Managing possible antibiotic allergy in children

Impact of penicillin allergy labels among pneumonia admissions at an academic children's center

Background: Pneumonia is the most common reason for pediatric hospitalizations. The impact of penicillin allergy labels among children with pneumonia has not been well studied. Objective: This study assessed the prevalence and impact of penicillin allergy labels among children admitted with pneumonia over a 3-year period at a large academic children's center. Methods: Inpatient charts of pneumonia admissions with a documented allergy to a type of penicillin from January to March in 2017, 2018, and 2019 were reviewed and compared with pneumonia admissions without the label over the same time with regard to days of antimicrobial treatment, route of antimicrobial therapy, and days of hospitalization. Results: There were 470 admissions for pneumonia during this time period, of which 48 patients (10.2%) carried a penicillin allergy label. Hives and/or swelling comprised 20.8% of the allergy labels. Other labels included nonpruritic rashes, gastrointestinal GI symptoms, unknown/undocumented reactions, or other reasons. There were no significant differences between those with a penicillin allergy label to those without regarding days of antimicrobial treatment (inpatient and outpatient), route of antimicrobial therapy, and days of hospitalization. Those with a penicillin allergy label were less likely to be prescribed a penicillin product (p < 0.002). Of the 48 patients who were allergy labeled, 23% (11/48) were given a penicillin medication without adverse reaction. Conclusion: Ten percent of pediatric admissions for pneumonia had a label of penicillin allergy, similar to the overall population. The hospital course and clinical outcome were not significantly affected by the penicillin allergy label. The majority of documented reactions were of low risk for immediate allergic reactions.

Diagnosing Single and Multiple Drug Hypersensitivity in Children: A Tertiary Care Center Retrospective Study

Drug hypersensitivity reactions (DHRs) are a type of adverse drug reactions with heterogeneous pathophysiological mechanisms and a broad spectrum of clinical manifestations. Since over-diagnosing is common in children, a complete allergy work-up is needed. A cross-sectional study was conducted at a tertiary care institution, covering the five-year period. Five hundred and four patients of both sexes, mean age 7.5 and with a medical history suggestive of DHR were evaluated. ENDA/EAACI guidelines were used for a diagnostic algorithm. Single drug hypersensitivity was registered in 375 patients and multiple drug hypersensitivity in 129. The main culprits in medical history were antibiotics (83%), non-steroidal anti-inflammatory drugs (NSAIDs) (8.4%) and analgoantipyretics (3.8%). Skin involvement was registered in 96.2%. DHRs were confirmed in 4.4% patients-six patients had positive skin tests and 13 had a positive drug provocation test. In the proven DHRs group, the main agents were antibiotics (72.7%), followed by NSAIDs (8.3%), and of all the skin manifestations, urticaria was most common (78.2%), followed by exanthema (10.5%) and angioedema (5.3%). Considering the above, anticipating DHRs and a proper referral of children to an allergologist is a key step in the assessment of drug hypersensitivity. A complete allergy work-up prevents unnecessary drug exclusion and allows most children to safely continue the use of first-line medications when needed.

Establishing Amoxicillin Allergy in Children Through Direct Graded Oral Challenge (GOC): Evaluating Risk Factors for Positive Challenges, Safety, and Risk of Cross-Reactivity to Cephalosporines

BACKGROUND

Data on the diagnostic properties of direct oral challenges without the use of skin tests in children with suspected amoxicillin allergy are sparse.

OBJECTIVE

Assess the use of direct oral challenges.

METHODS

A cohort study was conducted between March 2013 and March 2020, in Montreal and Winnipeg. All children referred with reported history of benign reactions (ie, limited to the skin with no mucosal lesions and no vesicles) to amoxicillin were recruited and a 2-step graded oral challenge (GOC) was conducted. Data were collected on demographic characteristics, clinical characteristics, and comorbidities. Eligible children were followed to assess reactions to subsequent use of amoxicillin and to assess the safety of cephalexin use in children with a positive GOC.

