Assessing the Diagnostic Properties of a Graded Oral Provocation Challenge for the Diagnosis of Immediate and Nonimmediate Reactions to Amoxicillin in Children

Mill, Christopher; Primeau, Marie-Noël; Medoff, Elaine J.; Lejtenyi, Christine; O’Keefe, Andrew; Netchiporouk, Elena; Dery, Alizée; Ben‐Shoshan, Moshe

doi:10.1001/jamapediatrics.2016.0033

Cited by 258 publications

(242 citation statements)

References 43 publications

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“…Indeed, more than 95% of patients who report penicillin allergy, and are tested, are found to tolerate penicillins and related beta-lactams. 8–13 Because of this large discrepancy, penicillin allergy evaluation in some form is encouraged by the Centers for Disease Control and Prevention, 14 the National Quality Forum, 15 the American Board of Internal Medicine, 16 the Infectious Disease Society of America, 17 the Society for Healthcare Epidemiology in America, 17 and the American Academy of Allergy, Asthma, and Immunology. 18 As guidelines and position statements accrue, allergists have a unique opportunity to collaborate with colleagues from infectious diseases, pharmacy, and quality improvement to design and implement system-based solutions to help improve antibiotic choices among patients with reported penicillin allergy.…”

Section: Introductionmentioning

confidence: 99%

“…13,38,47–50 Test doses can be used with or without prior skin testing, depending on allergy history and assessed risk. 9,13,38,47–50 The aim of the test dose is to rule out IgE-mediated drug hypersensitivity; that is, test doses are for patients unlikely to be truly allergic. Test doses have been safely used in both outpatient and inpatient settings; MGH introduced non-allergist providers to beta-lactam antibiotic test doses in 2013 with the original guideline, 38 and since that time has performed over 800 inpatient test doses.…”

Section: Introductionmentioning

confidence: 99%

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Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation

Blumenthal

Shenoy

Wolfson

et al. 2017

The Journal of Allergy and Clinical Immunology: In Practice

111

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Addressing inaccurate penicillin allergies is encouraged as part of antibiotic stewardship in the inpatient setting. However, implementing interventions targeted at the 10–15% of inpatients reporting a prior penicillin allergy can pose substantial logistic challenges. We implemented a computerized guideline for patients with reported beta-lactam allergy at five hospitals within a single healthcare system in the Boston area. In this paper, we describe our implementation roadmap, including both successes achieved and challenges faced. We explain key implementation steps, including assembling a team, stakeholder engagement, developing or selecting an approach, spreading the change, establishing measures, and measuring impact. The objective is to detail the lessons learned while empowering others to be part of this important, multi-disciplinary work to improve the care of patients with reported beta-lactam allergies.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation

Blumenthal

Shenoy

Wolfson

et al. 2017

The Journal of Allergy and Clinical Immunology: In Practice

111

View full text Add to dashboard Cite

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“…This could partly be explained by the absence of standardized skin tests and skin measurement cut offs to diagnose antibiotic allergies, by the lack of control for gender effect in all of these studies, and by the genetic heterogeneity of the populations assessed. In addition, studies suggest that almost three percent [13] to ten percent [6] of individuals diagnosed as tolerant to a penicillin derivative, based either on a negative skin test or challenge, can develop non-life-threatening reactions upon subsequent treatment with full antibiotics dosages. It is thus possible that we have under-estimated the prevalence of allergies to these antibiotics.…”

Section: Discussionmentioning

confidence: 99%

“…The diagnosis of allergy to penicillin derivatives antibiotics is often challenging given that history as well as skin tests are reported to have poor sensitivity [5,6]. Further studies suggest that the rate of true positive results in penicillin skin tests is lower in older patients and in those with a longer time interval between the hypersensitivity reaction and the clinical assessment.…”

Section: Introductionmentioning

confidence: 99%

“…They also report that over the past two decades, there has been a decreasing rate of positive findings on penicillin skin tests, likely due to the decreased use of parenteral antibiotics [7,8] and the increased use of amoxicillin rather than penicillin V [9]. Confirmation or exclusion of the diagnosis of drug allergy often depends on drug challenges, which are more time-consuming and currently non-standardized [6].…”

Section: Introductionmentioning

confidence: 99%

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Positive penicillin allergy testing results: a systematic review and meta-analysis of papers published from 2010 through 2015

