January 25, 2019
A new penicillin allergy review recommends that clinicians perform a comprehensive allergy history to assess risk level.
More than 95% of people in the United States with a documented penicillin allergy can be treated safely with penicillin according to a review published in The Journal of the American Medical Association (JAMA).
The American Academy of Allergy, Asthma, and Immunology (AAAAI), the Infectious Diseases Society of America (IDSA), and the Society for Healthcare Epidemiology of America (SHEA) appointed representatives to form a writing group. The group searched PubMed for articles published between January 1, 2005, and September 30, 2018. Search terms included penicillin, β-lactam, antibiotic, allergy, skin test, and more than a dozen others.
Following the literature review, the committee developed a consensus manuscript detailing best practices for the evaluation and management of reported penicillin allergies. The authors note that the key to distinguishing between patients who are allergic to the group of antibiotics and those who are not is to carefully examine past reactions that led to allergic designations. The review recommends that clinicians perform a comprehensive allergy history to assess reported reactions and determine risk level.
Patients who have reported isolated nonallergic symptoms or who have a family history of penicillin allergy, pruritus without rash, or unknown reactions >10 years ago are considered at low risk. The review recommends that clinicians prescribe amoxicillin or perform a direct amoxicillin challenge.
Patients with a history of pruritic rashes or reactions with features of IgE-mediated reactions but not anaphylactic reactions are considered to be at moderate risk. The review recommends penicillin skin testing followed by direct amoxicillin challenge if the test result is negative.
Patients with a history of high-risk reactions including anaphylaxis and hypersensitivities to multiple β-lactam antibiotics are considered to be at high risk. High-risk patients should be evaluated by a specialist.
The authors concluded that clinicians should evaluate patients for penicillin allergy prior to deciding against using penicillin or other β-lactam antibiotics.
Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and management of penicillin allergy: a review. JAMA. 2019;321(2):188-199.