Hypersensitivity reactions due to antibiotics: the significance of provocation tests in determining alternative antibiotics

Giriş: Toplumumuzda antibiyotiklere bağlı hiper- sensitivite reaksiyonlarının özellikleri tam olarak bi- linmemektedir. Çalışmanın amacı, ilaçlara bağlı hi- persensitivite reaksiyonu nedeniyle başvuran hasta- larda antibiyotiklere bağlı hipersensitivite reaksiyon- larının sıklığını ve alternatif antibiyotik seçimindeki kullanılacak güvenli tanı yöntemini belirlemektir. Gereç ve Yöntem: Çalışmaya bir yıl içinde ilaçla- ra bağlı hipersensitivite reaksiyonu tarif eden toplam 393 hasta alındı. Anamnezle bildirilen şüpheli anti- biyotikler sınıflandırıldı ve hastaların atopik hasta- lıkları sorgulandı. Alternatif antibiyotikler için deri prik ve intradermal testleri uygulandı. Deri testlerin- de negatif sonuç veren ilaçlarla çift-kör plasebo kontrollü ilaç provokasyon testleri uygulandı. Bulgular: Anamneze göre toplam 393 hastanın 192 (%48.9)’sinde antibiyotiklere bağlı hipersensiti- vite reaksiyonu öyküsü mevcuttu. Antibiyotiklere bağlı olarak bildirilen hipersensitivite reaksiyonları- nın, hastalardaki atopi, astım ya da kronik ürtiker varlığıyla ilişkili olmadığı görüldü. Hipersensitivite reaksiyonlarından sorumlu antibiyotikler sıklık sı- rasına göre; amoksisilin (%15.3), penisilin (%12.5), ampisilin (%12), kinolonlar (%5.9), ikinci kuşak se- falosporinler (%5.3), klaritromisin (%4.8), sülfona- midler (%3.6), klindamisin (%2), birinci kuşak sefa- losporinler (%2), üçüncü kuşak sefalosporinler (%1.5), gentamisin (%1.3), tetrasiklin (%1.3) ve makrolidlerdi (< %1). Anamnezde sıklık sırasına gö- re tarif edilen reaksiyonlar; ürtiker, anafilaksi ve di- ğer deri belirtileriydi. Deri testlerinde siprofloksasi- ne duyarlı olmayan 40 hastanın 36’sında aynı ilaç ile provokasyon testi de negatif bulundu. Benzer şe- kilde sefuroksim aksetil ile deri testi negatif sapta- nan 82 hastanın 77’si ve klindamisin ile deri testi negatif saptanan 38 hastanın 35’i oral provokasyon testinde reaksiyon yaşamadı. Amoksisilin, ampisilin ve penisiline bağlı hipersensitivite reaksiyonu tarif eden hastaların çoğu sefuroksim aksetili (29/31, 22/25, 18/20) ve klindamisini (21/29, 22/24, 15/17) tolere edebildi. Altı ay içinde hiçbir hasta önerilen ilaç kullanımına bağlı reaksiyon nedeniyle tekrar başvurmadı. Sonuç: Çalışma grubumuzda aminopenisilinler ve penisilin en çok reaksiyon tarif edilen ilaçlar, sefuroksim aksetil ve klindamisin ise en güvenli alternatifler olarak saptanmıştır. Deri testi sonuçları çoğunlukla provokasyon testleriyle uyumlu bulunmuş olsa da, provokasyon sırasında az sayıda da olsa sistemik belirtiler gelişen hastalar saptandığından, antibiyotik allerjisinde alternatif ilaç önerilmesinde provokasyon testleri uygulanmasının gerektiği kanaatine varılmıştır.Objective: In our population the properties of hypersensitivity reactions to antibiotics aren&amp;#8217;t well studied. The aim of our study is to determine the rate of hypersensitivity reactions to different antibiotics and the appropriate method to find out alternatives. Materials and Methods: 393 patients, self reporting hypersensitivity reactions to drugs within the past year were enrolled. History was taken and the reported reactions to antibiotics were classified. Skin tests with alternative antibiotics were applied. Double-blind placebo controlled drug provocation tests were done to the patients with negative skin test results. Results: 192 (48.9%) patients were determined as having hypersensitivity reactions to antibiotics. These reactions were not associated with atopy, asthma or chronic urticaria. The reported antibiotics were amoxicillin (15.3%), penicillin (12.5%), ampicillin (12%), quinolones (5.9%), 2nd generation cephalosporins (5.3%), clarithromycin (4.8%), sulphonamides (3.6%), clindamycin (2%), 1st generation cephalosporins (2%), 3rd generation cephalosporins (1.5%), gentamycin (1.3%), tetracycline (1.3%), and macrolides (&lt; 1%) respectively. The most frequent reaction was urticaria, followed by anaphylaxis and other skin reactions. Thirty six out of 40 patients, 77 of 82 patients and 35 of 38 patients with negative skin test results due to ciprofloxacin, cefuroxime acetyl and clindamycin were successfully challenged with each drug respectively. Most of the patients reporting hypersensitivity reactions to amoxicillin, ampicillin and penicillin did not react to cefuroxime acetyl (29/31, 22/25, 18/20 patients, respectively) and clindamycin (21/29, 22/24, 15/17 patients, respectively) in challenge tests. None of the patients with negative challenge tests returned to the clinic due to following adverse reactions. Conclusion: In our study population aminope- nicillins and penicillin are likely to be the most frequent causes of hypersensitivity reactions and clindamycin and cefuroxime axetyl seem to be safe alternatives. Although skin test results were mostly concordant with double blind placebo controlled drug provocation tests, double-blind placebo controlled drug provocation tests must be applied in all patients as a confirmative diagnostic procedure in antibiotic allergy

