Documenting Penicillin Allergy: The Impact of Inconsistency

Background

Allergy documentation is frequently inconsistent and incomplete. The impact of this variability on subsequent treatment is not well described.

Objective

To determine how allergy documentation affects subsequent antibiotic choice.

Design

Retrospective, cohort study.

Participants

232,616 adult patients seen by 199 primary care providers (PCPs) between January 1, 2009 and January 1, 2014 at an academic medical system.

Main Measures

Inter-physician variation in beta-lactam allergy documentation; antibiotic treatment following beta-lactam allergy documentation.

Key Results

15.6% of patients had a reported beta-lactam allergy. Of those patients, 39.8% had a specific allergen identified and 22.7% had allergic reaction characteristics documented. Variation between PCPs was greater than would be expected by chance (all p<0.001) in the percentage of their patients with a documented beta-lactam allergy (7.9% to 24.8%), identification of a specific allergen (e.g. amoxicillin as opposed to “penicillins”) (24.0% to 58.2%) and documentation of the reaction characteristics (5.4% to 51.9%). After beta-lactam allergy documentation, patients were less likely to receive penicillins (Relative Risk [RR] 0.16 [95% Confidence Interval: 0.15–0.17]) and cephalosporins (RR 0.28 [95% CI 0.27–0.30]) and more likely to receive fluoroquinolones (RR 1.5 [95% CI 1.5–1.6]), clindamycin (RR 3.8 [95% CI 3.6–4.0]) and vancomycin (RR 5.0 [95% CI 4.3–5.8]). Among patients with beta-lactam allergy, rechallenge was more likely when a specific allergen was identified (RR 1.6 [95% CI 1.5–1.8]) and when reaction characteristics were documented (RR 2.0 [95% CI 1.8–2.2]).

Conclusions

Provider documentation of beta-lactam allergy is highly variable, and details of the allergy are infrequently documented. Classification of a patient as beta-lactam allergic and incomplete documentation regarding the details of the allergy lead to beta-lactam avoidance and use of other antimicrobial agents, behaviors that may adversely impact care quality and cost.     

Detection of allergy to antibiotics in dermatology--venereology practice

A total of 205 stationary patients with and without drug disease were examined with the purpose of diagnosing allergy to the widely used antibiotics. The reaction of leucocytosis was used in the studies and the antibiotic concentration was increased up to 1 gamma/ml. Sufficiently high specificity of the reaction for diagnosis of the medicamentous allergy was determined. Increased sensitivity was most frequent to penicillins. Participation of biologically active substances, such as heparin and histamine in exacerbation reaction in syphilitic patients treated with penicillin was found. The most pronounced increase in the levels of these substances in the blood of the patients was observed 6 hours after the beginning of the treatment without any connection without any connection with the clinical signs of the exacerbation reaction.     

Toll-like receptor 4 signaling by intestinal microbes influences susceptibility to food allergy

The mechanisms by which signaling by the innate immune system controls susceptibility to allergy are poorly understood. In this report, we show that intragastric administration of a food allergen with a mucosal adjuvant induces allergen-specific IgE, elevated plasma histamine levels, and anaphylactic symptoms in three different strains of mice lacking a functional receptor for bacterial LPS (Toll-like receptor 4 (TLR4)), but not in MHC-matched or congenic controls. Susceptibility to allergy correlates with a Th2-biased cytokine response in both the mucosal (mesenteric lymph node and Peyer's patch) and systemic (spleen) tissues of TLR4-mutant or -deficient mice. TLR4-mutant mice are not inherently impaired in their ability to regulate Th1 cytokine production because they respond to stimulation via TLR9. Coadministration of CpG oligodeoxynucleotides during sensitization of TLR4-mutant mice with allergen plus CT abrogates anaphylactic symptoms and Ag-specific IgE, and results in a Th1-polarized cytokine response. When the composition of the bacterial flora is reduced and altered by antibiotic administration (beginning at 2 wk of age), TLR4 wild-type mice become as susceptible to the induction of allergy as their TLR4-mutant counterparts. Both allergen-specific IgE and Th2 cytokine responses are reduced in antibiotic-treated mice in which the flora has been allowed to repopulate. Taken together, our results suggest that TLR4-dependent signals provided by the intestinal commensal flora inhibit the development of allergic responses to food Ags.     

