Who needs penicillin allergy testing?

Abstract

Credit can now be obtained, free for a limited time, by reading the review article and completing all activity components. Please note the instructions listed below: Review the target audience, learning objectives and all disclosures. Complete the pre-test. Read the article and reflect on all content as to how it may be applicable to your practice. Key Messages All individuals with an unconfirmed penicillin allergy should have their penicillin allergy evaluated and, if appropriate, tested to confirm current hypersensitivity or tolerance. All individuals with a penicillin-associated history of anaphylaxis, rash, gastrointestinal symptoms, headaches, other low-risk symptoms, an unknown history, or a reported family history of penicillin allergy can undergo testing to confirm current tolerance and convince the patient that penicillins can safely be used. The reference standard test to confirm current penicillin class antibiotic hypersensitivity or tolerance is an oral challenge with a therapeutic dose, typically 250 mg for adults, and 1 hour of observation to confirm acute tolerance, followed by 5 days of at home follow-up to confirm the absence of clinically significant T-cell−mediated delayed-onset hypersensitivity. Low-risk individuals, with penicillin reaction histories that are unlikely to be IgE mediated, can safely go to a direct oral amoxicillin challenge with a therapeutic dose to confirm current tolerance. Puncture and intradermal skin testing using only penicilloyl-polylysine, with at least 5 mm of wheal and flare greater than wheal as the criteria for a positive test result, is now sufficient to rule out a high risk of having anaphylaxis during a confirmatory oral amoxicillin challenge. Individuals with positive skin test results should not undergo oral challenges and, like individuals with immediately positive oral challenge results, undergo oral penicillin desensitization if they have a documented infection for which a penicillin is the drug of choice.

Health and Economic Outcomes of Home Maintenance Allergen Immunotherapy in Select Patients with High Health Literacy during the COVID-19 Pandemic: A Cost-Effectiveness Analysis During Exceptional Times

“…Provided education is appropriate, there is every reason to think that 12 maintenance injections could be handled as such in a pandemic setting, in select patients. To contextualize risk, the estimated rate of AIT fatality per injection, 1.3 Â 10 À7 , is on par with the estimated risks of fatal penicillin anaphylaxis (8.0 Â 10 À8 ), 46 per-patient omalizumab fatality (5.8 Â 10 À6 ), 42,47,48 and the general population risk of homepeanut introduction in US infants (0.3-3 Â 10 À7 ) 49 (see Figure E4 in this article's Online Repository at www.jaciinpractice.org). Penicillin is administered without mandated routine medical observation in the general population, omalizumab is approved for preference-sensitive home administration after the first 4 uneventful doses in Europe at provider discretion for patients with appropriate indication, and young infants routinely have peanut introduced at home.…”

Sustaining and spreading penicillin allergy delabelling: A narrative review of the challenges for service delivery and patient safety

“…Although most studies have shown direct oral challenges to be safe (no documented anaphylaxis or serious delayed reactions), relatively mild cutaneous reactions after a direct oral challenge 30,40,43 occur, justifying a place for such an intervention in acute care hospitals with an immediate access to management of allergic reactions. 2,44 Caution and concern about potential false negative tests for those patients where the index drug is amoxicillin-clavulanic acid or flucloxacillin has also been raised, unless these antibiotics are used for the confirmatory challenges. 45 • Patient did want to take time (9.43)…”

“…Whilst these studies have generated proof of concept in favour of a direct oral penicillin challenge procedure for PenA delabelling, they were limited due to: relatively small sample size; little or no assessment of views and perspectives of healthcare professionals and patients regarding their confidence in embedding such an approach into routine clinical practice; lack of exploration of reasons for patients' unwillingness to consent to direct oral challenge or re‐expose to penicillins; and failure to update medical documentation with the outcome of the direct oral challenge. Although most studies have shown direct oral challenges to be safe (no documented anaphylaxis or serious delayed reactions), relatively mild cutaneous reactions after a direct oral challenge occur, justifying a place for such an intervention in acute care hospitals with an immediate access to management of allergic reactions . Caution and concern about potential false negative tests for those patients where the index drug is amoxicillin–clavulanic acid or flucloxacillin has also been raised, unless these antibiotics are used for the confirmatory challenges …”

Rational use of the fluoroquinolones

“…[45] It is, however, probably necessary to perform allergy testing more frequently than is currently done, as most patients who believe they are allergic to BL are probably not. [46]…”