Allergy to β-lactams
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Correspondence 10.1517/14740338.5.2.193 © 2006 Ashley Publications ISSN 1474-0338 193 Ashley Publications www.ashley-pub.com Allergy to β-lactams Response to: RODRIGUEZ-PENA R, ANTUNEZ C, MARTIN E et al.: Allergic reactions to β-lactams. Expert Opin. Drug Saf. (2006) 5:31-48. Rakesh Chandra University of Tennessee, Health Science Center, Department of Otolaryngology – Head and Neck Surgery, Memphis, TN 38163, USA Expert Opin. Drug Saf. (2006) 5(2):193 I read with great interest the article entitled ‘Allergic reactions to β-lactams’ by Rodriquez-Pena et al. [1]. Penicillins remain the drugs of choice for so many conditions, particularly in my specialty of otorhinolaryngology. It is truly unfortunate that many factors, including overlabelling patients as allergic [2], have resulted in the overuse of alternative antibiotics. This has led to microbial resistance and increased heath care costs. Unfortunately there is no universal protocol to work-up patients with self-pro- claimed β-lactam allergy. Skin testing is considered by many who manage allergic disease to be a valuable modality given that it as an in vivo modality. However, in the extensive and comprehensive review of this topic, the authors acknowledge that the number of positive cases after skin testing is somewhat variable. Furthermore, patients with nonanaphylactic reactions (i.e., rash alone) may have a lower preva- lence of positive skin test. The tendency to react positively, as reviewed by the authors, can also depend on the reagent tested [3]. Oral challenge may also be neces- sary to elucidate the in vivo significance of a positive response. The summation of these observations suggests that assessment of β-lactam allergy is best accomplished through some algorithm involving a skin test panel [4] of selected reagents followed by oral challenge. These in vivo modalities would identify the reactions of practical significance without the expense of immunoassay or flow cytometry. The question still remains of what that algorithm should be: What elements of the patient history necessitate skin testing? What reagents (or panel thereof ) will have the highest specificity so that patients testing negatively will not be incorrectly labelled as nonallergic, yet will be sensitive enough so as not to miss those with bona fide allergic reactions? Just as in an environmental allergy workup, where a cost-effective panel is selected to correspond to the prevalence of the various pollens in the particular region, a similar algorithm can be proposed here. This can include statements about the exact roles of oral challenge and in vitro testing. It would be helpful to the readers if the authors suggested such a clinical pathway. Bibliography 1. RODRIGUEZ-PENA R, ANTUNEZ C, MARTIN E et al.: Allergic reactions to β-lactams. Expert Opin. Drug Saf. (2006) 5:31-48. 2. LANGLEY JM, HALPERIN SA, BARTOLUSSI R: History of penicillin allergy and referral for skin testing: evaluation of a pediatric allergy testing program. Clin. Invest. Med. (2002) 25:181-184. 3. WARRINGTON RJ, SIMONS FE, HO HW, GORSKI BA: Diagnosis of penicillin allergy by skin testing: the Manitoba experience. Can. Med. Assoc. J. (1978) 118:787-791. 4. SALKIND AR, CUDDY PG, FOXWORTH JW: The rational clinical examination. Is this patient allergic to penicillin? An evidence-based analysis of the likelihood of penicillin allergy. JAMA (2001) 285:2498-2505. Affiliation Rakesh Chandra MD Assistant Professor, University of Tennessee, Health Science Center, Department of Otolaryngology – Head and Neck Surgery, Memphis, TN 38163, USA Fax: +1 901 448 5120; E-mail: [email protected] For reprint orders, please contact: [email protected] Expert Opin. Drug Saf. Downloaded from informahealthcare.com by 198.28.62.3 on 10/29/14 For personal use only.
Transcript of Allergy to β-lactams
Correspondence
10.1517/14740338.5.2.193 © 2006 Ashley Publications ISSN 1474-0338 193
Ashley Publicationswww.ashley-pub.com
Allergy to β-lactamsResponse to: RODRIGUEZ-PENA R, ANTUNEZ C, MARTIN E et al.: Allergic reactions to β-lactams. Expert Opin. Drug Saf. (2006) 5:31-48.
Rakesh ChandraUniversity of Tennessee, Health Science Center, Department of Otolaryngology – Head and Neck Surgery, Memphis, TN 38163, USA
Expert Opin. Drug Saf. (2006) 5(2):193
I read with great interest the article entitled ‘Allergic reactions to β-lactams’ byRodriquez-Pena et al. [1]. Penicillins remain the drugs of choice for so many conditions,particularly in my specialty of otorhinolaryngology. It is truly unfortunate that manyfactors, including overlabelling patients as allergic [2], have resulted in the overuse ofalternative antibiotics. This has led to microbial resistance and increased heath care costs.
Unfortunately there is no universal protocol to work-up patients with self-pro-claimed β-lactam allergy. Skin testing is considered by many who manage allergicdisease to be a valuable modality given that it as an in vivo modality. However, in theextensive and comprehensive review of this topic, the authors acknowledge that thenumber of positive cases after skin testing is somewhat variable. Furthermore,patients with nonanaphylactic reactions (i.e., rash alone) may have a lower preva-lence of positive skin test. The tendency to react positively, as reviewed by theauthors, can also depend on the reagent tested [3]. Oral challenge may also be neces-sary to elucidate the in vivo significance of a positive response. The summation ofthese observations suggests that assessment of β-lactam allergy is best accomplishedthrough some algorithm involving a skin test panel [4] of selected reagents followedby oral challenge. These in vivo modalities would identify the reactions of practicalsignificance without the expense of immunoassay or flow cytometry.
The question still remains of what that algorithm should be: What elements ofthe patient history necessitate skin testing? What reagents (or panel thereof ) willhave the highest specificity so that patients testing negatively will not be incorrectlylabelled as nonallergic, yet will be sensitive enough so as not to miss those with bonafide allergic reactions? Just as in an environmental allergy workup, where acost-effective panel is selected to correspond to the prevalence of the various pollensin the particular region, a similar algorithm can be proposed here. This can includestatements about the exact roles of oral challenge and in vitro testing. It would behelpful to the readers if the authors suggested such a clinical pathway.
Bibliography1. RODRIGUEZ-PENA R, ANTUNEZ C,
MARTIN E et al.: Allergic reactions to β-lactams. Expert Opin. Drug Saf. (2006) 5:31-48.
2. LANGLEY JM, HALPERIN SA, BARTOLUSSI R: History of penicillin allergy and referral for skin testing: evaluation of a pediatric allergy testing program. Clin. Invest. Med. (2002) 25:181-184.
3. WARRINGTON RJ, SIMONS FE, HO HW, GORSKI BA: Diagnosis of penicillin allergy by skin testing: the Manitoba experience. Can. Med. Assoc. J. (1978) 118:787-791.
4. SALKIND AR, CUDDY PG, FOXWORTH JW: The rational clinical examination. Is this patient allergic to penicillin? An evidence-based analysis of the likelihood of penicillin allergy. JAMA (2001) 285:2498-2505.
AffiliationRakesh Chandra MDAssistant Professor, University of Tennessee, Health Science Center, Department of Otolaryngology – Head and Neck Surgery, Memphis, TN 38163, USAFax: +1 901 448 5120; E-mail: [email protected]
For reprint orders, please contact:[email protected]
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