients with suspected or confirmed antibiotic allergy. A systematic literature review was performed by a medical librarian. The questions were distributed among panel members who selected the most relevant references, summarized the evidence, and formulated graded recommendations when possible. The answers to all the questions were finally reviewed by all panel members. A systematic approach to patients with suspected or confirmed antibiotic allergy was recommended to improve antibiotic selection and, consequently, clinical outcomes. A clinically oriented, 3-category risk-stratification strategy was recommended for patients with suspected antibiotic allergy. Complementary assessments should consider both clinical risk category and preferred antibiotic agent. Empirical therapy recommendations for the most relevant clinical syndromes in patients with suspected or confirmed ß-lactam allergy were formulated, as were recommendations on the implementation and monitoring of the impact of the guidelines. Antimicrobial stewardship programs and allergists should design and implement activities that facilitate the most appropriate use of antibiotics in these patients (AU)

En la práctica clínica, un antecedente de alergia a los antibióticos, confirmada o sospechada, es frecuente y condiciona la selección de antibióticos, requiriendo con frecuencia el uso de fármacos menos eficaces, más tóxicos o más caros que los antibióticos de primera línea. La optimización del uso de antibióticos en pacientes con este antecedente es una de las prioridades de los programas de optimización de uso de antibióticos (PROA) en varios países. Estas guías pretenden formular recomendaciones para evaluar de una manera sistemática a estos pacientes mediante una aproximación basada en la evidencia. Un panel multidisciplinar constituido por alergólogos, infectólogos, farmacéuticos hospitalarios e intensivistas formularon una serie de preguntas sobre el manejo de estos pacientes; una documentalista realizó la revisión bibliográfica. Las preguntas se distribuyeron entre los miembros del grupo de trabajo, quienes seleccionaron las referencias más relevantes y formularon las correspondientes recomendaciones, que fueron revisadas y aprobadas por todos los miembros del grupo. Es necesaria una aproximación sistemática a los pacientes con antecedentes de alergia a antibióticos para optimizar la selección del tratamiento antibiótico y mejorar los resultados clínicos de estos pacientes cuando precisan antibioterapia. El presente documento recomienda una estrategia de estratificación clínica del riesgo en 3 categorías. La recomendación de realizar evaluaciones complementarias se basa en el riesgo clínico y el antibiótico de primera línea necesario. Además, se formulan recomendaciones de tratamiento antibiótico empírico para los principales síndromes infecciosos en pacientes con alergia confirmada o sospechada. Finalmente, se formulan recomendaciones sobre la implementación y monitorización del impacto de las recomendaciones de la guía (AU)

Serie de 12 casos de alergia al trigo dependiente de ejercicio físico en Aragón, España / Series of 12 cases of wheat-dependent exercise-induced allergy in Aragon, Spain

Antecedentes y objetivo: La omega-5 gliadina (omega5G) se considera el alérgeno principal en la anafilaxia inducida por ejercicio dependiente del trigo (WDEIA). Estos pacientes presentan reacciones anafilácticas tras la ingesta de trigo y la realización de ejercicio físico. El objetivo de nuestro estudio es describir las principales características de 12pacientes con este diagnóstico. Materiales y métodos: Estudio descriptivo, retrospectivo, mediante revisión de historias clínicas de 12pacientes diagnosticados de hipersensibilidad a omega5G. Resultados: La edad media fue 37 años, el 50% varones y el 50% mujeres. La mayoría tenía antecedente de episodios similares sin estudiar. El tiempo de latencia variaba desde inmediato hasta 150 min. La clínica más frecuente fue la urticaria (83%), seguida de broncoespasmo (58%), angioedema (42%), hipotensión (25%) y síntomas gastrointestinales (16%). El cofactor más implicado fue el ejercicio físico. El estudio alergológico se realizó con prick test y determinación de IgE total y específicas. Conclusiones: La WDEIA es una forma de alergia alimentaria relativamente rara pero potencialmente grave, por lo que es importante su conocimiento para poder llegar a un correcto diagnóstico

Background and objectives: The omega-5 gliadin (omega5G) is considered the main allergen in wheat-dependent exercise-induced anaphylaxis (WDEIA). These patients experience anaphylactic reactions after consuming wheat and performing physical exercise. The aim of our study was to describe the main characteristics of 12 patients with this diagnosis. Material and methods: A descriptive, retrospective study was conducted by reviewing the medical records of 12 patients diagnosed with omega-5G hypersensitivity. Results: The patients' mean age was 37 years, with 50% men and 50% women. Most of the patients had a history of similar unexamined episodes. The latency period varied from immediate to 150min. The most common symptoms were urticaria (83%), bronchospasms (58%), angio-oedema (42%), hypotension (25%) and gastrointestinal symptoms (16%). The most often involved cofactor was physical exercise. The allergy study was conducted with prick tests and total and specific IgE readings. Conclusions: WDEIA is a relatively rare but potentially severe food allergy. Understanding this allergy is therefore important for a correct diagnosis

Series of 12 cases of wheat-dependent exercise-induced allergy in Aragon, Spain. / Serie de 12 casos de alergia al trigo dependiente de ejercicio físico en Aragón, España.

