First pediatric electronic algorithm to stratify risk of penicillin allergy

Abstract

Beta-lactam allergy is reported in 5–10% of children in North America, but up to 94–97% of patients are deemed not allergic after allergist assessment. The utility of standardized skin testing for penicillin allergy in the pediatric population has been recently questioned. Oral drug challenges when appropriate, are preferred over skin testing, and can definitively rule out immediate, IgE-mediated drug allergy. To our knowledge, this is the only pediatric study to assess the reliability of a penicillin allergy stratification tool using a paper and electronic clinical algorithm. By using an electronic algorithm, we identified 61 patients (of 95 deemed not allergic by gold standard allergist decision) as low risk for penicillin allergy, with no false negatives and without the need for allergist assessment or skin testing. In this study, we demonstrate that an electronic algorithm can be used by various pediatric clinicians when evaluating possible penicillin allergy to reliably identify low risk patients. We identified the electronic algorithm was superior to the paper version, capturing an even higher percentage of low risk patients than the paper version. By developing an electronic algorithm to accurately assess penicillin allergy risk based on appropriate history, without the need for diagnostic testing or allergist assessment, we can empower non-allergist health care professionals to safely de-label low risk pediatric patients and assist in alleviating subspecialty wait times for penicillin allergy assessment.

New diagnostıc perspectives in the management of pediatrıc beta‐lactam allergy

“…In pediatric data, it was defined as high risk if the duration of symptoms was less than 24 h 71 or 48 h, 73 and as low risk if it persisted for more than 24 h after discontinuation of BL. 71,73 Furthermore, in contrast to studies in adults, a recent pediatric study classified symptoms of anaphylaxis as a moderate risk but not high risk. 74 The authors also classified immediate symptoms (less than 24 h after the first penicillin dose) as a moderate risk, in agreement with an adult risk stratification study.…”

“…Although an increasing number of adult risk assessment studies have been published in the literature for BL allergy, there are limited data on risk stratification in the pediatric population 26,71–74 . In children, mild cutaneous NIR to BLs is generally accepted as a low risk 2,35,36,42,49 .…”

“…On the other hand, in a pediatric study by Vyles et al, urticarial reactions, although potentially IgE‐mediated, were also classified as low risk 72 . Besides that, in pediatric studies, itching with rash, isolated vomiting, diarrhea, abdominal pain, headache, cough, runny nose, a family history of penicillin allergy alone, delayed‐onset urticaria or maculopapular rash (after first day of therapy or >2 h after last dose), and duration of symptoms >24 h were considered low risk 26,71,73,74 …”

“…Finally, if a child had low‐risk symptoms, a 3‐step penicillin testing procedure (SPT, IDT, and DPT) or direct DPTs were suggested, depending on the patient's convenience 26 . However, other clinical algorithms proposed only direct DPT in patients with low‐risk BL allergy 71,73,74 . Of note, some characteristics of pediatric patients such as age, atopy, family history of drug allergy, and some specific comorbidities should be considered when determining risk status.…”

Model Based Evaluation of Hypersensitivity Adverse Drug Reactions to Antimicrobial Agents in Children

“…Careful physical examination and investigation of signs and symptoms including type of skin rash (e.g., urticarial, maculopapular, purpuric, bullous or eczematous) may aid differentiating drug-induced reactions from other disease conditions such as viral or bacterial infections. One method to exclude drugs is to find out whether the patient has tolerated the drug in the past, although this is not absolutely true in all cases as patients may develop reaction to drugs after taking them for years, notably in the case of Type I allergic reactions (Roberts et al, 2020).…”