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659 Can oral penicillin challenge replace minor determinant skin testing?
J ALLERGYCLIN IMMUNOL VOLUME 97, NUMBER 1, PART3
657
Oral Desensitization to Trimethoprim Sulfamethoxazole in P a t i e n t s w i t h HIV
Abstracts
659
A n t i b i o t i c A l l e r g y in H I V - I n f c e t e d C h i l d r e n . SJ Schuval. V R Bonagura, N e w H y d e Park, N.Y. The incidence o f drug allergy in H I V - i n f e c t e d adults is 865%. To determine the incidence o f drug allergy in HIVinfected children, a retrospective chart r e v i e w w a s conducted. The medical records o f 100 H I V - i n f e c t e d children f o l l o w e d b y our Pediatric I m m u n o l o g y Clinic were r e v i e w e d for antibiotic sensitivity. T w e n t y - e i g h t patients reported allergic reactions to 57 antibiotics. Thirteen patients were allergic to 1 antibiotic; the remainder reported sensitivity to > 1 antibiotic. The m o s t c o m m o n drug allergy was sulfa (37%), followed by penicillin (30%), cephalosporin (12%), and other (21%). Manifestations o f drug allergy included rash o f u n k n o w n description (25%), maeulopapular rash (30%), urticaria ( 1 8 % ) , local urticaria at the site o f injection (4%), rash and fever (11%), e r y t h e m a multiforme (4%), Stevens J o h n s o n S y n d r o m e (5%), and w h e e z i n g (2%). U p o n rechallenge, 10/16 patients were able to tolerate drugs to w h i c h they were previously c o n s i d e r e d allergic: 4 received suspect antibiotics inadvertently, 3 received cautious readministration, and 4 patients underwent oral desensitization for treatment or prophylaxis o f pneumoc;ystis carinii pneumonia. A l t h o u g h drug allergy is c o m m o n in pediatric HIV infection, a substantial n u m b e r o f patients can tolerate antibiotics upon re-administration.
Can oral penicillin challenge replace minor d e t e r m i n a n t s k i n t e s t i n g ? JM DeMasi. M. D_ Albany, NY. Oblective Without commercially available minor determinant (MD), patients at risk for penicillin (PCN) anaphylaxis cannot be identified with complete certainty. This pilot study was undertaken to evaluate the safety, efficacy and predictability of substituting an oral challenge for minor determinant skin testing. Me.thada/o.~ Patients with a history of PCN allergy and a PCN requirement were skin tested with Penicillin G (PG) and PrePon (PP). In lieu of MD testing, skin test negative patients received an oral challenge with the suspect drug and were observed for adverse reaction. Phone follow-up to the referring physician was made regarding subsequent use of penicillin or related antibiotic. Results Over a 24 month period, 26 patients met the criteria for evaluation. There were 16 males and 10 females ages 18 months to 90 years (mean of 18.9 years). Suspect drugs included penicillin (8, 30%), Amoxieillin (15, 58%), Augmeutin (2, 8%) and unlmown (1, 4%). The most common reaction was urticaria (19, 73%), urticaria and angioedema (6, 23%), no recoltection (i, 4%). There were no cases of angioedema alone and no patients had involvement of the respiratory, cardiovascular, gastrointestinal or neuromuscular systems. The interval between reaction and testing was 1 year to 72 years (mean of 8.7 years). No reactions were noted up to one hour following oral challenge. Twenty patients, 71% received 28 courses of penicillin or related treatment following evaluation. One patient had a nonaUergic reaction to Amoxicillin. There were no other adverse events. Can.c,/u$/o~ This pilot study suggests a negative oral challenge combined with negative skin test reactivity to PenG and PP may safely identify those patients who are no longer at risk for renewed therapy.
M F Lee-Wono MD. D Resnick hiD. M Waldron MD, New York, NY The incidence of hypersensitivity to trimethoprim sulfamethoxazole (TS) has been reported to be higher in II1V patients (44-69%) than in patients (pts) with normal immunity (3-8%). Oral TS desensitization was offered to 57 HIV pts who ne,eded TS for either treatment or prophylaxis of Pneumocystis carinii. Pts with history of Stevens Johnson or toxic epidermal neerolysis were excluded. Although 18 refused, 39 underwent oral desensitization via 2 protocols. The pts (35) who presented with delayed type rash or fever to TS were desensitized with a "10 day" once a day protocol used by Absar et al published in J Allergy Clin Immunol; 93,1001 - 1005. Whereas the pts (4) who presented with anaphylactic reaction to TS were desensitized in our ICU with a "6 hour" q one hour protocol used by Oluekstein ct al presented at 4th International Conference on AIDS. Ofthe 10 day protocol, 31 successfully completed desensitization. Only four did not complete the protocol. One died from renal failure, one had to be discontinued because of drop in WBC. Two were terminated as per the pt because of rash and fever without attempting to '" treat thru" the reaction. Another 5 pts developed a pruritie rash of which 2 also had fever. These 5 pts successfully completed desensitization by "treating thru" by using H1 and I-t2 blocker for the rash and prednisone for the fever. There were no complications in the 6 hr protocol so all 4 pts successfully completed desensitization. Of the 39,a total of 35 successfully enmpleted desensitization protocols. Also, pts who develop pntritus, rash or fever can often be "treated thru" such reactions with HI, H2 blockers and prednisone. Thus, we concur with other reports that the majority of I-IIVpts can successfully undergo TS desensitization and would derive tremendous benefit from doing so.
658
347
660
THE EFFECT OF PENICILLIN SKIN TESTING ON ANTIBIOTIC USAGE IN A LARGE HMO. E M Macv. MD and the Kaiser Permanente Allerav Deoartrn~nt San Diego, CA. Penicillin (Pen) skin testing (PST) using the major and minor determinants and amoxicillin (Amox) is an established method to identify patients who have IgE mediated reactions to Pen class antibiotics. It is unknown whether this information changes antibiotic (AB) usage in clinical practice. We skin tested 118 patients with histories of adverse "allergic" reactions to Pen class AB between 3-16-93 and 7-26-94. 110 patients obtained all of their medications from our pharmacies and their AB utilization 1 year pre-test and 1 year post-test were reviewed. Most patients received AB from their primary care physicians with no intervention from the Allergy Department except noting in their medical record that they were PST+ or PST-. The number of AB, Pen class AB, patients (Pt) receiving at least 1 AB, as well as drug acquisition "cost" were determined. One PST- patient was excluded because his AB cost alone was >22% of the entire cohort leaving 109 patients for evaluation. There were 87 Pen- (80%), 17 Pen+ (16%), 4 Pen+/Amox+ (4%), and 1 Amox + (1%) patients. #AB PST- (Pre) 307 PST- (Post) 252 PST+ (Pre) 70 PST+ (Post) 66
#AB/Pt 4.1 3.6 3.9 3.7
#PenAB Pt~IAB 50(16%) 75 113(45%) 70 11(16%) 18 1 (2%) 18
Cost/AB $22.61 $22.70 $20.16 $26.31
Penicillin skin testing, if negative, increases Penicillin class antibiotic usage. Being identified as Penicillin skin test negative does not appear to effect drug "cost".
657
Oral Desensitization to Trimethoprim Sulfamethoxazole in P a t i e n t s w i t h HIV
Abstracts
659
A n t i b i o t i c A l l e r g y in H I V - I n f c e t e d C h i l d r e n . SJ Schuval. V R Bonagura, N e w H y d e Park, N.Y. The incidence o f drug allergy in H I V - i n f e c t e d adults is 865%. To determine the incidence o f drug allergy in HIVinfected children, a retrospective chart r e v i e w w a s conducted. The medical records o f 100 H I V - i n f e c t e d children f o l l o w e d b y our Pediatric I m m u n o l o g y Clinic were r e v i e w e d for antibiotic sensitivity. T w e n t y - e i g h t patients reported allergic reactions to 57 antibiotics. Thirteen patients were allergic to 1 antibiotic; the remainder reported sensitivity to > 1 antibiotic. The m o s t c o m m o n drug allergy was sulfa (37%), followed by penicillin (30%), cephalosporin (12%), and other (21%). Manifestations o f drug allergy included rash o f u n k n o w n description (25%), maeulopapular rash (30%), urticaria ( 1 8 % ) , local urticaria at the site o f injection (4%), rash and fever (11%), e r y t h e m a multiforme (4%), Stevens J o h n s o n S y n d r o m e (5%), and w h e e z i n g (2%). U p o n rechallenge, 10/16 patients were able to tolerate drugs to w h i c h they were previously c o n s i d e r e d allergic: 4 received suspect antibiotics inadvertently, 3 received cautious readministration, and 4 patients underwent oral desensitization for treatment or prophylaxis o f pneumoc;ystis carinii pneumonia. A l t h o u g h drug allergy is c o m m o n in pediatric HIV infection, a substantial n u m b e r o f patients can tolerate antibiotics upon re-administration.
