Patients with questionable penicillin (beta-lactam) allergy: Causes and solutions

Abstract

Background: In Europe, North America, and Australia, 5% to 10% of the population are now classified as penicillin (β-lactam) allergic. Only ~ 10% of these questionable diagnoses, mostly made in childhood, can be confirmed by allergy diagnostics. Materials and methods: The aim of this review is to show causes and consequences as well as recommendations for dealing with the often questionable diagnosis of penicillin (β-lactam) allergy (BLA). Results: An incorrect BLA diagnosis may negatively impact antibiotic treatment needed in the future, by using a less effective antibiotic or using a broad-spectrum antibiotic, for example, further exacerbating the problem of increasing antibiotic resistance. Accordingly, there is growing pressure from antibiotic stewardship programs to critically challenge the BLA diagnosis. Conservatively, a suspected BLA is reviewed by an allergist using medical history, skin testing, laboratory testing, and provocation. This clarification is costly and is not remunerated in the German health care system; that is the reason why this testing is only offered in a few specialized clinics and practically not at all in general practice. In view of thousands of affected patients, additional strategies are needed to treat patients with a low risk of hypersensitivity reaction despite suspected allergy with a β-lactam antibiotic. In recent years, various methods have been proposed to eliminate suspected allergy as promptly as possible and directly before necessary treatment with a β-lactam antibiotic, including standardized history (also in the form of an algorithm), skin test with immediate reading after 15 minutes, or administration of a small test dose. Investigations of small case series and also multi-center studies to date have yielded promising results in terms of feasibility and safety. Conclusion: Of the large number of patients with (questionable) BLA, most have never been tested and – if antibiotic treatment becomes necessary – simply receive an alternative antibiotic. The diagnosis of BLA therefore requires new approaches besides classical allergy testing to critically question BLA.

Viral infections and drug hypersensitivity

“…For example, infected children might be labeled as drug ("penicillin")allergic, but later no sensitization to drugs is observed in skin tests and the eliciting drug is again well tolerated. 36 In cases where a clear relationship between drug intake and symptom onset cannot be established, the differentiation between viral/paraviral and drug-induced exanthema during viral infection is a major challenge. The incidence of these respective entities is not entirely clear but is around 158/10 000 for DHR exanthems.…”

“…These observed exanthemas are mostly mild and transitory but can have lasting consequences. For example, infected children might be labeled as drug (“penicillin”)‐allergic, but later no sensitization to drugs is observed in skin tests and the eliciting drug is again well tolerated 36 …”

Changes in Sensitization Patterns in the Last 25 Years in 619 Patients with Confirmed Diagnoses of Immediate Hypersensitivity Reactions to Beta-Lactams

“…Avoiding all BLs represents a significant public health issue [ 24 , 25 , 26 , 27 ] with well-documented consequences, including greater use of second-line antibiotics, increasing antibiotic-resistant infections, more adverse effects, more extended hospitalization, hospital re-admissions, and higher costs. An accurate study of reactions and sensitization profiles allows avoidance of allergy reactions due to cross-reactivity or too broad avoidance recommendations, ensuring an optimized use of the medicines [ 28 , 29 , 30 , 31 ].…”

Barriers to paediatric penicillin allergy de-labelling in UK secondary care: a regional survey

“…Of note, 37.1% of clinicians surveyed reported they had experienced caregivers resisting de-labelling. Removing an incorrect penicillin allergy label from medical records in children who clearly report side effects rather than allergic reactions or family history entails good allergy knowledge 15. Well-informed, motivated paediatricians can educate families on the negative consequences of unverified penicillin allergy and benefits of removing labels from medical records.…”