Allergies to Antimicrobials
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• Recognize that the majority of reported penicillin allergies are not confirmed upon testing and expose patients to undue harm • Understand when diagnostic testing, including skin testing, is indicated to confirm an antimicrobial allergy • Employ strategies to determine if cephalosporins can be used in patients with reported penicillin allergies.
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Allergies to Antimicrobials
- 2. Course content Courseroadmap Basic concepts Common infections 2
- 3. “This may even bring the end of modern medicine as we know it. We need to act now to make sure this does not happen.” Dr. Margaret Chan New York, USA 18 April 2016 3
- 4. Core competencies for antimicrobial prescribing C1: Understands the patient and the patient’s clinical needs C2: Understands treatment options and how they support the patient’s clinical needs C3: Works in partnership with the patient and other healthcare professionals to develop and implement a treatment plan C4: Communicates the treatment plan and its rationale clearly to the patient and other health professionals C5: Monitors and reviews the patient’s response to treatment 4 Core Competencies
- 5. Objectives • Recognize that the majority of reported penicillin allergies are not confirmed upon testing and expose patients to undue harm • Understand when diagnostic testing, including skin testing, is indicated to confirm an antimicrobial allergy • Employ strategies to determine if cephalosporins can be used in patients with reported penicillin allergies. 5
- 6. Antibiotic Allergies Complicate choice of therapy PCN most common Limited confirmatory testing Leads to costly ineffective treatment 6
- 7. Antibiotic Allergies De-labeling removal of the false indication of antibiotic allergy from a patient’s record. 7
- 8. Categorization of Allergies Drug Allergy drug hypersensitivity reaction that is mediated by a patient’s immunologic response to a drug 8
- 9. Categorization of Allergies Immediate reaction • Occur rapidly • IgE mediated – Urticaria – Angioedema – Anaphylaxis
- 10. Categorization of Allergies Immediate reaction • Occur rapidly • IgE mediated – Urticaria – Angioedema – Anaphylaxis Delayed reactions • Occur later • Most commonly T-cell mediated 10
- 11. Timeline to establish relationship between drug and symptoms Diagnosis of drug allergy 11
- 12. Diagnosis of drug allergy Immediate reaction Severity Drug Prior exposure 12
- 13. Diagnosis of drug allergy Severe reactions Anaphylaxis SJS/TEN DRESS 13
- 14. Severe reactions Anaphylaxis Hives, flushing, itching, erythema, angioedema followed by respiratory compromise 14
- 15. Severe reactions Stevens-Johnson syndrome (SJS) Toxic epidermal necrolysis (TEN) Extensive necrosis and detachment of the epidermis 15
- 16. Severe reactions Drug Reaction Eosinophilia Systemic Symptoms (DRESS) Fever, facial edema, rash Eosinophilia, transaminitis and/or end organ failure 16
- 17. Diagnosis of drug allergy: Testing 17 • ~80% of patients do not react upon repeat exposure • Objective testing helpful
- 18. Diagnosis of allergy: Testing 18 Tryptase In vitro testing Skin testing Graded dose challenge Patch testing
- 19. Diagnosis of allergy: Testing 19 Tryptase In vitro testing Skin testing Graded dose challenge Patch testing
- 20. Skin Testing • Used for immediate reactions • Skin prick test followed by intradermal • Contraindicated in patients with: – history of severe anaphylaxis, – certain skin conditions – certain medications 20 WHO/ E. Robilotti
- 21. Skin Testing • A negative skin test does not exclude a drug allergy 21 WHO/ E. Robilotti
- 22. Diagnosis of allergy: Testing 22 Tryptase In vitro testing Skin testing Graded dose challenge Patch testing
- 23. Graded Dose Challenge Used for patients unlikely to be allergic Skin prick test followed by intradermal Perform in a controlled setting protocols start with low doses A negative challenge does not absolutely mean the patient will not develop an allergic reaction 23
- 24. Diagnosis of allergy: Testing 24 Tryptase In vitro testing Skin testing Graded dose challenge Patch testing
- 25. Penicillin allergies Immediate Hypersensitivity Delayed Hypersensitivity 25
- 26. Penicillin Skin Testing • Common • Uses penicillin degradation products = Major and minor determinants • Skin prick test followed by intradermal • Positive skin test + history can confirm penicillin allergy 26 WHO/ E. Robilotti
- 27. Case 1 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 27 Core Competencies 1, 2, 3 & 5
- 28. 25 y/o pregnant female (16 weeks) Treponema pallidum enzyme immunoassay positive RPR 1:16 HIV negative gonorrhea and chlamydia negative 28
- 29. Penicillin skin testing for treatment of syphilis in pregnancy • If skin testing negative perform graded dose challenge • If skin testing positive patient should undergo desensitization 29 WHO/ E. Robilotti
- 30. Case 1 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 30 • Skin testing = negative • Graded challenge with penicillin tolerated Core Competencies 1, 2, 3 & 5
- 31. Case 1 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 31 • Given benzathine penicillin G Core Competencies 1, 2, 3 & 5
- 32. Case 2 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 32
- 33. 65 y/o male planned for hip arthroplasty Vague history of penicillin reaction Skin testing if available Review history of abx consumption Timing of reaction is important 33
- 34. Caring for Patients with Allergies Avoid unnecessary antimicrobials Prevent Infections • Control comorbidities • Vaccinate 34
- 36. Review: Antimicrobial Allergies Drug Dose Duration Route prescription ............. ............. ............. Majority of penicillin allergies are not confirmed upon testing. False allergies expose patients to harm. Testing can assist clinicians in evaluating immediate reactions.
- 37. Review: Antimicrobial Allergies Avoid unnecessary antimicrobials in patients with drug allergies. Drug Dose Duration Route prescription ............. ............. .............
- 38. Quiz time! Please click “Next” to proceed.