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Blumenthal KG, Smith LR, Mann JTS, Salciccioli I, Accarino JJO, Shah RJ, Alvi FI, Cardoso-Fernandes A, Ferreira-da-Silva R, Schunemann HJ, Sousa-Pinto B. Reaction Risk to Direct Penicillin Challenges: A Systematic Review and Meta-Analysis. JAMA Intern Med 2024:2823686. [PMID: 39283610 PMCID: PMC11406457 DOI: 10.1001/jamainternmed.2024.4606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2024]
Abstract
Importance While direct penicillin challenges might support the expansion of penicillin allergy delabeling efforts, the perceived risk of reactions remains a key barrier. Objective To evaluate the frequency of reactions to direct penicillin challenges in individuals with penicillin allergy labels and to identify factors associated with such reactions. Data Sources Three electronic databases were searched (MEDLINE, Web of Science, and Scopus) from inception to July 19, 2023, for primary studies assessing patients undergoing direct penicillin challenges. Articles were included regardless of publication year, language, status, or definition of allergy risk. Study Selection Two reviewers independently selected original studies reporting the frequency of immunologically mediated reactions following a direct penicillin challenge in patients reporting a penicillin allergy. Data Extraction and Synthesis Two reviewers independently extracted data and independently assessed the quality of each primary study using a risk-of-bias tool for prevalence studies. Main Outcomes and Measures The primary outcome was the frequency of reactions to direct penicillin challenges as calculated using random-effects bayesian meta-analysis of proportions. Secondary outcomes included risk factors for reactions and the frequency of severe reactions. Results A total of 56 primary studies involving 9225 participants were included. Among participants, 438 experienced reactions to direct penicillin challenges without prior testing, corresponding to an overall meta-analytic frequency of 3.5% (95% credible interval [CrI], 2.5%-4.6%). Meta-regression analyses revealed that studies performed in North America had lower rates of reaction to direct challenges (odds ratio [OR], 0.36; 95% CrI, 0.20-0.61), while studies performed in children (OR, 3.37; 95% CrI, 1.98-5.98), in outpatients (OR, 2.19; 95% CrI, 1.08-4.75), and with a graded (OR, 3.24; 95% CrI, 1.50-7.06) or prolonged (OR, 5.45; 95% CrI, 2.38-13.28) challenge had higher rates of reaction. Only 5 severe reactions (3 anaphylaxis, 1 fever with rash, and 1 acute kidney injury) were reported, none of which were fatal. Conclusions and Relevance This systematic review and meta-analysis found that reactions to direct penicillin challenges are infrequent, with rates comparable to indirect challenges after allergy testing. These findings suggest that direct challenges are safe for incorporation into penicillin allergy evaluation efforts across age groups and clinical settings.
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Affiliation(s)
- Kimberly G Blumenthal
- Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology. Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston
- Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Massachusetts General Hospital, Boston
| | - Liam R Smith
- Division of Rheumatology. Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston
- Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Massachusetts General Hospital, Boston
| | | | - Ingrid Salciccioli
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Mount Auburn Hospital, Cambridge, Massachusetts
| | - John J O Accarino
- Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology. Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston
- Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Massachusetts General Hospital, Boston
| | - Ruchi J Shah
- Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology. Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Fatima I Alvi
- Harvard School of Public Health, Boston, Massachusetts
| | - António Cardoso-Fernandes
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Renato Ferreira-da-Silva
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Holger J Schunemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology and Research Center, Humanitas University and Humanitas Research Hospital, Milan, Italy
| | - Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal
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Lucas M, von Ungern-Sternberg BS, Arnold A, Trevenen M, Herrmann S, Braconnier L, Ali S, Jepp C, Sommerfield D, Murray K, Rueter K. Comparing Skin and Serum Testing to Direct Challenge Outcomes in Children With β-Lactam Allergies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00842-0. [PMID: 39173971 DOI: 10.1016/j.jaip.2024.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 08/08/2024] [Accepted: 08/12/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND There is a scarcity of prospective studies investigating the relative roles of skin prick and intradermal testing, serum specific IgE, and extended oral challenges in diagnosing children with reported β-lactam allergies. OBJECTIVE To determine the sensitivity and specificity of skin testing and serum specific IgE in children with β-lactam allergies, with immediate and nonimmediate historic reactions. METHODS Four hundred children with parent-reported β-lactam allergies were recruited into an open-label prospective study. Detailed allergy histories were collected. Those with medically observed and documented histories of anaphylaxis, requiring epinephrine, or severe cutaneous adverse reactions were excluded. In total, 380 children underwent all testing modalities and a direct provocation test. Each child was followed up for a minimum of 3 years. RESULTS True allergy in children was uncommon; 8.3% reacted to the direct provocation challenge or the 5-day extended oral provocation challenge. Children reporting cephalosporin allergy or a reaction within 1 year were more likely to react to direct provocation testing. The sensitivity, specificity, and positive predictive value of skin testing were 12.5%, 98.8%, and 20.0% for direct challenge outcomes, 4.76%, 99.0%, and 25.0% for extended challenge outcomes, and 6.9%, 99.0%, and 40.0% for both challenges combined, respectively. Follow-up investigations revealed that 5.7% of children had a mild repeat reaction and 2.7% continued to avoid the culprit despite successful delabeling. The relabeling rate for children readmitted to hospital was 15%, with the relabeing being unfounded. CONCLUSIONS Genuine β-lactam allergies were rare, with over 90% of children effectively delabeled. Skin and serum specific IgE testing did not aid the diagnosis of β-lactam antibiotic allergy in children, regardless of medical history. Extended oral challenges proved valuable in confirming allergies and boosted parental confidence.
