Penicillin-allergic patients: Use of cephalosporins, carbapenems, and monobactams
- Roland Solensky, MD
Roland Solensky, MD
- The Corvallis Clinic
- Corvallis, Oregon
Penicillin allergy is reported by up to 10 percent of people. A common clinical question is whether these individuals can safely receive structurally-related antibiotics, such as cephalosporins, carbapenems, and monobactams.
This topic will discuss cross-reactivity between penicillins and structurally-related antibiotics in patients with type I, immunoglobulin E (IgE)-mediated allergy to penicillins. Penicillin allergy, skin testing, graded challenge (test dosing), and desensitization are reviewed separately. (See "Penicillin allergy: Immediate reactions" and "Penicillin skin testing".)
Antigenic components of penicillins — In order to understand the possible cross-reactivity among penicillins, cephalosporins, carbapenems, and monobactams, it is helpful to review the potential allergens in penicillins. Patients with IgE-mediated allergy to penicillins may be reactive to the beta-lactam ring structure that is common to all penicillins, or to the R group side chains that distinguish different penicillins from one another. In the United States, most penicillin-allergic patients are sensitive to the beta-lactam core. In contrast, in southern Europe where amoxicillin constitutes 90 percent of antibiotic use in some European countries, up to one-third of patients are said to react to the R group side chain. (See "Penicillin allergy: Immediate reactions", section on 'Allergens arising from side chains'.)
●A beta-lactam structure is also found in cephalosporins, carbapenems, and monobactams (figure 1).
●The aminopenicillins amoxicillin and ampicillin each have R group side chains that are identical to the side chains of certain cephalosporins (table 1).
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- Antigenic components of penicillins
- Multiple drug allergy syndrome
- Limitations of clinical cross-reactivity studies
- Risk of administration in patients with reported penicillin reactions
- Risk of administration in patients with confirmed penicillin allergy
- Algorithm for management
- - Penicillin skin testing is available
- - Penicillin skin testing is not available
- Graded challenge
- Patients selectively allergic to amoxicillin or ampicillin
- Patients with a history of penicillin allergy who have already tolerated a cephalosporin
- Recommended approach
- MONOBACTAMS (AZTREONAM)
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS