Testing clears nearly all antibiotic allergy labels in pediatric clinic
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Key takeaways:
- Delabeling included oral challenges with or without additional skin testing.
- 3.6% of patients reacted when challenged with amoxicillin or dicloxacillin.
- Graded doses may prevent severe reactions.
A pediatric allergy clinic safely delabeled nearly all the patients with reported antibiotic allergy that it tested between January 2016 and December 2017, according to a letter published in Annals of Allergy, Asthma & Immunology.
These tests eliminated the health risks that these patients would have faced with an antibiotic allergy label, Grant Pickett, MD, of Texas Children’s Hospital and Baylor College of Medicine, and colleagues wrote.
The retrospective review involved 69 children (median age at challenge, 7 years; 1:5 boy-to-girl ratio) with 79 suspected antibiotic allergies examined by 11 allergists. Also, 49 (71%) of these children had a history of atopy.
After 7 days with no antihistamine treatment, patients participated in oral challenges conducted in single or in graded doses, as determined by the evaluating physician, or in skin testing followed by oral challenges.
The 69 completed skin tests included 49 (71%) for amoxicillin, 13 (18.8%) for cephalosporin, three (4.3%) for azithromycin, two (2.9%) for amoxicillin/clavulanic acid, one (1.4%) each for clindamycin and dicloxacillin.
Results included one positive skin prick test for amoxicillin/clavulanic acid and one positive intradermal test for amoxicillin. There also were six patients who had skin testing but were lost to follow-up and did not return for an oral challenge.
The 73 completed oral challenges included 54 (74%) for amoxicillin, 12 (16.4%) for cephalosporins, three (4.1%) for azithromycin, two (2.7%) for amoxicillin/clavulanic acid, one (1.4%) each for clindamycin and dicloxacillin.
These oral challenges included 63 among patients who had negative skin test results and 10 among patients who did not have any prior skin testing. All direct oral challenges were negative, including one for cefdinir and two for amoxicillin/clavulanic acid.
Seven of these direct oral challenges were for patients with an initial reaction of nonspecific rash, two were for patients with a history of hives, and one was for a patient with a twin who had a penicillin allergy.
Five oral challenges used graded doses, including four for amoxicillin, of which three were conducted without previous skin testing in patients who had an initial nonspecific rash. These three patients all passed the oral challenge.
The authors also reported one patient with an initial reaction of anaphylaxis who failed a graded oral challenge after a negative skin test and developed pharyngeal edema within 5 minutes of receiving 40 mg (10%) of the total amoxicillin dose. Another patient passed a graded challenge for cefdinir after a negative skin test.
Overall, 3.6% of the cohort reacted to amoxicillin or dicloxacillin challenges. All 10 patients who had direct challenges had their allergy labels removed. Guidelines recommend direct penicillin challenges for children with histories of benign cutaneous reactions.
Most of the children in this cohort could have been delabeled without skin testing under these parameters, the researchers wrote.
The cohort also included four children with suspected non-beta lactam antibiotic (NBLA) allergies who had skin testing and a negative oral challenge, which the researchers called consistent with previous studies, adding that the safety of direct challenges for antibiotics aside from penicillin merits additional study.
Further, the researchers said that graded doses may improve safety for patients with high-risk histories after negative skin tests by decreasing the severity of any hypersensitivity reactions they may have, with additional study warranted here as well.
These safe and successful real-world pediatric cases of delabeled allergies add to previous studies supporting challenges for reported penicillin and NBLA allergies, the researchers wrote, enabling these patients to benefit from the standard of care.
Perspective
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These types of proactive delabeling programs are important because we know that an unverified penicillin allergy label has multiple deleterious effects on individuals (decreased infection cure rates, increased infection recurrence rates, increased side effects due to second-line antibiotics) and on public health (increased antimicrobial resistance, increased health care costs). Addressing the penicillin allergy proactively can mitigate these risks.
These findings are certainly in line with previous pediatric data that most kids can successfully be delabeled and that the evaluations are low risk. They also are in line with my experience in terms of pediatric patients tolerating penicillins. I have adjusted my practice in line with the current drug allergy practice parameters and employ direct oral challenges in the vast majority of kids.
There are great studies and resources available for practices that want to launch or improve their allergy delabeling programs through our professional societies such as the American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma & Immunology. I truly think that all allergy/immunology practices should offer this important service.
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