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Allergy Asthma Immunol Res. 2010 April;2(2):77-86. doi: 10.4168/aair.2010.2.2.77 pISSN 2092-7355 • eISSN 2092-7363

Update on the Management of Antibiotic Allergy
Bernard Yu-Hor Thong*
Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Drug allergy to antibiotics may occur in the form of immediate or non-immediate (delayed) hypersensitivity reactions. Immediate reactions are usually IgE-mediated whereas non-immediate hypersensitivity reactions are usually non-IgE or T-cell mediated. The clinical manifestations of antibiotic allergy may be cutaneous, organ-specific (e.g., blood dyscracias, hepatitis, interstitial nephritis), systemic (e.g., anaphylaxis, drug induced hypersensitivity syndrome) or various combinations of these. Severe cutaneous adverse reactions manifesting as Stevens Johnson syndrome or toxic epidermal necrolysis (TEN) may be potentially life-threatening. The management of antibiotic allergy begins with the identification of the putative antibiotic from a detailed and accurate drug history, complemented by validated in-vivo and in-vitro allergological tests. This will facilitate avoidance of the putative antibiotic through patient education, use of drug alert cards, and electronic medical records with in-built drug allergy/adverse drug reaction prescription and dispensing checks. Knowledge of the evidence for specific antibiotic cross-reactivities is also important in patient education. Apart from withdrawal of the putative antibiotic, immunomodulatory agents like high-dose intravenous immunoglobulins may have a role in TEN. Drug desensitization where the benefits outweigh the risks, and where no alternative antibiotics can be used for various reasons, may be considered in certain situations. Allergological issues pertaining to electronic drug allergy alerts, computerized physician prescriptions and decision support systems, and antibiotic de-escalation in antimicrobial stewardship programmes are also discussed. Key Words: Anaphylaxis; desensitization; drug hypersensitivity; Stevens Johnson syndrome; toxic epidermal necrolysis

Antibiotics are one of the most common causes of drug allergy in most epidemiological studies, both among adults and children.1-6 Among the various classes of antibiotics, beta-lactam antibiotics (penicillins and cephalosporins), cotrimoxazole and quinolones are some of the most common causes of antibiotic allergy. Antibiotic allergy may occur in the form of immediate or nonimmediate (delayed) hypersensitivity reactions. Immediate reactions are usually IgE-mediated whereas non-immediate hypersensitivity reactions are usually non-IgE or T-cell mediated.7 The clinical manifestations of antibiotic allergy may be cutaneous, organ-specific (e.g., blood dyscracias, hepatitis, interstitial nephritis), systemic (e.g., anaphylaxis, drug induced hypersensitivity syndrome) or various combinations of these. Severe cutaneous adverse reactions (SCAR) manifesting as Stevens Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) may be potentially life-threatening.8

cation of the putative antibiotic from a detailed and accurate drug history.9 Not infrequently, the drug history may need to be obtained from a combination of sources other than the patient, including care-givers, records from other prescribing physicians and both non-electronic and electronic medical records.10 With the use of digital photography, instructing patients to take digital photographs of the initial rash may become increasingly important in helping the allergist to diagnose a drug eruption, especially when the rash is likely to have resolved by the time the patient sees the allergist.11-13 In the diagnosis of immediate allergic reactions to antibiotics, the in-vivo tests available are skin prick tests (SPT) and intradermal tests (IDT).14,15 However, these have been well validated mainly for beta-lactam antibiotics and less so for other classes of antibiotics. For in-vitro tests, commercially available assays include fluorescent enzyme immunoassays (FEIA) (ImmunoCorrespondence to: Bernard Yu-Hor Thong, MBBS, MRCP (UK), Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore. Tel: +65-6357-7822; Fax: +65-6357-7837; E-mail: Received: October 18, 2009; Accepted: October 19, 2009.
•There are no financial or other issues that might lead to conflict of interest.