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Affiliation(s)
- Michaela Lucas
- Department of Clinical Immunology, Perth Children's Hospital, Perth, WA, Australia; UWA Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, WA, Australia; Department of Immunology, PathWest Laboratory Medicine, Perth, WA, Australia; Department of Immunology, Sir Charles Gardiner Hospital, Perth, WA, Australia.
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia & Pain Medicine, Perth Children's Hospital, Perth, WA, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, the University of Western Australia, Perth, WA, Australia; Institute for Pediatric Perioperative Excellence, the University of Western Australia, Perth, WA, Australia; Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia
| | - Annabelle Arnold
- Department of Clinical Immunology, Perth Children's Hospital, Perth, WA, Australia
| | - Michelle Trevenen
- Centre for Applied Statistics, University of Western Australia, Perth, WA, Australia
| | - Susan Herrmann
- UWA Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, WA, Australia
| | - Laure Braconnier
- Department of Clinical Immunology, Perth Children's Hospital, Perth, WA, Australia
| | - Syed Ali
- Department of Clinical Immunology, Perth Children's Hospital, Perth, WA, Australia
| | - Catherine Jepp
- Department of Clinical Immunology, Perth Children's Hospital, Perth, WA, Australia
| | - David Sommerfield
- Department of Anaesthesia & Pain Medicine, Perth Children's Hospital, Perth, WA, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, the University of Western Australia, Perth, WA, Australia; Institute for Pediatric Perioperative Excellence, the University of Western Australia, Perth, WA, Australia; Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia
| | - Kevin Murray
- Centre for Applied Statistics, University of Western Australia, Perth, WA, Australia; School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - Kristina Rueter
- Department of Clinical Immunology, Perth Children's Hospital, Perth, WA, Australia; Institute for Pediatric Perioperative Excellence, the University of Western Australia, Perth, WA, Australia; Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia; UWA Medical School, UWA Centre for Child Health Research, the University of Western Australia, Perth, WA, Australia; Department of Emergency Medicine, Perth Children's Hospital, Nedlands, WA, Australia
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Bodega-Azuara J, Belles Medall MD, Edo-Peñarrocha J, Puplá-Bartoll A, Ferrando Piqueres R, Torres-Górriz MC, Germán-Sánchez A, Enrique E. Beta-lactam allergy in patients: an antibiotic stewardship challenge. Eur J Hosp Pharm 2024; 31:307-313. [PMID: 36564160 PMCID: PMC11265552 DOI: 10.1136/ejhpharm-2022-003304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 12/12/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patients are commonly reported as being allergic to beta-lactam (BL) antibiotics. However, many patients with this reported allergy are able to receive BL treatments because they do not have true allergies. In many cases these are simply intolerances due to side effects reported as an allergy. Delabelling these patients leads to better clinical outcomes, optimal antibiotic usage, decreased bacterial resistance and reduced healthcare costs. Therefore, the aims of this study were to identify incorrectly labelled BL allergies in hospitalised patients and to assess antibiotic use in delabelled patients in order to establish a quality indicator to optimise antimicrobial treatments. METHODS A prospective study was conducted in which hospitalised patients treated with antimicrobial drugs and labelled as 'BL-allergic' were identified by clinical pharmacists. An allergist assessed whether patients were suitable candidates for a skin test or oral challenge. The Allergy Service removed 'BL-allergic' labels if negative results were obtained. Delabelled patients were followed up by clinical pharmacists to study the use of BL antibiotics as a result of the delabelling programme. RESULTS A total of 176 suspected allergic patients were identified and 91 (51.7%) were tested either by a skin test or oral challenge based on the patient indicators. Seven (16.4%) patients tested were allergic to BL antibiotics, 76 (83.5%) were totally delabelled and eight (0.1%) were partially delabelled. Thirty-two (38.1%) delabelled patients required antibiotic treatment in another inpatient or outpatient setting, of whom 27 (84.3%) patients with a new infectious episode received BL treatments while five (15.7%) continued to receive antimicrobial treatments without BL. CONCLUSION After the implementation of a protocol to detect incorrect BL allergy labels, 83.5% of the patients in this cohort were completely delabelled. This shows that there is a clear opportunity to optimise the use of antibiotics by delabelling 'BL-allergic' patients.