BACKGROUND AND OBJECTIVES: The ω-5 gliadin (ω5G) is considered the main allergen in wheat-dependent exercise-induced anaphylaxis (WDEIA). These patients experience anaphylactic reactions after consuming wheat and performing physical exercise. The aim of our study was to describe the main characteristics of 12 patients with this diagnosis. MATERIAL AND METHODS: A descriptive, retrospective study was conducted by reviewing the medical records of 12 patients diagnosed with ω-5G hypersensitivity. RESULTS: The patients' mean age was 37 years, with 50% men and 50% women. Most of the patients had a history of similar unexamined episodes. The latency period varied from immediate to 150min. The most common symptoms were urticaria (83%), bronchospasms (58%), angio-oedema (42%), hypotension (25%) and gastrointestinal symptoms (16%). The most often involved cofactor was physical exercise. The allergy study was conducted with prick tests and total and specific IgE readings. CONCLUSIONS: WDEIA is a relatively rare but potentially severe food allergy. Understanding this allergy is therefore important for a correct diagnosis.

Síndrome coronario agudo y anafilaxia / Acute coronary syndrome and anafilaxia

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Fixed drug eruption due to lorazepam

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Study of cross-reactivity between proton pump inhibitors.

Several studies have demonstrated different cross-reactivity patterns between proton pump inhibitors (PPIs). The aim of this study was to investigate cross-reactivity between commercially available PPIs and establish a procedure for performing cutaneous tests for verifying PPI allergy. We performed skin prick and intradermal tests with all commercially available PPIs in 5 patients with clinical allergy to omeprazole and observed positive results in all patients. We report 5 cases of immunoglobulin (Ig) E-mediated allergy to omeprazole and document cross-reactivity by skin testing between all the PPIs studied. We also found that the probability of confirming an IgE-mediated mechanism with skin tests decreases with time. Finally, we propose a hypothesis that could explain the different PPI cross-reactivity patterns reported.

Alergología e Inmunología Clínica: final de una etapa / Allergology and Clinical Immunological: the end of a phase

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[Prevalence of tobacco dependency and its prevention in patients with persistent asthma]. / Prevalencia del tabaquismo y prevención en pacientes con asma persistente.

OBJECTIVES: To analyse in patients with persistent bronchial asthma the prevalence of tobacco dependency and its degree; and to assess measures of prevention. DESIGN: Cross-sectional, descriptive study. SETTING: Allergy Service of the Lozano Blesa University Hospital, Zaragoza, Spain. PARTICIPANTS: A total of 121 patients, from systematic selection of asthmatics attending for consultation. MAIN MEASUREMENTS: Questionnaire filled out in the consulting room, recording social, demographic and clinical variables. RESULTS: A sample of 121 patients was obtained, 62.7% women and 37.3% men. They had 5.87 +/- 4.99 years mean evolution of asthma. 21.5% were daily smokers, 4.1% occasional smokers, 27.3% ex-smokers, and 47.1% non-smokers. The ages of starting to smoke were < 10 years old, 1.7%; 10-15, 30%; 15-20, 56.7%; 20-25, 6.7%, and > 25, 5% (P > .05). There were significant differences between gender and tobacco dependency and between age and tobacco dependency (P < .01 and P < .014, respectively). 96.8% of smokers thought that tobacco was harmful to their health. This figure was 100% in daily smokers and 80% in occasional smokers (P < .02). 83.9% of smokers had the intention of giving up. Counselling to give up was received from the specialist (41.9%), the primary care doctor (12.9%), and both (9.7% of cases). 35.5% received no counselling. CONCLUSIONS: The prevalence of tobacco dependency in patients with persistent asthma is lower than in the population as a whole; over a third receive no counselling about giving up. Interventions must be conducted in still healthy smokers and chronically ill patients in both primary and specialist care.

La investigación en Alergología en España y su proyección internacional. Análisis cuantitativo y cualitativo / Allergology research in Spain and its international projection: quantitative and qualitative analysis

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Intestinal anisakiasis mimicking intestinal obstruction.

We report one case of acute abdomen after the ingestion of raw or undercooked fish containing nematode larvae of the genus Anisakis. Early diagnosis is very important as it could prevent unnecessary surgical procedures since the symptoms of intestinal anisakiasis may mimic other illnesses such as appendicitis, ileitis or peritonitis. We suggest that anisakiasis should be considered in the differential diagnosis of patients with acute abdomen.

Anisakis, anisakiasis and IgE-mediated immunity to Anisakis simplex.

