Allergologia et Immunopathologia

Allergologia et Immunopathologia

Volume 39, Issue 6, November–December 2011, Pages 337-341
Allergologia et Immunopathologia

Original Article
Short protocol for the study of paediatric patients with suspected betalactam antibiotic hypersensitivity and low risk criteria

https://doi.org/10.1016/j.aller.2010.10.002Get rights and content

Abstract

Background

Suspected hypersensitivity to betalactam antibiotics in children is a frequent cause of consultation that proves costly in terms of resource utilization – particularly time. Such hypersensitivity is, however, rarely confirmed.

Methods

A short protocol was introduced in which patients at low risk (single episode with mild, non-immediate skin symptoms after the administration of a betalactam antibiotic via the oral route) were subjected to oral provocation (following the obtaining of informed consent) without any other prior evaluations. Patients failing to meet these requirements were studied according to the protocol of the EAACI (specific IgE and skin testing prior to oral provocation).

Results

A total of 78 patients (56 at low risk) were studied. Five patients had tolerated the medication after the episode, while another six patients failed to complete the study. The study with oral provocation was completed in the remaining 67 patients: according to the protocol of the EAACI in 17 patients, and using the short protocol in 50 patients. Only one patient showed a positive provocation test, of a delayed and mild nature.

Conclusions

Direct oral provocation in low risk patients has been shown to be effective and safe in discarding hypersensitivity to betalactam antibiotics in the majority of the patients studied.

Introduction

The suspicion of hypersensitivity (HS) to drugs is a very frequent cause of medical consultation. In Spain, such situations account for about 7.5% of all patients seen in paediatric allergology clinics.1 Betalactam antibiotics (BLAs) are the drugs most often implicated in cases of suspected HS, due to their widespread use in the empirical treatment of infections in childhood. However, evaluation of these patients rarely confirms such suspicion.2, 3, 4 In our prior series of 503 children under 15 years of age seen for suspected HS to BLAs over a period of seven years, tolerance was confirmed in 68% of the cases, while 25% failed to complete the study (generally due to lack of consent or dropout), and only 6% (32) were diagnosed with allergy to BLA.5 This diagnosis proved significantly more probable in patients with a history of repeated or serious reactions, and in those administered BLAs via the parenteral route.

Based only on the clinical history, it is often difficult to establish whether the suspect reaction was of an immediate type or not. Although skin and laboratory tests are of little help in studying non-immediate reactions6 – which seem to be the reactions most commonly seen in children – they are often performed in order to add supposed safety and reliability to the study of the patients. The study protocols developed by different scientific societies require several patient visits and are targeted at adults.7 Only oral provocation allows the establishment of a definitive diagnosis.8

Based on these considerations, our group developed a protocol for the clinical study of children referred to our clinics with suspected HS to BLAs. The main characteristic of the protocol is its simplicity, justified by the very low frequency of HS to BLAs in childhood, and the mild nature of the symptoms involved. The present study describes the results obtained in the first year of application of the protocol, with a view to establishing its clinical applicability, and proposes a study algorithm inspired by the experience gained.

Section snippets

Material and methods

After evaluating our own experience and reviewing the recent literature, a protocol was developed for the study of paediatric patients (under 15 years of age) referred for the evaluation of suspected HS to some BLA. The data compiled on the first visit allowed us to evaluate the plausibility of the suspicion and assign the patients to one of the following two groups:

  • Group A, corresponding to risk subjects, defined by the presence of at least one of the following circumstances:

    • *

      Typical urticaria

Results

In the first year of application of the described protocol, we attended 78 children referred due to suspected HS to BLA. There were 37 males and 41 females, with a mean age of 3.4 years at the time of the suspect episode and of 6.7 years at the time of consultation. The implicated drugs are reported in Figure 1. Twenty-two patients were assigned to group A (Table 1) and 56 (72%) to group B. Compilation of the case history in turn showed that five patients had tolerated the suspect BLA at some

Discussion

As in many other aspects of medical and allergological practice, children are not small adults. The study protocols proposed by the main expert groups and warranted by the scientific societies are based on experiences and studies from adult populations.11 Studies in children are fewer, and have not allowed the development of specific protocols for securing a correct diagnosis.

However, paediatric allergology clinics receive an important number of patients requiring evaluation for suspected

Financial support

This study has received no external funding, but has been awarded the second prize for the best oral communication at the XXXIV Congress of the Spanish Society of Pediatric Allergy and Clinical Immunology.

Conflicts of interest

No specific conflict of interest can be detected.

References (16)

  • A. Goldberg et al.

    Skin testing and oral penicillin challenge in patients with a history of remote penicillin allergy

    Ann Allergy Asthma Immunol

    (2008)
  • M.D. Ibáñez et al.

    Allergy in patients under fourteen years of age in Alergológica 2005

    J Investig Allergol Clin Immunol

    (2009)
  • F. Martin-Muñoz et al.

    Evaluation of drug-related hypersensitivity reactions in children

    J Investig Allergol Clin Immunol

    (1999)
  • J. Hershkovich et al.

    Betalactam allergy and resensitization in children with suspected betalactam allergy

    Clin Exp Allergy

    (2009)
  • E. Rebelo Gomes et al.

    Drug allergy claims in children: from self-reporting to confirmed diagnosis

    Clin Exp Allergy

    (2008)
  • L. Moral et al.

    Alergia a antibióticos betalactámicos en una población pediátrica: descripción de una serie amplia

    Allergol Immunopathol

    (2008)
  • A. Padial et al.

    Non-immediate reactions to beta-lactams: diagnostic value of skin testing and drug provocation test

    Clin Exp Allergy

    (2008)
  • A. Romano et al.

    Diagnosis of non-immediate reactions to betalactams antibiotics

    Allergy

    (2004)
There are more references available in the full text version of this article.

Cited by (38)

  • Direct Challenges for the Evaluation of Beta-Lactam Allergy: Evidence and Conditions for Not Performing Skin Testing

    2021, Journal of Allergy and Clinical Immunology: In Practice
    Citation Excerpt :

    However, given that DPTs are more frequently positive for children reporting immediate than nonimmediate index reactions, strict hospital monitoring may be justified for benign immediate reactions.41,42,56 DPTs are generally started at low doses of the culprit BL followed by a gradual increase.29,31,33,41-47,49,51,57 However, only a minority of reactions occur immediately after the administration of the first dose.

  • Children with reported penicillin allergy: Public health impact and safety of delabeling

    2020, Annals of Allergy, Asthma and Immunology
    Citation Excerpt :

    The study concluded that graded challenges may be the optimal way to test for penicillin allergy in children because skin tests often have a high false-negative or false-positive result. Moral et al26 also evaluated the safety of direct oral provocation testing in low-risk patients via a short clinic-based protocol. They found that in 67 patients who underwent challenge, only 1 patient had a reaction, and it was delayed and mild in nature.

  • Economic Impact of Drug Allergy

    2018, Drug Allergy Testing
View all citing articles on Scopus
View full text