The management of antibiotic allergy begins with the identifi-

© Copyright The Korean Academy of Asthma, Allergy and Clinical Immunology • The Korean Academy of Pediatric Allergy and Respiratory Disease


quinolones. anxious people who would refuse to take the recommended drug without proof of tolerance • to exclude cross-reactivity of related drugs in proven hypersensitivity.Thong CAP®. eczema.. ampicillin). vagal symptoms following the use of an antibiotic • to provide safe pharmacologically and/or structurally nonrelated drugs in proven hypersensitivity e. Baboon’s syndrome). isoniazid. metronidazole. or when alternative drugs are more expensive). Recent studies of in vitro rapid antigen desensitizations implicate mast cells and basophils as cellular targets. slow desensitization results in patients achieving the total target dose within a few days to weeks.g. but rarely positive in TEN. TREATMENT OF ANTIBIOTIC ALLERGY Definitive treatment involves cessation of the suspected antibiotic. sulfonamides. minocycline.4168/aair. the sensitivity of the test is usually drug. up-regulation of cell surface activation markers (e. and also because non-immediate reactions are generally more common than Volume 2. meropenam. mostly in Europe. DPT can generally be carried out safely with careful patient selection.g..2(2):77-86. April 2010 immediate reactions in clinical practice. cefotaxime). 78 http://e-aair. imipenam. Desensitization is a method of reintroducing antibiotics into highly sensitized patients to induce tolerance. However.28 Blinded (single. Like the patch test. LTT are often positive in MPE. Desensitization should be avoided should the initial reaction be potentially life-threatening reactions like immunobullous eruptions and SJS/TEN. symmetric drug-related intertriginous and flexural exanthema (SDRIFE.21 This test can be technically difficult to carry out and are thus often done in specialized centres. the LTT is usually positive in a drug. day 4. e. fixed drug eruptions (FDE) (when done on the lesional skin). MPE during aminopenicillin treatment with negative allergological tests. CD69). It is occasionally positive in hepatitis and nephritis. Similar to patch tests.18 For non-immediate reactions.2. infection with multiresistant organisms. In certain instances where the antibiotic is required because there are no better alternatives (e.19 In-vivo tests available for non-immediate reactions include the lymphocyte transformation test (LTT) which is a proliferation assay which detects drug-specific T-cells.or double-blind placebo-control) challenges may sometimes be needed in patients with nonsuggestive history and non-specific symptoms. Phadia) which are less sensitive and specific compared to skin tests. clarithromycin. RAST) have over the years been replaced with the FEIA assays. as well as syk.22 Novel in-vitro tests evaluating cytokine secretion. clindamycin. metronidazole. and drug rash with eosinophilia and systemic symptoms (DRESS).29 Rapid desensitization results in patients achieving the target total dose of the drug through rapidly escalating doses usually within 24 hours. Radioimmunoassays previously used mainly for the diagnosis of penicillin allergy (including the radioallergosorbent test. Patch tests have been described in the diagnosis of non-immediate reactions to amoxicillin.16. Number 2. e.g. streptomycin. with the exception of anaphylaxis. cotrimoxazole. Patch tests are often done in Europe to assist in the diagnosis of non-immediate reactions to various antibiotics. a signal transducing molecule.and reaction-specific manner. these tests are available mainly for penicillins and cephalosporins. AGEP. rifamipicin. and signal transducer and activator of transcription 6 (STAT6). cytopaenias and vasculitis. rifampicin. doi: 10. e. erythromycin. drug provocation tests (DPT) often have to used in the diagnostic evaluation of drug allergy.23-27 The indications for DPT are as follows:23 • to exclude hypersensitivity in non-suggestive history of drug hypersensitivity and in patients with non-specific symptoms. and analysis of cytotoxic potential (granzyme B. cefcapene pivoxil. ciprofloxacin. Again. Sweden). cotrimoxazole. isoniazid and rifampicin.17 Flow-cytometric based basophil activation tests (BAT) (flow assay stimulation test. non-conclusive or non-available allergologic tests. Various desensitization protocols are available for penicillin (benzylpenicillin. vancomycin and fluoroquinolones. Buhlmann Laboratories) which measure CD69 or CD203c on drug-specific activated basophils may have a role in the diagnosis of antibiotic allergy.19 Delayed reactions are considered positive when there is an infiltrated erythematous reaction. The tests are read on day 2. FAST/FlowCAST®.2. spiramycin.g. However such individuals are still considered as being allergic to the antibiotic. pristinamycin.g. but have not been shown to be very useful in SJS/ TEN and Allergy Asthma Immunol Res.and reactionspecific. acute generalized exanthematous pustulosis (AGEP). tetracycline. delayed readings of IDT are done at 24 hours and 72 hours. a cephalosporin in a penicillin-allergic subject • to establish a firm diagnosis in suggestive history of drug hypersensitivity with negative. 2010 April. cephalosporins (ceftazidime. ethambutol.20 The patch test allergens can be prepared in-house or using commercially available products (Chemotechnique Diagnostics®.g. teicoplanin and vancomycin. drug desensitization can be carried out. Antibiotics which have been found to often test positive in LTT are beta-lactams. isoniazid.22 In view of the limited number of in-vivo and in-vitro tests commercially available for most antibiotics. and the vehicle used is usually petrolatum.2010. doxycycline. other antibiotics in beta lactam-allergic patients. and day 7 (if negative on days 2 and 4). with studies so far mainly focused on beta-lactam allergy. Patch tests are generally useful in maculopapular exanthema (MPE).21. CD107) remain as research tools. fluoroquinolones. which is responsible for the transcription of interleukin (IL)-4 and IL-13.77 . macrolides. bullous exanthema.

