The impact of penicillin skin testing on clinical practice and antimicrobial stewardship

Rimawi, Ramzy H.; Cook, Paul P.; Gooch, Michael D.; Kabchi, Badih A.; Ashraf, Muhammad Salman; Rimawi, Bassam H.; Gebregziabher, Mulugeta; Siraj, Dawd

doi:10.1002/jhm.2036

Cited by 128 publications

(110 citation statements)

References 10 publications

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“…There have been American reports of a decreasing rate of positive skin tests in the last two decades [35][36][37]. This may be partially the result of a decreased topical and parenteral use of penicillins, larger weal size requirement for a positive result implemented by American centres, changes in prescribing and different concentrations of amoxicillin used for skin tests in comparison with European studies.…”

Section: Epidemiology Of Skin Testingmentioning

confidence: 99%

Management of allergy to penicillins and other beta‐lactams

Mirakian

Leech

Krishna

et al. 2015

Clin Experimental Allergy

225

229

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SummaryThe Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and an expert panel have prepared this guidance for the management of immediate and non-immediate allergic reactions to penicillins and other beta-lactams. The guideline is intended for UK specialists in both adult and paediatric allergy and for other clinicians practising allergy in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking, the panel reached consensus. During the development of the guideline, all BSACI members were consulted using a Web-based process and all comments carefully considered. Included in the guideline are epidemiology of allergic reactions to beta-lactams, molecular structure, formulations available in the UK and a description of known beta-lactam antigenic determinants. Sections on the value and limitations of clinical history, skin testing and laboratory investigations for both penicillins and cephalosporins are included. Cross-reactivity between penicillins and cephalosporins is discussed in detail. Recommendations on oral provocation and desensitization procedures have been made. Guidance for beta-lactam allergy in children is given in a separate section. An algorithm to help the clinician in the diagnosis of patients with a history of penicillin allergy has also been included.Keywords allergy, anaphylaxis, beta-lactam, BSACI, carbapenem, cephalosporin, children, cross-reactivity, desensitization, drug provocation test, epidemiology, hypersensitivity, monobactam, oral challenges, paediatrics, penicillin, serum-specific IgE, skin tests, Standards of Care Committee • This guideline addresses immediate and non-immediate allergic reactions to beta-lactams.• Up to 20% of drug-related anaphylaxis deaths in • Individuals with a positive skin test to an aminopenicillin but negative skin tests to penicillin determinants are likely to be sensitized to the aminopenicillin side chain. (B) In this situation, a cautious challenge to benzyl or phenoxymethyl penicillin can be considered to ascertain whether the patient has a selective penicillin allergy. (D) • If a cephalosporin is required in a patient with a clinical history of penicillin allergy and positive skin tests -the patient should undergo skin testing using a cephalosporin with a different side chain and, if negative, provocation testing should be undertaken to exclude allergy to the specific cephalosporin. (D)• If penicillin is required in a patient with a clinical history of cephalosporin allergy, skin testing should be undertaken with penicillins and, if negative, provocation testing to exclude allergy to penicillin. (B) If skin tests are positive, then penicillin avoidance or desensitization can be considered. (B)• If a cephalosporin is required by a patient with a previous reaction, skin testing to penicillins and the required cephalosporin should be carried out to establish whether sensitization is to the beta-lactam core or side chain. (B) This should be followed by either provo...

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Section: Epidemiology Of Skin Testingmentioning

confidence: 99%

Management of allergy to penicillins and other beta‐lactams

Mirakian

Leech

Krishna

et al. 2015

Clin Experimental Allergy

225

229

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“…Although a few integrative data sources were described [5,6], most were not developed and individualized for antimicrobial stewardship purposes. Studies that provided mention of ASP specific systems or databases [7][8][9][10][11][12][13][14] generally offered little description of their capacity for ASP evaluation and research.…”

