Drug provocation tests to betalactam antibiotics: experience in a paediatric setting

Abstract

Background: Few studies have been performed in children with suspected betalactam allergy. We aimed to assess the role of the drug provocation test (DPT) with betalactams in a paediatric setting and to study the association between allergy to betalactam antibiotics and other allergic diseases. Methods: We included all the patients under 15 years old who were consecutively referred to the Immunoallergy Department, Dona Estefânia Hospital, Portugal (January 2002 to April 2008) for a compatible history of allergic reaction to betalactam. All were submitted to a DPT. Children were proposed to perform skin tests (ST) to betalactam antibiotics followed by DPT. If they decline ST, a DPT with the culprit drug was performed. Results: We studied 161 children, 60% were boys, with a median age of 5 years old at the time of the DPT. Thirty-three patients (20.5%) had an immediate reaction and 33 (20.5%) a non-immediate reaction. The severity of the reported reactions was low in most cases. Skin tests to betalactams were performed in 47 children and were positive in 8. DPT was positive in only one (3.4%) of the patients skin tested and in 11 (13.4%) of those not skin tested. The severity of the DPT reaction was low. Asthma and food allergy were associated with a positive DPT in the later group. Conclusions: DPT seems a safe procedure even in the absence of ST in non-severe cases. This could be a practical option in infants and pre-school children, where ST are painful and difficult to perform. Additional caution should be taken in children with asthma and food allergy.

Usefulness of drug provocation tests in children with a history of adverse drug reaction

“…In our study, clinical symptoms indicating positive DPTs included skin rash in 11 of 16 (68%) patients, angioedema in 2 (18%), and pruritus in 2 (18%). In addition, dizziness, anaphylaxis, dyspnea, and abdominal pain accompanied by vomiting occurred in 1 each, and these results are similar patterns to other studies7,13). Because drug allergies may involve organs other than the skin and skin lesions may appear in various patterns, the presence of a skin lesion per se is not helpful in diagnosing the allergy or determining its method of treatment17).…”

“…According to the individual DPTs, there were 17 (23.9%) positive DPTs in 71 events of DPTs. In this study the positive rate of DPTs are relatively higher than those of other studies7,13). In one retrospective study performed in children and adult ADRs, they confirmed that 241 (17.6%) of 1,372 patients were positive on the drug provocation test7).…”

The diagnosis and management of antibiotic allergy in children: Systematic review to inform a contemporary approach

“…Three studies highlighted that anaphylaxis, urticaria and angio-oedema index responses were associated with a higher likelihood of positive DPT or ID responses when compared with non-specific rashes, however did not preclude investigation 24 34–36. One study suggested that food allergy was a risk factor for β-lactam allergy among 161 Portuguese children (p=0.047) 37. Kidon and See38 found that having asthma predisposed towards failing drug DPTs, however was unable to correct for their increased medication requirement.…”

Drug provocation tests in hypersensitivity drug reactions

“…Among children, a recent study [22] regarding nonimmediate reaction to cephalosporin has demonstrated similar results, with low reproducibility of the reaction (two out of 105; 2%), one detected by positive response to skin tests, and another by positive DPT. In particular situations with noncooperative young children (only 47 out of 161; 29% of children accepted skin testing in one study), DPT without previous skin testing was considered a relatively well tolerated procedure in children with a history of mild cutaneous eruption to b-lactams [29]. However, further studies in large numbers of patients and in different age groups are required before the safety of this approach can be established.…”