Prospective study of 5-day challenge with penicillins in children

Abstract

ObjectivesTo examine if a 5-day challenge with penicillin improves the diagnostic sensitivity compared with a single full dose in children with mild skin reactions.DesignSubjects referred with suspected allergy to penicillin were consecutively included. Irrespectively of the morphology of the index reaction and the result of specific IgE, all subjects underwent a two-step titrated drug provocation test (DPT) with the culprit drug followed by a 5-day challenge at home.ParticipantsChildren and adolescents aged 0–18 years referred to allergic workup for penicillin hypersensitivity at two paediatric Danish centres. Only subjects with non-severe skin reactions were included.ResultsA total of 305 subjects were included and 22 (7%) of the DPTs were positive. Three subjects reacted within 1 hour of the first full dose and nine reacted 1–8 hours after the first full dose. Additional 10 positive reactions were observed during the prolonged provocation. Seven subjects reacted after the second full dose and three reacted after 3–6 days. Only mild skin rashes were observed. Eighteen subjects had a specific IgE to a penicillin >0.1 kU/L. Only one of these had a positive DPT.ConclusionIn children, a DPT with penicillins should include at least two full doses. In children with mild hypersensitivity reactions it may be safe to perform DPTs despite a low specific IgE.Trial registration numberNCT04331522

Simplifying the drug provocation test in non‐immediate hypersensitivity reactions to amoxicillin in children: The experience of a tertiary care allergy unit

“…In terms of the number of patients, prevalence of positive DPT and timing of reactions, our results are very similar to the recent paper of Petersen et al 17 where the incidence of positive DPT was 6.7% (22/305), and none of the children reacted on the first 1/10 of the full dose.…”

“…In that paper 42 out of 1914 (2.2%) children had a mild immediate reaction (IR) to DPT, with 3 of these patients (7%) reacting to the first dose of the DPT, however, it should be taken into account that the children included in the study were also those with history of IR. 4 In terms of number of patients, prevalence of positive DPT and timing of reactions, our results are very similar to the recent paper of Petersen et al 17 where the incidence of positive DPT was 6.7% (22/305), and none of the children reacted on the first 1/10 of the full dose.…”

“…In addition, a prolonged DPT results in increased confidence in the future use of the same drug when compared with a single‐day DPT. On the other hand, a prolonged DPT is questioned because of its impact on the gut microbiota and the potential risk of increasing antibiotic resistance 1,3,8–24 . So far there is no agreement on the best protocol to be used that reaches the best compromise between safety, time consumption, and potential side effects.…”

“…On the other hand, a prolonged DPT is questioned because of its impact on the gut microbiota and the potential risk of increasing antibiotic resistance. 1,3,[8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] So far there is no agreement on the best protocol to be used that reaches the best compromise between safety, time consumption, and potential side effects. Today it is a matter of debate the way of administering the first dose of antibiotic during the DPT, in particular, if it would be better to fraction or not the drug dose (calculated according to the bodyweight).…”

Drug provocation tests in children: All that glitters is not gold

“…21 This question has been extensively analyzed by other authors and is not the focus of our study. [22][23][24][25][26][27][28][29] Rather, in this paper, we review the factors that may contribute to an incorrect interpretation of DPT resultsespecially focusing on the apparently positive ones-in the pediatric population, and which may have an impact on the positive predictive value of the test.…”