In the JournalsPerspective

Majority of children at low risk for penicillin allergy are not allergic

All children who were considered minimal risk for penicillin allergy in a questionnaire demonstrated no allergy to the antibiotic in a study published in Pediatrics.

“A recent study in the pediatric ED revealed that the majority of the symptoms of penicillin allergy reported by families are low risk for true allergy,” David Vyles, DO, from the department of pediatric emergency medicine at the Medical College of Wisconsin, Milwaukee, and colleagues wrote. “… Because there is no process to safely and rapidly diagnose true penicillin allergy in an acute care setting, providers in the pediatric ED are reluctant to prescribe penicillin antibiotics to children with a reported penicillin allergy.”

To test the hypothesis that all children who come into the pediatric ED with low-risk penicillin allergy symptoms do not have a true penicillin allergy, the researchers administered an allergy questionnaire to 597 parents. One hundred prespecified children who had reported symptoms were further tested for penicillin allergy. They then calculated the number of negative allergy tests with a 95% confidence interval.

Of the 597 parents who completed the questionnaire, 51% (n = 302) of the children aged 4 to 18 years were eligible to be tested for the allergy based on their low-risk status. The median age of those tested was 9 years, and they were diagnosed at 1 year. The most frequently attributed symptoms included rash (97%) and itching (63%).

Every child tested (n = 100) demonstrated negative immunoglobulin E-mediated hypersensitivity to penicillin (95% CI [96.4%-100%]). Because of this testing, all could have the allergy removed from their medical record.

“The ability of the questionnaire to successfully identify a population likely to be at low risk for penicillin allergy was validated by subsequent gold standard allergy testing,” Vyles and colleagues wrote. “It identified a group of low-risk children who successfully passed an oral drug challenge. This highlights the questionnaire’s potential as a safe alternative to time-consuming, costly, and labor-prohibitive penicillin skin testing in the ED setting for select patients.” — by Katherine Bortz

Disclosure: The researchers provide no relevant financial disclosures.

All children who were considered minimal risk for penicillin allergy in a questionnaire demonstrated no allergy to the antibiotic in a study published in Pediatrics.

“A recent study in the pediatric ED revealed that the majority of the symptoms of penicillin allergy reported by families are low risk for true allergy,” David Vyles, DO, from the department of pediatric emergency medicine at the Medical College of Wisconsin, Milwaukee, and colleagues wrote. “… Because there is no process to safely and rapidly diagnose true penicillin allergy in an acute care setting, providers in the pediatric ED are reluctant to prescribe penicillin antibiotics to children with a reported penicillin allergy.”

To test the hypothesis that all children who come into the pediatric ED with low-risk penicillin allergy symptoms do not have a true penicillin allergy, the researchers administered an allergy questionnaire to 597 parents. One hundred prespecified children who had reported symptoms were further tested for penicillin allergy. They then calculated the number of negative allergy tests with a 95% confidence interval.

Of the 597 parents who completed the questionnaire, 51% (n = 302) of the children aged 4 to 18 years were eligible to be tested for the allergy based on their low-risk status. The median age of those tested was 9 years, and they were diagnosed at 1 year. The most frequently attributed symptoms included rash (97%) and itching (63%).

Every child tested (n = 100) demonstrated negative immunoglobulin E-mediated hypersensitivity to penicillin (95% CI [96.4%-100%]). Because of this testing, all could have the allergy removed from their medical record.

“The ability of the questionnaire to successfully identify a population likely to be at low risk for penicillin allergy was validated by subsequent gold standard allergy testing,” Vyles and colleagues wrote. “It identified a group of low-risk children who successfully passed an oral drug challenge. This highlights the questionnaire’s potential as a safe alternative to time-consuming, costly, and labor-prohibitive penicillin skin testing in the ED setting for select patients.” — by Katherine Bortz

Disclosure: The researchers provide no relevant financial disclosures.

    Perspective
    Rachel G. Robison

    Rachel G. Robison

    Rashes in childhood are common and often coincide with an antibiotic course; however, many times the rash is just as, if not more likely to be caused by the underlying illness for which the antibiotics were prescribed. This study by Vyles et al. adds pediatric data to a growing body of work in both adults and children supporting that penicillin allergy is over reported.

