when Prescribing Blactams for Patients with a known Penicillin Allergy Meghan N Jeffres PharmD Elizabeth A HallLipsy JD MPH S Travis King PharmD BCPS AQID John D Cleary PharmD FCCP BCPS AQID ID: 930294
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Slide1
Slide2Systemic Review of Professional Liability
when Prescribing B-lactams for Patients
with a known Penicillin Allergy
Meghan N. Jeffres, PharmD
Elizabeth A. Hall-Lipsy, JD, MPH
S. Travis King, PharmD, BCPS (AQ-ID)John D. Cleary, PharmD, FCCP, BCPS, (AQ-ID)
Ann Allergy Asthma Immunol.
November
2018;121
(5):530-536
Slide3Systemic Review of Professional Liability
when Prescribing
β
-lactams for Patients
with a known Penicillin Allergy
Key MessagesJeffres MN, et al. Ann Allergy Asthma Immunol. November 2018;121(5):530-536Patients labeled as penicillin-allergic are more likely to receive second line non-β-lactam antibiotics, experience higher rates of treatment failure, and incur higher antibiotic costs.Fear of litigation has been identified as a potential reason clinicians avoid using β-lactams in a patient with a penicillin allergy. Since 1959, 27 medical malpractice or negligence cases have been published in which a patient with a penicillin allergy received a β-lactam and experienced an adverse reaction.Defendants (providers) were found liable in 3 of 7 cases in which a penicillin-based antibiotic was prescribed to a patient with a known penicillin allergy.Defendants were not found liable in any cases in which a cephalosporin or carbapenem was prescribed excluding 1 case in which physicians settled out of court.Judges have cited a lack of scientific evidence demonstrating cephalosporins or carbapenems are contraindicated for patients with a penicillin allergy.
Slide4Number of Medical Malpractice or
Negligence Cases per Decade
Jeffres MN, et al. Ann
Allergy Asthma Immunol.
November
2018;121(5):530-536
Slide5Penicillin Minor Determinants: History
and Relevance for Current Diagnosis
N. Franklin Adkinson Jr, MD
Louis M. Mendelson, MD
Charlotte Ressler, PhD
John C. Keogh, MWC, ELS
Ann Allergy Asthma Immunol.
November
2018;121
(5):537-544
Slide6Penicillin Minor Determinants: History
and Relevance for Current Diagnosis
Key Messages
Adkinson Jr, NF, et al. Ann
Allergy Asthma Immunol.
November 2018;121(5):537-544Early immunochemical studies of penicillin allergy showed minor antigenic determinants in addition to the major penicilloyl determinant.These minor penicillin determinants are often involved in more severe and serious cases of anaphylaxis to penicillins.The use of skin testing with benzylpenicillin alone is insufficient to detect all immunoglobulin E with minor determinant specificities.A “minor determinant mixture” composed of equal quantities of benzylpenicillin and both its alkaline and acid hydrolysate products (penicilloate and penilloate) has been used successfully in multiple large studies over 5 decades to detect clinically significant minor penicillin-determinant immunoglobulin E antibodies by skin testing.
Slide7Chemical Structures of the Principal
Minor Penicillin Determinants
Adkinson Jr, NF, et al. Ann
Allergy Asthma Immunol.
November
2018;121(5):537-544
Slide8Management of Anaphylaxis and Allergies in Patients with Long QT Syndrome: A Review of the Current Evidence
Tatjana Welzel, MD
Victoria C. Ziesenitz, MD
Stefanie Seitz, MD
Birgit Donner, MD, PhD
Johannes N. van den Anker, MD, PhD
Ann Allergy Asthma Immunol.
November
2018;121
(5):545-551
Slide9Management of Anaphylaxis and Allergies
in Patients with Long QT Syndrome:
A Review of the Current Evidence
Key Messages
Welzel T, et al. Ann
Allergy Asthma Immunol. November 2018;121(5):545-551Management of anaphylaxis and allergic reactions in patients with inherited long QT syndrome (iLQTS) needs a modified and more personalized antiallergic drug administration.Epinephrine should be used in patients with iLQTS despite risk of torsades de pointes, but close monitoring and possibility of defibrillation should be ensured.Glucagon as add-on therapy may become necessary if epinephrine is ineffective in patients with iLQTS and b-blocker therapy.Corticosteroid administration (orally or intravenously) seems to be safe in patients with iLQTS.Ipratropium bromide should be used as first choice instead of inhaled b2-adrenergic agents for supplemental treatment of bronchoconstriction in patients with iLQTS.Treatment of local allergic symptoms with fexofenadine, levocetirizine, desloratadine, and cetirizine seems to be safe in patients with iLQTS, whereas clemastine may have a risk for torsades de pointes.
Slide10Anaphylactic Reactions in Patients with
Long QT Syndrome (LQTS)
Welzel T, et al. Ann
Allergy Asthma Immunol.
November
2018;121(5):545-551
Slide11High-risk Drug Rashes
Sasha A. Alvarado, DO
Diana Munoz-Mendoza, MD
Sami L. Bahna, MD, DrPH
Ann Allergy Asthma Immunol.
November 2018;121
(5):552-560
Slide12High-risk Drug Rashes
Key Messages
Alvarado SA, et al.Ann
Allergy Asthma Immunol.
November
2018;121
(5):552-560
Drug rashes are common and mostly benign, but some carry high risk of morbidity and mortality.
Early diagnosis and prompt management are essential in cases of Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms syndrome, multiple drug hypersensitivity syndrome, acute generalized exanthematous pustulosis, and drug-induced bullous pemphigoid.
The lack of reliable routine tests for identification of the causative agent imposes difficulty in patients receiving multiple medications.
In addition to immediate discontinuation of use of the suspected drug(s), management is basically monitoring of vital organ functions and individualized supportive treatment.
Immunomodulatory and/or immunosuppressant agents may be judicially used as guided by published studies.
Slide13Stevens-Johnson
S
yndrome in a 4-year-old Girl
after
R
eceiving Thiabendazole
Alvarado SA, et al.Ann
Allergy Asthma
Immunol. November
2018;121
(5):552-560
Slide14Toxic
Epidermal
Necrolysis
with Extensive Epidermal Detachment
and Mucosal Involvement in a Young Girl after Taking Phenytoin
Alvarado SA, et al.Ann
Allergy Asthma Immunol.
November
2018;121
(5):552-560
Slide15Desquamation in the
Healing Stage
of
Stevens
-Johnson
Syndrome
Alvarado SA, et al.Ann
Allergy Asthma Immunol.
November
2018;121
(5):552-560
Slide16Facial
Edema
and
Diffuse Erythema
in a Young
Woman with Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome
Alvarado SA, et al.Ann
Allergy Asthma Immunol.
November
2018;121
(5):552-560
Slide17Acute Generalized Exanthematous Pustulosis
Alvarado SA, et al.Ann
Allergy Asthma
Immunol. November 2018;121(5):552-560
Slide18Tense
Bullae
C
haracteristic
of Bullous
Pemphigoid
Alvarado SA, et al.Ann
Allergy Asthma Immunol.
November
2018;121
(5):552-560