The search of the published literature yielded no cases of anaphylaxis in patients receiving standard doses of IV antibiotics at standard rates of administration in hospital or as outpatients, and no allergic reactions to medications within a day of initiation of IV antibiotic therapy. Still, the results of the vancomycin study were limited by small sample size.8 However, no studies specifically designed to determine the incidence of adverse effects with the first dose of IV antibiotics were identified.

The overall incidence of anaphylactic events with the first dose of IV antibiotics in Canada could not be determined from the CADRIS database alone, as infor­mation for this database is collected primarily through voluntary reporting, which results in underestimation of adverse reaction rates. In many cases, the database information is also incomplete, without consistent specification of the route of drug administration or timing of adverse reactions with respect to the first dose. However, the 14 reports of anaphylaxis in association with first doses of IV antimicrobials, 2 of which resulted in death, are cause for serious consideration. A key factor missing from these reports is information about patient susceptibility to hypersensitivity reactions (e.g., history of previous reactions to drugs of the same class or any other drug).
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The results of the literature and CADRIS searches highlight the need for more standardized data collection and interpretation of drug-related adverse effects. Particularly important would be data about the timing of these events with respect to initiation of therapy for patients receiving IV antibiotics.

Although the incidence of hypersensitivity reactions to any agent is difficult to determine because the clinical manifestations are often indistinct, with severity ranging from a mild rash to shock and death, 6-lactams (such as penicillins and cephalosporins) and sulfonamides are known as the most likely to induce an immunologic reaction. Penicillins are the most common therapeutic drugs causing anaphylaxis. Allergy to penicillin is estimated to exist in 0.7% to 10% of the population, causing approximately 75% of fatal anaphylaxis cases in the United States and an incidence of anaphylaxis of 32 cases per 100 000 exposures.

Nevertheless, the overall incidence of anaphylaxis due to medications is reportedly low. In an international multicentre study, the prevalence of severe anaphylaxis to drugs was 135 per million hospital inpatients. Of these reactions, 57% occurred within the first 2 days of drug administration and 75% occurred within the first 5 days. The in-hospital mortality rate has been estimated at 5% in cases of severe anaphylaxis. In a 20-year Dutch retrospective cohort study, the estimated annual incidence of drug-induced anaphylaxis was approximately 3 to 4 events per million people. Fatal drug-related anaphylactic shock was very rare in Denmark, with an estimated rate of 0.3 per million inhabitants per year. In a 5-year retrospective international study, the estimated incidence of drug-induced anaphylaxis was 5 to 15 per 100 000 exposures. cialis soft tablets

The CCAC, CIDS, and PSN surveys were created to compare existing policies of infectious disease specialists and other health care professionals involved in IV antibiotic therapy. The results indicate that the majority of hospitals and practices require the first dose of IV antibiotics to be administered in hospital, despite a lack of substantive evidence that this is the best practice in terms of efficiency, patient satisfaction, and resource management.

Investigation of the various CCAC policies for first- dose administration of home IV therapy uncovered a lack of consensus about the standard of care and what constitutes acceptable risk. Without consensus, it is foreseeable that policies may progress toward an American-style “avoid-litigation-at-any-cost” approach, which evades safety assessment and may limit the best use of health care dollars. As seen in the results from the CCAC survey, private for-profit nursing agencies are already more resistant to giving the first dose of therapy at home than are nonprofit agencies. Contextual factors play a role in policy, with some jurisdictions accommodating issues such as physician shortages and problems related to access to care in rural settings.
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