    In several previous studies, over 95% of patients with a reported penicillin allergy are actually able to tolerate penicillins and related beta lactam antibiotics. Specific limitations of this study include a testing sample size of only 100 and a focus only on those considered “low risk” for allergy. For these and other reasons, the Vyles data may not be generalizable to a pediatric population with reported penicillin allergy. The authors go farther and propose that their questionnaire may be used as an alternative to skin testing for select ED patients.

    To this effect, it is important to note that no children with possible systemic IgE-mediated symptoms were included and a proportion of subjects included had symptoms that many allergists may not even consider allergic reactions, but instead expected adverse reactions to medication, such as headache, dizziness and isolated gastrointestinal symptoms (nausea, diarrhea). These symptoms would likely not have required skin testing and graded challenge at all if evaluated by an allergist.

    Regardless of the limitations of this particular study, it is important for pediatric providers to be skeptical of reported penicillin allergy in their patients and to be aware that standardized testing both exists and can be helpful in determining a patient’s risk with subsequent beta lactam antibiotic use. Taking a detailed history of a child’s reported reaction and referring to an allergist-immunologist for evaluation can help a child avoid years of unnecessary beta lactam avoidance as well as use of unnecessary broad spectrum antibiotics.

    • Rachel G. Robison, MD
    • Attending physician, Division of Allergy & Immunology Ann & Robert H. Lurie Children’s Hospital of Chicago Assistant professor of pediatrics Northwestern University Feinberg School of Medicine

    Disclosures: Dr. Robison reported no relevant financial disclosures.

    Perspective
    Jennifer A. Sherman

    Jennifer A. Sherman

    Allergy to penicillin and related antibiotics is the most commonly reported drug allergy in the United States. While approximately 10% of patients self-report as being penicillin allergic, 90% of those patients are later found not to be allergic after undergoing testing. In addition, 50% of penicillin-allergic patients lose their sensitivity after 5 years, with 80% losing their sensitivity after 10 years.

    Vyles et al highlights the fact that the majority of the symptoms of penicillin allergy reported by families are low-risk for true allergy. Utilizing a 17-item questionnaire, the researchers hypothesized that children presenting to the pediatric emergency department with low-risk symptoms of allergy would test as negative for true penicillin allergy. One hundred children underwent percutaneous and intradermal penicillin allergy testing followed by oral challenge; all (100%) of those children were found to have negative results for penicillin allergy after an oral challenge.

    These findings are important for several reasons. Patients who are labeled as penicillin allergic are frequently treated with broad-spectrum antibiotics, which tend to have increased side effects and are often less efficacious, leading to a more complicated clinical course. Additionally, this practice contributes to antibiotic resistance and increased health care costs. Communication between families, pediatricians (in both outpatient and acute care settings), and pediatric allergy specialists in combination with available testing is crucial to removing the “penicillin-allergic” label and optimizing patient care.

    • Jennifer A. Sherman, DO
    • Allergy & Immunology The Valley Hospital

    Disclosures: Dr. Sherman reports no relevant financial disclosures.

    Perspective
    Purvi Parikh

    Purvi Parikh

    Many infections, especially in the pediatric population, cause rashes. While antibiotics, such as penicillin, are often blamed for the rash, in fact, the child is merely breaking out in a rash as a response to the infection. Infections can irritate our immune system in the same way an allergen, so diagnosis can often be confusing. 

    Moreover, many patients get diagnosed as “allergic” to penicillin when the symptoms they are experiencing are either a side effect of the medication or unrelated to the drug itself. For this reason, I recommend skin testing and a graded-dose challenge by a board-certified allergist to ensure that patients are not avoiding penicillin for no reason, especially among children that are low risk as the study delineates. 

    The natural history of a true penicillin allergy is that 90% of patients ‘outgrow’ it over time. Even if a patient correctly has a penicillin allergy, they should be monitored down the road by a board-certified allergist to determine if the allergy is disappearing as they may not need to avoid the drug unnecessarily their entire life.

    • Purvi Parikh, MD
    • Allergist/immunologist Allergy & Asthma Network

    Disclosures: Parikh provide no relevant financial disclosures.