Clinical Experience With Penicillin Skin Testing in a Large Inner-City STD Clinic

Gadde, J.; Spence, Michael R.; Wheeler, Barbara; Nf, Adkinson

doi:10.1001/jama.1993.03510200062033

Cited by 278 publications

(159 citation statements)

References 33 publications

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“…The negative predictive value of skin tests for penicillin is not as high as originally reported by early American studies at a time when narrow-spectrum penicillins were prescribed [20,82,[151][152][153].…”

Section: Predictive Value Of Skin Tests For Penicillinmentioning

confidence: 59%

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Management of allergy to penicillins and other beta‐lactams

Mirakian

Leech

Krishna

et al. 2015

Clin Experimental Allergy

228

229

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SummaryThe Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and an expert panel have prepared this guidance for the management of immediate and non-immediate allergic reactions to penicillins and other beta-lactams. The guideline is intended for UK specialists in both adult and paediatric allergy and for other clinicians practising allergy in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking, the panel reached consensus. During the development of the guideline, all BSACI members were consulted using a Web-based process and all comments carefully considered. Included in the guideline are epidemiology of allergic reactions to beta-lactams, molecular structure, formulations available in the UK and a description of known beta-lactam antigenic determinants. Sections on the value and limitations of clinical history, skin testing and laboratory investigations for both penicillins and cephalosporins are included. Cross-reactivity between penicillins and cephalosporins is discussed in detail. Recommendations on oral provocation and desensitization procedures have been made. Guidance for beta-lactam allergy in children is given in a separate section. An algorithm to help the clinician in the diagnosis of patients with a history of penicillin allergy has also been included.Keywords allergy, anaphylaxis, beta-lactam, BSACI, carbapenem, cephalosporin, children, cross-reactivity, desensitization, drug provocation test, epidemiology, hypersensitivity, monobactam, oral challenges, paediatrics, penicillin, serum-specific IgE, skin tests, Standards of Care Committee • This guideline addresses immediate and non-immediate allergic reactions to beta-lactams.• Up to 20% of drug-related anaphylaxis deaths in • Individuals with a positive skin test to an aminopenicillin but negative skin tests to penicillin determinants are likely to be sensitized to the aminopenicillin side chain. (B) In this situation, a cautious challenge to benzyl or phenoxymethyl penicillin can be considered to ascertain whether the patient has a selective penicillin allergy. (D) • If a cephalosporin is required in a patient with a clinical history of penicillin allergy and positive skin tests -the patient should undergo skin testing using a cephalosporin with a different side chain and, if negative, provocation testing should be undertaken to exclude allergy to the specific cephalosporin. (D)• If penicillin is required in a patient with a clinical history of cephalosporin allergy, skin testing should be undertaken with penicillins and, if negative, provocation testing to exclude allergy to penicillin. (B) If skin tests are positive, then penicillin avoidance or desensitization can be considered. (B)• If a cephalosporin is required by a patient with a previous reaction, skin testing to penicillins and the required cephalosporin should be carried out to establish whether sensitization is to the beta-lactam core or side chain. (B) This should be followed by either provo...

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Section: Predictive Value Of Skin Tests For Penicillinmentioning

confidence: 59%

“…Systemic reactions have been reported in 0.7% to 11% of those with positive skin test results [8,20,82,110], reviewed in [52,109]. In a cohort of 998 patients with suspected allergy to beta-lactams, 8.8% of skin test-positive patients experienced a systemic reaction with five cases occurring after prick tests [109].…”

Section: Safety Of Skin Testsmentioning

confidence: 99%

Management of allergy to penicillins and other beta‐lactams

Mirakian

Leech

Krishna

et al. 2015

Clin Experimental Allergy

228

229

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“…Patient self-reported rates for penicillin allergy can be as high as 15% with 10% a generally accepted figure, [105][106][107][108] with true rates of penicillin allergy likely to be much lower. 105,106,109 We therefore used the cost of levofloxacin either orally or intravenously for 10% of patients who required antibiotics. The unit costs per Table 83.…”

Section: Oscillation In Ards Trial Economic Analysismentioning

confidence: 99%

A randomised controlled trial and cost-effectiveness analysis of high-frequency oscillatory ventilation against conventional artificial ventilation for adults with acute respiratory distress syndrome. The OSCAR (OSCillation in ARDS) study