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Affiliation(s)
- Julia Bodega-Azuara
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | | | - Josep Edo-Peñarrocha
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | - Aarón Puplá-Bartoll
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | - Raul Ferrando Piqueres
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | | | - Adrián Germán-Sánchez
- Allergology, Hospital General Universitari de Castello, Castellon de la Plana, Spain
| | - Ernesto Enrique
- Allergology, Hospital General Universitari de Castello, Castellon de la Plana, Spain
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Barbaud A, Garvey LH, Torres M, Laguna JJ, Arcolaci A, Bonadonna P, Scherer Hofmeier K, Chiriac AM, Cernadas J, Caubet JC, Brockow K. EAACI/ENDA position paper on drug provocation testing. Allergy 2024; 79:565-579. [PMID: 38155501 DOI: 10.1111/all.15996] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/30/2023]
Abstract
In drug hypersensitivity, drug provocation testing (DPT), also called drug challenge, is the gold standard for investigation. In recent years, risk stratification has become an important tool for adjusting the diagnostic strategy to the perceived risk, whilst still maintaining a high level of safety for the patient. Skin tests are recommended before DPT but may be omitted in low-risk patients. The task force suggests a strict definition of such low-risk patients in children and adults. Based on experience and evidence from studies of allergy to beta-lactam antibiotics, an algorithm on how to adjust DPT to the risk, and when to omit skin tests before DPT, is presented. For other antibiotics, non-steroidal anti-inflammatory drugs and other drugs, skin tests are poorly validated and DPT is frequently necessary. We recommend performing DPT with chemotherapeutics and biologicals to avoid unnecessary desensitization procedures and DPT with skin tests negative contrast media. We suggest DPT with anesthetics only in highly specialized centers. Specifics of DPT to proton pump inhibitors, anticonvulsants and corticosteroids are discussed. This position paper provides general recommendations and guidance on optimizing use of DPT, whilst balancing benefits with patient safety and optimizing the use of the limited available resources.
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Affiliation(s)
- Annick Barbaud
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Tenon, Service de dermatologie et allergologie, Paris, France
| | - Lene Heise Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Maria Torres
- Allergy Unit, Regional University Hospital of Malaga-IBIMA-UMA-ARADyAL, Malaga, Spain
| | - Jose Julio Laguna
- Allergy Unit, Allergo-Anaesthesia Unit, Faculty of Medicine, Hospital Central de la Cruz Roja, Alfonso X El Sabio University, ARADyAL, REI, Madrid, Spain
| | - Alessandra Arcolaci
- Immunology Unit, University Hospital of Verona, Policlinico G.B. Rossi, Verona, Italy
| | - Patrizia Bonadonna
- Allergy Unit, University Hospital of Verona, Policlinico G.B. Rossi, Verona, Italy
| | - Kathrin Scherer Hofmeier
- Allergy and Dermatology, Cantonal Hospital Aarau, Cantonal Hospital Aarau, Aarau, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Anca Mirela Chiriac
- Allergy Unit, University Hospital of Montpellier and IDESP, UMR UA11, Univ. Montpellier - INSERM, Montpellier, France
| | - Josefina Cernadas
- Hospital Lusíadas, Porto, Portugal
- Centro Hospitalar Universitário H. S. João, Porto, Portugal
| | - Jean Christoph Caubet
- Department of Women-Children-Teenagers, University Hospital of Geneva, Geneva, Switzerland
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Faculty of Medicine and Health, Munich, Germany
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Kulalert P, Phinyo P, Chiriac AM, Demoly P, Saokaew S, Kanchanaphoomi K, Srisuwatchari W. Is a Prolonged Drug Provocation Test Better Than a Single-Day Drug Provocation Test? A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:431-448. [PMID: 38000713 DOI: 10.1016/j.jaip.