What Constitutes a “Low-Risk” Penicillin Allergy History?

[Argirios Argiriou]

SUMMARY AND COMMENT | GENERAL MEDICINE, INFECTIOUS DISEASES
February 27, 2020

What Constitutes a “Low-Risk” Penicillin Allergy History?

David J. Amrol, MD reviewing Stevenson B et al. J Allergy Clin Immunol Pract 2020 Feb

Patients who meet a specific definition of low risk can safely undergo an oral challenge.

Ninety percent of patients who report penicillin allergy can tolerate the drug, and it has been shown that using alternative non–β-lactam antibiotics in these patients leads to higher healthcare costs and adverse events. Institutions are trying to delabel patients, but there are too few allergists to evaluate them all. Recent studies have confirmed the safety of clinician-administered oral challenges in low-risk patients, without prior skin testing (NEJM JW Gen Med Aug 15 2017 and J Allergy Clin Immunol Pract 2017; 5:669), but the definition of “low-risk patient” is unclear.

To better define this group, researchers in Australia retrospectively analyzed the records of 447 patients who had undergone skin testing, oral challenge, or both to confirm alleged penicillin allergy. The researchers determined that the optimal definition of low-risk history was “benign, immediate, or delayed rash (without angioedema, mucosal ulceration, or systemic symptoms) more than 1 year before review.” Of the patients reviewed, 55% met this definition, and 97% of these patients tolerated oral challenge. None experienced anaphylaxis.

COMMENT
If this Australian cohort is representative of patients generally, more than half of all penicillin-allergy–labeled patients could be delabeled by undergoing a 90-minute observed challenge administered in a primary care setting. The challenge is to increase primary care clinicians' comfort in administering oral challenges, and to get healthcare systems to support this practice. Patients with histories of severe adverse cutaneous reactions (e.g., Stevens-Johnson syndrome, DRESS [drug rash with eosinophilia and systemic symptoms], or acute generalized pustulosis) or patients with serum sickness should not be tested and should never receive the drug again. Patients with angioedema or systemic symptoms (e.g., respiratory or cardiovascular) and patients with penicillin-associated rash during the previous year should undergo penicillin skin testing or evaluation by an allergist.

EDITOR DISCLOSURES AT TIME OF PUBLICATION

Disclosures for David J. Amrol, MD at time of publication

Leadership Positions in Professional Societies

Southeastern Allergy, Asthma and Immunology Society (Board of Directors)

CITATION(S):

Stevenson B et al. Multicenter Australian study to determine criteria for low- and high-risk penicillin testing in outpatients. J Allergy Clin Immunol Pract 2020 Feb; 8:681. (Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος)

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