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Drug Allergy
Published in Pudupakkam K Vedanthan, Harold S Nelson, Shripad N Agashe, PA Mahesh, Rohit Katial, Textbook of Allergy for the Clinician, 2021
A 55-year-old woman with multiple myeloma reports that 10 years ago she received oral amoxicillin for pneumonia and developed immediate hives and throat swelling after the first dose. She was treated with diphenhydramine and steroids and switched to levofloxacin. In the years prior to this she had been treated with penicillin on at least two occasions without adverse events. She has avoided penicillin since that event. Five years ago she was treated with oral cephalexin for cellulitis and after the first dose developed immediate hives and wheezing. She has since been labeled with a penicillin and cephalosporin allergy and has avoided all beta-lactam antibiotics. She will likely need antibiotics during her upcoming therapy and is referred for evaluation and planning for desensitization. Given this history, skin testing is performed with penicillin, penicilloyl-polylysine, amoxicillin and ceftazadime. The only positive reaction is to amoxicillin. It is determined she is allergic to the shared side chain that is in both amoxicillin and cephalexin and not to the core beta-lactam ring of either penicillin or cephalosporin. Her allergies are specific to the aminopenicillin and a small subset of cephalosporin that share this common side chain. She tolerates all other beta-lactam antibiotics without issue.
Cutaneous Adverse Drug Reactions in HIV-Infected Persons
Published in Kirsti Kauppinen, Kristiina Alanko, Matti Hannuksela, Howard Maibach, Skin Reactions to Drugs, 2020
Hélène Bocquet, Jean-Claude Roujeau
Several studies have suggested that the risk of cutaneous drug reaction increased with the progression of the disease.1,7,12,50 Patients with CD4 T-lymphocyte counts below 200/ml had more rashes to aminopenicillin and to trimethoprim-sulfamedioxazole. It has also been proposed that in patients with the most profound immunodepression (CD4 T-lymphocyte counts below 20 or 25/ml) the risk decreased again. This dome-shaped relationship between the number of blood CD4 T-lymphocytes and the rate of skin drug reactions has not been observed in some other series.2,3,51
Drug eruption from amoxicillin
Published in Alisa McQueen, S. Margaret Paik, Pediatric Emergency Medicine: Illustrated Clinical Cases, 2018
Non-pruritic maculopapular rashes are a common adverse effect associated with amoxicillin. About 3%–7% of patients may develop this type of reaction during treatment with an aminopenicillin (Bass et al., 1973). Frequently, the non-pruritic rash develops 3 to 10 days after initiating the antibiotic. The rash is thought to be idiopathic and is unlikely to be IgE-mediated (Pichichero 2005). In most cases, a child such as the one in the description can receive beta-lactam antibiotics in the future (Bierman et al., 1972). Careful documentation of the rash in the patient's allergies is important to ensure appropriate future antibiotic treatment options.
Resistance studies with Streptococcus pneumoniae using an in vitro dynamic model: amoxicillin versus azithromycin at clinical exposures
Published in Journal of Chemotherapy, 2019
Maria V. Golikova, Elena N. Strukova, Yury A. Portnoy, Svetlana A. Dovzhenko, Mikhail B. Kobrin, Stephen H. Zinner, Alexander A. Firsov
In the present study that simulates clinical antibiotic exposures, there was no enrichment of S. pneumoniae mutants resistant to amoxicillin. In contrast, azithromycin-resistant mutants were enriched in all simulations. This difference is directly related to the different times above the MPC: 60–100% of the dosing interval for the aminopenicillin versus zero percentage for the azalide. Obviously, such different T>MPCs are due to the much lower MPCs of amoxicillin (0.03–1 mg/L) as compared to the MPCs of azithromycin (2–4 mg/L) – see Table 1. At least for S. pneumoniae strains used in simulated treatments the determined MPCs were in concordance with reported MPC50 and MPC90 values (1 and 4 mg/L, respectively).8 Due to the high MPCs of azithromycin, resistant S. pneumoniae were enriched even at the higher AUC24/MIC ratios (up to 23 and 45 h in simulations with 1000-mg azithromycin) than reported previously (0.3–10 h).23,24 It is noteworthy that resistant mutants of S. pneumoniae ATCC 6303 exposed to azithromycin AUC24/MIC of 45 h were enriched more intensively than mutants of S. pneumoniae ATCC 49619 and 9/5 at AUC24/MIC of 23 h (Figure 4). The different time courses of resistant mutants can be attributed to the difference in the time inside MSW (TMSW): 57% of the dosing interval in the former case versus only 13% in the two latter cases (Table 2).
Recent developments in drug hypersensitivity in children
Published in Expert Review of Clinical Immunology, 2019
Ilknur Kulhas Celik, Emine Dibek Misirlioglu, Can Naci Kocabas
There are limited data in the literature pertaining to the natural history of DHR to BL antibiotics. In a recent study, Tonson la Tour et al. found that 89% of 16 patients with nonimmediate DHR to BL antibiotics developed tolerance to the responsible drug within a mean of 3.5 years of their initial positive DPT [33]. The literature data regarding cross-reactivity between BLs in children are also limited. In a recent systematic review, the authors stated that skin tests can anticipate IgE-mediated reactions and described cross-reactivity between penicillins and early generation cephalosporins having similar side chains. They also demonstrated that later-generation cephalosporins, which have different side chains, do not cause any skin test cross-reactivity with penicillin or amoxicillin [11]. Misirlioglu et al. found that a large proportion of children with immediate hypersensitivity reactions to BL antibiotics were selective responders. They also demonstrated that most of the patients with reactions to aminopenicillin and cephalosporins safely tolerated penicillin V and BL antibiotics with different side chains after negative allergy workup results [34].
Pleural infection: a closer look at the etiopathogenesis, microbiology and role of antibiotics
Published in Expert Review of Respiratory Medicine, 2019
Eihab O. Bedawi, Maged Hassan, David McCracken, Najib M. Rahman
Whilst certainly dated, lacking in humans, and based on ancient regimes, the literature seems to suggest that most antibiotics show good pleural fluid penetration, with the antibiotic exceeding the minimum inhibitory concentration (MIC) for the bacteria for which it would be normally used [73]. As mentioned earlier, the notable exception is gentamicin and current guidelines, therefore, recommend against the use of aminoglycosides in pleural infection [40,74]. The initial selection of agent should always depend on whether the patient is likely to have a community or hospital-acquired infection, given our greater understanding in the last decade, of the variation in microbiology as described above. This should then be correlated with local hospital policies and antibiotic resistance patterns. In community-acquired infection, treatment with an aminopenicillin will cover the common causative organisms, but a beta-lactamase inhibitor such as co-amoxiclav or metronidazole should also be given due to the frequent co-existence of penicillin-resistant aerobes (including staph aureus) and anaerobic bacteria. Clindamycin, alone, or in combination with ciprofloxacin or a cephalosporin are likely to provide good alternatives for patients with penicillin allergy [40]. In the setting of hospital-acquired or post-surgical infection, vancomycin and piperacillin/tazobactam will cover the added risk of MRSA and Pseudomonas. Vancomycin and meropenem may be indicated if there is a history or suspicion of extended-spectrum beta-lactamase producing organisms [40,80].