Evaluating Penicillin Allergies Without Skin Testing
Purpose of Review
An unconfirmed penicillin allergy is known to confer significant risk to patients. Only a small minority of patients labeled with penicillin allergy will be confirmed to be hypersensitive with the current reference standard test, an oral amoxicillin therapeutic dose challenge. Skin testing has been recommended prior to oral challenges to reduce the risk of severe acute challenge reactions. The rate of severe acute anaphylactic reactions with oral amoxicillin is currently extremely low. Unfortunately, penicillin skin testing, as commonly performed, has a high rate of false positive results.
Encouraging skin testing in all individuals with an unconfirmed penicillin allergy, prior to a confirmatory oral challenge, would be technically difficult, make testing all individuals with an unconfirmed penicillin allergy very unlikely, and ultimately increase the risk to patients because of suboptimal antibiotic use. Most patients, who are appropriate candidates for a direct oral amoxicillin challenge, to confirm current penicillin tolerance, can be safely identified by their clinical histories. Higher risk individuals, those with a history of anaphylaxis or other acute onset potentially IgE-mediated reaction such as hives within 6 h of the first dose of the last course of a penicillin, may benefit from properly performed puncture and intradermal skin testing, using commercially available penicilloyl-polylysine, prior to an oral challenge, if skin test negative.
Direct oral amoxicillin challenges in low-risk individuals are well accepted by patients and a safe and effective part of penicillin allergy delabeling.
KeywordsAdverse drug reaction Antibiotic stewardship program Amoxicillin Delabeling Oral challenge Drug allergy Penicillin Hypersensitivity Skin testing
American Board of Internal Medicine
Antibiotic stewardship program
US Food and Drug Administration
Kaiser Permanente Southern California
Methicillin-sensitive Staphylococcus aureus
Serious cutaneous adverse reaction
Compliance with Ethical Standards
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Conflict of Interest
EM is a partner in the Southern California Permanente Medical Group. EM has received research support from the Southern California Permanente Medical Group, grants from ALK Abello, Inc. to study adverse drug reactions, and has served on clinical trial safety and monitoring committees for BioMarin, Ultragenyx, and Audentes.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
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