What testing and referrals are recommended for a patient in primary care following hospitalization for new anaphylaxis to Levaquin (levofloxacin)?

From the Guidelines

For a patient in primary care following hospitalization for new anaphylaxis to Levaquin (levofloxacin), referral to an allergist/immunologist is strongly recommended for comprehensive evaluation and management. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of specialist evaluation for patients with anaphylaxis 1. Initial testing should include serum tryptase levels within 3 hours of the reaction if not already obtained during hospitalization, as elevated levels can confirm mast cell activation. The primary care provider should prescribe an epinephrine auto-injector (such as EpiPen or Auvi-Q 0.3mg for adults, 0.15mg for children) and educate the patient on proper use, as epinephrine is the first-line pharmacotherapy for anaphylaxis 1.

Some key points to consider in the management of this patient include:

• Documentation of the allergy should be prominent in the medical record, and the patient should be provided with medical alert identification.
• The allergist will likely perform skin testing and/or drug provocation tests to confirm the fluoroquinolone allergy and assess for cross-reactivity with other antibiotics in this class.
• The primary care provider should review all current medications to identify potential cross-reactive drugs and ensure the patient understands which antibiotics to avoid until specialist evaluation is complete.
• Patient education on anaphylaxis, including avoidance of identified triggers, presenting signs and symptoms, biphasic anaphylaxis, treatment with epinephrine, and the use of epinephrine auto-injectors, is crucial 1.
• The patient should be instructed to wear and/or carry identification denoting his or her condition (eg, Medic Alert jewelry) 1.

It is essential to prioritize the patient's safety and well-being by ensuring they receive comprehensive evaluation and management from an allergist/immunologist, as anaphylaxis can be life-threatening if not properly managed 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Testing and Referrals for Anaphylaxis to Levaquin

• The patient should be referred to an allergist for follow-up after an emergency department evaluation for anaphylaxis, as recommended by current guidelines 2, 3.
• Testing may include:
  • Mast cell tryptase (MCT) test, with serum samples taken within 1-2 hours but no later than 4 hours from the onset of symptoms 4.
  • Skin tests to confirm an immediate hypersensitivity reaction to levofloxacin 5.
• The patient should be prescribed an epinephrine auto-injector and receive training on its use 2, 6.
• The patient should be observed for 6-12 hours after the onset of symptoms due to the risk of relapse, and children under 16 years should be admitted and supervised by a pediatrician 4.
• Allergist follow-up is crucial, as it can lead to alterations in the diagnosis or suspected trigger of anaphylaxis, and may result in immunotherapy or desensitization 3.
• Collaboration between emergency medicine clinicians, allergists, and pharmacists is necessary to streamline treatment and follow-up 6.