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Brillant-Marquis F, Proulx É, Ratnarajah K, Lavoie A, Gauthier A, Gagnon R, Boursiquot JN, Verreault N, Marois L, Bédard MA, Boivin M, Bédard PM, Ouakki M, De Serres G, Drolet JP. Safety of Direct Drug Provocation for the Evaluation of Penicillin Allergy in Low-Risk Adults. J Allergy Clin Immunol Pract 2024; 12:451-457.e2. [PMID: 38572700 DOI: 10.1016/j.jaip.2023.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/08/2023] [Accepted: 10/17/2023] [Indexed: 04/05/2024]
Abstract
BACKGROUND About 10% of patients have a penicillin allergy label, but less than 5% of them are actually allergic. Unnecessary penicillin avoidance is associated with serious medical consequences. Given the growing number of these labels, it is imperative that our diagnostic strategy for penicillin allergy be as efficient as possible. The validity of traditionally used skin tests (STs) has been questioned, whereas drug provocation testing (DPT), the criterion standard, without previous ST appears very safe in most cases. OBJECTIVE To evaluate the safety of direct DPT without consideration for ST results and the validity of ST in the diagnosis of penicillin allergy. METHODS In this prospective cohort study without a control group, we recruited patients consulting an allergist for penicillin allergy. Patients underwent ST followed by DPT regardless of ST results. Patients with anaphylaxis to penicillin within the past 5 years or a severe delayed reaction were excluded, as were those with significant cardiorespiratory comorbidity. RESULTS None of the 1002 recruited patients had a serious reaction to DPT. Ten (1.0%) had a mild immediate reaction, of whom only 1 (0.1%) was considered likely IgE-mediated. The positive and negative predictive values of ST for an immediate reaction were 3.6% and 99.1%, respectively. CONCLUSIONS In a low-risk adult population reporting penicillin allergy, ST has very poor positive predictive value. Direct DPT without ST is safe and appears to be an ideal diagnostic strategy to remove penicillin allergy labels that could be implemented in first-line practice.
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Affiliation(s)
- Frédéric Brillant-Marquis
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Émilie Proulx
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Kayadri Ratnarajah
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Aubert Lavoie
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Amélie Gauthier
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Rémi Gagnon
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Jean-Nicolas Boursiquot
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Nina Verreault
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Louis Marois
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Marc-Antoine Bédard
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Martine Boivin
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Pierre-Michel Bédard
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Manale Ouakki
- Institut National de Santé Publique du Québec, Québec City, Québec, Canada
| | - Gaston De Serres
- Institut National de Santé Publique du Québec, Québec City, Québec, Canada
| | - Jean-Philippe Drolet
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada.
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