Correspondence

Antibiotic Allergy

N Engl J Med 2006; 354:2293-2294May 25, 2006

Article

To the Editor:

Gruchalla and Pirmohamed (Feb. 9 issue)1 recommend that before the initiation of cephalosporin therapy, skin testing should be performed for patients with a suspected history of IgE-mediated reactions to penicillins. We would like to add that it is equally important to recognize the potential for cross-reactivity between penicillins and carbapenems. From our experience, this relationship is often not recognized among clinicians. With the emergence of multidrug-resistant bacteria with extended-spectrum beta-lactamases, the use of carbapenems has somewhat expanded beyond the traditional use in only the sickest of patients.

The authors adroitly state that the rate of cross-reactivity of “more than 10 percent” between penicillins and cephalosporins has not been well established. Concerning cross-reactivity between penicillins and carbapenems, three retrospective clinical studies reported rates of reaction to carbapenems of 9 to 11 percent among inpatients with a reported penicillin allergy.2-4 An earlier study reported that of 20 subjects with a positive penicillin skin test, 10 reacted to an imipenem reagent.5 We would recommend that in patients with a history of penicillin allergy, the same concerns and caveats apply to both the cephalosporins and carbapenems.

Gregory A. Eschenauer, Pharm.D.
Randolph E. Regal, Pharm.D.
Daryl D. DePestel, Pharm.D.
University of Michigan Health System, Ann Arbor, MI 48109
gregorye@med.umich.edu

Dr. DePestel reports having received research support and consulting fees from Pfizer and Cubist Pharmaceuticals and lecture fees from Wyeth, Sanofi-Aventis, Elan, and Cubist Pharmaceuticals.

5 References

1
Gruchalla RS, Pirmohamed M. Antibiotic allergy. N Engl J Med 2006;354:601-609
Full Text | Web of Science | Medline

2
Prescott WA Jr, DePestel DD, Ellis JJ, et al. Incidence of carbapenem-associated allergic reactions among patients with versus patients without a reported penicillin allergy. Clin Infect Dis 2004;38:1102-1107
CrossRef | Web of Science | Medline

3
McConnell SA, Penzak SR, Warmack TS, Anaissie EJ, Gubbins PO. Incidence of imipenem hypersensitivity reactions in febrile neutropenic bone marrow transplant patients with a history of penicillin allergy. Clin Infect Dis 2000;31:1512-1514
CrossRef | Web of Science | Medline

4
Sodhi M, Axtell SS, Callahan J, Shekar R. Is it safe to use carbapenems in patients with a history of allergy to penicillin? J Antimicrob Chemother 2004;54:1155-1157
CrossRef | Web of Science | Medline

5
Saxon A, Adelman DC, Patel A, Hajdu R, Calandra GB. Imipenem cross-reactivity with penicillin in humans. J Allergy Clin Immunol 1988;82:213-217
CrossRef | Web of Science | Medline

Author/Editor Response

We agree that caution should be exercised in the administration of carbapenems (as well as cephalosporins and semisynthetic penicillins) to patients with a history of penicillin allergy. The recommendations that we put forth regarding the use of cephalosporins in patients with penicillin allergy should also be applied to the use of semisynthetic penicillins and carbapenems in these patients.

Rebecca S. Gruchalla, M.D., Ph.D.
University of Texas Southwestern Medical Center, Dallas, TX 75390-8859
rebecca.gruchalla@utsouthwestern.edu

Munir Pirmohamed, Ph.D., F.R.C.P.
University of Liverpool, Liverpool L69 3GE, United Kingdom

Citing Articles (2)