stamping out amoxicillin allergy - yk-health.org out amoxicillin allergy k jane mcclure 1.7.2013...
TRANSCRIPT
WHY• AlargenumberofpaIent’samoxicillinallergylabelsareincorrect.
• AmoxicillinandAugmenInaretheBESTfirstlineopIonfortreaIngoIIsmediaandpneumoniainchildren.
• NotbeingabletouseamoxicillindrasIcallyreducesthenumberandtypesofanIbioIcsthatcanbeusedforapaIent.
• TherearenotmanyopIonsforothergoodanIbioIcsinthevillage(wanttoavoidsendingoutOmniceforusingCeQriaxone)
• Increaseduseofcephalosporinsforunproven‘amoxiciilinallergic’paIentswillcreateresistance.
HowDidThesePa1entAllergyLabelsGetThere??
• ImportedfromRPMSinEHRconversion• Chartlore• LackofeducaIonaboutsignsandsymptomsofatrueAmoxicillinallergy
• ImproperlabelingofpaIentsasAmoxicillinallergicbyproviders,CHAsparentsandcaretakers
UGLY–ImmediateReac1onANAPHYLLAXISAnaphylaxisisdefinedasaseriousallergicorhypersensiIvityreacIonthatisrapidinonset(minutestoseveralhours)and
maycausedeathTherearethreediagnosIccriteria:Criterion1—Acuteonsetofanillness(minutestoseveralhours)involvingtheskin,mucosalIssue,orboth(e.g.,
generalizedhives,pruritusorflushing,swollenlips-tongue-uvula)andatleastoneofthefollowing:●Respiratorycompromise(e.g.,dyspnea,wheeze-bronchospasm,stridor,reducedpeakexpiratoryflow,hypoxemia).OR●Reducedbloodpressure(BP)orassociatedsymptomsandsignsofend-organdysfuncIon(e.g.,hypotonia[collapse]
syncope,inconInence).Note:Skinsymptomsandsignsarepresentinupto90percentofanaphylacIcepisodes.Thiscriterionwilltherefore
frequentlybehelpfulinmakingthediagnosisCriterion2—TwoormoreofthefollowingthatoccurrapidlyaQerexposuretoaLIKELYallergenforthatpa1ent(minutes
toseveralhours):●Involvementoftheskin-mucosalIssue(e.g.,generalizedhives,itch-flush,swollenlips-tongue-uvula).●Respiratorycompromise(e.g.,dyspnea,wheeze-bronchospasm,stridor,reducedpeakexpiratoryflow,hypoxemia).●ReducedBPorassociatedsymptomsandsigns(e.g.,hypotonia[collapse],syncope,inconInence).●PersistentgastrointesInalsymptomsandsigns(e.g.,crampyabdominalpain,vomiIng).Criterion3—ReducedBPaQerexposuretoaKNOWNallergenforthatpa1ent(minutestoseveralhours):●ReducedBPinadultsisdefinedasasystolicBPoflessthan90mmHgorgreaterthan30percentdecreasefromthat
person'sbaseline●Ininfantsandchildren,reducedBPisdefinedaslowsystolicBP(agespecific)*orgreaterthan30percentdecreasein
systolicBP
STOPEXPOSURE----EPINEPHRINE----OXYGEN----FLUIDS----AIRWAYMANAGEMENT
BAD-DelayedUrIcarial(Hive-like)ErupIons
DelayedurIcarialerupIons(+/-angioedema)areanothercommoncutaneouspenicillinreacIon.ThesereacIonsareparIcularlyprevalentinchildren.
ThesymptomsbeginmorethananhouraQerthelastadministereddose.Usually1-3daysintocourse.
AnevaluaIonforIgE-mediatedallergyshouldbeperformed(aQeragefive)beforefutureuseofpenicillinandrelateddrugscanbeconsidered
Good(orOK…)• ThemostcommonreacIonstopenicillinsaredelayed
cutaneouserupIons-mostlikelymediatedbyTcellsintheskin.
• DelayedcutaneouserupIonsareusuallymaculopapularormorbilliformandoQenassociatedwithaviralinfecIon
• ThesedrugerupIonsdonotinvolvefever,systemicsymptoms,orevidenceofspecificorganinvolvement
• Pruritusmayormaynotbeafeature• Theserashesaremoreprevalentinchildren(usuallyunder
12months)
KISSAllergicReacIonOverviewBAD=ImmediateType1IGEmediatedreacIonsHives,+/-swellingoflips/tongue/uvula,+/-respiratorydistress,+/-
decreasedbloodpressure.Don’tevergivedrugagainwithoutallergistevalua1on
UGLY=DelayedcutaneousTcellmediatedreacIonsHives/angioedemawithoutevidenceofanaphylaxis…ProbablyneedtorefertoallergistaTerfiveyearsoldtoevaluate
GOOD=DelayedcutaneousreacIonsMaculopapular/morbilliformrashwithoutevidenceofanaphylaxis.OQenassociatedwithviralinfecIons…Thisiswhatwemostlysee.
Pleasetryamoxicillinagain!!!
TruePenicillinAllergyisRare• Anaphylaxisoccursin1-4/10,000administraIons
• InlargestudiesofpenicillinskintesIng,approximately85to90percentoftheseindividualsarefoundnottohaveposiIveskintestsandareabletotoleratepenicillins
• TheprevalenceofIgE-mediatedpenicillinhasdeclinedoverthelasttwodecades
• EvidenceislimitedforgeneIcfactorsplayingaroleintheexpressionofpenicillinandotheranIbioIcallergies
• PenicillinskintesIngisthepreferredmethodofevaluaIonanddiagnosisofimmediatereacIons.Invitrostudiesarenothelpful
• Referral—ReferraltoanallergyspecialistfordiagnosIctesIngshouldbeconsideredforanypaIentwithahistoryofpenicillinallergyconsistentwithapossibleIgE-mediatedmechanism.TesIngofchildrencanbedoneaQeragefive
CutaneousreacIons—IfapaIentclearlydescribesadelayed-onseterupIonthatdidnotitchorinvolveurIcaria,wasnotaccompaniedbyanysystemicsymptoms,anddidnotinvolveblisteringorexfoliaIonoftheskin,thenitcanbereasonablyassumedthatthepaIenthadadelayedmaculopapularcutaneousreacIon.SuchpaIentscanbetreatedwiththesameorotherpenicillinsinthefuture,withtherecogniIonthatsuchreacIonsmayrecur.
Safere-administraIonwiththesameorsimilardrugsiswelldocumentedinchildren,inwhomdelayedcutaneouserupIonsregularlyoccurintheseongofviralinfecIons.Inastudyof88childrenwithdelayedurIcarialormaculopapularrashesonbeta-lactam(mostlyamoxicillin)anIbioIcs,only6of88(7percent)reactedagainwhenre-challengedwiththesameanIbioIctwomonthsaQertheoriginalreacIon.
OpIonsfortreatmentwithPenicillinsinfuture:UTD
OpIonsfortreatmentinfutureconInued:UTD
ConcomitantanIhistaminetherapy—ForthosewithahistoryofpruriIcrasheswithprioranIbioIcs,theremaybesomevalueinadministeringananIhistamineduringtreatmentwithfutureanIbioIcadministraIon.Thisapproachhasnotbeenstudiedformally,butthereisaclinicalimpressionthatitmayhavesomevalueinprevenIngmild,nonspecificcutaneousreacIons.
HIVESOR???Hivesareraisedandintensely
pruri1cViralordelayedcutaneousexanthemcanbemaculopapularormorbilliform
HIVESOR???Hivescomeandgo,movearoundandchangeshape
Viralordelayedcutaneousexanthemsarefixedbutcanexpandoverbodyoverseveraldays
MaculopapularandMorbilliformRashes
• NonpruriIc,maculopapularrashesthatdevelopduringthecourseoftherapyarereportedin3to7percentofchildrengivenampicillin.
• Pruritusmayormaynotbeafeature.• TheserashesarebelievedtobemediatedbyTcells,are
moreprevalentinchildrenandarecommonlycausedbyamoxicillin
• TheonsetoftheerupIonisusuallywithintwoweeksofbeginningtherapy,andwithindaysofre-exposureifthepaIenthadtakenthemedicaIononpreviousoccasions.Occasionally,anerupIontopenicillinsmaybeginaslateasthreeweeksaQerbeginningtheanIbioIc,orfirstappearuptotwoweeksaQerthetherapywascompleted.
STEP1:GetmoreinformaIonWhattypeofreacIondidthepaIenthave?1.VomiIngordiarrhea?2.Rash?-Atwhatagedidtherashoccur?-DidtherashstartshortlyaQertakingthemedicineora
numberofdayslater?-ArethereanypicturesordocumentaIonofwhatthe
rashlookedlike?-DidtherashlooklikeHIVESorErythemaMul1forma
thatareraised,itchy,biggerthandimesizeandmovearoundthebodyandchangeshapeandsize?
-ORwastherashafineredrashonthebodythatlookedlikethis?
3.Swellingofthelipsand/ortroublebreathing?4.HasthepaIentreceivedanytreatmentwith
Penicillin,AmoxicillinorAugmenInsincetheyhadthefirstreacIon?
STEP2:DecideWASitatrueallergy-Hivesorswellingoftheface,lips,tongueandthroatordifficulty
breathingAREsignsofanallergicreac1on.IftherashisintenselypruriIcandhivelikeitispossiblyanIGEmediatedallergicresponse.TrueallergicIGEmediatedresponsesareimmediatei.e.occurwithinafewminutestoafewhoursaQerthe1stor2nddoseofmedicineandwillresolvein12-24hoursaQerstoppingthemedicine.
ORnotatrueallergy-Afineredrashonthebody(especiallyinpaIentsunderayearofage)
isusuallyarashassociatedwithavirusthatoQenappearswhenapaIentisgivenamoxicillin.MildrashestoAmoxicillinusuallyoccur3-7daysaQerstarIngamoxicillinandmaylastuptoaweekortwoevenifthemedicineisstopped.
-VomiInganddiarrheaareusuallysideeffectsofamedicaIon…NOTanallergy
STEP3:Nowwhat?IfapaIenthadaredrashonthebodywhentheywerelivle,butnooneremembersorhasdocumentedthatthepaIenthadtruehivesorswellingordifficultybreathing,thenitisimportanttoconsidergivingatrialofamoxicillinagain.
IfapaIenthadhivesand/orlipswellingandtroublebreathingoranyseriousconcernsforanallergicreacIon,thenitisimportanttowaitandhaveanallergisttestthepaIentinAnchorageaQertheyarefiveyearsofage.
OpIonsfordoingatrialofamoxicillinIfitisunlikelythatapaIenthadatrueallergicresponseinthepast,thepaIentcanbeofferedatriallof
Amoxicillinifthecaregiver,CHAand/orproviderarecomfortablewiththisopIon.Inthevillage:thepaIentcanbegivenadoseofamoxicillinandbeobservedintheclinicareaforan
houraQertakingthedose.TheCHA’swillhaveBenadrylandepinephrineonhandforthepossibilityofareacIontothemedicine.IfthereisnoreacIon,thepaIentcanbesenthomewitharegularprescripIonofAmoxicillin.ThepaIentwillbegivenBenadryltotakehometogiveforanyconcerningrash.Thecaretaker’sshouldbecounseledtocalltheCHAorreturntoclinicforanysignificantreacIon.
ORIntheERorBethelClinic:thepaIentcanbegivenadoseofamoxicillinandbeobservedinthe
adjacentwaiIngareaforanhouraQertakingthedoseanddischargedtotheHostelornearbyhousingwitharegularprescripIonofAmoxicillin.IfthepaIenthasnosignificantreacIonin24hours,thenthepaIentcanreturntothevillageandfinishthecourseofAmoxicillin.Thecaretaker’sshouldbecounseledtocalltheCHAorreturntoclinic/ERforanysignificantreacIon.
OROntheInpa1entUnit:thepaIentcanbegiventhefirst1-3dosesofamoxicillinpriortobeing
dischargedhome.Thecaretaker’sshouldbecounseledtocalltheCHAorreturntoclinic/ERforanysignificantreacIon.
NOTE:IfthepaIenthash/ohives,theycanbesenttoAnchorageAllergyandImmunologyforskintesIng
aQertheageoffive.
ExampleAutotextforRMTForAmoxicillinTrial
• *InsertAddendumHere:• Reviewofthemedicalhistorydoesnotindicateanyevidenceofallergyto
amoxicillin• CHAandfamilyareOKwithtrialofAmoxicillin• RecommendstarIngAmoxicillinperordersbyweightandwatchingfor
onehour• ThefirstdoseofAmoxicillinistobegivenintheclinicwithepinephrine
available.• PaIentwillstayinclinicforanhouraQerwardsforobservaIoninwaiIng
room• Ifnoproblemswiththefirstdose,thenthepaIentcangohomeand
conInuemedicineasprescribed.• Benadrylbyweightwillbegiventotakehomeforanyrashorswelling• Ifarashoranyconcernsdevelop,thepaIentshouldbebroughtbackto
clinic,atelemedpicturetakenandRMTsentin
-ClickonyourAmoxicillin/Augmen1n/PCNallergyalertatthetopleTsideofathepa1ent’schartandlookatthenotesbeforeyouprescribeand/orsendoutanalternatedrug.AND-Getasmuchinforma1onaspossibleaboutanyreported‘allergy’AND-Educatethefamilythatdiarrheaorafineredrash(nothives),especiallyininfants,isnotanallergy.Fineredrashesalloverthebodyareusuallyduetoaninterac1onwithavirusandAmoxicillinthatdoesnotqualifyasatrueallergyAND-Documentcarefullyand/ortakeapictureontelemed,ofanytrueallergicreac1onAND-Getasecond(orthird)opinionbeforeyoudiagnoseanAmoxicillinallergyAND-Consideratrialofamoxicillininthevillage,ERorbethelclinicifthereisnohistoryofhivesordifficultybreathingAND-Callapediatricianforadviceifneeded.AND-ForahistoryofatrueAmoxicillinAllergy-referpa1ents5yearsoroldertoAllergyandImmunologyinAnchorageforPCNskintes1ngbeforetheygettoooldAND-Removeamoxicillinallergybannerswheneverpossible
GotoAllergyAlertsandclickonit
DoubleclickonAllergy GotoAllergyDetails
GotoStatusandchangetocanceled ChangeReasontoOKonRetrialor…. ClickApply
MakesuretheAllergyhasbeenchangedto‘NoKnownAllergy’andDisplaysaysAcIve Note:IfapaIentwasoncerecordedashavingnoallergiesandthenrecordedashavinganallergy,andthenyoucanceltheexisIngallergy,theAllergiesstatusdefaultsto"Allergiesnotrecorded,"andifyougointotheAllergiespage,the"NoKnownAllergies"buvonwillbeditheredout.Youactuallyhavetochangeyourviewto"AllAllergies"(itdefaultsto"AcIveAllergies")andthenmodifytheoriginally-canceled"NoKnownAllergies"entrybackto"AcIve"inordertomakethebannerdisplaycorrectly.