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All penicillins are cross-sensitizing and cross-reacting The responsible antigenic determinants appear to be degradation products of penicillins, particularly penicilloic acid and products of alkaline hydrolysis (minor antigenic determinants) bound to host protein Skin tests with penicilloyl-polylysine, with minor antigenic determinants, and with undegraded penicillin can identify most individuals with IgE-mediated reactions (hives, bronchospasm) Among positive reactors to skin tests, the incidence of subsequent immediate severe penicillin reactions is high Although IgG antibodies to antigenic determinants of penicillin develop in many persons, the presence of such antibodies is not correlated with allergic reactivity (except for rare instances of hemolytic anemia), and serologic tests have little predictive value A history of a penicillin reaction in the past is not reliable Only 15 20% of patients with a history of penicillin allergy have an adverse reaction when challenged with the drug The decision to administer penicillin or related drugs (other -lactams) to patients with an allergic history depends on the severity of the reported reaction, the severity of the infection being treated, and the availability of alternative drugs For patients with a history of severe reaction (anaphylaxis), alternative drugs should be used In the rare situations when there is a strong indication for using penicillin (eg, syphilis in pregnancy) in allergic patients, desensitization can be performed If the reaction is mild (nonurticarial rash), the patient may be rechallenged with penicillin or may be given another -lactam antibiotic Allergic reactions include anaphylaxis, serum sickness (urticaria, fever, joint swelling, angioneurotic edema 7 12 days after exposure), skin rashes, fever, interstitial nephritis, eosinophilia, hemolytic anemia, other hematologic disturbances, and vasculitis The incidence of hypersensitivity to penicillin is estimated to be 1 5% among adults in the United States Lifethreatening anaphylactic reactions are very rare (005%) Ampicillin produces maculopapular skin rashes more frequently than other penicillins, but many ampicillin (and other -lactam) rashes are not allergic in origin The nonallergic ampicillin rash usually occurs after 3 4 days of therapy, is maculopapular, is more common in patients with coexisting viral illness (especially Epstein-Barr infection), and resolves with continued therapy The maculopapular rash may or may not reappear with rechallenge Rarely, penicillins can induce.

These include hypersensitivity reactions, direct toxicity, superinfection by drug-resistant microorganisms, and drug interactions If the infection is life-threatening and treatment cannot be stopped, the reactions are managed symptomatically or another drug is chosen that does not cross-react with the offending one (Table 30 4) If the infection is less serious, it may be possible to stop all antimicrobials and monitor the patient closely

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To increment a value before assigning it, you use the prefix operator (++x); to increment the value after assigning it, use the postfix operator (x++). The same rule applies to the decrement operator. The relational operators compare two values and return a Boolean. These operators are often used in conditional statements. The conditional operator ( : ) is the only ternary operator found in C#. The test condition is found to the left of the question mark; it invokes the expression to the left of the colon if the tested condition evaluates true and the expression to the right of the colon if the tested condition evaluates false. The compiler evaluates operators according to a series of precedence rules, and parentheses have the highest precedence. It is good programming practice to use parentheses to make your order of precedence explicit if there may be any ambiguity. You saw a lot of math in this chapter, which is certainly useful, because your programs will often perform mathematical operations. We also mentioned several times that these operators will be useful in 5. 5 deals with branching, the technique by which you enable your program to take different actions depending on the values contained in the variables. 5 is going to tie together what you ve learned so far, and enable you to take the next step with your programming skills.

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