Oral Challenge without Penicillin Skin Tests in Children with Suspected Beta-Lactam Hypersensitivity

Abstract

Objective A misdiagnosed “penicillin allergy” is a common problem in childhood. Recently, skipping skin tests (STs) and performing a direct oral challenge test (OCT) have become an increasingly common approach in children with suspected β-lactam (BL) allergy. In our study, we aimed to evaluate the safety and efficacy of OCT without using ST in children who had a history of hypersensitivity reactions with BL antibiotics. Materials and Methods We retrospectively evaluated direct OCT outcomes in children with both nonimmediate and immediate-type reaction history with BL antibiotics. STs were not performed before the challenge test. The patients were monitored for 4 hours after the challenge and continued using the drug in two divided doses for 3 days at home. Results In this study, 72 patients were included, with median age of 7 years (interquartile range: 4; min: 1 year to max: 16 years), and of these, 56% were male. Forty-five subjects (63%) reported immediate-type adverse reactions. The most common clinical manifestation was urticaria/angioedema (51%, n: 37) and maculopapular exanthema in 46% (n: 33) of patients, respectively. The most commonly suspected drug was 71% amoxicillin-clavulanate. A 3-day OCT without preceding ST was performed in all patients. Only three patients (4.2%) showed a positive response to the oral drug challenge test. None of these reactions observed was more severe than index reactions. Conclusion Performing OCT without STs is a safe and convenient method to exclude BL hypersensitivity in the pediatric age group.

Safety of direct oral provocation test to delabel reported mild beta-lactam allergy in infants

“…35,36 In fact, some working groups had included direct DPTs in their recommendations. 1,31,[37][38][39][40] The decision to prolong DPT at home is divergent between different studies; nevertheless, in our study, we accepted that extension had an important impact on delabeling, and was safe.…”

Tools for Etiologic Diagnosis of Drug-Induced Allergic Conditions

“…In children, a direct challenge without prior skin testing has been proposed to study mild exanthema associated with infectious diseases and beta-lactam treatments based on the frequency of infectious mild exanthema not caused by the antibiotic treatment [ 127 , 128 ]. Several cohorts have reported the safety of this diagnostic pathway in children, with a rate of negative challenges higher than 95% of cases, including the study of immediate and delayed reactions [ 129 ]. Compared with the safety rate when oral challenges with beta-lactams are performed after negative skin testing, it is similar (3.4% vs. 2.4%, respectively), endorsing this practice [ 130 ].…”