Can oral penicillin challenge replace minor d e t e r m i n a n t s k i n t e s t i n g ? JM DeMasi. M. D_ Albany, NY. Oblective Without commercially available minor determinant (MD), patients at risk for penicillin (PCN) anaphylaxis cannot be identified with complete certainty. This pilot study was undertaken to evaluate the safety, efficacy and predictability of substituting an oral challenge for minor determinant skin testing. Me.thada/o.~ Patients with a history of PCN allergy and a PCN requirement were skin tested with Penicillin G (PG) and PrePon (PP). In lieu of MD testing, skin test negative patients received an oral challenge with the suspect drug and were observed for adverse reaction. Phone follow-up to the referring physician was made regarding subsequent use of penicillin or related antibiotic. Results Over a 24 month period, 26 patients met the criteria for evaluation. There were 16 males and 10 females ages 18 months to 90 years (mean of 18.9 years). Suspect drugs included penicillin (8, 30%), Amoxieillin (15, 58%), Augmeutin (2, 8%) and unlmown (1, 4%). The most common reaction was urticaria (19, 73%), urticaria and angioedema (6, 23%), no recoltection (i, 4%). There were no cases of angioedema alone and no patients had involvement of the respiratory, cardiovascular, gastrointestinal or neuromuscular systems. The interval between reaction and testing was 1 year to 72 years (mean of 8.7 years). No reactions were noted up to one hour following oral challenge. Twenty patients, 71% received 28 courses of penicillin or related treatment following evaluation. One patient had a nonaUergic reaction to Amoxicillin. There were no other adverse events. Can.c,/u$/o~ This pilot study suggests a negative oral challenge combined with negative skin test reactivity to PenG and PP may safely identify those patients who are no longer at risk for renewed therapy.
M F Lee-Wono MD. D Resnick hiD. M Waldron MD, New York, NY The incidence of hypersensitivity to trimethoprim sulfamethoxazole (TS) has been reported to be higher in II1V patients (44-69%) than in patients (pts) with normal immunity (3-8%). Oral TS desensitization was offered to 57 HIV pts who ne,eded TS for either treatment or prophylaxis of Pneumocystis carinii. Pts with history of Stevens Johnson or toxic epidermal neerolysis were excluded. Although 18 refused, 39 underwent oral desensitization via 2 protocols. The pts (35) who presented with delayed type rash or fever to TS were desensitized with a "10 day" once a day protocol used by Absar et al published in J Allergy Clin Immunol; 93,1001 - 1005. Whereas the pts (4) who presented with anaphylactic reaction to TS were desensitized in our ICU with a "6 hour" q one hour protocol used by Oluekstein ct al presented at 4th International Conference on AIDS. Ofthe 10 day protocol, 31 successfully completed desensitization. Only four did not complete the protocol. One died from renal failure, one had to be discontinued because of drop in WBC. Two were terminated as per the pt because of rash and fever without attempting to '" treat thru" the reaction. Another 5 pts developed a pruritie rash of which 2 also had fever. These 5 pts successfully completed desensitization by "treating thru" by using H1 and I-t2 blocker for the rash and prednisone for the fever. There were no complications in the 6 hr protocol so all 4 pts successfully completed desensitization. Of the 39,a total of 35 successfully enmpleted desensitization protocols. Also, pts who develop pntritus, rash or fever can often be "treated thru" such reactions with HI, H2 blockers and prednisone. Thus, we concur with other reports that the majority of I-IIVpts can successfully undergo TS desensitization and would derive tremendous benefit from doing so.
658
347
660
THE EFFECT OF PENICILLIN SKIN TESTING ON ANTIBIOTIC USAGE IN A LARGE HMO. E M Macv. MD and the Kaiser Permanente Allerav Deoartrn~nt San Diego, CA. Penicillin (Pen) skin testing (PST) using the major and minor determinants and amoxicillin (Amox) is an established method to identify patients who have IgE mediated reactions to Pen class antibiotics. It is unknown whether this information changes antibiotic (AB) usage in clinical practice. We skin tested 118 patients with histories of adverse "allergic" reactions to Pen class AB between 3-16-93 and 7-26-94. 110 patients obtained all of their medications from our pharmacies and their AB utilization 1 year pre-test and 1 year post-test were reviewed. Most patients received AB from their primary care physicians with no intervention from the Allergy Department except noting in their medical record that they were PST+ or PST-. The number of AB, Pen class AB, patients (Pt) receiving at least 1 AB, as well as drug acquisition "cost" were determined. One PST- patient was excluded because his AB cost alone was >22% of the entire cohort leaving 109 patients for evaluation. There were 87 Pen- (80%), 17 Pen+ (16%), 4 Pen+/Amox+ (4%), and 1 Amox + (1%) patients. #AB PST- (Pre) 307 PST- (Post) 252 PST+ (Pre) 70 PST+ (Post) 66
#AB/Pt 4.1 3.6 3.9 3.7
#PenAB Pt~IAB 50(16%) 75 113(45%) 70 11(16%) 18 1 (2%) 18
Cost/AB $22.61 $22.70 $20.16 $26.31
Penicillin skin testing, if negative, increases Penicillin class antibiotic usage. Being identified as Penicillin skin test negative does not appear to effect drug "cost".