Non-immediate reactions range from mild MPE and FDE to serious SJS and TEN. specific IgE assays.36 depending on when the sample was taken from the time of the initial clinical reaction. with the FEIA currently being the most widely commercially available test. In September 2009. the sensitivity (42-74%) and specificity (85-100%) reported varied among studies. MDM and/or amoxicillin in the respective studies.39 Using a combination of skin tests.42 Cephalosporin allergy The reported cross-reactivity for IgE-mediated hypersensitivity between cephalosporins and penicillins in patients with Ig-E COTRIMOXAZOLE ALLERGY Cotrimoxazole is an immunogenic drug which may cause both immediate and non-immediate reactions. this may the reason why the penicillin allergic individuals appear to be able to tolerate most third and fourth generation cephalosporins. should be carried out with benzylpenicillin.43. hence a positive test is useful in confirming beta lactam allergy but a negative test does not rule it out. and thus could result in potentially positive drug provocation tests being done.48 Similarly. but rarely positive (<10%) in blood dyscracias and TEN associated with drug allergy.31 In 2004. followed by cellular tests in negative patients.5% based on patients with cell-mediated allergy to penicillins showing positive patch tests to at least one penicillin reagent and imipenem-cilastatin. Allergopharma and Hollister-Stier announced their decision to stop the commercial production of penicillin reagents (Allergopen® and PrePen® respectively). shared by penicillins and cephalosporins.37. LTT for beta lactam allergy has a low sensitivity of 60-70%. this may miss patients who may have tested positive to PPL or MDM. cephalothin and cephaloridine. and specificity of 93%.41 Patch tests when used.38 Carbapenem allergy Earlier studies from the late 1980s showed that cross-reactivity between penicillin and imipenem allergy was 50% based on 10 of 20 patients with penicillin allergy being skin test positive to one or more penicillin or imipenem determinants.49 Recent prospective studies in adults and children with penicillin (predominantly amoxicillin) IgE-mediated allergy have shown that the cross-reactivity based on positive skin tests to imipenamcilastatin50 and meropenam51. The LTT is often positive in AGEP and DRESS. and that patients who were SPT/IDT negative to imipenam-cilastatin and meropenam were able to tolerate a graded.30.AAIR Management of Antibiotic Allergy mediated penicillin allergy of 5-10%.52 was 0. seems to play a dominant role in determining the specificity of immunologic reactions to cephalosporins. penicillin can be administered safely to patients allergic to cephalosporins and with a negative skin test result to penicillin determinants.4168/aair.2010.56 Slow acetylator phenotype and genotype.14 The R1 side chain rather than the betalactam structure. For delayed reactions to carbapenams. minor determinant mix (MDM) and benzylpenicillin G or amoxicillin have been validated in various studies and shown to be useful in the evaluation of suspected immediate reactions to penicillin. This is especially prevalent in HIV-infected individuals where cotrimoxazole is used for the treatment and prophylaxis for Pneumocystis jiroveci infection and toxoplasmosis. ampicillin. when used in the diagnosis of beta-lactam allergy.44 In addition. the cross-reactivity with penicillins was 5.33 and is presently used in many countries worldwide.58 and major histocompatibility complex (MHC) polymorphisms59 have not been shown to be major predisposing risk factors for cotrimoxazole hypersensi- Allergy Asthma Immunol Res. 2010 April. Pre-Pen® was approved for marketing by the Food and Drug Administration (FDA) through ALK-Abello and Allerquest LLC. and the outcomes of skin tests to PPL. All patients with negative patch test and delayed IDT reading to imipenamcilastatin tolerated an intramuscular provocation test.35. The determinants used in FEIA are benzylpenicilloyl and amoxicilloyl. 