Anisakis simplex is a common parasite in fish and cephalopods and is not only capable of causing anisakiasis in humans through visceral invasion of the third-stage larvae but can also cause anaphylactic reactions, as has recently been demonstrated. We present the clinical case of a 56-year-old man who initially presented anaphylactic reactions related to eating fish. Shortly afterwards, he began to experience self-limiting recurrences of very intense epigastric pain, nausea and vomiting. Skin tests for immediate hypersensitivity (prick tests) with a commercial extract as well as the determination of specific IgE in the patient's serum were clearly positive for A. simplex. The hemogram did not show eosinophilia. Copro-cultures and parasites in the patient's feces were repeatedly negative. Gastroscopy was normal. The intestinal tract showed contrast flocculation and dilation of ansas in the distal duodenum and proximal jejunum. Biopsy samples of gastric and distal duodenum mucous showed an active process of chronic inflammation with a predominance of eosinophils in the lamina propria. After subjecting the patient to a fish and cephalopod-free diet and treating him with thiabendazole 350 mg every 12 hours for 6 days, he showed no sign of symptoms while awaiting new tests. Even though the diagnosis of IgE-mediated allergy caused by A. simplex offers no room for doubt, we are unable to present a firm diagnosis of anisakiasis as no larva has been seen. Nevertheless, the clinical pattern, the image of the intestinal tract, the eosinophilic infiltrate in the biopsies and the good response to thiabendazole all lead to the suspected existence of anisakiasis in this patient coexisting with IgE-mediated allergy to this parasite.

[The usefulness of theophylline in the treatment of moderate-severe asthma]. / Utilidad de la teofilina en el tratamiento del asma moderada-severa.

Theophylline has shown itself to be a useful bronchodilator in the treatment of asthma, although its use has been restricted of late due to its lesser potency and greater side effects when compared with beta-adrenergic inhalants. The objective of our study is to evaluate its clinical effectiveness in moderately severe asthma. We study 12 patients with stable chronic asthma on whom a spirometry in basal conditions was performed and after therapeutic levels of theophyllinemia were reached. Peak flow and clinical symptomatology were monitored during one-week periods in both phases of the study. Daytime and night-time symptoms were evaluated independently. No significant changes were observed in the spirometric values. No changes were observed in the bronchodilation test, the concomitant consumption of bronchodilators, or in the maximum expiratory fluids. However, significant differences were observed in the overall computation of symptoms and in the quantification of nocturnal symptoms. We conclude that retarded theophylline presents little usefulness in the treatment of asthma, even though its use can be recommended as symptomatic treatment of nocturnal asthma given its prolonged bronchodilating effect.

[Persistence of nonspecific bronchial hyperreactivity in children with non-IgE dependent bronchial asthma: pharmacologic study with the Carbachol test]. / Persistencia de la hiperreactividad bronquial inespecífica en niños con asma bronquial no IgE dependientes: estudio farmacológico mediante test de carbacol.

The authors revise their preliminary experiment with the bronchial provocation test using carbachol in 50 children of 5 to 14 years with non-IgE dependent bronchial asthma who had been asymptomatic for one year prior to the test in order to make a clinical evaluation of asthma. The observe the evolution of the non-specific bronchial hyperreactivity (NSBH) with respect to the clinical remission and determine whether the persistence of NSBH is correlated to certain clinical, epidemiological and analytical parameters (peripheral eosinophilia, total IgE). In 22 children (44%) the functional respiratory examination was normal throughout each phase of the test. In the other 56%, the functional respiratory study using carbachol showed exhalation reductions which suggested NSBH. The most significant parameters were the reductions in FEV1, PEF (p less than 0.001) and FMEF (p = 0.001). Thus the patients revealing NSBH in the carbachol test are characterised for having revealed acute asthma of higher intensity, more often associated with an acute respiratory infection and with lower values of total IgE (p less than 0.05) with respect to the group without NSBH in the carbachol test.

Long-term modification on histamine-induced bronchoconstriction by disodium cromoglycate and ketotifen versus placebo.

In order to compare long-term changes induced on a wide spectrum of bronchial hyperreactivity (BH) by the antiallergic drugs disodium cromoglycate (DSCG) and ketotifen, 56 asthmatic patients (age range 15-55 years) were studied. Patients were allocated to three groups with similar age and BH level. During 2 months, 15 individuals inhaled 20 mg DSCG four times a day, 14 took ketotifen 1 mg twice a day orally and 14 one placebo (lactose) capsule twice a day. After preliminary results, an additional group of 13 patients took clemastine 1 mg orally twice a day for 1 week. Only the ketotifen and clemastine groups differed significantly from the placebo group on shifting log dose-response curves of inhaled histamine. In addition, no significant difference was seen between the ketotifen and clemastine groups. These results suggest that changes induced by ketotifen were mainly related to its powerful antihistamine action; similarly, nonspecific BH is not wholly dependent on mediator release.