Lall

Hamilton

Young

et al. 2015

Health Technology Assessment

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BackgroundPatients with the acute respiratory distress syndrome (ARDS) require artificial ventilation but this treatment may produce secondary lung damage. High-frequency oscillatory ventilation (HFOV) may reduce this damage.ObjectivesTo determine the clinical benefit and cost-effectiveness of HFOV in patients with ARDS compared with standard mechanical ventilation.DesignA parallel, randomised, unblinded clinical trial.SettingUK intensive care units.ParticipantsMechanically ventilated patients with a partial pressure of oxygen in arterial blood/fractional concentration of inspired oxygen (P : F) ratio of 26.7 kPa (200 mmHg) or less and an expected duration of ventilation of at least 2 days at recruitment.InterventionsTreatment arm HFOV using a Novalung R100®ventilator (Metran Co. Ltd, Saitama, Japan) ventilator until the start of weaning.Control arm Conventional mechanical ventilation using the devices available in the participating centres.Main outcome measuresThe primary clinical outcome was all-cause mortality at 30 days after randomisation. The primary health economic outcome was the cost per quality-adjusted life-year (QALY) gained.ResultsOne hundred and sixty-six of 398 patients (41.7%) randomised to the HFOV group and 163 of 397 patients (41.1%) randomised to the conventional mechanical ventilation group died within 30 days of randomisation (p = 0.85), for an absolute difference of 0.6% [95% confidence interval (CI) −6.1% to 7.5%]. After adjustment for study centre, sex, Acute Physiology and Chronic Health Evaluation II score, and the initial P : F ratio, the odds ratio for survival in the conventional ventilation group was 1.03 (95% CI 0.75 to 1.40;p = 0.87 logistic regression). Survival analysis showed no difference in the probability of survival up to 12 months after randomisation. The average QALY at 1 year in the HFOV group was 0.302 compared to 0.246. This gives an incremental cost-effectiveness ratio (ICER) for the cost to society per QALY of £88,790 and an ICER for the cost to the NHS per QALY of £78,260.ConclusionsThe use of HFOV had no effect on 30-day mortality in adult patients undergoing mechanical ventilation for ARDS and no economic advantage. We suggest that further research into avoiding ventilator-induced lung injury should concentrate on ventilatory strategies other than HFOV.Trial registrationCurrent Controlled Trials ISRCTN10416500.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 19, No. 23. See the NIHR Journals Library website for further project information.

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“…A small proportion of these patients responded to other penicillin metabolites defined as minor determinants. Over the years, studies have demonstrated that combining PPL with minor determinants is appropriate for the evaluation of patients suspected of having immediate allergy to BL [15,16]. Nevertheless, recent data suggest that the shift from using the classic benzylpenicillin antibiotic towards the new semisynthetic penicillins, especially AMX and AMX-C, has made PPL no longer the most relevant hapten in the evaluation of penicillin allergy [17].…”

Section: Discussionmentioning

confidence: 99%

The Importance of Amoxicillin and Amoxicillin-Clavulanate Determinants in the Diagnosis of Immediate Allergic Reactions to β-Lactams

Confino‐Cohen

Rosman

Lachover

et al. 2016

Int Arch Allergy Immunol

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Background: Immediate allergic reactions to β-lactam antibiotics are considered to be one of the most important drug hypersensitivities. A positive skin test (ST) with a combination of major and minor penicillin determinants is usually sufficient to recommend avoidance of the culprit drug, whereas a negative ST is usually followed by an oral challenge test (OCT). Recently, concern has been raised regarding the role of amoxicillin (AMX) ST in the diagnosis of AMX allergy. Objective: The aim of this study was to examine the additive value of AMX determinants in STs of patients with immediate hypersensitivity reactions to AMX or AMX-clavulanate (AMX-C). Methods: Patients with a history of immediate AMX or AMX-C allergy underwent an ST using a combination of penicilloyl-polylysine (PPL) and minor determinants as well as AMX. An ST with AMX-C was added when appropriate. Results: Thirty-one patients were evaluated. Eight patients, all of them with a history of AMX allergy, had positive reactions only to the AMX component. Two patients with AMX-C allergy had a positive ST reaction only to the AMX-C component. Moreover, only 14 patients (13 with AMX and 1 with AMX-C allergy) had a positive reaction to PPL, whereas most patients (54.8%) had positive reactions to other determinants. One patient, who was positive for AMX, developed several urticarial lesions after the test. Conclusions: Skin testing with AMX and AMX-C is mandatory in patients with immediate allergy to these drugs. Failure to perform it may result in a false-negative ST jeopardizing these patients with anaphylactic reactions during a hazardous OCT.

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Clinical Experience With Penicillin Skin Testing in a Large Inner-City STD Clinic

Cited by 278 publications

References 33 publications

Management of allergy to penicillins and other beta‐lactams

Management of allergy to penicillins and other beta‐lactams

A randomised controlled trial and cost-effectiveness analysis of high-frequency oscillatory ventilation against conventional artificial ventilation for adults with acute respiratory distress syndrome. The OSCAR (OSCillation in ARDS) study

The Importance of Amoxicillin and Amoxicillin-Clavulanate Determinants in the Diagnosis of Immediate Allergic Reactions to β-Lactams

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