79 .2.53 BETA-LACTAM ALLERGY Penicillin allergy Allergic reactions to beta-lactam antibiotics are the most common cause of drug allergies in most epidemiological studies on adverse drug reactions. doi: 10.27 this is recommended by the British Society of Allergy and Clinical Immunology (BSACI)46 and the European Academy of Allergy and Clinical Immunology (EAACI). The flow cytometric BAT assay. and any suspect penicillins and/ or cephalosporins. amoxicillin.34 However. In countries where commercial PPL and MDM are not available.45 Although the practice parameters of the AAAAI in 1999 did not advocate the use of cephalosporin skin testing.38 However. A Spanish product (Diater®) was subsequently found to be a reliable and consistent alternative32.57.9%. SPT and IDT using commercially available penicilloyl polylysine (PPL). can facilitate confirmation of betalactam allergy.54. the test is unable to differentiate between selective reactors and cross-reactors. were based on early studies from the 1970s on patients with a history of penicillin allergy who developed allergic reactions to cephalexin. has a sensitivity of 50%. The flow cytometric BAT assay appears to be a promising invitro test in the diagnosis of cephalosporin allergy as well as penicillin allergy. early cephalosporin antibiotics contained traces of penicillin.47 Thus. In-vitro tests are often less sensitive and more expensive when compared to skin tests. challenge dose of intravenous imipenam-cilastatin and meropenam respectively.55 and are more common than immediate reactions. skin testing with benzylpenicillin may be used in lieu.77 http://e-aair. and tests become negative the longer the duration from the initial reaction.2(2):77-86. avoiding DPT in up to two-thirds of patients.2.40 Using an alternative marker like CD203c may increase the sensitivity of these tests.37.

77 .84. patch tests and oral challenges if skin tests are negative.91-95 there have also been reports of patients with teicoplanin who tolerated vancomycin. subepidermal.65 Thus.68 TETRACYCLINE ALLERGY Minocycline can cause serious adverse reactions including drug hypersensitivity syndrome. which is commonly associated with too rapid an infusion of vancomycin resulting in direct mast cell histamine Allergy Asthma Immunol Res. in particular drug allergies to doxycycline and tetracycline are relatively rare. adverse drug reactions. TUBERCULOUS DRUG ALLERGY Mycobacterium tuberculosis (MTC) infection remains endemic in certain parts of Asia.72 Apart from exanthematous eruptions.69 Apart from photodermatoses and photo-onycholysis which are usually phototoxic in nature.80-83 Linear IgA bullous dermatosis (LABD) is an autoimmune.60 Volume 2. patients with allergy to a fluoroquinolone should avoid other fluoroquinolones. Teicoplanin.74 The use of a combination of skin prick tests.78 FLUOROQUINOLONE ALLERGY Fluoroquinolone allergy may present in the form of immediate and non-immediate reactions. with non-IgE mediated reactions occurring after the first dose with no previous history of sensitization. Non-immediate reactions are much more common than immediate reactions to 80 http://e-aair. Immediate reactions [anaphylaxis86. Rapid and slow desensitization to cotrimoxazole especially in the setting of HIV infection. Allergic reactions to macrolide antibiotics appear to be relatively uncommon (0.62 and delayed reactions through generation and analysis (flow cytometry and proliferation assays) of quinolone-specific T cell clones respectively. This is in contrast to vancomycin red man syndrome. Successful desensitization has also been reported.79 Anaphylaxis from vancomycin may be through IgE mediated allergic mechanisms or non-IgE mediated non-allergic mechanisms.2. These occur on average within 4 weeks of therapy.70 CLINDAMYCIN ALLERGY Clindamycin may be associated with both immediate and non-immediate allergic reactions. April 2010 AGEP73 and TEN.97 Pre-operative allergy clinic assessment together with penicillin skin testing has been shown to be an effective intervention in reducing unnecessary use of prophylactic vancomycin perioperatively. midecamycin) macrolides. appear to be more useful compared to SPT and IDT alone as negative skin tests may still result in positive challenges.85 Lesions typically appear during vancomycin therapy. Although there have been reports of cross-reactivity between individuals with vancomycin and teicoplanin allergy.2(2):77-86. toxic epidermal necrolysis and leukocytoclastic vasculitis have been reported.4% to 3% of treatments).62 Although previous studies had shown that skin tests to quinolones lack sensitivity and specificity. vesiculobullous disease that has been commonly associated with the use of vancomycin. another glycopeptide. cases reported in the literature include contact dermatitis.61. Number 2.87] and non-immediate reactions [rash. in children and adults. rifampicin.98. MACROLIDE ALLERGY Macrolides are classified according to the number of carbon atoms in the chemical structure: 14 membered (erythromicin.96.Thong tivity in HIV-infected individuals. doi: 10. has rarely been reported to be associated with allergic drug reactions including exfoliative dermatitis and maculopapular rash. The immediate reactions may be IgE mediated or non IgE mediated. has fewer side effects compared to vancomycin. showing linear IgA and C3 deposits at the basement membrane zone on direct immunofluorescence. 