is it safe to use cephalosporin

8/6/2019 Is It Safe to Use Cephalosporin

1/22

Emergency Medicine

Is It Safe to UseIs It Safe to Use

Cephalosporin in a PatientCephalosporin in a Patient

with Penicillin Allergy??with Penicillin Allergy??

Joe Lex, MD, FAAEMJoe Lex, MD, FAAEM

Temple University School of MedicineTemple University School of MedicinePhiladelphia, PAPhiladelphia, PA


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Emergency Medicine

DisclosureDisclosure


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Emergency Medicine


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Emergency Medicine

Common WisdomCommon Wisdom

About 10% of patientsAbout 10% of patients

who are allergic towho are allergic topenicillin will have apenicillin will have a

crosscross--reactivity toreactivity tocephalosporin.cephalosporin.

Physicians Desk Reference, 57Physicians Desk Reference, 57thth ed.ed. 20032003


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Emergency Medicine

Penicillin AllergyPenicillin Allergy Kids?Kids?

298 children with history of adverse298 children with history of adversereaction to oral penicillinreaction to oral penicillin

Given oral challenge with penicillinGiven oral challenge with penicillin

No severe reactionsNo severe reactions 30 (10%) had slight to moderate30 (10%) had slight to moderate

skin rash on 7skin rash on 7thth to 10to 10thth day ofday oftreatmenttreatment

GraffGraff--Lonnevig V, et al. Arch Dis Child. 1988Lonnevig V, et al. Arch Dis Child. 1988

Nov;63 11 :1342Nov;63 11 :1342--6.6.


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Emergency Medicine

Penicillin AllergyPenicillin Allergy Kids?Kids?

One to four years after oralOne to four years after oralchallenge, 222 childrenchallenge, 222 children

reinvestigated by interviewreinvestigated by interview

103 / 110 (94%) tolerated penicillin103 / 110 (94%) tolerated penicillintreatment without adverse reactionstreatment without adverse reactions

Conclusion: the term penicillinConclusion: the term penicillinallergy is often misusedallergy is often misused

GraffGraff--Lonnevig V, et al. Arch Dis Child. 1988Lonnevig V, et al. Arch Dis Child. 1988

Nov;63 11 :1342Nov;63 11 :1342--6.6.


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Emergency Medicine

Penicillin AllergyPenicillin Allergy Adults?Adults?

132 patients who gave history of132 patients who gave history ofimmediate reaction to penicillinimmediate reaction to penicillin

Four patients confirmed to haveFour patients confirmed to have

penicillin allergy by the radiopenicillin allergy by the radio--

allergosorbent testallergosorbent test

Other 128

had oral penicillinOther 128

had oral penicillinchallenge without ill effectchallenge without ill effect

Surtees SJ, et al. BMJ. 1991 MaySurtees SJ, et al. BMJ. 1991 May

4;302 6784 :10514;302 6784 :1051--2.2.


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Emergency Medicine

MetaMeta--AnalysisAnalysis

History of penicillin allergy: +LR =History of penicillin allergy: +LR =1.9 (95% CI, 1.51.9 (95% CI, 1.5--2.5)2.5)

No history of penicillin allergy:No history of penicillin allergy: --LR =LR =

0.5 (95% CI, 0.40.5 (95% CI, 0.4--0.6)0.6)

~ 10%~ 10% -- 20% of patients reporting20% of patients reporting

history of allergy are truly allergichistory of allergy are truly allergic

Salkind AR, et al. JAMA. 2001 MaySalkind AR, et al. JAMA. 2001 May

16;285 19 :249816;285 19 :2498--505.505.


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Emergency Medicine

First Conclusion:First Conclusion:

Maybe 10% of patientsMaybe 10% of patients

who say,who say, Im allergic toIm allergic topenicillinpenicillin are reallyare really

allergic to penicillinallergic to penicillin


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Emergency Medicine

Is It Important??Is It Important??

101 inpatients who claimed101 inpatients who claimedpenicillin allergy had skin testingpenicillin allergy had skin testing

92 negative, 5 positive, 4 unsure92 negative, 5 positive, 4 unsure

49% with negative results given49% with negative results givenpenicillinpenicillin--based drugbased drug

48% with negative results given4

8% with negative results givencephalosporincephalosporin

Nadarajah K, et al. Ann Allergy AsthmaNadarajah K, et al. Ann Allergy Asthma

Immunol. 2005 Dec;95 6 :541Immunol. 2005 Dec;95 6 :541--5.5.


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Emergency Medicine

Is It Important??Is It Important??

Reduced use of vancomycin byReduced use of vancomycin by95% (67/70)95% (67/70)

Reduced use of fluoroquinolonesReduced use of fluoroquinolones

by 96% (23/24)by 96% (23/24)

No serious reactions to skin testNo serious reactions to skin test

No reaction to penicillin orNo reaction to penicillin orcephalosporin if skin test negativecephalosporin if skin test negative

Nadarajah K, et al. Ann Allergy AsthmaNadarajah K, et al. Ann Allergy Asthma

Immunol. 2005 Dec;95 6 :541Immunol. 2005 Dec;95 6 :541--5.5.


