Investigating True β-lactam Allergy in the Outpatient Allergy Clinics at a Public Children’s Hospital, Ceará, Brazil

Abstract

Objective: The aim of the study was to investigate true β-lactam allergy at a public pediatric hospital. Material and Methods: Children and adolescents with allergy symptoms were referred to the Allergy and Immunology Service, Hospital Infantil Albert Sabin, Fortaleza, Brazil. During the allergist interviews, β-lactam drug allergy was suspected in 24 patients. Results: Urticaria, angioedema, erythematous macules and papules were the clinical manifestations most frequently reported in 23 patients with immediate reaction. The drugs implicated were amoxicillin (58.3%), penicillin (20.8%), ceftriaxone (12.5%) and ampicillin (8.4%). The majority of the patients showed negative results for ampicillin, penicillin and ceftriaxone in skin testing and also negative results in Oral Provocation Testing (OPT) to amoxicillin. One patient with clinical history of ceftriaxone allergy showed positive prick test to the drug and negative OPT to amoxicillin. Conclusion: b-lactam drugs are a very useful choice for treatment of bacterial infections in children. In this way, it is reasonable that hypothesis of allergy to those drugs be investigated. For this reason, during consultation, it is necessary that the allergist questions about drug allergy, apart from the original complaint (if it is not directly related to drug allergy). Upon suggestive history, the hypothesis of drug allergy should be ruled out by doing a careful laboratorial and clinical investigation. In order to rationalize the operating and economical costs related to skin testing and OPT, we suggest grouping a number of patients for whom the tests will be performed during a half-day period two to three times a year.

Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta‐analysis

“…After excluding 2451 records in the screening phase, 351 articles were fully read, of which a total of 112 studies were included in the systematic review 21–50 ,51–100 ,101–132 Of these studies, 108 were included in all general analyses, 21–38 ,40–54 …”

“…Included studies were published between 1965 and 2019, and were mostly performed in North America ( n = 46, 41.1%) 21–23,25–27,31,32,34,36–38,40,41,44–46,53,58,69–71,74,75,84,85,88,90,96,99,102,104–107,110–112,114,116,122,123,125–127,131 and Europe ( n = 44, 39.3%) 24,28–30,33,35,39,42,43,47,50,52,55–57,59,61–66,68,73,76–80,82,83,86,91,92,94,97,100,109,118,121,124,128,129,132 . Thirty‐eight studies (34.9%) analyzed exclusively children 23,28,35,36,40,51,56,58–61,63,67,73,74,77,78,82,83,86,87,89,90,95,100,103,106‐110,113,115,118,120,121,130,132 and 28 (25.7%) only analyzed adult patients 21,31,32,37,38,41,49,52,53,62,68,71,76,79,88,94,101,102,104,105,114,117,123–125,127,128,131 . Most studies only included outpatients ( n = 69, 66.3%) …”

“…Most studies only included outpatients ( n = 69, 66.3%) 28–30,32–34,36,39,40,42–45,47–50 ,52–55,57,59–66,68,72 ,73,75,76,78–81,84–86,90–93,95,97–100 ,103,104,107,108,110,111,115,118 ,120–122,124‐126,128–130,132 From the 96 studies reporting information on the timing of the index reaction, 15 studies (15.6%) only evaluated patients reporting immediate allergic reactions, 24,30,33,38–40,42,54,60 ,67,80,91,102,103,130 and 12 studies (10.7%) exclusively evaluated patients reporting non‐immediate index reactions 50,55,56,76,78,79,86,95,98,100,119,121 …”

“…Prolonged challenges were performed in 41 (39.4%) of the included studies, 22,26,28,29,31,36–38,41,45,47–50 ,55,56,61,65,68,77,78,80,82,86,89,95,98,100 ,101,108,110,115,118–121,124,128–130,132 while graded challenges were performed in 37 (35.6%) studies, 21,23,24,27,33,35,39,42,51,52,54,57–60,62,63,67,69,72,73,75,76,87,88,90,91,94,97,99,103,106,107,116,122,126,127 and 17 (16.3%) studies opted for single dose DPTs 30,34,40,44,53,70,71,79,84,96,104,105,111,112,117,125,131 . Half of the studies ( n = 59, 52.7%) performed a DPT with the suspected culprit drug 25,33,35,36,39,40,47–51,54–57 …”

“…Half of the studies ( n = 59, 52.7%) performed a DPT with the suspected culprit drug 25,33,35,36,39,40,47–51,54–57 ,59–61,63,65–69,71,73,75–78,80,81,83–87,89–95,98,100 ,103,108–110,115,117,118,121,124,128–130,132 In 12 studies (10.9%), direct DPTs (DPTs without previous skin/in vitro tests) were performed, 69,82,87,90,95,110,119,121,122,125,127,128 while in 87 studies (79.1%) challenges were always preceded by previous tests 21–24,26–42,44‐58,60–68,70–81,83,84,86,88,89,91–94,96–98,100–104,106–109,114,118,120,123,124,129–132 . Eleven studies (10.0%) included patients undergoing both direct DPTs and DPTs preceded by other tests …”