Evaluation of penicillin allergy before deciding not to use penicillin or other β-lactam antibiotics is an important tool for antimicrobial stewardship. Many patients report they are allergic to penicillin but few have clinically significant reactions. Clinicians performing penicillin allergy evaluation need to identify what methods are supported by their available resources. Moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95% and approaches 100% when combined with amoxicillin challenge. Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories. Broad-spectrum antimicrobial agents also increase the risk of developing Clostridium difficile (also known as Clostridioides difficile) infection. The goals of antimicrobial stewardship are undermined when reported allergy to penicillin leads to the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance, including increased risk of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Although monobactams and carbapenems are. Monobactams have a monocyclic ring structure and the carbapenems have a bicyclic nucleus comprised of a -lactam ring with an accompanying five-membered ring. Monobactams and carbapenems are two other types of -lactam antibiotics. A high-risk history includes patients who have had anaphylaxis, positive penicillin skin testing, recurrent penicillin reactions, or hypersensitivities to multiple β-lactam antibiotics. Cephalosporin Cross-Reactivity with Monobactams and Carbapenems. A moderate-risk history includes urticaria or other pruritic rashes and reactions with features of IgE-mediated reactions. Although many patients report that they are allergic to penicillin, clinically significant IgE-mediated or T lymphocyte-mediated penicillin hypersensitivity is uncommon (10 years) unknown reactions without features suggestive of an IgE-mediated reaction. Many patients report allergies to these drugs that limit their use, resulting in the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance and adverse events.Īpproximately 10% of the US population has reported allergies to the β-lactam agent penicillin, with higher rates reported by older and hospitalized patients. Thus, our data indicate that cephalosporins can be considered for patients with penicillin allergy.Β-Lactam antibiotics are among the safest and most effective antibiotics. Cross-reactivity is not an adequate explanation for this increased risk, and the risk of anaphylaxis is very low. Patients with allergic-like events after penicillin had a markedly increased risk of events after either subsequent cephalosporins or sulfonamide antibiotics. The unadjusted risk ratio for sulfonamide antibiotic, rather than cephalosporin after penicillin allergic-like events was 7.2 (confidence interval 3.8-13.5). Results: Of 420 patients allergic to penicillins, 95 patients (22.62) showed specific-cephalosporin IgE positive, 73 patients (17.38) showed IgEs positive to both penicillins and cephalosporins. The absolute risk of anaphylaxis after a cephalosporin was less than 0.001%. The cross-reactivity and different molecules recognition by IgE were studied with a radioallergosorbent inhibition test. Among patients receiving a penicillin followed by a cephalosporin, the unadjusted risk ratio of an allergic-like event for those who had a prior event, compared with those who had no such prior event, narrowly defined, was 10.1 (confidence interval 7.4-13.8). Comparison was made with a population of patients receiving a prescription for a penicillin followed by a prescription for a sulfonamide antibiotic.Ī total of 3,375,162 patients received a penicillin 506,679 (15%) received a subsequent cephalosporin. Allergic events were defined by 2 sets of codes: 1 more restrictive, 1 more inclusive. However, penicillin allergy may not preclude the use of piperacillin-tazobactam, as the benzyl functionality of penicillin G, to which the reaction likely occurred, is structurally very different from the R 1 groups of cefepime or. We selected all patients receiving a prescription for penicillin followed by a prescription for a cephalosporin and identified allergic-like events within 30 days after each prescription. Many clinicians, wary of cross-reactivity, will even avoid the cephalosporin class and prescribe a carbapenem. We conducted a retrospective cohort study using the United Kingdom General Practice Research Database. We sought to determine the risk of an allergic reaction to a cephalosporin exposure in those with prior penicillin reactions.
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