Self-reported beta-lactam intolerance: not a class effect, dangerous to patients, and rarely allergy

ABSTRACT

Introduction: About 8% of the United States population carries an unconfirmed penicillin ‘allergy’ in their medical record. Many physicians needlessly avoid other beta-lactam use in individuals with unconfirmed penicillin allergies. There is a significantly increased risk of developing serious antibiotic-resistant infections, and increased morbidity and mortality in those who report penicillin allergy.

Areas covered: Within this study, we reviewed the relevant literature on self-reported beta-lactam allergy. We discuss how the myth of serious allergy to penicillin developed and then discuss and in detail clinically significant immunologically mediated hypersensitivity reactions. Following this discussion, we delineate the risks of not using a beta-lactam when it is the drug of choice and then discuss the epidemiology of beta-lactam-associated anaphylaxis, serious cutaneous adverse reactions, and serious systemic immunologically mediated reactions. Following these topics, we further discuss the consensus current best practices to de-label patients with reported penicillin allergy.

Expert opinion: An unconfirmed allergy to penicillin offers considerable harm to patients. Many patients have low-risk allergy symptoms to penicillin who could likely tolerate the medication without having an allergic reaction. The current best practices to de-label reported penicillin allergy is the utilization of a single dose oral challenge, with 1 h of observation, in low-risk patients.

KEYWORDS:

• Adverse drug reaction
• cephalosporin
• drug allergy
• oral challenge
• penicillin

Article highlights

• About 8% of the United States population carries an unconfirmed penicillin ‘allergy’ in their medical record.

• Many physicians needlessly avoid other beta-lactam use in individuals with unconfirmed penicillin allergies.

• There is a significantly increased risk of developing serious antibiotic-resistant infections, along with an increase in morbidity and mortality in those who report penicillin allergy.

• Less than 5% of the individuals with an unconfirmed penicillin allergy will have clinically significant acute or delayed onset hypersensitivity confirmed after appropriate testing.

• Low-risk patients can safely undergo a direct oral amoxicillin challenge to confirm current tolerance.

• Higher-risk patients warrant Allergy or other specialist consultation able to perform penicillin skin testing prior to an oral amoxicillin challenge to confirm current tolerance.

Declaration of interest

E Macy is a partner in the Southern California Permanente Medical Group, is a member of the Ask An Expert Panel of the American Academy of Allergy, Asthma, and Immunology, has received research grants from ALK Abello, Inc. to study adverse drug reactions, and has served on clinical trial safety and monitoring committees for BioMarin, Ultragenyx, and Audentes. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.