Improving the Effectiveness of Penicillin Allergy De-labeling

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Presentation transcript:

Improving the Effectiveness of Penicillin Allergy De-labeling Jack Bourke, MBBS, Rebecca Pavlos, PhD, Ian James, PhD, Elizabeth Phillips, MD The Journal of Allergy and Clinical Immunology: In Practice Volume 3, Issue 3, Pages 365-374.e1 (May 2015) DOI: 10.1016/j.jaip.2014.11.002 Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Figure 1 Clinical testing protocol. Testing procedures that were applied to 405 consecutive patients referred for assessment of penicillin allergy. 1—Excluding skin test positive specific penicillins; 2—Unless skin testing is positive to that specific penicillin; 3—If oral challenge to specific penicillin cannot be performed (eg, parenteral-only product), then it should be avoided, even if the skin test is negative; 4—Whenever possible, skin testing to the specific cephalosporin should be performed; 5—Excluding skin test positive cephalosporins (and those with shared side chains); specific cephalosporin responsible for reaction until oral challenge has been performed, even if the skin test is negative. SPT, skin prick testing; histamine 1 mg/mL, normal saline, BP 10,000 U/mL, Diater PPL, Diater MDM, amoxicillin 20 mg/mL. IDT, intradermal testing; normal saline, BP 1000 U/mL, BP 10,000 U/mL, Diater PPL, Diater MDM, amoxicillin 20 mg/mL, cefazolin 1 mg/mL, ceftriaxone 1 mg/mL. BP, benzylpenicillin; MDM, minor determinants mixture; PPL, penicilloyl poly-l-lysine. The Journal of Allergy and Clinical Immunology: In Practice 2015 3, 365-374.e1DOI: (10.1016/j.jaip.2014.11.002) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Figure 2 Skin test results, reaction time and time since testing. (A) Skin test results by time since testing. (B) Skin test results by reaction type. (C) Skin test results by reaction type and time since testing. Risk for positive skin prick testing and intradermal testing (SPT/IDT) occurs mainly in patients with immediate reactions occurring <6 months before SPT/IDT. Lowest risk patients have nonimmediate reaction histories that occur >6 months from testing. IMM, immediate reaction history; NIM, nonimmediate reaction history. Patients grouped based on implicated antibiotic into penicillin (n = 341) or nonpenicillin beta-lactams (n = 60, with 59/60 to a cephalosporin, 1/60 to ertapenem). The Journal of Allergy and Clinical Immunology: In Practice 2015 3, 365-374.e1DOI: (10.1016/j.jaip.2014.11.002) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Figure 3 Proposed modified testing protocol. If applied to our cohort, 252 (62.2%) of patients would have proceeded to oral challenge (OC) without skin prick testing and intradermal testing (SPT/IDT) with up to 8 additional positive OC. 1—Nonimmediate history (onset >1 hour after dosing, reaction localized to skin), 2—Immediate history, reaction >6 months before testing, 3—Immediate history, reaction <6 months before testing, 4—Initially to penicillin VK, followed by other beta-lactams if indicated. Single vs multiple dose depending on history, 5—Plus further beta-lactam challenges as indicated. ADR, adverse drug reaction; MDM, minor determinants mixture; PPL, penicilloyl poly-l-lysine. The Journal of Allergy and Clinical Immunology: In Practice 2015 3, 365-374.e1DOI: (10.1016/j.jaip.2014.11.002) Copyright © 2015 American Academy of Allergy, Asthma & Immunology Terms and Conditions