RESULTS

Among 1914 children recruited, 1811 (94.6%) tolerated the GOC, 42 (2.2%) developed mild immediate reactions, and 61 (3.2%) developed mild nonimmediate reactions. Among 265 participants who had a negative GOC and reused amoxicillin, 226 (85.3%) reported tolerance and 39 (14.7%) had mild cutaneous reactions. Chronic urticaria (adjusted odds ratio [aOR], 1.16; 95% CI, 1.09-1.23) and an index reaction occurring within 5 minutes of exposure (aOR, 1.09; 95% CI, 1.04-1.14) were associated with immediate reactions during the GOC. Symptoms lasting longer than 7 days (aOR, 1.05; 95% CI, 1.02-1.09) and parental drug hypersensitivity (aOR, 1.04; 95% CI, 1.03-1.06) were associated with nonimmediate reactions. Among those reacting to the GOC, 12.5% reacted with mild cutaneous reactions to cephalexin challenge.

CONCLUSIONS

Direct GOCs are an accurate and safe confirmatory to establish true hypersensitivity among children reporting benign reactions to amoxicillin.

Mild to moderate hypersensitivity reactions to beta-lactams in children: a single-centre retrospective review

OBJECTIVE

Beta-lactam (BL) antibiotics are the most reported drugs in hypersensitivity reactions in children. More than 90% of these children tolerate the suspected drug after diagnostic work-up. Skin tests (STs) show low sensitivity. Our aim was to assess the performance of drug provocation tests (DPTs) without previous ST in mild and moderate delayed reactions and to propose a new DPT protocol.

DESIGN OF THE STUDY

Charts from 213 children under 15 years of age referred for suspected BL allergy from 2011 to 1013 were reviewed. Prick, intradermal and patch tests were performed with major determinant penicilloyl-polylysine, minor determinant mixture, amoxicillin (AMX), cefuroxime, penicillin G and AMX-clavulamate. Children with negative skin tests underwent DPT. After an initial full dose of antibiotic, DPT was carried on for 3 days at home in patients reacting within the first 3 days of treatment. If the reaction took place from day 4 on of treatment, patients took the antibiotic for 5 days.

RESULTS

We included 108 girls and 105 boys. Mean age at the time of reaction was 3.66±3.06 years. 195 patients (91.5%) reacted to one BL. 154 reactions (67.2%) were non-immediate. Mild to moderate skin manifestations were most frequently reported. AMX-clavulanate was the most frequently involved (63.4%). DPT confirmed the diagnosis of drug hypersensitivity in 17 (7.3%) cases. These 17 patients had negative ST.

CONCLUSION

In mild and moderate cases of BL hypersensitivity, diagnosis can be performed by DPT without previous ST.

Fifteen-minute consultation: A child with a suspected drug allergy

Adverse drug reactions are common in children, but true drug allergy is rare. It can be difficult to determine whether signs such as skin rashes are caused by the underlying illness or medications prescribed. Accurate diagnosis is important for patient safety and optimal treatment. We review the presentation of drug allergy and discuss current management options for children.

Antibiotic Allergy in Pediatrics

The overlabeling of pediatric antibiotic allergy represents a huge burden in society. Given that up to 10% of the US population is labeled as penicillin allergic, it can be estimated that at least 5 million children in this country are labeled with penicillin allergy. We now understand that most of the cutaneous symptoms that are interpreted as drug allergy are likely viral induced or due to a drug-virus interaction, and they usually do not represent a long-lasting, drug-specific, adaptive immune response to the antibiotic that a child received. Because most antibiotic allergy labels acquired in childhood are carried into adulthood, the overlabeling of antibiotic allergy is a liability that leads to unnecessary long-term health care risks, costs, and antibiotic resistance. Fortunately, awareness of this growing burden is increasing and leading to more emphasis on antibiotic allergy delabeling strategies in the adult population. There is growing literature that is used to support the safe and efficacious use of tools such as skin testing and drug challenge to evaluate and manage children with antibiotic allergy labels. In addition, there is an increasing understanding of antibiotic reactivity within classes and side-chain reactions. In summary, a better overall understanding of the current tools available for the diagnosis and management of adverse drug reactions is likely to change how pediatric primary care providers evaluate and treat patients with such diagnoses and prevent the unnecessary avoidance of antibiotics, particularly penicillins.

Management of Children with Hypersensitivity to Antibiotics and Monoclonal Antibodies

Proper management of drug allergy in children is based on a thorough history, in vitro testing (if available), in vivo testing, and drug challenge. This approach has been well developed with beta-lactam drugs but not with non-beta-lactam drugs and monoclonal antibodies. Children commonly develop rashes during an antibiotic course, which can lead to misdiagnosis of drug allergy. Clinical reactions to monoclonal antibodies vary and are managed depending on the type. A better knowledge of drug reactions that can occur in antibiotic allergy and monoclonal allergy can aid a provider in better management of their drug-allergic pediatric patients.