微波热凝治疗变应性鼻炎的临床应用研究及治疗机制探讨

目的:研究微波热凝治疗变应性鼻炎的临床意义。方法:将6 3例变应性鼻炎随机分为两组,观察组31例施以微波凝固筛前神经鼻外侧支治疗,对照组32例施以抗组胺药物治疗。结果:两组近期和远期有效率分别是93.5 %、81.5 %和5 3.1%、4 5 .4 %。两组间疗效有显著差异(p <0 .0 1)。结论:微波热凝治疗变应性鼻炎是一种安全有效经济实用的方法,具有临床使用价值。     

Lymphocytes with antigen receptors in drug allergy

The data on the possibility of using the rosette-formation tests for the diagnosis of drug allergy are presented. Tests based on changes in the levels of activated T- and B-lymphocytes after their incubation with allergenic drugs have proved to be low informative. The test found to be highly informative is the antigen-specific rosette-formation test based on the detection of lymphocytes, capable of binding allogeneic erythrocytes loaded with antibiotics causing allergy in patients, in the peripheral blood. This test may be of importance not only in diagnosis, but also for prognosis, as it permits the detection of sensitization to a drug before the clinical manifestations of allergy.     

Focus: Allergic Diseases and Type II Immunity: Development of New White Fish Allergy after Bone Marrow Transplantation from a Non-atopic Donor

Background: Transplant-acquired food allergy has become increasingly recognized in solid organ and bone marrow transplantation. As food allergy has no cure and causes considerable impact on the lives of patients who require strict avoidance of foods to avoid potentially severe or fatal reactions, it is crucial for physicians to better understand the risk factors and mechanisms driving development of food allergy post-transplant. We report a case of new food allergy to whitefish in an elderly patient post-bone marrow transplant in which neither donor nor recipient had a history of atopy. Methods: A 70-year-old man experienced an anaphylactic reaction to Swai whitefish (Pangasius hypophthalmus) 6 months post-transplant that he had previously tolerated on multiple occasions both pre-transplant and in the preceding months post-transplant. This allergy was investigated by commercial serum specific IgE testing and fresh prick-to-prick skin test to Swai whitefish. Results: Fresh prick-to-prick demonstrated large positive reaction to the Swai whitefish with wheal of 10 mm and flare of 22 mm compared to positive histamine control with a wheal/flare of 5x8mm. Serum specific IgE testing to commercial whitefish was negative (specific IgE <0.10kU/L). The patient continues to strictly avoid Swai whitefish but tolerates all other fish and shellfish. Conclusions: The unique development of specific Swai whitefish allergy in an elderly man after bone marrow transplant where both donor and recipient had no prior history of atopy strongly supports transplant-related immunomodulation as a major mechanism for transplant-acquired allergy and suggests that that absence of atopy or advanced age may not necessarily be protective.     

Skin testing for allergy in children.

In diagnostic testing for IgE-mediated allergy in children the skin-prick test is preferred because it is safer, less painful and more specific than the intracutaneous test, and cheaper and more sensitive than the radioallergosorbent test (RAST). The intracutaneous test and RAST are useful in certain circumstances, however. While a positive result from any of these tests indicates hypersensitivity, it does not necessarily mean that the allergen giving the positive result is responsible for the patient''s symptoms. That can only be decided by interpreting the result in light of the allergy history. This paper outlines the indications for the prick test, the allergens that may be employed, the method of doing the test, and its place among the other tests that are used in a modern pediatric allergy practice.     

Evaluation of TLR4 expression and chosen parameters of oxidative-antioxidative balance in young children with food allergy

The authors evaluated mRNA TLR4 expression on neutrophils and the chosen parameters of oxidative-antioxidative balance in blood of 35 children with food allergy (17 of them with IgE-dependent allergy and 18 with IgE-independent allergy) and 15 healthy children without any allergy. The age of these children ranged from 1 to 36 months. Children with food allergy in comparison with healthy children were found to have lower mRNA TLR4 expression, higher average value of chemiluminescence (CL) and its increase after stimulation by fMLP, PMA and OZ as well as lower TAS values. Disturbances of oxidative-antioxidative balance were found in children with food allergy. We suggest that natural immunity is involved in the development of food allergy mechanisms. Moreover, chemiluminescence can be used as an additional diagnostic test.     

