Allergy to bacitracin

Author: Dr Julie Fraser, Intern, Modbury Hospital, Adelaide; Chief Editor: Hon A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand, September 2015.


Allergy to bacitracin
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Synonyms:
Bacitracin allergy
Categories:
Reactions to external agents
ICD-10-CM:
L23.3
ICD-11 MMS:
EK00.Z
SNOMED CT:
5220000, 370330005, 238575004

Introduction

Bacitracin was declared the Contact Allergen of the Year for 2003 by the American Contact Dermatitis Society (ACDS). Allergic contact dermatitis caused by bacitracin is among the top ten allergens in the US causing allergic contact dermatitis.1

Bacitracin is the active ingredient of a large variety of topical antibacterial agents.2

What is bacitracin and where is it found?

Bacitracin is a polypeptide broad-spectrum antibiotic. It is synthesised from organisms of the licheniformis group of Bacillus subtilis var Tracy, first isolated in the 1940s.3 It is bacteriostatic (or bacteriocidal in sufficient quantities) and acts on gram-positive and some gram-negative bacteria by disrupting cell wall and peptidoglycan synthesis.

What is bacitracin used for?

Ophthalmic and ear medications

Bacitracin is used in superficial eye infections involving the conjunctiva (conjunctivitis) or cornea (keratitis), and for infections of the external ear canal (otitis externa).4,6

Topical use on the skin surface

  • To prevent infection in minor cuts, scrapes and burns.
  • During and after surgery to prevent infection.

Bacitracin is used alone or in combination with other products, including:

Treatment of large areas of skin can be dangerous due to toxicity to the nervous system and kidneys, particularly in children, in the elderly, and in those with renal impairment.

Injection

  • The only systemic use of bacitracin is in neonatal pneumonia and empyema caused by susceptible staphylococci. Renal function must be monitored for nephrotoxicity.

Bacitracin is not used orally because it is toxic and does not work well orally.

How does bacitracin allergy present?

Bacitracin allergy presents as classic allergic contact dermatitis, either as an acute vesicular dermatitis or as a chronic dermatitis that is becoming worse.5 It can also rarely present as systemic contact dermatitis.

When bacitracin ointment is applied to broken skin, systemic absorption may result in anaphylactoid reactions. Bacitracin has been identified as the most common topical antibiotic to cause anaphylaxis.6 Severe reactions have occurred — some during surgery and some in healthy people after applying bacitracin ointment to abrasions. 7Anaphylactoid reactions have ranged from cardiac arrest, unconsciousness and apnoea, to swelling of the lips and face, sweating, and generalised itching.

Am I allergic to topical bacitracin?

Allergic reactions may be due to bacitracin or to irritation from or allergy to other components of the preparation, such as the antibacterial agent neomycin, which is known to be a potent sensitiser.

Bacitracin allergy is confirmed by performing patch tests to bacitracin. The correct concentration is uncertain, ranging from 1% to 20% bacitracin in petrolatum (petroleum jelly).8,9 About 50 percent of patients have a delayed reaction with the positive bacitracin patch test seen only at the 96-hour reading.10

Cross-sensitivities

It is important to note that bacitracin and neomycin may co-react, even though they are chemically unrelated. Additionally, bacitracin sensitivity may be experienced along with sensitivities against other antibiotics. This may be due to using multiple antibiotics at the same time.

Treatment of bacitracin allergy

Treatment depends on the severity of the reaction. Once allergy has been confirmed, the first step is to avoid any contact with it.

Treatment of contact dermatitis is as for any acute dermatitis/eczema, i.e. topical corticosteroids, emollients, antibiotic treatment of any secondary bacterial infection (Staphylococcus aureus), etc.

Bacitracin may be retained in fabric and may be difficult to wash out. New clothing may be required to solve the dermatitis.6

Severe anaphylaxis is a medical emergency. Those at risk of this type of reaction should wear or carry some form of medical alert (eg "Medic Alert" bracelet) to warn health-care personnel to avoid using bacitracin-containing products.

What should I do to avoid bacitracin allergy?

Ask your dermatologist or pharmacist for a full list of all the substances that should be avoided and for safe alternatives. Your doctor may have further specific advice relating to your particular situation.

Alert your pharmacist and your doctors to your allergy, so that suitable alternatives to bacitracin can be prescribed.

Further information

Formula: C66H103N17O16S

CAS number: 1405-87-4

Cross reactions:

Cross-reactions are reported to:

  • Neomycin
  • Gentamicin
  • Kanamycin
  • Streptomycin
  • Spectinomycin
  • Tobramycin
  • Paromomycin
  • Butirosin
  • Polymyxin, which is also obtained from Bacillus subtilis6

Sensitiser: bacitracin

Patch test: 5% bacitracin in petrolatum

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References

  1. Bates, Betsy. Common topical antibiotic is among top contact allergens: bacitracin. Family Practice News 1 Feb. 2004: 45. Expanded Academic ASAP. Web. 15 Sept. 2015.
  2. Bacitracin – ChemoTechnique Diagnostics
  3. Drugbank Version 4.3 [Internet] Canadian Institutes of Health Research, Alberta Innovates – Health Solutions, and The Metabolomics Innovation Centre (TMIC) – Bacitracin; [updated September 16, 2013].
  4. Drugs.com [Internet]. Bacitracin Opthalmic Ointment USP from Drugs.com; [Updated: 12/2013].
  5. Vazirnia A, Jacob SE. Review ACDS Allergen of the Year 2000-2015. The Dermatologist [Internet] Volume 22 – Issue 11 November 2014.
  6. Douglas JD. Allergic Contact Dermatitis and Topical Antibiotics. Bacitracin.
  7. Jacob SE, James WD. Bacitracin after clean surgical procedures may be risky. Journal of the American Academy of Dermatology, [Internet] December 2004 Volume 51, Issue 6, Page 1036 [cited 15 September 2015].
  8. Drugs.com [Internet].Bacitracin Zinc topical from Drugs.com [Updated June 3, 2015].
  9. Nelson J, Mowad CM. Allergic Contact Dermatitis. Patch Testing Beyond the TRUE Test. J Clin Aesthet Dermatol. 2010 Oct; 3(10): 36–41. PubMed Central PMCID: PMC2958195
  10. Gehrig KA, Warshaw EM. Allergic contact dermatitis to topical antibiotics: Epidemiology, responsible allergens, and management. J Am Acad Dermatol. 2008 Jan;58(1):1-21. PubMed PMID: 18158924

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