Allergy Testing in Children With Low-Risk Penicillin Allergy Symptoms

Vyles, David; Adams, Juan; Chiu, Asriani; Simpson, Pippa; Nimmer, Mark; Brousseau, David C.

doi:10.1542/peds.2017-0471

Cited by 111 publications

(87 citation statements)

References 15 publications

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“…In our prospective study, only 5.2% of all children reporting a DHR to a BL had a proven hypersensitivity to the suspected BL, which is a lower percentage if compared with previous reports . This might be due to the characteristics of our pediatric population, with >90% of patients having a non‐immediate initial reaction, which rarely results to be true DHRs.…”

Section: Resultscontrasting

confidence: 69%

“…In children treated with BLs, skin eruptions, mostly described as maculopapular or urticarial, are frequently assumed to be a DHR, although most of these eruptions are not allergic, with viral infections being often considered as the major differential diagnosis. 3,16 It is therefore very important to complete an allergy workup in patients reporting a history of BL DHR. 16 Older EAACI/ENDA guidelines do not differentiate between children and adults and advise to perform several ST (both SPTs and IDTs) before running a DPT.…”

Section: Con Clus Ionmentioning

confidence: 99%

“…3,16 It is therefore very important to complete an allergy workup in patients reporting a history of BL DHR. 16 Older EAACI/ENDA guidelines do not differentiate between children and adults and advise to perform several ST (both SPTs and IDTs) before running a DPT. [6][7][8] This is a limiting factor in pedi- On the other hand, in recent years, it has been suggested not to perform ST in children, in mild-to-moderately severe delayed reactions, but to simply prescribe a DPT.…”

Section: Con Clus Ionmentioning

confidence: 99%

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Skin tests are important in children with β‐lactam hypersensitivity, but may be reduced in number

Diaferio

Chiriac

Leoni

et al. 2019

Pediatric Allergy Immunology

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Background There is no perfect agreement on how to perform an allergy workup in suspected beta‐lactam (BL)–allergic children, since skin test (ST)–induced pain is often a limitation. The aim of the study was to assess the possibility of reducing the number of ST in children when performing a complete allergy workup for BL hypersensitivity reactions. Methods A retrospective analysis of all patients referring to the Allergy Unit of the University Hospital of Montpellier (France) with positive responses in immediateand non–immediate‐reading ST to a BL over a 16‐year period was performed, to determine the positive predictive value (PPV) of ST. All pediatric patients with a suspected BL hypersensitivity were skin‐tested with the suspected drug only, during the following 54 months. Results A total of 319 patients reporting 328 BL reactions were included in the retrospective study. The PPV of ST for the reported drug was of 99.4%. Based on the results, the number of patients to include in the prospective study was estimated to be 101. In the prospective study, 229 children were included. We diagnosed a BL hypersensitivity in 12 children (5.2%): Diagnosis was reached in 6 (50.0%) through ST (delayed reading for all) and in 6 through drug provocation test (DPT). Conclusion ST with BL should therefore be performed as a screening test, before DPT, and testing only the suspected drug may be sufficient when dealing with children.

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Section: Resultscontrasting

confidence: 69%

Section: Con Clus Ionmentioning

confidence: 99%

Section: Con Clus Ionmentioning

confidence: 99%

See 1 more Smart Citation

Skin tests are important in children with β‐lactam hypersensitivity, but may be reduced in number

Diaferio

Chiriac

Leoni

et al. 2019

Pediatric Allergy Immunology

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“…[95][96][97][98] At present, direct ingestion has been done in carefully selected cohorts, predominantly healthy children or healthy adults, whose historical symptoms were at lower risk of true penicillin allergy. 39,43,95,99 (Table 2) Direct provocation of a penicillin-labeled patient without preceding skin testing appears to be an important tool in the de-labeling toolkit, as tolerance demonstrates the absence of immediate hypersensitivity. This approach has been particularly relevant in children where the pretest risk of true anaphylaxis was very low.…”

Section: Patients With a Low-risk History Or A History Inconsistent Wmentioning

confidence: 99%

The challenge of de‐labeling penicillin allergy

Stone

Trubiano

Coleman

et al. 2019

Allergy

186

160

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Background Even though 8%‐25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de‐labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. Methods We performed an evidence‐based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de‐labeling. Over the period 1928‐2018 in Pubmed and Medline, search terms used included “penicillin allergy” or “penicillin hypersensitivity” alone or in combination with “adverse events,” “testing,” “evaluation,” “effects,” “label,” “de‐labeling,” “prick or epicutaneous,” and “intradermal” skin testing, “oral challenge or provocation,” “cross‐reactivity,” and “antimicrobial stewardship”. Results Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. Conclusions Operationalizing penicillin allergy de‐labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de‐labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.

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“…An evaluation conducted in a pediatric emergency department that involved 100 children with a history of penicillin allergy found that 100% (95% CI 96.4%-100%) of these children with low-risk symptoms had negative results for allergy testing (skin testing and drug provocation test). 37 Evaluation is especially useful if the reaction occurred more than 5 to 10 years ago, because there is a high rate of resolution for penicillin allergy. [38][39][40] For example, a retrospective study involving 740 patients with a history of β-lactam allergy found that 93% of these patients had a positive result for skin testing if the reaction was in the past year; this decreased to 22% of patients with a positive test result if they were evaluated 10 or more years after their clinical reaction.…”

Section: Penicillinmentioning

confidence: 99%