Interactions of mast cell degranulating peptides with model membranes: A comparative biophysical study

In the last decade, there has been renewed interest in biologically active peptides in fields like allergy, autoimmune diseases and antibiotic therapy. Mast cell degranulating peptides mimic G-protein receptors, showing different activity levels even among homologous peptides. Another important feature is their ability to interact directly with membrane phospholipids, in a fast and concentration-dependent way. The mechanism of action of peptide HR1 on model membranes was investigated comparatively to other mast cell degranulating peptides (Mastoparan, Eumenitin and Anoplin) to evidence the features that modulate their selectivity. Using vesicle leakage, single-channel recordings and zeta-potential measurements, we demonstrated that HR1 preferentially binds to anionic bilayers, accumulates, folds, and at very low concentrations, is able to insert and create membrane spanning ion-selective pores. We discuss the ion selectivity character of the pores based on the neutralization or screening of the peptides charges by the bilayer head group charges or dipoles.     

The management of allergic patients; the role of the internist

There has been an increasing trend in the United States toward intensive specialization in allergic diseases. Whereas the tendency toward specialization has led to greater knowledge of the scientific aspects of allergic phenomena, it has somewhat diverted the specialists' attention from the many clinical problems that await solution. Effective treatment of the allergic patient depends in no small measure on the broad viewpoint and clinical experience of the internist. This fact has been reemphasized by the growing awareness of the significance of the secondary or precipitating causes, such as climatic, nutritional, hormonal and psychogenic factors which influence allergic manifestations. Overemphasis on specialization in allergic diseases with their wide ramifications may defeat the main objective-a successful therapeutic result. To meet this challenge, the internist should be trained in allergy and yet retain a broad approach to the more basic problems of internal medicine. This objective may be attained by certain modifications in undergraduate medical instruction in allergy. Postgraduate training sponsored by our national allergy societies affords internists an excellent opportunity to advance their knowledge of clinical allergy.     

Persistence of antibiotic resistance in bacterial populations

Unfortunately for mankind, it is very likely that the antibiotic resistance problem we have generated during the last 60 years due to the extensive use and misuse of antibiotics is here to stay for the foreseeable future. This view is based on theoretical arguments, mathematical modeling, experiments and clinical interventions, suggesting that even if we could reduce antibiotic use, resistant clones would remain persistent and only slowly (if at all) be outcompeted by their susceptible relatives. In this review, we discuss the multitude of mechanisms and processes that are involved in causing the persistence of chromosomal and plasmid-borne resistance determinants and how we might use them to our advantage to increase the likelihood of reversing the problem. Of particular interest is the recent demonstration that a very low antibiotic concentration can be enriching for resistant bacteria and the implication that antibiotic release into the environment could contribute to the selection for resistance. Several mechanisms are contributing to the stability of antibiotic resistance in bacterial populations and even if antibiotic use is reduced it is likely that most resistance mechanisms will persist for considerable times.     

黄芩苷作为一种抗生物制剂的过敏反应的研究

通过黄芩苷抗生物制剂过敏反应的研究,在不影响疫苗免疫效果的前提下,解决注射生物制剂引起的过敏反应问题,为生物制品与天然药物相结合开辟了一条新路。采用生物制品过敏试验常规检测方法。黄芩苷使用安全,抗过敏作用明显,具有抑制肥大细胞脱颗粒和降低毛细血管通透性作用。黄芩苷与生物制品相结合,初步试验结果表明有抗动物过敏反应的效果。     

Mast cell changes in experimental diabetes: focus on attenuation of allergic events

The prevalence of atopic diseases and diabetes is increasing worldwide though the concurrence of these pathologies in individual patients is found less frequent than it would be predicted. Moreover, co-existence of diabetes and allergy is generally marked by attenuation of their respective symptoms, and effective treatment of one disease exacerbates the other. This review gives an update of the state-of-the-art concerning the intercurrence of allergy and diabetes, particularly focusing on the consequences to the allergen-evoked vascular and cellular changes. It is proposed that the reduction in mast cell numbers and reactivity may be a pivotal mechanism behind the mutual exclusion phenomenon.     

Extracorporeal treatment with L-asparaginase (author's transl)]

L-asparaginase therapy is often limited by allergy or toxicity and probably in some cases by antibody mediated inactivation of the enzyme. These problems can be avoided by extracorporeal application of l-asparaginase. As the enzyme is a stable tetramer with high molecular weight it cannot pass through the dialysis membrane in contrast to the amino acid l-asparagin which is destroyed. The resulting l-asparagin depletion of the plasma is sufficient for therapeutic success. Effective extracorporeal l-asparaginase therapy is demonstrated in two patients with ALL who were resistant to other chemotherapy and could not be treated intravenously because of allergy and toxicity.     

Rsistance to streptomycin in a producing strain of Streptomyces griseus.

Streptomyces griseus S 104 was sensitive to streptomycin during exponential growth in a medium which, in the subsequent stationary phase, supported production of the antibiotic in yields above 200 mug/ml. When antibiotic production began cultures developed a tolerance toward their lethal metabolite. This was not due to an increase in pH associated with antibiotic production, since pH effects on streptomycin sensitivity in S. griseus were in the reverse direction. However, the degree of tolerance was directly related to the amount of cell material present. Streptomycin production caused no change in the proportion of resistant variants in the population, nor did it cause the severe inhibition of protein synthesis observed in non-producing cultures exposed to the antibiotic. The lack of an effect on protein synthesis is attributed to the absence of streptomycin with in the cytoplasm since soluble extracts from mycelium harvested in the production phase were inactive when bioassayed immediately after cell disruption. However, they developed antibacterial activity rapidly when heated, and more slowly when incubated at 25 degrees C. The addition of phosphatase inhibitors during incubation prevented the appearance of antibiotic activity, and it was concluded that a small amount of streptomycin phosphate is present in the mycelium during antibiotic production. Differences in (14C) streptomycin uptake suggested that the mycelium was appreciably less permeable to the antibiotic in the production phase than during exponential growth. However, a small amount was taken up and much of it was in the soluble fraction of disrupted cells. Bioassays showed that this 14C-labeled antibiotic within the cells had been partially inactivated, suggesting that conversion of streptomycin to an inactive derivative is involved in the mechanism which protects the organism from its metabolite.     

Enhancement of CGRP sensory afferent innervation in the gut during the development of food allergy in an experimental murine model

Recent advances in neuroscience and immunology have revealed a bidirectional interaction between the nervous and immune systems. Therefore, the gastrointestinal tract may be modulated by neuro–immune interactions, but little information about this interaction is available. Intrinsic and extrinsic primary afferent neurons play an important role in this interaction because of their abilities to sense, process and transmit various information in the intestinal microenvironment. Calcitonin gene-related peptide (CGRP) is exclusively contained in intrinsic and extrinsic primary afferent neurons in the mouse intestine. Therefore, we investigated CGRP-immunoreactive nerve fibers in the colonic mucosa of mice induced to develop food allergy. CGRP-immunoreactive nerve fibers were specifically increased with the development of food allergy, and the fibers were juxtaposed to mucosal mast cells in the colonic mucosa of food allergy mice. Denervation of the extrinsic afferent neurons using neonatal capsaicin treatment did not affect the development of food allergy or the density and distribution of CGRP-immunoreactive nerve fibers in the colonic mucosa of food allergy mice. Furthermore, the mRNA and plasma level of CGRP was increased in food allergy mice. These results suggest that the activation of intrinsic primary afferent neurons in the intestine contributes to the development and pathology of food allergy.     

Successful management of allergy to the insulin excipient metacresol in a child with type 1 diabetes: a case report

ABSTRACT: INTRODUCTION: Insulin allergy to human insulin preparations during the treatment of diabetes is suggested to occur at rates ranging from <1.0% to 2.4%. These reactions vary from mild localized reactions, which resolve with repeated exposure, to life-threatening anaphylaxis and death. The management of persistent insulin allergy in type 1 diabetes mellitus is particularly complicated because ongoing treatment with insulin is essential. CASE PRESENTATION: We present the case of a 12-year-old Caucasian girl with localized allergy to the insulin excipient metacresol, and the subsequent desensitization therapy using continuous subcutaneous insulin infusion with simultaneous intravenous insulin infusion. CONCLUSIONS: This is the first documented case of allergy to the metacresol component of insulin in the pediatric type 1 diabetes literature. We describe an approach to diagnosis and management of metacresol allergy in type 1 diabetes.     

Quality of life in patients with food allergy

Food allergy has increased in developed countries and can have a dramatic effect on quality of life, so as to provoke fatal reactions. We aimed to outline the socioeconomic impact that food allergy exerts in this kind of patients by performing a complete review of the literature and also describing the factors that may influence, to a greater extent, the quality of life of patients with food allergy and analyzing the different questionnaires available. Hitherto, strict avoidance of the culprit food(s) and use of emergency medications are the pillars to manage this condition. Promising approaches such as specific oral or epicutaneous immunotherapy and the use of monoclonal antibodies are progressively being investigated worldwide. However, even that an increasing number of centers fulfill those approaches, they are not fully implemented enough in clinical practice. The mean annual cost of health care has been estimated in international dollars (I$) 2016 for food-allergic adults and I$1089 for controls, a difference of I$927 (95 % confidence interval I$324–I$1530). A similar result was found for adults in each country, and for children, and interestingly, it was not sensitive to baseline demographic differences. Cost was significantly related to severity of illness in cases in nine countries. The constant threat of exposure, need for vigilance and expectation of outcome can have a tremendous impact on quality of life. Several studies have analyzed the impact of food allergy on health-related quality of life (HRQL) in adults and children in different countries. There have been described different factors that could modify HRQL in food allergic patients, the most important of them are perceived disease severity, age of the patient, peanut or soy allergy, country of origin and having allergy to two or more foods. Over the last few years, several different specific Quality of Life questionnaires for food allergic patients have been developed and translated to different languages and cultures. It is important to perform lingual and cultural translations of existent questionnaires in order to ensure its suitability in a specific region or country with its own socioeconomic reality and culture. Tools aimed at assessing the impact of food allergy on HRQL should be always part of the diagnostic work up, in order to provide a complete basal assessment, to highlight target of intervention as well as to evaluate the effectiveness of interventions designed to cure food allergy. HRQL may be the only meaningful outcome measure available for food allergy measuring this continuous burden.     

How to fit allergen immunotherapy in the elderly

Asthma, allergic rhinitis (AR) and atopic dermatitis are very common in young people, but in the latest decades it was increasingly recognized that also individuals of higher ages, including the population over 65 years, are concerned. Actually, it is now acknowledged the aging does not considerably alter the immune response to allergens. Allergen immunotherapy (AIT) is the only treatment that works on the causes of allergy, but elderly people are commonly excluded from AIT, except the cases of insect sting allergy. A number of recent studies showed that aged individuals also successfully respond to AIT for respiratory allergy. Therefore, there is no reason to exclude elder patients from AIT. Anyhow, clinical conditions that are considered absolute or relative contraindications are quite frequent in this aged population, thus the risk/benefit ratio must be carefully evaluated for each patient, taking into account that the more frequent occurrence of co-morbidities and the consequent need of daily-based multidrug regimen can favor adverse effects. An important issue concern the ability of AIT, and particularly of sublingual immunotherapy, to significantly improve the quality of life, that often is particularly impaired in the elderly, reducing symptoms and drugs consumption.     

Peanut allergy in relation to heredity,maternal diet,and other atopic diseases: results of a questionnaire survey,skin prick testing,and food challenges.

OBJECTIVES: To determine rates of other atopic manifestations in people with peanut allergy and the prevalence of such allergy in their families. DESIGN: A survey of people with self reported peanut allergy and people referred by their general practitioner for suspected peanut allergy; survey and skin testing of 50 children with reported peanut allergy and their available first degree relatives. SUBJECTS: 622 adults and children with reported, suspected, or known peanut allergy. MAIN OUTCOME MEASURES: Prevalence of peanut allergy and other allergies in the families of people with peanut allergy. RESULTS: 622 valid completed questionnaires were returned out of the 833 questionnaires dispatched (74.7%). All forms of atopy were both more common in successive generations (P < 0.0001) and more common in maternal than paternal relatives (P < 0.0001). Peanut allergy was reported by 0.1% (3/2409) of grandparents, 0.6% (7/1213) of aunts and uncles, 1.6% (19/1218) of parents, and 6.9% (42/610) of siblings. Consumption of peanuts while pregnant or breast feeding was more common among mothers of probands aged < or = 5 years than mothers of probands aged > 5 years (P < 0.001). Age of onset correlated inversely with year of birth (r = -0.6, P < 0.001). Skin prick testing of 50 children with reported peanut allergy and their families: 7 probands (14%) had a negative result for peanut. Peanut allergy was refuted by food challenge in all those tested (5/7). No parent and 13% (5/39) of siblings had a positive result on skin prick testing for peanut. Two of these siblings had negative challenge with peanuts. The prevalence of peanut allergy in siblings is therefore 3/39 (7%). CONCLUSIONS: Peanut allergy is more common in siblings of people with peanut allergy than in the parents or the general population. Its apparently increasing prevalence may reflect a general increase of atopy, which is inherited more commonly from the mother. Peanut allergy is presenting earlier in life, possibly reflecting increased consumption of peanut by pregnant and nursing mothers.