15 membered (azithromycin) and 16 membered (spiramycin. whereas minocycline-induced lupus occurs on average 2 years after the initiation of therapy.99 This would be helpful in the long-term in reducing the spread of vancomycin resistant infections in hospitals and within the community.67 and non-immediate reactions like fixed drug eruptions.2010. roxithromycin. 2010 April. dirithromycin. Various effective desensitization regimes have been described in the treatment of vancomycin anaphylaxis.4168/aair.76 Clindamycin desensitization has been reported in the literature in particular in HIV-infected individuals. josamycin.2. ethambutol and pyrazinamide.88 AGEP89 and DHS90] are infrequent. serum sickness and drug-induced lupus. Histopathologic examination and immunofluorescence studies are diagnostic. Withdrawal of vancomycin is all that is required.63 a negative skin test could predict a negative challenge test in 94% of the challenged cases. clarithromycin).75.71 However.64 Cross-reactivity has been demonstrated for immediate reactions through positive skin tests to a range of quinolones. and the need for potentially expensive antibiotics like linezolid and tigecycline. the prevalence of such reactions is rare. 24 hours to 15 days after the first dose.77. for clarithromycin and azithromycin. has been shown to be effective and safe.66 Cases of immediate reactions in the form of anaphylaxis.79 Red man syndrome is very unusual with teicoplanin because this compound does not cause histamine release even at faster infusion rates than those of vancomycin. VANCOMYCIN AND TEICOPLANIN ALLERGY Vancomycin. a glycopeptide. Treatment of MTC infections involves combinations of anti-tuberculous drugs including isoniazid.

because leaving patients on anti-tuberculous monotherapy would increase the risk of emergence of drug-resistant tuberculosis.. systemic corticosteroids (0. the use of systemic corticosteroids has been supported by case reports and series (prospective and retrospective) which showed positive outcomes with the early use of corticosteroids (prednisolone 1 mg/kg/day or methylprednisolone 1-2 mg/kg/day) within 72 hours was beneficial in arresting the pro- Allergy Asthma Immunol Res. macrolides). The risks of desensitization need to be explained carefully to the patient provided combinations of second-line anti-tuberculous drugs (e.112 In DHS. there were also other studies which showed harm or no benefit. different brands of IVIg used with different dosing regimens. The most common long-term sequelae is sicca syndrome. Diagnosis using LTT have not been useful to date. In SJS. followed by antibiotic drugs (in descending order of frequency: cephalosporins. Although there were wide variation in patients and treatment protocols.107-111 These regimes often involve reintroducing the anti-tuberculous drugs as soon as the allergic reaction has settled. quinolones.AAIR anti-tuberculous drugs. High-dose IVIg did not appear to reduce the severity of visually significant ocular complications. DHS. Others include corneal ulceration.103 have all been reported in the literature. and fornix sweeping.83 g/day in the treatment of TEN. HLA B*38 showed only a weak association with sulfamethoxazole induced SJS/TEN54 in contrast to antiepileptic drugs and allopurinol where HLA associations are stronger and ethnically related.126 Other therapies like cyclophosphamide127 and plasmapharesis128 have not been shown to be useful. however. and hence the effectiveness of systemic corticosteroids. and long-term sequelae from 1% to 50%. desensitization would need to be considered very carefully in consultation with the attending infectious diseases physician or pulmonologist. Drug eruptions100 in the form of MPE and lichenoid drug eruptions.. Management of Antibiotic Allergy gression of SJS.20 In practice.8 In the study of Roujeau et al. Combination therapy also arrested progression earlier and decreased the hospitalization time. with at most a 3-5 day