Harandian

Pham

Ben‐Shoshan

2016

Postgraduate Medicine

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β-lactam antibiotics are the most widely used group of antibiotics, given their effectiveness for the most common bacterial pathogens and their relatively low price. Adverse reactions, mainly cutaneous, are often reported to be associated with their use and hence, less effective and usually more costly alternative antibiotics are prescribed. However, it is not clear what is the risk of immediate immune-mediated (i.e. developing within one hour of administration) and potentially life-threatening reactions among those using β-lactam antibiotic. We conducted a systematic review to assess the prevalence of immediate adverse reactions to β-lactam antibiotics, specifically penicillin derivatives, in patients with a reported adverse reaction to β-lactam antibiotics. In addition, we determined the effect of age on the prevalence of immediate reactions. Assessing the true risk of using β-lactam antibiotics in patients with a reported allergy could prevent physicians from unnecessarily discouraging the use of β-lactam antibiotics. We conducted a systematic review and a meta-analysis using the PubMed, OVID, and Embase databases of work published in English and in French in the last 5 years. Studies were only eligible if they established the prevalence of immediate penicillin reactions with skin testing or challenges in case of negative skin tests. The meta-analysis was conducted using Stata version 12.0. The prevalence of immediate reactions to penicillin derivatives in patients reporting a β-lactam hypersensitivity is 1.98% (95%CI; 1.35%, 2.60%) in the pediatric (under 18 years old) group, 7.78% (95%CI; 6.53%, 9.04%) in the adult group, and 2.84% (95%CI; 1.77%, 3.91%) in the combined group, as tested in various studies, using skin tests and oral challenges. The I(2) value ranged between 87.2% and 97.0%. Our results indicate that the prevalence of immediate reactions is higher in adults than in children. However, wide confidence intervals and a large study heterogeneity preclude conclusive estimates.

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Evaluation and Management of Penicillin Allergy

Shenoy

Macy²,

Rowe

et al. 2019

JAMA

591

531

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IMPORTANCE β-Lactam antibiotics are among the safest and most effective antibiotics. Many patients report allergies to these drugs that limit their use, resulting in the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance and adverse events.OBSERVATIONS Approximately 10% of the US population has reported allergies to the β-lactam agent penicillin, with higher rates reported by older and hospitalized patients. Although many patients report that they are allergic to penicillin, clinically significant IgE-mediated or T lymphocyte-mediated penicillin hypersensitivity is uncommon (<5%). Currently, the rate of IgE-mediated penicillin allergies is decreasing, potentially due to a decreased use of parenteral penicillins, and because severe anaphylactic reactions to oral amoxicillin are rare. IgE-mediated penicillin allergy wanes over time, with 80% of patients becoming tolerant after a decade. Cross-reactivity between penicillin and cephalosporin drugs occurs in about 2% of cases, less than the 8% reported previously. Some patients have a medical history that suggests they are at a low risk for developing an allergic reaction to penicillin. Low-risk histories include patients having isolated nonallergic symptoms, such as gastrointestinal symptoms, or patients solely with a family history of a penicillin allergy, symptoms of pruritus without rash, or remote (>10 years) unknown reactions without features suggestive of an IgE-mediated reaction. A moderate-risk history includes urticaria or other pruritic rashes and reactions with features of IgE-mediated reactions. A high-risk history includes patients who have had anaphylaxis, positive penicillin skin testing, recurrent penicillin reactions, or hypersensitivities to multiple β-lactam antibiotics. The goals of antimicrobial stewardship are undermined when reported allergy to penicillin leads to the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance, including increased risk of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Broad-spectrum antimicrobial agents also increase the risk of developing Clostridium difficile (also known as Clostridioides difficile) infection. Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories. Moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95% and approaches 100% when combined with amoxicillin challenge. Clinicians performing penicillin allergy evaluation need to identify what methods are supported by their available resources.CONCLUSIONS AND RELEVANCE Many patients report they are allergic to penicillin but few have clinically significant reactions. Evaluation of penicillin allergy before deciding not to use penicillin or other β-lactam antibiotics is an important tool for antimicrobial stewardship.

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Assessing the Diagnostic Properties of a Graded Oral Provocation Challenge for the Diagnosis of Immediate and Nonimmediate Reactions to Amoxicillin in Children

Cited by 258 publications

References 43 publications

Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation

Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation

Positive penicillin allergy testing results: a systematic review and meta-analysis of papers published from 2010 through 2015

Evaluation and Management of Penicillin Allergy

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