Expert Opinion on Practice Patterns in Mild Asthma After the GINA 2019 Updates: A Major Shift in Treatment Paradigms from a Long-Standing SABA-Only Approach to a Risk Reduction-Based Strategy with the Use of Symptom-Driven (As-Needed) Low-Dose ICS/LABA

Purpose of Review This expert opinion, prepared by a panel of chest disease specialists, aims to review the current knowledge on practice patterns in real-life management of mild asthma and to address the relevant updates in asthma treatment by The Global Initiative for Asthma (GINA) to guide clinicians for the best clinical practice in applying these new treatment paradigms. Recent Findings On the basis of the emerging body of evidence suggesting the non-safety of short-acting beta 2-agonists (SABA)-only therapy and comparable efficacy of the as-needed inhaled corticosteroids (ICS)-formoterol combinations with maintenance ICS regimens, GINA recently released their updated Global Strategy for Asthma Management and Prevention Guide (2019). The new GINA 2019 recommendations no longer support the SABA-only therapy in mild asthma but instead includes new off-label recommendations such as symptom-driven (as-needed) low-dose ICS-formoterol and low dose ICS taken whenever SABA is taken. The GINA 2019 asthma treatment recommendations include a major shift from long-standing approach of clinical practice regarding the use of symptom-driven SABA treatment alone in the management of mild asthma. This expert opinion supports the transition from a long-standing SABA-only approach to a risk reduction-based strategy, with the use of symptom-driven (as-needed) low-dose ICS/LABA in mild asthma patients, particularly in those with poor adherence to controller medications. The thoughtful and comprehensive approach of clinicians to these strategies is important, given that the exact far-reaching impact of this major change in management of mild asthma in the real-world settings will only be clarified over time.AstraZeneca TurkeyThis expert panel study was supported by AstraZeneca Turkey which played a role in organization of expert panel meeting in collaboration with The Turkish Respiratory Society and compensation for editorial support. Astra-Zeneca Turkey had no role in the study design, selection of experts, data collection and analysis, decision to publish, or preparation of the manuscript. The authors would like to thank Cagla Ayhan, MD, and Prof. Sule Oktay, MD, PhD. from the KAPPA Consultancy Training Research Ltd, Istanbul, who provided editorial support funded by Astra-Zeneca Turkey

Psychiatric comorbidity and quality of life in patients with drug hypersensitivity

Background: Compared with advances in a drug hypersensitivity diagnosis and management, little is known about the mental health status of patients with drug hypersensitivity and the impact of this psychological distress on their quality of life (QoL). Objective: The objectives were to evaluate anxiety, depression, and QoL levels in patients with drug hypersensitivity, assess how some related factors may affect them, and determine the impact of disease on their QoL. Methods: A total of 203 patients with drug hypersensitivity and 80 healthy controls were evaluated with the Beck Anxiety Results: The mean +/- standard deviation (SD) BAI scores of the patients and the controls were 13.46 +/- 11.78 and 1.94 +/- 1.93, respectively (p < 0.0001). The mean +/- SD BDI scores were higher in the patient group (9.23 +/- 6.36) than in the control group (2.18 +/- 2.02) (p < 0.0001). The patients had significantly increased risk of anxiety versus the controls (48.8% versus 7.5%) (odds ratio [OR] 11.74 [95% confidence {CI}, 4.88-28.20]; p <0.0001) and depression versus the controls (31.5% versus 6.2%) (OR 6.90 [95% CI, 2.66-17.90]; p = 0.0001). The comparison of patients' BAI and BDI scores showed that those with more severe reactions had higher scores than those with moderate and mild reactions. A negative correlation was found Conclusion: Anxiety and depressive symptoms have a high prevalence in patients with confirmed drug hypersensitivity, which leads to a notable decrease in QoL. Self-administered psychological questionnaires were shown to be useful in the psychological examination and management of patients with drug hypersensitivity. Therefore, we found that psychological support is critical to reducing the negative outcomes of hypersensitivity reactions in patients

Country-based report: the safety of omalizumab treatment in pregnant patients with asthma

Background/aim: We aimed to report outcomes of pregnant patients with asthma under omalizumab treatment and their infants in our country. Materials and methods: Patients with asthma who received omalizumab for at least 6 months and at least one dose during their pregnancy were retrospectively evaluated using a questionnaire regarding their disease and therapy and the health of their infants. Results: Twenty pregnant patients and their 23 infant's data were analyzed. The mean delivery age was 31.8 +/- 7.4 years. They received omalizumab for 28.9 +/- 21.8 months. Eight (36.4%) patients showed exacerbation of the disease during pregnancy. Forced expiratory volume in 1 s (FEV1) and asthma control test (ACT) scores at the starting time of omalizumab administration, first month of the pregnancy, and after delivery were 71 +/- 18%, 83.4 +/- 10.5%, and 80.5 +/- 13% (FEV1), and 11.9 +/- 4.9, 20.2 +/- 2.6, and 20.4 +/- 2.2 (ACT), respectively. One patient gave birth to twin infants, two patients to two infants each in different years, and 17 to one infant each. Three (13%) infants had low birth weight and five (21.7%) were born prematurely. No congenital anomalies were detected. Seven (30.4%) infants presented atopic diseases during their life. Conclusion: Omalizumab treatment during pregnancy seems to be safe for both patients and their infants