interval apart. aminopenicillins. SJS/TEN102. The decrease in the mortality rate. In early TEN. 2010 April.g. meaning that the total dose of corti- SEVERE CUTANEOUS ADVERSE REACTIONS (SCAR) Severe cutaneous adverse reactions (SCAR) include SJS.101 haematological reactions.5 to 1 mg/kg/day) tapered over 6-8 weeks rapidly improves symptoms and laboratory measurements.4168/aair. If the initial allergic reaction was SJS/TEN. valproic acid. In the last decade. hepatitis. human herpes virus 6. of duration of up to 3 weeks in case series of patients with severe TEN suggest that the risks of infection outweighed the benefits. Relapses of rash and hepatitis may occur as corticosteroids are tapered. between 10-30% of epidermal detachment occurs which can sometimes be diagnosed clinically from a positive Nikolsky’s sign or histological evidence of epidermal necrolysis. topical corticosteroids. are standard of care for which there are no controlled trials.113 Sequential reactivation of herpes viruses (e. and lamotrigine). the overall mortality rate was around 20% with earlier re-epithelialization demonstrated in some of the studies. The rationale for the use of IVIg is based on the inhibition of Fas-mediated keratinocyte apoptosis in TEN by naturally occurring Fas-blocking antibodies within the IVIg. which in the end may not be 81 . phenytoin.122 Systemic corticosteroids should not been used as most series have suggested that the risks outweigh the benefits. Treatment modalities for ocular complications include topical antibiotics. it is often not clinically feasible to leave MTC infection untreated for 6 weeks pending evaluation using LTT or patch tests. was not statistically significant. tetracyclines. cycloserine) are not an option.121 TEN is defined as the detachment of the epidermis affecting more than 30% body surface area of skin involvement. doi: 10. carbamazepine. then nonsteriodal anti-inflammatory drugs (especially oxicam) and allopurinol.2010. but its impact on the long term disease course is not known.135 Significant dry eye problems and photophobia may also be avoided with this intervention.. Controlled clinical trials are lacking on the use of systemic corticosteroids in DHS. The prevalence of acute ocular complications ranges from 6% to 100%.19.2(2):77-86.2. corneal epithelial defect. anticonvulsants (phenobarbital.123-125 The only doubleblind placebo-controlled trial to date in the management of TEN.54 sulfonamides were the most strongly associated with TEN. quinolones. Ebstein Barr virus. early referral to a specialized unit. A recent retrospective study from China suggested that combination therapy with corticosteroid and high dose IVIG exhibited a tendency to reduce the mortality rate in comparison with administration of corticosteroid alone. dapsone. more than one drug often needs to be reintroduced. supportive measures including specialized nursing. The use of oral and intravenous cyclosporine 3-5 mg/kg/day. cytomegalovirus)114 and subsequent triggering of autoimmunity115 may explain these relapses. symblepharon and fornix foreshortening.77 http://e-aair. skin care including the use of Biobrane dressings.116-120 However.134 Early intervention with cryopreserved amniotic membrane transplantation was shown in a recent study to suppress inflammation and promote epithelial healing at the acute stage. In addition. TEN and DHS or DRESS).2.g. As such. Apart from prompt withdrawal of the suspected drug. rapid oral desensitization regimes have been described for isoniazid. lubricants. nutritional and respiratory care and support. imidazole antifungals. rifampicin and ethambutol.104-106 Patch tests are also not consistently useful as they are dependent on the type of cutaneous drug eruption. several case series129-133 have described the use of high dose intravenous immunoglobulins (IVIg) from 0. using thalidomide was stopped because there was excessive mortality in the thalidomide group.

Jick H. DRUG-INDUCED LUPUS Drug-induced lupus erythematosus (DILE) is defined as a lupus-like syndrome temporally related to continuous drug exposure which resolves after discontinuation of the offending drug. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organization. Lanier BQ. clinical pharmacists.136 Volume 2. McCaig LF.256: 3358-63. visceral involvement. Bigby M. meropenam). Stern RS. Thong BY. a 20-year survey. 273:214-9. In most cases of classic DILE. Cars O. 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