Lack of uniformity in the investigation and management of suspected β-lactam allergy in children

BACKGROUND

Beta-lactam allergy is commonly suspected in childhood with health implications for the individual and wider public. Diagnostic modalities include skin prick tests (SPT), specific immunoglobulin-E (sp-IgE) tests, intradermal tests (IDT) and drug provocation challenges (DPC). The aim of this research was to establish whether variation exists around the world in the investigation and management of beta-lactam allergy.

METHODS

Anonymized electronic questionnaire surveys were distributed over 3 months through International Allergy Societies for completion by clinicians who investigate drug allergy in children.

RESULTS

Eighty-one clinicians, practising in 16 countries, completed the questionnaire. There is variability in the selection of diagnostic tests used by clinicians around the world and poor agreement on positive cut-off values (sp-IgE, SPT and IDT) and practical techniques used to measure SPT or IDT wheal diameters. DPC were considered the gold standard investigation with 94% of respondents undertaking DPC over the last 12 months; 64% of respondents considered DPC extremely useful for both exclusion and confirmation of beta-lactam allergy. However, there is a lack of consensus on when and how DPC should be performed. Overall, DPC are safe - only 3% of our respondents had patients who required intramuscular adrenaline and none had patients requiring admission to intensive care.

CONCLUSIONS

There is lack of consistency amongst clinicians in different countries in the diagnosis and management of suspected beta-lactam allergy. The development of a standardized approach is a priority.

Drug hypersensitivity in children: report from the pediatric task force of the EAACI Drug Allergy Interest Group

When questioned, about 10% of the parents report suspected hypersensitivity to at least one drug in their children. However, only a few of these reactions can be confirmed as allergic after a diagnostic workup. There is still a lack of knowledge on drug hypersensitivity (DH) epidemiology, clinical spectrum, and appropriate diagnostic methods particularly in children. Meanwhile, the tools used for DH management in adults are applied also for children. Whereas this appears generally acceptable, some aspects of DH and management differ with age. Most reactions in children are still attributed to betalactams. Some manifestations, such as nonsteroidal anti-inflammatory drug-associated angioedema and serum sickness-like reactions, are more frequent among young patients as compared to adults. Risk factors such as viral infections are particularly frequent in children, making the diagnosis challenging. The practicability and validity of skin test and other diagnostic procedures need further assessment in children. This study presents an up-to-date review on epidemiology, clinical spectrum, diagnostic tools, and current management of DH in children. A new general algorithm for the study of these reactions in children is proposed. Data are presented focusing on reported differences between pediatric and adult patients, also identifying unmet needs to be addressed in further research.

Amoxicillin allergy in children: five-day drug provocation test in the diagnosis of nonimmediate reactions

BACKGROUND

The drug provocation test (DPT) is the gold standard to rule out drug hypersensitivity. There are standardized DPT protocols to diagnose immediate reactions to drugs, but not for nonimmediate reactions.

OBJECTIVE

The aim of this study was to show the sensitivity and specificity of an allergy work-up that included a 5-day DPT in children with histories of nonimmediate reactions to amoxicillin through focusing on a pediatric population with histories of immediate and nonimmediate reactions to amoxicillin.

METHODS

Two hundred consecutive patients with histories of amoxicillin reactions referred to the Allergy Unit of Anna Meyer Children's Hospital for suspected drug allergy from 2008 to 2011 underwent in vivo tests with the culprit drug according to European Academy of Allergy and Clinical Immunology guidelines. Moreover, most of those children, regardless of the skin tests results, were challenged with amoxicillin for a total of 5 days.

RESULTS

In 4 years, 200 patients were evaluated for a history of drug hypersensitivity to amoxicillin. The majority of patients (76%) had a history of mild nonimmediate reactions. All 200 patients underwent skin tests, and 9 of 200 tested positive. A total of 177 DPTs were performed with amoxicillin for 5 days in each child. Diagnosis of amoxicillin allergy was confirmed by a DPT in 17 patients (9.6%); 14/17 had history of nonimmediate reactions; 4/14 (26.6%) reacted on day 5.

CONCLUSION

According to our results, a long-term DPT protocol increases the sensitivity of the allergy work-up, and it should be recommended for patients with a history of amoxicillin nonimmediate reaction.