Section: Data Sourcesmentioning

confidence: 98%

“…Others estimated actual or potential cost savings related to stewardship interventions. For example, Rimawi et al estimated cost savings related to changes in antimicrobial therapy including PICC line insertion and removal, drug level testing and calibration, and nursing care [12]. Another group estimated potential cost savings by considering costs of hospital stay, antimicrobial therapy costs (including costs of drug administration) and costs of community support necessary for discharge [41].…”

Section: Drug Costs/other Costsmentioning

confidence: 98%

“…Few studies attempted more detailed economic evaluations related to stewardship interventions [5,6,12,29,33,36,41,80]. Of these, several measured total costs of hospital care [5,6,29,33] or total costs of hospital care related to the infection [5,6].…”

Section: Drug Costs/other Costsmentioning

confidence: 99%

“…This tool was used to identify the levels of evidence for the publications included in this review. About half of the included studies (29/58) employed a before-and-after study design [6, 7, 9-11, 13, 14, 17-38], and 62 % (36/ 58) constituted level IV evidence [6,7,[9][10][11][12][13][14]. During the review period, there were no level I publications (systematic reviews of randomized controlled trials (RCTs)), and we identified only five (9 %) published RCTs (level II) [45, 46, 47•, 48, 49].…”

Section: Study Design Study Design and Hierarchy Of Evidencementioning

confidence: 99%

See 2 more Smart Citations

Antimicrobial Stewardship Programs: A Review of Recent Evaluation Methods and Metrics

Palmay

Walker

Leis

et al. 2014

Curr Treat Options Infect Dis

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Evaluation and Management of Penicillin Allergy

Shenoy

Macy²,

Rowe

et al. 2019

JAMA

558

531

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IMPORTANCE β-Lactam antibiotics are among the safest and most effective antibiotics. Many patients report allergies to these drugs that limit their use, resulting in the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance and adverse events.OBSERVATIONS Approximately 10% of the US population has reported allergies to the β-lactam agent penicillin, with higher rates reported by older and hospitalized patients. Although many patients report that they are allergic to penicillin, clinically significant IgE-mediated or T lymphocyte-mediated penicillin hypersensitivity is uncommon (<5%). Currently, the rate of IgE-mediated penicillin allergies is decreasing, potentially due to a decreased use of parenteral penicillins, and because severe anaphylactic reactions to oral amoxicillin are rare. IgE-mediated penicillin allergy wanes over time, with 80% of patients becoming tolerant after a decade. Cross-reactivity between penicillin and cephalosporin drugs occurs in about 2% of cases, less than the 8% reported previously. Some patients have a medical history that suggests they are at a low risk for developing an allergic reaction to penicillin. Low-risk histories include patients having isolated nonallergic symptoms, such as gastrointestinal symptoms, or patients solely with a family history of a penicillin allergy, symptoms of pruritus without rash, or remote (>10 years) unknown reactions without features suggestive of an IgE-mediated reaction. A moderate-risk history includes urticaria or other pruritic rashes and reactions with features of IgE-mediated reactions. A high-risk history includes patients who have had anaphylaxis, positive penicillin skin testing, recurrent penicillin reactions, or hypersensitivities to multiple β-lactam antibiotics. The goals of antimicrobial stewardship are undermined when reported allergy to penicillin leads to the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance, including increased risk of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Broad-spectrum antimicrobial agents also increase the risk of developing Clostridium difficile (also known as Clostridioides difficile) infection. Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories. Moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95% and approaches 100% when combined with amoxicillin challenge. Clinicians performing penicillin allergy evaluation need to identify what methods are supported by their available resources.CONCLUSIONS AND RELEVANCE Many patients report they are allergic to penicillin but few have clinically significant reactions. Evaluation of penicillin allergy before deciding not to use penicillin or other β-lactam antibiotics is an important tool for antimicrobial stewardship.

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The impact of penicillin skin testing on clinical practice and antimicrobial stewardship

Cited by 128 publications

References 10 publications

Management of allergy to penicillins and other beta‐lactams

Management of allergy to penicillins and other beta‐lactams

Antimicrobial Stewardship Programs: A Review of Recent Evaluation Methods and Metrics

Evaluation and Management of Penicillin Allergy

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