Allergy evaluation for immediate penicillin allergy: Skin test-based diagnostic strategies and cross-reactivity with other beta-lactam antibiotics
- Kimberly G Blumenthal, MD, MSc
Kimberly G Blumenthal, MD, MSc
- Assistant Professor of Medicine
- Harvard Medical School
- Roland Solensky, MD
Roland Solensky, MD
- Oregon State University/Oregon Health and Science University College of Pharmacy
Penicillin allergy is the most common drug allergy reported by patients. Penicillins are one group within the family of beta-lactam antibiotics, which also includes cephalosporins, carbapenems, and monobactams. This topic will present diagnostic strategies used by allergy specialists for evaluating a patient with suspected or confirmed immediate (ie, immunoglobulin E [IgE]-mediated) allergy to penicillins. Studies of cross-reactivity between penicillins and other beta-lactam antibiotics are also reviewed.
●An algorithmic approach to the use of related antibiotics, with or without access to allergy consultation and penicillin skin testing, is discussed in detail separately (algorithm 1). (See "Choice of antibiotics in penicillin-allergic hospitalized patients".)
●Delayed reactions to penicillins, ranging from maculopapular drug eruptions to severe systemic reactions, are reviewed elsewhere. (See "Penicillin allergy: Delayed hypersensitivity reactions".)
Penicillin allergy is reported by up to 10 percent of patients. However, more than 90 percent of patients with a reported penicillin allergy do not have immunoglobulin E (IgE) antibodies when skin testing is performed, either because they were inappropriately labeled as allergic or because they had an earlier allergy that resolved with time [1-5]. Among patients with an IgE-mediated penicillin allergy that has been confirmed with skin testing, available studies suggest that 97 percent will tolerate cephalosporins and 99 percent will tolerate carbapenems, as reviewed in detail in this topic. However, despite these reassuring figures, beta-lactam drugs are among the leading causes of drug-induced anaphylaxis, and there are methodologic issues with the data that should be appreciated to understand the limitations of the literature.
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- GENERAL CONCEPTS
- Features of immediate reactions
- Antigenic components of penicillins
- Multiple antibiotic allergy syndrome
- Population differences
- Studies estimating the risk of cross-reactivity
- Allergy evaluation and penicillin skin testing
- - Negative result
- - Positive result
- Penicillin skin testing is not available
- Patients reporting a past reaction to amoxicillin or ampicillin
- - Selective allergy confirmed by skin testing
- Recommended approach
- MONOBACTAMS (AZTREONAM)
- TEST DOSING (OR GRADED CHALLENGE)
- Indications and precautions
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS