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Clinical Practice Guidelines for Diagnosis and Management of Hypersensitivity Reactions to Quinolones

Doña I1, Blanca-López N2, Boteanu C3, Cueva-Oliver B4, Fernández-Sánchez FJ5, Gajate P6, García-Avilés MC7, García-Núñez I8,9, Lobera T10, Moreno E11, Rojas P12, Rosado A13

1Allergy Unit, Hospital Regional Universitario de Málaga, Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Regional Universitario de Málaga, Málaga, Spain
2Allergy Service, Infanta Leonor University Hospital, Madrid, Spain
3Allergy Service, Hospital Central De la Cruz Roja San José y Santa Adela, Madrid, Spain
4Allergy Section, Hospital General Universitario de Alicante, ISABIAL, Alicante, Spain
5Allergy Section, Hospital General Universitario de Alicante, UMH-ISABIAL, Alicante, Spain
6Allergy Service, Hospital Rey Juan Carlos, Móstoles (Madrid), Spain
7Allergy Unit, Hospital Universitario Moncloa, Madrid, Spain
8Allergy and Pulmonology Department, Hospital Quirón Salud Campo de Gibraltar, Cádiz, Spain
9Allergy Department, Hospital Quirónsalud Córdoba, Córdoba, Spain
10Department of Allergy, San Pedro University Hospital, Logroño (La Rioja), Spain
11Allergy Service, University Hospital of Salamanca, Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
12Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
13Allergy Unit, Hospital Universitario Fundación Alcorcón, Madrid, Spain

J Investig Allergol Clin Immunol 2021; Vol 31(4) : 292-307
doi: 10.18176/jiaci.0669

The consumption of quinolones as first-line treatment has increased in recent years, leading to an increase in the incidence of hypersensitivity reactions (HSRs) to this antibiotic group. Both diagnosis and management of HSRs to quinolones are complex and controversial. These practical guidelines aim to provide recommendations for effective clinical practice. The recommendations were drafted by an expert panel that reviewed the literature regarding HSRs to quinolones and analyzed controversies in this area.
Most HSRs to quinolones are immediate and severe. The risk for HSRs is higher in patients who report allergy to ß-lactams, moxifloxacininduced anaphylaxis, and immediate reactions than in patients who report reactions to quinolones inducing other symptoms. The usefulness of skin tests in diagnosing HSRs to quinolones is controversial, with sensitivity and specificity varying between studies. Most in vitro tests are produced in-house, with no validated commercial options. The basophil activation test has proven useful for diagnosing immediate reactions, albeit with diverse results regarding sensitivity. Drug provocation testing is currently the gold standard for confirming or excluding the diagnosis and for finding safe alternatives, although it is contraindicated in patients with severe reactions. Cross-reactivity between quinolones has proven controversial in several studies, with the lowest cross-reactivity reported for levofloxacin. Desensitization may be considered in allergy to quinolones when no other alternatives are available.

Key words: Drug allergy, Quinolones, Anaphylaxis, Skin test, Drug provocation test, Basophil activation test