Correspondence

Lost in Transcription

N Engl J Med 2007; 356:311January 18, 2007

Article

To the Editor:

In the Clinical Problem-Solving article, “Lost in Transcription” (Oct. 5 issue),1 Kalus and colleagues quickly home in on a medication error involving methotrexate overdosing as the likely cause of the patient's fever and presumed urosepsis. However, they do not discuss the fact that this patient, who was reportedly allergic to penicillin, received piperacillin–tazobactam as treatment for her urosepsis — an error that could be more deadly in the immediate future if she did have a true allergy.

Jennifer Harris, M.D.
Alameda County Medical Center, Oakland, CA 94602

1 References

1. 1

   Kalus RM, Shojania KG, Amory JK, Saint S. Lost in transcription. N Engl J Med 2006;355:1487-1491
   Full Text | Web of Science | Medline

Author/Editor Response

Harris points out the potential risk of giving a beta-lactam antibiotic to a patient with a documented penicillin allergy. Although our patient did report a history of an allergy to penicillin, we explored this history in more detail before prescribing antibiotics. She described a nonspecific rash after receiving penicillin in the past, but a record review indicated that she had subsequently tolerated several courses of beta-lactams, including piperacillin–tazobactam, without incident. In many patients who report a history of penicillin hypersensitivity, penicillin-specific IgE antibodies are not detected on skin testing.1 In this case, although we did not have information from skin testing, we considered the patient's tolerance of piperacillin–tazobactam on previous occasions to be reassuring. No adverse reaction to the beta-lactam was noted on this occasion, despite careful observation for signs and symptoms.

Robert M. Kalus, M.D.
Harborview Medical Center, Seattle, WA 98104
rkalus@u.washington.edu

Kaveh G. Shojania, M.D.
Ottawa Health Research Institute, Ottawa, ON K1Y 4E9, Canada

Sanjay Saint, M.D., M.P.H.
Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI 48105

1 References

1. 1

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