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Emergency Medicine

Is It Safe??Is It Safe??


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Emergency Medicine

We Dont Do Skin TestingWe Dont Do Skin Testing

You have GOT to be joking


14/22

Emergency Medicine

But Thats Okay BecauseBut Thats Okay Because

Incidence of adverse reactions fromIncidence of adverse reactions fromcephalosporins: also 1% to 10%cephalosporins: also 1% to 10%

Anaphylaxis: fewer than 2 in 10,000Anaphylaxis: fewer than 2 in 10,000 PostPost--marketing studies of2marketing studies of2ndnd andand

33rdrd generation cephalosporins: nogeneration cephalosporins: no

increase allergic reactions inincrease allergic reactions inpatients with penicillin allergypatients with penicillin allergy

Anne S, et al. Ann Allergy Asthma Immunol.Anne S, et al. Ann Allergy Asthma Immunol.

1995 Feb;74 2 :1671995 Feb;74 2 :167--70.70.


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Emergency Medicine

But Thats Okay BecauseBut Thats Okay Because

Penicillin skin tests do not predictPenicillin skin tests do not predictallergy to cephalosporin in patientsallergy to cephalosporin in patients

with histories of penicillin allergywith histories of penicillin allergy

One reaction occurred in 98One reaction occurred in 98patients (1%) with positive skin testpatients (1%) with positive skin test

Six reactions occurred in 310Six reactions occurred in 310patients (2%) with negative skin testpatients (2%) with negative skin test

Anne S, et al. Ann Allergy Asthma Immunol.Anne S, et al. Ann Allergy Asthma Immunol.

1995 Feb;74 2 :1671995 Feb;74 2 :167--70.70.


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Emergency Medicine

Second Conclusion:Second Conclusion:

Severe reaction toSevere reaction to

cephalosporins arecephalosporins areeven less common thaneven less common than

penicillin allergiespenicillin allergies


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Emergency Medicine

The BIG StudyThe BIG Study

Retrospective cohort study of hugeRetrospective cohort study of hugedatabasedatabase

United Kingdom General PracticeUnited Kingdom General PracticeResearch DatabaseResearch Database

3,375,162 patients got penicillin3,375,162 patients got penicillin

534,810 patients also got534,810 patients also gotcephalosporin within 60 dayscephalosporin within 60 days

Apter AJ, et al. Am J Med. 2006Apter AJ, et al. Am J Med. 2006

Apr;119(4):354.e11.Apr;119(4):354.e11.


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3,375,162 got penicillin3,375,162 got penicillin

534,810 also got cephalosporin within 60 days534,

810 also got cephalosporin within 60 days

ALE within 30 days ofALE within 30 days of

penicillin:penicillin: 3920 (0.001%)3920 (0.001%)

No ALE within 30 daysNo ALE within 30 days

of penicillin: 530,890of penicillin: 530,890

Given CephalosporinGiven Cephalosporin

ALE within 30ALE within 30days:days: 43 (1.1%)43 (1.1%)

ALE within 30ALE within 30days:days: 581 (0.1%)581 (0.1%)

Emergency Medicine

ALE = AllergicALE = Allergic--like eventlike event


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Reaction typeReaction type

PenicillinPenicillin

(N=3920)(N=3920)

Cephalo.Cephalo.

(N=624)(N=624)

Same ALESame ALE

after bothafter both

AnaphylaxisAnaphylaxis 2525 1313 11

AngioedemaAngioedema 106106 1515 33

LaryngospasmLaryngospasm 1919 22 00

UrticariaUrticaria 2904 (74.1%)2904 (74.1%) 461 (73.9%)461 (73.9%) 3030

ErythemaErythema

multiformemultiforme174174 2424 11

TENTEN 22 11 00

Other dermOther derm 1313 11 00

UnspecifiedUnspecified 677677 107107 22


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Emergency Medicine


Anaphylaxis after penicillin: 25Anaphylaxis after penicillin: 25 Anaphylaxis after cephalosporin: 13Anaphylaxis after cephalosporin: 13

Anaphylaxis to penicillin followed byAnaphylaxis to penicillin followed byanaphylaxis to cephalosporin: 1anaphylaxis to cephalosporin: 1 ALE to penicillin followed by ALE toALE to penicillin followed by ALE to

cephalosporin: 43cephalosporin: 43 Number that were urticaria: 30Number that were urticaria: 30


Apr;119(4):354.e11.Apr;119(4):354.e11.


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Emergency Medicine


1.1% of the patients who had an1.1% of the patients who had anevent after penicillin also had anevent after penicillin also had an

event after the cephalosporinevent after the cephalosporin

BUTBUT

1.6% of the patients who had an1.6% of the patients who had an

event after penicillin also had anevent after penicillin also had anevent after aevent after a sulfonamidesulfonamide


Apr;119(4):354.e11.Apr;119(4):354.e11.


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Emergency Medicine

Final Conclusion:Final Conclusion:

Any cephalosporin canAny cephalosporin can

safely be given to asafely be given to apenicillinpenicillin--allergic patientallergic patient

who did not havewho did not haveanaphylaxisanaphylaxis

is it safe to use cephalosporin

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