- Email: [email protected]
sulfamethoxazole
S180 Abstracts
Penicillin Skin Testing in Pregnant Women With a History of Penicillin Allergy and Group B Streptococcus Colonization E. M. Macy; Allergy, SCPMG-Kaiser Permanente, San Diego, CA. RATIONALE: Pregnant women with histories of penicillin allergy and group B streptococcus (GBS) colonization may receive sub-optimal antibiotic therapy at delivery. METHODS: A group of 47 pregnant women with a history of both penicillin allergy and GBS colonization had a penicillin skin test (PST) with a complete panel of PST reagents including Pre-Pen®, penicillin, amoxicillin, penilloate, and penicilloate between 8-28-02 and 5-13-04. If PSTs were negative, it was recommended that penicillin class antibiotics be used at delivery for GBS prophylaxis per CDC guidelines. All antibiotic exposure and all adverse drug reaction (ADR) reports between the PST and up to 6 months postpartum were collected. RESULTS: The mean time between index penicillin ADR and PST was 18.5 ± 9.1 years. The mean time between PST and delivery was 59.7 ± 74.2 days. There were 2 mild adverse reactions associated with PSTs. Only 3 (6.4%) of the women were PST positive. There were 33 normal spontaneous vaginal deliveries, 14 cesareans, and 1 vacuum assisted vaginal delivery. Among the PST negative, 39 (88.6%) received at least one penicillin class antibiotic, almost all for peripartum GBS prophylaxis. There were 2 delayed onset rashes associated with peripartum penicillins and one immediate onset rash with peripartum vancomycin given to a PST positive woman. There were 6 total ADRs associated with 97 antibiotic courses administered between the PST and delivery plus 6 months as of 8-15-04. CONCLUSIONS: PSTs can be safely performed in pregnant women and, if negative, allows penicillins to be used at delivery for GBS prophylaxis per CDC guidelines. Funding: Kaiser Permanente Health Care Program
717
Case Report of Tolerance to Telithromycin in Erythromycin Allergic Patients G. E. Sharon; Asthma and Allergy Center, Bloomingdale, IL. RATIONALE: Ketolides a new class of antibiotic (telithromycin), contraindicated in those allergic to Macrolides, but no reports of challenge to this drug in Macrolide allergic patient exists. METHODS: Two Macrolide allergic patients 1) 39 y/o WF with reactions to PCN, Cephalosporin, Sulfa, Quinolones but tolerated IV Vancomycin. Prior reaction 10 years ago to Emycin was facial flushing, hives, cough and rash after several doses. Azithromycin (2 years ago) caused immediate anaphylaxis. 2) 44 y/o WM with reactions to PCN, Cephalosporin, and a prior reaction to Erythromycin 5 years ago with pruritic rash. Telithromycin test dose is unknown but prior studies suggest starting dose 10-2 of daily dose. We used 8 mg/ml as our test dose prick then .02cc ID and then oral challenge with 10, 25, 50, 75,100,150 mg of liquid Telithromycin administered every 15 minutes. Total oral dose or 400 mg was tolerated. The patients were observed for an additional hour. They were continued on full doses of 800 mg daily for 3 days. RESULTS: Patients were rechecked by phone in 2 hours, and daily for 2 days after the challenge. Both patients tolerated the testing, challenge then oral full dose therapy without an adverse reaction. CONCLUSION: These two cases are important as they may point the way to further studies on Macrolide-Ketolide cross reactivity. Since this new antibiotic Telithromycin has unique and distinct advantages over Macrolides it would be to our advantage to learn if Macrolide sensitive patients can in fact safely take this new class of antibiotic.
718
MONDAY
719
Infliximab Desensitization
S. Bangash1, D. Kaufman1, I. Moissidis1, S. Mahmoud1, P. Jordan2, S. L. Bahna1; 1Allergy/Immunology Section, LSUHSC, Shreveport, LA, 2Gastroenterology Section, LSUHSC, Shreveport, LA.
J ALLERGY CLIN IMMUNOL FEBRUARY 2005
RATIONALE: Infliximab (Remicade; Centocor Inc.), a chimeric IgG1 monoclonal antibody against TNF-, has been increasingly used to treat Crohn’s disease and rheumatoid arthritis. Systemic reactions occur in up to 3% of infusions and often result in switching to less effective therapy. METHODS: We were consulted on patients with significant reactions to infliximab, whose illness did not improve on other medications. We designed a desensitization protocol starting with 0.01mg IV, with increasing increments every 15 minutes until reaching the recommended therapeutic dose. Skin prick testing was performed using infliximab solution as is (5mg/ml) and if negative, intradermal tests were done with 1mcg/ml then with 5mcg/ml. Such concentrations did not cause reactions in controls. This protocol was applied so far to 6 patients (22-76 years): 4 Crohn’s disease, 1 rheumatoid arthritis, and 1 psoriatic arthritis. The reactions involved multiple systems in 3 patients, skin only in 2, and respiratory only in 1. Prior to the reaction, our patients received infliximab 1-12 times (median 4). RESULTS: The skin test was positive in only 1 patient. Desensitization was performed without premedication and was successful in all 6 patients, who have since received 1-3 desensitizations without any adverse effect. The cumulative dose was the recommended therapeutic dose (range 270575mg), and the process took 4-5 hours. CONCLUSION: Infliximab can cause systemic reactions that hinder its administration, and apparently are mostly non-IgE mediated. Our desensitization protocol appears to be safe and effective in this series and is being applied to more subjects to allow continuation of such an effective drug. Funding: Louisiana State University Health Sciences Center Drug Rash With Eosinophilia and Systemic Symptoms (DRESS) Secondary to Trimethoprim/Sulfamethoxazole A. Kewalramani, L. Wild; Allergy/Immunology, Tulane University Health Sciences Center, New Orleans, LA. RATIONALE: DRESS syndrome is a severe form of drug hypersensitivity. The clinical manifestations of DRESS syndrome are similar to those of an infectious process; hence, its diagnosis requires a high index of suspicion. METHODS: A 41-year-old female with recurrent furuncles was started on TMP/SMX 22 days prior to hospital admission. The medication was discontinued secondary to a pruritic rash involving her neck and arms. She was admitted to the hospital 6 days later with a widespread morbilliform rash, high fevers, exudative tonsillitis, lymphadenopathy, hepatomegaly, and severe facial swelling. Initially, the patient had a leukocytosis of 21,400/L with 10% atypical lymphocytes, mild renal insufficiency and elevated transaminases. RESULTS: A throat culture was negative for group A streptococcus. Monospot was negative and EBV titers were consistent with previous infection. Hepatitis panel and HIV were negative. CRP was 12.5 mg/dL and ESR was 8 mm/hr. During her hospitalization, the leukocytosis peaked to 51,500/L with 18% eosinophils. A skin biopsy was consistent with drug eruption. The patient slowly improved on high dose corticosteroids, but she required a prolonged taper. Her rash progressed to diffuse erythroderma and resolved with desquamation and scaling. The facial edema resolved by discharge 2 weeks later and the leukocytosis, eosinophilia, renal insufficiency and transaminases improved. CONCLUSIONS: DRESS syndrome can be associated with severe and possibly fatal multiorgan involvement. Hence, one must have a high index of suspicion of DRESS since the clinical manifestations may continue to progress in spite of discontinuing the medication.
720
Penicillin Skin Testing in Pregnant Women With a History of Penicillin Allergy and Group B Streptococcus Colonization E. M. Macy; Allergy, SCPMG-Kaiser Permanente, San Diego, CA. RATIONALE: Pregnant women with histories of penicillin allergy and group B streptococcus (GBS) colonization may receive sub-optimal antibiotic therapy at delivery. METHODS: A group of 47 pregnant women with a history of both penicillin allergy and GBS colonization had a penicillin skin test (PST) with a complete panel of PST reagents including Pre-Pen®, penicillin, amoxicillin, penilloate, and penicilloate between 8-28-02 and 5-13-04. If PSTs were negative, it was recommended that penicillin class antibiotics be used at delivery for GBS prophylaxis per CDC guidelines. All antibiotic exposure and all adverse drug reaction (ADR) reports between the PST and up to 6 months postpartum were collected. RESULTS: The mean time between index penicillin ADR and PST was 18.5 ± 9.1 years. The mean time between PST and delivery was 59.7 ± 74.2 days. There were 2 mild adverse reactions associated with PSTs. Only 3 (6.4%) of the women were PST positive. There were 33 normal spontaneous vaginal deliveries, 14 cesareans, and 1 vacuum assisted vaginal delivery. Among the PST negative, 39 (88.6%) received at least one penicillin class antibiotic, almost all for peripartum GBS prophylaxis. There were 2 delayed onset rashes associated with peripartum penicillins and one immediate onset rash with peripartum vancomycin given to a PST positive woman. There were 6 total ADRs associated with 97 antibiotic courses administered between the PST and delivery plus 6 months as of 8-15-04. CONCLUSIONS: PSTs can be safely performed in pregnant women and, if negative, allows penicillins to be used at delivery for GBS prophylaxis per CDC guidelines. Funding: Kaiser Permanente Health Care Program
717
Case Report of Tolerance to Telithromycin in Erythromycin Allergic Patients G. E. Sharon; Asthma and Allergy Center, Bloomingdale, IL. RATIONALE: Ketolides a new class of antibiotic (telithromycin), contraindicated in those allergic to Macrolides, but no reports of challenge to this drug in Macrolide allergic patient exists. METHODS: Two Macrolide allergic patients 1) 39 y/o WF with reactions to PCN, Cephalosporin, Sulfa, Quinolones but tolerated IV Vancomycin. Prior reaction 10 years ago to Emycin was facial flushing, hives, cough and rash after several doses. Azithromycin (2 years ago) caused immediate anaphylaxis. 2) 44 y/o WM with reactions to PCN, Cephalosporin, and a prior reaction to Erythromycin 5 years ago with pruritic rash. Telithromycin test dose is unknown but prior studies suggest starting dose 10-2 of daily dose. We used 8 mg/ml as our test dose prick then .02cc ID and then oral challenge with 10, 25, 50, 75,100,150 mg of liquid Telithromycin administered every 15 minutes. Total oral dose or 400 mg was tolerated. The patients were observed for an additional hour. They were continued on full doses of 800 mg daily for 3 days. RESULTS: Patients were rechecked by phone in 2 hours, and daily for 2 days after the challenge. Both patients tolerated the testing, challenge then oral full dose therapy without an adverse reaction. CONCLUSION: These two cases are important as they may point the way to further studies on Macrolide-Ketolide cross reactivity. Since this new antibiotic Telithromycin has unique and distinct advantages over Macrolides it would be to our advantage to learn if Macrolide sensitive patients can in fact safely take this new class of antibiotic.
718
MONDAY
719
Infliximab Desensitization
S. Bangash1, D. Kaufman1, I. Moissidis1, S. Mahmoud1, P. Jordan2, S. L. Bahna1; 1Allergy/Immunology Section, LSUHSC, Shreveport, LA, 2Gastroenterology Section, LSUHSC, Shreveport, LA.
J ALLERGY CLIN IMMUNOL FEBRUARY 2005
RATIONALE: Infliximab (Remicade; Centocor Inc.), a chimeric IgG1 monoclonal antibody against TNF-, has been increasingly used to treat Crohn’s disease and rheumatoid arthritis. Systemic reactions occur in up to 3% of infusions and often result in switching to less effective therapy. METHODS: We were consulted on patients with significant reactions to infliximab, whose illness did not improve on other medications. We designed a desensitization protocol starting with 0.01mg IV, with increasing increments every 15 minutes until reaching the recommended therapeutic dose. Skin prick testing was performed using infliximab solution as is (5mg/ml) and if negative, intradermal tests were done with 1mcg/ml then with 5mcg/ml. Such concentrations did not cause reactions in controls. This protocol was applied so far to 6 patients (22-76 years): 4 Crohn’s disease, 1 rheumatoid arthritis, and 1 psoriatic arthritis. The reactions involved multiple systems in 3 patients, skin only in 2, and respiratory only in 1. Prior to the reaction, our patients received infliximab 1-12 times (median 4). RESULTS: The skin test was positive in only 1 patient. Desensitization was performed without premedication and was successful in all 6 patients, who have since received 1-3 desensitizations without any adverse effect. The cumulative dose was the recommended therapeutic dose (range 270575mg), and the process took 4-5 hours. CONCLUSION: Infliximab can cause systemic reactions that hinder its administration, and apparently are mostly non-IgE mediated. Our desensitization protocol appears to be safe and effective in this series and is being applied to more subjects to allow continuation of such an effective drug. Funding: Louisiana State University Health Sciences Center Drug Rash With Eosinophilia and Systemic Symptoms (DRESS) Secondary to Trimethoprim/Sulfamethoxazole A. Kewalramani, L. Wild; Allergy/Immunology, Tulane University Health Sciences Center, New Orleans, LA. RATIONALE: DRESS syndrome is a severe form of drug hypersensitivity. The clinical manifestations of DRESS syndrome are similar to those of an infectious process; hence, its diagnosis requires a high index of suspicion. METHODS: A 41-year-old female with recurrent furuncles was started on TMP/SMX 22 days prior to hospital admission. The medication was discontinued secondary to a pruritic rash involving her neck and arms. She was admitted to the hospital 6 days later with a widespread morbilliform rash, high fevers, exudative tonsillitis, lymphadenopathy, hepatomegaly, and severe facial swelling. Initially, the patient had a leukocytosis of 21,400/L with 10% atypical lymphocytes, mild renal insufficiency and elevated transaminases. RESULTS: A throat culture was negative for group A streptococcus. Monospot was negative and EBV titers were consistent with previous infection. Hepatitis panel and HIV were negative. CRP was 12.5 mg/dL and ESR was 8 mm/hr. During her hospitalization, the leukocytosis peaked to 51,500/L with 18% eosinophils. A skin biopsy was consistent with drug eruption. The patient slowly improved on high dose corticosteroids, but she required a prolonged taper. Her rash progressed to diffuse erythroderma and resolved with desquamation and scaling. The facial edema resolved by discharge 2 weeks later and the leukocytosis, eosinophilia, renal insufficiency and transaminases improved. CONCLUSIONS: DRESS syndrome can be associated with severe and possibly fatal multiorgan involvement. Hence, one must have a high index of suspicion of DRESS since the clinical manifestations may continue to progress in spite of discontinuing the medication.
720