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Several methods of desensitization have been described for penicillin, including use of both oral and intravenous preparations All methods start with very small doses of drug and gradually increase the dose until therapeutic doses are achieved For penicillin, 1 unit of drug is given intravenously and the patient observed for 15 30 minutes If there is no reaction, some recommend doubling the dose while others recommend increasing it tenfold every 15 30 minutes until a dosage of 2 million units is reached; then give the remainder of the desired dose For recommendations on skin testing and desensitization for other preparations (eg, botulism antitoxin and diphtheria antitoxin), the manufacturer s package inserts should be consulted

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Penicillin is the drug that most frequently serves as an indication for sensitivity testing and desensitization A clinical history of penicillin allergy has a positive predictive value of only 15% In determining whether allergy testing should be performed, its nature should be determined IgG-mediated delayed reactions such as erythematous or maculopapular skin rash or serum sickness should be distinguished from immediate-type IgE-mediated reactions, such as urticaria, angioedema, and anaphylaxis Only patients with the latter history who require penicillin or a cephalosporin should undergo hypersensitivity testing Skin testing requires two preparations: PPL (penicilloyl-polylysine) and a minor determinant mixture Several points should be emphasized in performing and interpreting these tests Whenever possible, both PPL and a minor determinant should be used, since 85% of skin test reactors are positive to PPL but 15% react only to the minor determinant mixture In addition, if penicillin G is used instead of the minor determinant mixture, some allergic patients will be missed About 25% of individuals who react to minor determinant mixture may not react to penicillin G, and such patients may still have an anaphylactic or accelerated reaction to penicillin A pinprick test is performed with each solution at different sites by placing a small drop of solution on the skin and making small indentations of the skin with a needle If there is no reaction within 10 minutes, 001 002 mL is injected intradermally, raising a small bleb Development of a wheal greater than 5 mm in diameter is considered a positive test and an indication for desensitization Even if the test is negative, about 1 2% of patients will have an immediate or accelerated reaction, but an anaphylactic reaction is rare Thus, if the test is negative, the drug can be administered with relative safety, but the first dose should be medically supervised and the patient observed for 1 hour (serious reactions after 1 hour are rare).

If a mild reaction occurs, drop back to the next lower dose and continue with desensitization If a severe reaction occurs, administer epinephrine (see below) and discontinue the drug unless treatment is urgently needed If desensitization is imperative, continue slowly, increasing the dosage of the drug more gradually

If bronchospasm occurs, epinephrine, 03 05 mL of 1:1000 dilution, should be given subcutaneously every 10 20 minutes, followed by corticosteroids (250 mg of hydrocortisone or 50 mg of methylprednisolone intravenously every 6 hours for two to four doses), if needed Hypotension should be treated with intravenous fluids (saline or colloid), epinephrine (1 mL of 1:1000 dilution in 500 mL of D5W intravenously at a rate of 05 5 mcg/min), and antihistamines (25 50 mg of hydroxyzine or diphenhydramine intramuscularly or orally every 6 8 hours as needed) Cutaneous reactions, manifested as urticaria or angioedema, respond to epinephrine subcutaneously and antihistamines in the doses set forth above

Arroliga ME et al Penicillin allergy: consider trying penicillin again Cleve Clin J Med 2003 Apr;70(4):313 4, 317 8, 320 1 passim [PMID: 12701985] Centers for Disease Control and Prevention Sexually transmitted diseases treatment guidelines 2006 MMWR Recomm Rep 2006 Aug 4;55(RR-11):1 94 [PMID: 16888612] Gruchalla RS et al Clinical practice Antibiotic allergy N Engl J Med 2006 Feb 9;354(6):601 9 [PMID: 16467547]

Kim TY et al Metastasis to the thyroid diagnosed by fine-needle aspiration biopsy Clin Endocrinol (Oxf) 2005 Feb;62(2):236 41 [PMID: 15670202] Robbins RJ et al Real-time prognosis for metastatic thyroid carcinoma based on 2-[18F]fluoro-2-deoxy-D-glucose-positron emission tomography scanning J Clin Endocrinol Metab 2006 Feb;91(2):498 505 [PMID: 16303836]

This KOFI access sequence may be kept for most business, with the possible exception that maybe not all the condition tables would be used If this was the case it would be advisable to copy the access sequence, rename it, and then allocate it to the relevant account determination type (condition type) Within the new access sequence you would now be able to delete condition tables that are not being used, thus improving on system performance and response times As in the standard condition techniques, you can assign a requirement to the condition tables within the access sequence if necessary

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