Anaphylactic shock penicillins

The penicillins in general, ate renowned for their lack of toxicity. The most common adverse effect of the use of penicillins is an allergic reaction which can change from a mild rash to fatal anaphylactic shock in rate cases. AH penicillins cross the placenta and ate excreted in maternal milk. However, the relative freedom from toxicity tenders these compounds valuable agents during pregnancy and lactation. 

Idsoe, O., Guthe, T., Willcox, R.R., and DeWeck, A.L. (1968). Nature and extent of penicillin side-reactions, with particular reference to fatalities from anaphylactic shock. Bull. WHO 38 159-188. 

Hypersensitivity reactions Serious and occasionally fatal immediate-hypersensitivity reactions have occurred. The incidence of anaphylactic shock is between 0.015% and 0.04%. Anaphylactic shock resulting in death has occurred in approximately 0.002% of the patients treated. These reactions are likely to be immediate and severe in penicillin-sensitive individuals with a history of atopic conditions. 

Hypersensitivity reactions to antimicrobial drugs or their metabolic products frequently occur. For example, the penicillins, despite their almost absolute selective microbial toxicity, can cause serious hypersensitivity problems, ranging from urticaria (hives) to anaphylactic shock. 

Simple patch skin testing is naturally most useful in diagnosing contact dermatitis, but it is unreliable for other allergies. Skin prick tests are helpful in specialist hands for diagnosing IgE-dependent drug reactions, notably due to penicillin, cephalosporins, muscle relaxants, thiopental, streptokinase, cis-platin, insulin and latex. They can cause anaphylactic shock. False positive results occur. 

There is cross-allergy between all the various forms of penicillin, probably due in part to their common structure, and in part to the degradation products common to them all. Partial cross-allergy exists between penicillins and cephalosporins (a maximum of 10%) which is of particular concern when the reaction to either group of antimicrobials has been angioedema or anaphylactic shock. Carba-penems (meropenem and imipenem-cilastatin) and the monobactam aztreonam apparently have a much lower risk of cross-reactivity. 

Kanny G, Puygreuier J, Beaudoin E, Moneret-Vautrin DA. Choc anaphylactique alimentaire implication des residues de peuicUliue. [Alimentary anaphylactic shock impheation of penicillin residues.) Allerg Immunol (Paris) 1994 26(5) 181-3. 

The patient s serum was tested for antibodies against five penicillins and 30 different cephems (that is all types of cephalosporins), using protocols to detect drug adsorption as well as immune-complex mechanisms. His serum contained an IgM antibody that formed immune complexes with 10 of the 30 cephems. The 10 drugs were classified as oxime-type cephalosporins, that is they had a common structural formula at the C7 position on 7-aminocephalosporinic acid. This antibody did not show any cross-reactivity with five kinds of penicillins (ampiciUin, aspoxicillin, carbenicil-lin, piperacillin, sulbeniciUin). The authors asked a difficult question Why did anaphylactic shock accompany acute hemolysis Their answer was that the complex of ceftizoxime with IgM anti-ceftizoxime might act like anti-A or anti-B. This hypothesis will surely be further tested. In the meantime, it would be wise not to use the newer cephalosporins too freely. 

Anaphylactic shock can occur, even after oral administration of penicillin and skin testing. However, anaphylactic shock is less common after oral than parenteral administration (171). In one study the incidence of anaphylactic shock was 0.04% of all patients treated with penicillin (7). It is also low in patients receiving long-term benzathine penicillin (1.2 million units every 4 weeks). Four episodes of anaphylaxis occurred in 0.012% of injections (1.2 reactions to 10 000 injections) (172). Anaphylactic shock resulting in death occurred in 0.002% of all patients treated with penicillin (7) and in 0.003% of those treated with benzathine penicillin (172). 

In nearly half of the cases, the course of anaphylactic shock, especially that induced by penicillin and other small molecular substances, is that of a cardiovascular reaction without any other effects suggestive of an allergic mechanism (173-175). There is an extensive list of articles on anaphylactic shock to penicillins (7-10,173,174,176,177). General anesthesia does not inhibit the development of anaphylactic shock in penicillin allergy (178). 

Hoigne R, Schoch K. Anaphylaktischer Schock und akute nichtallergische Reaktionen nach Procain-Penicillin. [Anaphylactic shock and acute nonallergic reactions following procaine-penicillin.] Schweiz Med Wochenschr 1959 89 1350-6. 

Allergic reactions to tetracyclines are less than half as common as allergic reactions to penicillin. For this reason, tetracyclines are alternatives in patients with allergic reactions to other antibiotics. Exceptional observations of anaphylactic shock have been reported (37,38). In a few cases tetracychnes were assumed to be the cause of hypersensitivity myocarditis (39). Pneumonitis with eosinophiha has been described in association with tetracychnes (40). A serum sickness-hke syndrome was probably associated with minocycline in a 19-year-old man treated for acne (41). Allergic and toxic reactions may in some cases have been caused by degraded formulations or additives (42). Tumor-inducing effects have not been reported. 

Adverse reactions to penicillins are rare diarrhoea can occur due to alteration in normal gastrointestinal bacteria. In fact, penicillins are probably the least toxic drugs known. Hypersensitivity reactions to penicillins occur in up to 10% of patients and vary from mild skin rashes to exfoliative dermatitis and Stevens-Johnson syndrome (immune vasculitis with arthritis, nephritis, central nervous system abnormalities and myocarditis) and from bronchoconstriction to life-threatening anaphylactic shock. 

Adverse effects, in general, are low. However, all penicillins have the potential for causing interstitial nephritis (of allergic origin), and serious allergic reactions resulting in urticaria progressing to anaphylactic shock. 

Allergy Cephalosporins cause a range of allergic reactions from skin rashes to anaphylactic shock. These reactions occur less frequently with cephalosporins than with penicillins. Complete cross-hypersensitivity between different cephalosporins should be assumed. Cross-reactivity between penicillins and cephalosporins is incomplete (5-10%), so penicillin-allergic patients are sometimes treated successfully with a cephalosporin. However, patients with a history of anaphylaxis to penicillins should not be treated with a cephalosporin. 

Allergic Reactions Penicillin reactions range from skin rashes to anaphylactic shock. The more severe reactions are uncommon, but potentially life-threaten-... 

A brief report describes 2 patients, one taking nadolol and one taking propranolol, who developed fatal anaphylactic shock after taking phe-noxymethylpenicillin. The authors suggested that, as fatal reactions to penicillins are rare, the reaction had been exacerbated by the presence of a non-selective beta blocker. ... 

Information is limited, but the absorption interaction appears to be established. The elinical importance awaits full evaluation but the modest effects on blood pressure and heart rate suggest that it is of limited importanee. Information about other beta blockers and penicillins is lacking. Information on potentiation of anaphylaxis is too limited to make comment, but note that some evidence suggests that anaphylactic shock in patients taking beta blockers may be resistant to treatment with adrenaline (epinephrine), see Beta blockers + Inotropes and Vasopressors , p.848. 

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