StampingOutAmoxicillinAllergyKJaneMcClure1.7.2013

WhatYouNeedtoKnowWhatYouCanDotoHelp

WHAT

• WanttoeliminateincorrectAmoxicillinlabelingandlabels

WHY•  AlargenumberofpaIent’samoxicillinallergylabelsareincorrect.

•  AmoxicillinandAugmenInaretheBESTfirstlineopIonfortreaIngoIIsmediaandpneumoniainchildren.

•  NotbeingabletouseamoxicillindrasIcallyreducesthenumberandtypesofanIbioIcsthatcanbeusedforapaIent.

•  TherearenotmanyopIonsforothergoodanIbioIcsinthevillage(wanttoavoidsendingoutOmniceforusingCeQriaxone)

•  Increaseduseofcephalosporinsforunproven‘amoxiciilinallergic’paIentswillcreateresistance.

HowDidThesePa1entAllergyLabelsGetThere??

•  ImportedfromRPMSinEHRconversion•  Chartlore•  LackofeducaIonaboutsignsandsymptomsofatrueAmoxicillinallergy

•  ImproperlabelingofpaIentsasAmoxicillinallergicbyproviders,CHAsparentsandcaretakers

PENICILLINALLERGICREACTIONS

TheGOODTheBADTheUGLY

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.

WhatDotheRashesLookLike?

HIVESOR???Hivesareraisedandintensely

pruri1cViralordelayedcutaneousexanthemcanbemaculopapularormorbilliform

HIVESOR???Hivescomeandgo,movearoundandchangeshape

Viralordelayedcutaneousexanthemsarefixedbutcanexpandoverbodyoverseveraldays

HIVESOR???ErythemaMul1formaserpigenous,some1meswithcentralclearing

Roseola

Maculopapular=flatandbumpy Morbilliform=measleslike

MaculopapularandMorbilliformRashes

•  NonpruriIc,maculopapularrashesthatdevelopduringthecourseoftherapyarereportedin3to7percentofchildrengivenampicillin.

•  Pruritusmayormaynotbeafeature.•  TheserashesarebelievedtobemediatedbyTcells,are

moreprevalentinchildrenandarecommonlycausedbyamoxicillin

•  TheonsetoftheerupIonisusuallywithintwoweeksofbeginningtherapy,andwithindaysofre-exposureifthepaIenthadtakenthemedicaIononpreviousoccasions.Occasionally,anerupIontopenicillinsmaybeginaslateasthreeweeksaQerbeginningtheanIbioIc,orfirstappearuptotwoweeksaQerthetherapywascompleted.

WHATCANYOUDO??

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.

PaIentEducaIonHandout

GoTo…Raven-PaIentEducaIon-PEDS-All-Amoxicillin

ExampleAutotextforRMTForAmoxicillinTrial

•  *InsertAddendumHere:•  Reviewofthemedicalhistorydoesnotindicateanyevidenceofallergyto

amoxicillin•  CHAandfamilyareOKwithtrialofAmoxicillin•  RecommendstarIngAmoxicillinperordersbyweightandwatchingfor

onehour•  ThefirstdoseofAmoxicillinistobegivenintheclinicwithepinephrine

available.•  PaIentwillstayinclinicforanhouraQerwardsforobservaIoninwaiIng

room•  Ifnoproblemswiththefirstdose,thenthepaIentcangohomeand

conInuemedicineasprescribed.•  Benadrylbyweightwillbegiventotakehomeforanyrashorswelling•  Ifarashoranyconcernsdevelop,thepaIentshouldbebroughtbackto

clinic,atelemedpicturetakenandRMTsentin

INSUMMARY

WhenLookingIntoaHistoryofAmoxicillinAllergy

-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

HowtochangetheallergyalertontheRavenbanner

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.