Patients with a history of atopic allergy e. Who should not be prescribed or administered penicillins? I ndividuals with a history of Type I allergy clinically recognisable by features of urticaria, laryngeal oedema, bronchospasm, hypotension or local swelling within 72 hours of administration, or development of a pruritic rash even after 72 hours should NOT receive a penicillin.
Are there situations where cephalosporins or other beta-lactam antibiotics can be prescribed for patients with penicillin hypersensitivity? The true incidence of cross-sensitivity is uncertain. Second and third generation cephalosporins are unlikely to be associated with cross reactivity as they have different side chains to penicillin. Patients with no evidence of Type I allergy to penicillin may be treated with any cephalosporin or beta lactam antibiotic for infections of any severity.
Patients with symptoms suggestive of a Type I allergy should avoid cephalosporins and other beta-lactam antibiotics for mild or moderate infections when a suitable alternative exists. In life threatening infections , when use of a non-cephalosporin antibiotic would be sub-optimal, consider giving, under observation, a second or third generation cephalosporin e. If necessary seek advice from ID or Microbiology.
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However, the reverse guidance on which penicillins may be problematic in patients that have an allergy to cephalexin one of our most commonly used first line cephalosporins is much more difficult to find. For example, Drs. Zagursky and Pichichero have written two excellent articles on beta-lactam cross-reactivity and R group similarities between cephalexin and several penicillins including ampicillin, piperacillin, and several others that are much less common in the western US.
However, there is not a clear comment on the likelihood of safety of amoxicillin in cephalexin allergic patients, which also appears to have a fairly similar R group differing by only a hydroxyl substitution on the benzene ring.
Is that difference sufficient to render amoxicillin safe for the majority of cephalexin allergic patients? I also am not aware of specific recommendations related to individuals with cephalosporin allergy with respect to treatment with a penicillin. It seems that most of the reactivity of cephalosporins, certainly beyond the first generation, are to side chains, and fortunately side chain reactions tend to be less severe.
With the frequent occurrence of amoxicillin rash, which could be a side-chain sensitivity though many times it is related to a concomitant viral infection, I do not see problems specifically with cephalexin reactions, despite the similarity of the side chains. Skin testing for penicillin allergy should be performed if any indication exists that the symptoms were secondary to an IgE-mediated hypersensitivity.
Testing is also indicated as a potential diagnostic procedure to definitively rule out penicillin allergy and document a negative allergy status in the medical record i. Because penicillin allergy testing does not test for multiple minor determinants, a person with a negative skin test should follow up with an oral challenge to confirm the negative status.
Persons with negative results of a penicillin skin test, followed by an amoxicillin oral challenge, can receive conventional penicillin therapy safely if needed. Persons with positive skin test results and for whom no other clinical options exist e.
Penicillin skin testing includes use of skin test reagents for identifying persons at risk for adverse reactions Box 3 , followed by initial pinprick screening with penicillin major determinants Pre-Pen and penicillin G, followed by intradermal testing if pinprick results are negative. Saline negative controls and histamine positive controls are an integral part of the procedure. Penicillin skin testing should not be performed for patients who have taken antihistamines within the past 7 days.
Skin testing can be safely performed by trained nonallergists and has been implemented as an antimicrobial stewardship intervention by internal medicine physicians, pharmacists, hospitalists, and infectious disease physicians , , , Patients tested should also receive documentation of status, and the results should be entered in the medical record.
Penicillin skin testing during pregnancy is considered safe. However, oral challenges should not be performed unless in a setting where additional support services are available.
The allergy testing results should be documented in the medical record. Patients who test negative should be informed that their risk for anaphylaxis is extremely low and is equivalent to a person who does not report an allergy history. If treatment with penicillin or ceftriaxone is indicated, it can be administered safely. Documentation of testing results should be provided to the patient.
Desensitization is required for persons who have a documented penicillin allergy and for whom no therapeutic alternatives exist e. Modified protocols might be considered on the basis of the clinical syndrome, drug of choice, and route of administration — Patients might require referral to a specialty center where desensitization can be performed. With increased access to skin testing kits and the need to better target therapy for gonorrhea and syphilis, programs should identify local allergy consultant resources.
Aged penicillin is not an adequate source of minor determinants. Penicillin G should either be freshly prepared or come from a fresh-frozen source.
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Facebook Twitter LinkedIn Syndicate. Penicillin Skin Testing Penicillin skin testing with a major determinant analog penicilloyl-polylysine and minor determinants benzylpenicilloate, benzylpenilloate, or benzylpenicillin isomers of penicillin are used for skin test evaluation for IgE-dependent penicillin allergy and can reliably identify persons at high risk for IgE-mediated reactions to penicillin , , Recommendations Persons with a history of severe adverse cutaneous reaction e.
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