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*For medical professionals only
If that doesn’t beat all!
In 2021, the National Health Care issued the "Guidelines for Skin Testing of β Lactam Antibacterial Drugs", which clearly states that before using cephalosporin antibacterial drugs, no skin test is required, except
for two specific situations.
Some general hospitals above the provincial and municipal levels have cancelled the link of cephalosporin skin test, which not only saves manpower, material and financial resources, but also saves patients from the pain of needle insertion, which can be said to be a joy for everyone
.
However, many hospitals still need to be equipped with corresponding rescue measures and technical apprehension
about the withdrawal of skin tests mentioned in them.
Departments differ in agreement, so a large number of hospitals are still not implementing the guidelines
.
Our hospital is also responding, but it has not yet
landed.
Today, I will share with you a real case of antibacterial skin test in the clinic, hoping to help
the clinic.
Introduction to the condition
Patient: Male, 15 years old, congenital disability, cerebral palsy, epilepsy, scoliosis
.
July 11, 202*, high fever, 39.
1 °C, local hospital diagnosed with "upper respiratory tract infection" Oral "cephalosporins" for 4 days, ineffective
.
Intravenous infusion of "ceftriaxone" for 2 days, ineffective
.
On July 18, 202*, I came to the emergency department
of our hospital.
Emergency Department Course Record (18 July – 26 July).
Physical examination: vital signs are stable
.
Stunted
growth.
The expression is indifferent, the examination is not cooperative, and there is no response
.
Spinal deformity, asymmetry of the thoracic cage, no obvious abnormalities on auscultation, and both lower limbs often curled up in front of
the chest.
Ancillary tests (blood count): WBC 7.
89x10 9/L, Hb 111g/L, PLT 148x109/L
.
Chest CT: consider minor inflammatory lesions in both lungs, scoliosis
.
Initial diagnosis: pneumonia, cerebral palsy, epilepsy, scoliosis
.
July 19-July 24: intermittent high fever, paroxysmal cough, sputum, no dyspnea
.
July 25: patient still high fever, purulent discharge from the right ear canal, marked swelling on the right ear, blood culture: anaerobic positive coccus, aerobic blood culture negative
.
Head CT: old lesions of the left cerebral hemisphere, obvious swelling of the soft tissues of the scalp, abscess of the right temporal parietal abscess, inflammatory changes
in bilateral mastoids, tympanic chambers, and right external auditory canal.
Temporal bone scan: bilateral middle ear mastoiditis, right otitis externa, right temporal bone mastoiditis, right ossicle destruction, obvious scalp soft tissue swelling, effusion, right temporal effusion
.
Figure 1
ENT consultation showed right mastoid cholesteatoma, otitis media, and pus
behind the ear.
July 26: Morning transfer to otolaryngology to continue treatment
.
At noon, cefotaxime skin test, positive, continued netilmicin, tinidazole
.
Emergency surgery at night: modified radical mastoidectomy of middle ear + incision and drainage of posterior auricular abscess, which lasted 3 hours
.
Opening the right mastoid, a large amount of cholesteatoma epithelium and purulent discharge in the lumen, pus under the scalp, drainage of 100 ml of black necrotic tissue
on the aponeurosis.
July 27: no fever, little urine, increased hydration
.
Ampicillin sulbactam test negative, started, 3g/8h
.
July 25: Specimens sent for examination showed Enterobacter cloacae, polydrug sensitivity
.
28 July: Dressing change through the incision, with more purulent discharge spilling
from the incision.
August 3: Head and face swelling gradually subsides
.
August 4: Switch to oral amoxicillin, clavulanate potassium
.
August 8: Antimicrobials
are stopped.
▎Medication:
7.
18-7.
22 moxifloxacin;
7-22 Positive ceftriaxone skin test;
7-22 Piracillin, tazobazolibal test, positive;
7.
22-7.
27 Tinidazole ; 7.
24-7.
27 netimicin
.
ReviewUpper
respiratory tract infection→ secondary otitis media→ secondary mastoiditis→ aggravation of infection→ bone destruction of the anterior wall of the mastoid → pus generates high pressure, breaks through the mastoid cavity→ pus flows from the subcutaneous tissue of the external auditory canal to the back of the ear, and further spread→ the skin of the external auditory canal is ruptured, and pus flows out of the external auditory canal
.
Let's discuss it in conjunction with the literature
Clinical significance
of antimicrobial skin testing.
Establish the basis for drug allergy diagnosis: drug allergy history, skin test, provocative test
.
Complete penicillin skin test, the detection reagent should include penicillin G, MDM, PPL, semi-synthetic penicillin, and a negative control (normal saline) and a positive control (histamine).
Studies have shown that through a complete and standardized skin test diagnosis method, the positive predictive value of penicillin skin test is 50%, and the negative predictive value is 70%~97%.
A routine penicillin skin test
is required prior to the use of penicillin-based antimicrobials.
Skin test solution: penicillin 500U/ml
.
Routine skin testing prior to cephalosporins is not recommended [1] and is only required in the following cases:
Patients with a clear history of penicillin or cephalosporin type I (immediate) allergy;
The drug label stipulates that a skin test is required
.
Penicillin/cephalosporin skin test [2], indications:
Patients with a history of alleged allergy to multiple antimicrobial drugs;
Patients with a clear history of penicillin/cephalosporin allergy, including immediate allergic reactions, several rashes, and frequent antimicrobial use;
Patients with a clear history of penicillin/cephalosporin allergy require β-lactams;
During general anesthesia, with the simultaneous use of penicillin and a variety of other drugs, allergic reactions occur, and allergens
need to be identified.
Skin testing process: 1) Skin Prick testing; 2) Intradermal injection, challenge test
.
Brief summary:
Treatment of infection was divided into pharmacological and non-pharmacological treatment, and the skin test results of this patient interfered with the choice of anti-infective drugs, and the treatment was delayed by about
5 days.
Before admission, oral cephalosporins were administered for 4 days and ceftriaxone intravenously for 2 days, and the possibility of allergy to cephalosporins was very small
.
The results of the skin test and medication are as follows:
July 18 Admitted to hospital;
July 22 Ceftriaxone skin test positive;
July 22 Piracillintamazolibal test positive;
July 26 Cefotaxime tested positive;
On July 27, ampicillin sulbactam tested negative and administered
.
More respiratory classics? Come to the "Doctor Station APP" and take a look 👇
at the references:
[1] Guidelines for skin testing of β-lactam antimicrobials (2021 edition)
[2] Management of allergy to penicillins and other beta-lactams.
Clinical & Experimental Allergy, 45 : 300–327