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND There is currently no standardized duration of drug provocation test (DPT) for confirming/delabeling beta-lactam hypersensitivity reaction (BL-HSR). OBJECTIVES This meta-analysis and systematic review aimed to investigate the added diagnostic value of extended-day over single-day DPT for confirming/delabeling BL-HSR in adults and children. METHODS The MEDLINE, EMBASE, Web of Science, and CINAHL online databases were searched from inception to March 15, 2023, for studies that performed extended-day DPT to confirm/delabel BL-HSR. Risk difference and risk ratio were used to compare the proportions of patients with confirmed BL-HSR by single-day or extended-day DPT. RESULTS A total of 10,371 DPTs from 42 studies were included. Extended-day DPTs ranged from 2 to 7 days, or as long as index reactions were reported (maximum 10 days). The overall prevalence of confirmed BL-HSR was 6.96% (3.31% during the first-day DPT, and 3.65% during extended-day DPT). Approximately half of the positive reactions during extended-day DPT occurred during the second/third day. The increased detected pool prevalence of confirmed BL-HSR yielded by extended-day DPT was 0.03 (95% CI, 0.02%-0.04%; I2 = 57.69%; P < .001), and the risk ratio of positive reactions between extended-day and single-day DPT was 1.94 (95% CI, 1.62-2.33; I2 = 36.26%; P < .001). The risk difference increased per 1% increase in prevalence of BL-HSR by 0.6% (95% CI, 0.4%-0.7%; P < .001). Twenty-three severe reactions occurred during DPT, and only 2 severe reactions (0.02%) occurred during extended-day DPT. An additional 28 extended-day DPTs were needed to identify 1 mild reaction. CONCLUSIONS The increased prevalence of confirmed BL-HSR observed during extended-day DPT could be attributed to the first-day DPT. As a result, our findings do not conclusively support the use of extended-day DPT over single-day DPT. Further studies, incorporating a washout period, are required to comprehensively compare these 2 approaches.
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Affiliation(s)
- Prapasri Kulalert
- Department of Clinical Epidemiology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand; Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Musculoskeletal Science and Translational Research Center (MSTR), Chiang Mai University, Chiang Mai, Thailand
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; UMR UA11 Univ Montpellier - INSERM IDESP, Montpellier, France
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; UMR UA11 Univ Montpellier - INSERM IDESP, Montpellier, France
| | - Surasak Saokaew
- UNIt of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Kantima Kanchanaphoomi
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Witchaya Srisuwatchari
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Heng YK, Liew YCC, Kong YL, Lim YL. β-Lactam allergy testing and delabeling-Experiences and lessons from Singapore. IMMUNITY INFLAMMATION AND DISEASE 2020; 8:371-379. [PMID: 32506796 PMCID: PMC7416033 DOI: 10.1002/iid3.318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/11/2020] [Accepted: 05/21/2020] [Indexed: 01/08/2023]
Abstract
Background β‐Lactam allergy is over‐reported and this leads to greater healthcare costs. Allergy testing has inherent risks, yet patients who test negative may continue avoiding β‐lactams. Objective To evaluate the safety and diagnostic value of β‐lactams allergy testing locally and usage of antibiotics following negative testing. Methods We performed a retrospective medical record review and follow‐up survey of patients who underwent β‐lactam testing between 2010 and 2016 at the National Skin Centre, Singapore. Results We reviewed the records of 166 patients, with a total of 173 β‐lactam allergy labels. Eighty (46.2%) labels were to penicillin, 75 (43.1%) to amoxicillin/amoxicillin‐clavulanic acid, 11 (6.4%) to cephalexin, and 5 (2.9%) to others. Skin tests were performed in 142 patients and drug provocation tests (DPTs) in 141 patients. Eleven (6.6%) patients defaulted DPTs after skin testing. Out of 166 patients, 22 (13.3%) patients were proven allergic by either skin tests (16) or DPTs (6). Patients who tested positive had nonsevere reactions. Out of 155 patients who were conclusively evaluated, 133 (85.8%) were not allergic. Of these patients, 30 (22.6%) used the tested β‐lactam subsequently, with one reporting a mild reaction. Fifty‐one (38.3%) patients were uncontactable or uncertain if they consumed a β‐lactam since testing negative. Fifty‐two (39.1%) patients had no re‐exposure (35 had no indication, 17 were fearful of reactions). Conclusion Drug allergy testing was safe and removed inappropriate labels. Clinical Implication Allergy testing is efficacious, but fears of subsequent rechallenge should be addressed to maximize the effectiveness of allergy delabeling.
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