How Many Patients With History of Penicillin Allergy Are Truly Allergic?

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Very Few Patients with Penicillin Allergy Histories Are Truly Allergic

David J. Amrol, MD reviewing Macy E and Ngor EW. J Allergy Clin Immunol Prac 2013 May.

Penicillin allergy testing can safely exclude IgE-mediated penicillin allergy.

Almost 8% of the U.S. population claims to be allergic to penicillin, but only a small proportion of these patients are truly allergic. Penicillin skin testing is the only way to identify IgE-mediated allergy (an immediate hypersensitivity reaction mediated by preformed IgE bound to the surface of mast cells and basophils). Penicilloyl-poly-lysine (Pre-Pen), the major determinant of penicillin allergy, has been available commercially since 2009, but clinicians rarely order skin testing. Some physicians are concerned that Pre-Pen testing is inadequate without also testing for minor determinants (penicilloate and penilloate), which are not readily available.

From 2010 to 2012, 500 patients with histories of penicillin allergy (based on diagnoses recorded in their records) were skin tested in a California allergy department using penicilloyl-poly-lysine and fresh penicillin G. Negative tests were followed by 1-hour observed oral challenges with amoxicillin. Four patients reacted to one of the two skin-test agents, and another four exhibited positive objective symptoms after oral challenges. None of these reactions [were] life threatening or required epinephrine.

COMMENT

In this study, fewer than 1 in 50 patients with penicillin allergy histories were truly allergic. We should stop accepting penicillin allergy history as a reason for lifelong avoidance. All drug reactions should be documented carefully. Patients with severe delayed reactions such as Stevens Johnson syndrome, drug reaction with eosinophilia and systemic symptoms (DRESS), or hemolytic anemia should never be challenged or tested; those with mild delayed reactions probably can undergo oral challenges. For those with potential IgE-mediated reactions (i.e., hives, edema, or other symptoms of anaphylaxis occurring within 1–2 hours), penicillin testing followed by oral challenge is safe and effective. Penicillin is the only antibiotic for which such testing is available.

Dr. Amrol is an Associate Professor of Clinical Internal Medicine and Director of the Division of Allergy and Immunology at the University of South Carolina School of Medicine in Columbia.

CITATION:

Macy E and Ngor EW. Safely diagnosing clinically significant penicillin allergy using only penicilloyl-poly-lysine, penicillin, and oral amoxicillin. J Allergy Clin Immunol Prac 2013 May; 1:258. [J Allergy Clin Immunol Prac article abstract]

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Independent Risk Factors for Urinary Tract Infection and for Subsequent Bacteremia or Acute Cellular Rejection: A Single-Center Report of 1166 Kidney Allograft Recipients

Transplantation - Published Ahead-of-Print Independent Risk Factors for Urinary Tract Infection and for Subsequent Bacteremia or Acute Cellular Rejection: A Single-Center Report of 1166 Kidney Allograft Recipients

Background: Urinary tract infection (UTI) is a frequent, serious complication in kidney allograft recipients. Methods: We reviewed the records of 1166 kidney allograft recipients who received their allografts at our institution between January 2005 and December 2010 and determined the incidence of UTI during the first 3 months after transplantation (early UTI). We used Cox proportional hazards models to determine the risk factors for early UTI and whether early UTI was an independent risk factor for subsequent bacteremia or acute cellular rejection (ACR). Results: UTI, defined as 105 or more bacterial colony-forming units/mL urine, developed in 247 (21%) of the 1166 recipients. Independent risk factors for the first episode of UTI were female gender (hazard ratio [HR], 2.9; 95% confidence intervals [CI], 2.2-3.7; P<0.001), prolonged use of Foley catheter (HR, 3.9; 95% CI, 2.8-5.4; P <0.001), ureteral stent (HR, 1.4; 95% CI, 1.1-1.8; P=0.01), age (HR, 1.1; 95% CI, 1.0-1.2; P=0.03), and delayed graft function (HR, 1.4; 95% CI, 1.0-1.9; P=0.06). Trimethoprim/sulfamethoxazole prophylaxis was associated with a reduced risk of UTI (HR, 0.6; 95% CI, 0.3-0.9; P=0.02). UTI was an independent risk factor for subsequent bacteremia (HR, 2.4; 95% CI, 1.2-4.8; P=0.01). Untreated UTI, but not treated UTI, was associated with an increased risk of ACR (HR, 2.8; 95% CI, 1.3-6.2; P=0.01). Conclusions: Female gender, prolonged use of Foley catheter, ureteral stent, age, and delayed graft function are independent risk factors for early UTI. UTI is independently associated with the development of bacteremia, and untreated UTI is associated with subsequent ACR. (C) 2013 by Lippincott Williams & Wilkins


http://pdfs.journals.lww.com/transplantjournal/9000/00000/Independent_Risk_Factors_for_Urinary_Tract.98474.pdf

One-year results of a prospective, randomized, trial comparing two machine perfusion devices used for kidney preservation

Transplant International One-year results of a prospective, randomized, trial comparing two machine perfusion devices used for kidney preservation

Studies have shown beneficial effects of machine perfusion (MP) on early kidney function and long-term graft survival. The aim of this study was to investigate whether the type of perfusion device could affect outcome of transplantation of deceased donor kidneys. A total of 50 kidneys retrieved from 25 donors were randomized to machine perfusion using a flow driven (FD) device (RM3; Waters Medical Inc) or a pressure driven (PD) device (LifePort; Organ Recovery Systems), 24 of these kidneys (n=12 pairs; 48%) were procured from expanded criteria donors (ECD). The primary endpoints were kidney function after transplantation defined using the incidence of delayed graft function (DGF), the number of hemodialysis sessions required, graft function at 12 months, and analyses of biopsy. DGF was similar in both groups (32%; 8/25). Patients with DGF in the FD group required a mean of 4.66 hemodialysis sessions versus 2.65 in the PD group (p=0.005). Overall 1-year graft survival was 80% (20/25) versus 96% (24/25) in the FD and PD groups. One-year graft survival of ECD kidneys was 66% (8/12) in the FD group versus 92% (11/12) in the PD group. Interstitial fibrosis and tubular atrophy were significantly more common in the FD group – 45% (5/11) versus 0% (0/9) (p=0.03) in PD group. There were no differences in creatinine levels between the groups.Machine perfusion using a pressure driven device generating lower pulse stress is superior to a flow driven device with higher pulse stress for preserving kidney function. This article is protected by copyright. All rights reserved.


http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Ftri.12169

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The Survival Benefit of Kidney Transplantation in Obese Patients

AJT - Early The Survival Benefit of Kidney Transplantation in Obese Patients

Obese patients have a decreased risk of death on dialysis but an increased risk of death after transplantation, and may derive a lower survival benefit from transplantation. Using data from the United States between 1995 and 2007 and multivariate non-proportional hazards analyses we determined the relative risk of death in transplant recipients grouped by body mass index (BMI) compared to wait-listed candidates with the same BMI (n = 208 498). One year after transplantation the survival benefit of transplantation varied by BMI: Standard criteria donor transplantation was associated with a 48% reduction in the risk of death in patients with BMI ≥ 40 kg/m2 but a ≥66% reduction in patients with BMI < 40 kg/m2. Living donor transplantation was associated with ≥66% reduction in the risk of death in all BMI groups. In sub-group analyses, transplantation from any donor source was associated with a survival benefit in obese patients ≥50 years, and diabetic patients, but a survival benefit was not demonstrated in Black patients with BMI ≥ 40 kg/m2. Although most obese patients selected for transplantation derive a survival benefit, the benefit is lower when BMI is ≥40 kg/m2, and uncertain in Black patients with BMI ≥ 40 kg/m2.


http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fajt.12331

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The effect of donor-recipient gender mismatch on short- and long-term graft survival in kidney transplantation: a systematic review and meta-analysis

Clinical Transplantation The effect of donor-recipient gender mismatch on short- and long-term graft survival in kidney transplantation: a systematic review and meta-analysis

Background There is no limitation of gender matching in renal transplantation. This study was intended to evaluate its effect on short- and long-term graft survival. Methods PubMed, the Web of Knowledge, Medline, the Cochrane Library, and two additional Chinese databases were searched. The data were then abstracted and meta-analyzed. Results 14 studies involving 445 279 patients were included. Each study reported data on the four gender matches (male donor-male recipient, MDMR; male donor-female recipient, MDFR; female donor-male recipient, FDMR; female donor-female recipient, FDFR). The pooled risk ratios (RRs) for 0.5-, 1-, 2-, 3-, 5-, and 10-yr graft survival rates showed that the FDMR group had the worst outcomes, and when recipients were female, short-term graft survival was worse, but long-term graft survival was better. The differences between groups changed with time. Conclusions FDMR patients showed poor graft survival. The female recipients had worse short-term graft survival but the best long-term graft survival. This study introduces an important consideration into donor-recipient matching in renal transplantation.


http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fctr.12191

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Analysis of Anti-HLA Antibodies in Sensitized Kidney Transplant Candidates Subjected to Desensitization with Intravenous Immunoglobulin and Rituximab

Transplantation - Most Popular Articles Analysis of Anti-HLA Antibodies in Sensitized Kidney Transplant Candidates Subjected to Desensitization with Intravenous Immunoglobulin and Rituximab

Background: Preexisting donor-specific antibodies against human leukocyte antigens are major risk factors for acute antibody-mediated and chronic rejection of kidney transplant grafts. Immunomodulation (desensitization) protocols may reduce antibody concentration and improve the success of transplant. We investigated the effect of desensitization with intravenous immunoglobulin and rituximab on the antibody profile in highly sensitized kidney transplant candidates.

Methods: In 31 transplant candidates (calculated panel-reactive antibody [cPRA], 34%–99%), desensitization included intravenous immunoglobulin on days 0 and 30 and a single dose of rituximab on day 15. Anti–human leukocyte antigen antibodies were analyzed before and after desensitization.

Results: Reduction of cPRA from 25% to 50% was noted for anti–class I (5 patients, within 20–60 days) and anti–class II (3 patients, within 10–20 days) antibodies. After initial reduction of cPRA, the cPRA increased within 120 days. In 24 patients, decrease in mean fluorescence intensity of antibodies by more than 50% was noted at follow-up, but there was no reduction of cPRA. Rebound occurred in 65% patients for anti–class I antibodies at 350 days and anti–class II antibodies at 101 to 200 days. Probability of rebound effect was higher in patients with mean fluorescence intensity of more than 10,700 before desensitization, anti–class II antibodies, and history of previous transplant.

Conclusions: The desensitization protocol had limited efficacy in highly sensitized kidney transplant candidate because of the short period with antibody reduction and high frequency of rebound effect.

http://journals.lww.com/transplantjournal/Fulltext/2013/07270/Analysis_of_Anti_HLA_Antibodies_in_Sensitized.12.aspx

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