Managing Persons Who Have a History of Penicillin Allergy
Penicillin and other ß-lactam antibiotics have a crucial role in treating STIs. Penicillin is recommended for all clinical stages of syphilis, and no proven alternatives exist for treating neurosyphilis, congenital syphilis, or syphilis during pregnancy. Ceftriaxone, a third-generation cephalosporin, is recommended for gonorrhea treatment. For extragenital site infections, especially pharyngeal, failure rates of nonceftriaxone regimens can be substantial. However, because of T. pallidum chromosomal mutations associated with azithromycin and other macrolide resistance and documented treatment failures in multiple geographic areas, azithromycin should not be used as treatment for syphilis (23,606–608). For patients with a diagnosis of gonorrhea and a concomitant reported allergy to penicillin, ceftriaxone is often avoided, even though the cross-reactivity between penicillin allergy and third-generation cephalosporins is low (652–654).
Prevalence of reported allergy to penicillin is approximately 10% among the U.S. population and higher among hospital inpatients and residents in health care–related facilities (655–658). One large study in an STI clinic revealed that 8.3% of patients reported penicillin or another ß-lactam antibiotic allergy (659). Penicillin allergy is often overreported, with the majority of patients who report penicillin allergy able to tolerate the medication (660). The prevalence of reported penicillin allergy in low-income countries is unknown; however, limited data indicate that penicillin is one of the most frequently reported antibiotic allergies (661).
Patients often are incorrectly labeled as allergic to penicillin and are therefore denied the benefit of a ß-lactam therapy. The presence of a penicillin allergy label considerably reduces prescribing options for affected patients. Moreover, penicillin allergy labels lead to the use of more expensive and less effective drugs and can result in adverse consequences, including longer length of hospital stay and increased risk for infection. Multiple studies have described that persons with reported penicillin or another ß-lactam antibiotic allergy have higher rates of surgical-site infections, methicillin-resistant Staphylococcus aureus infections, and higher medical care usage (653,662–664).
The overreported prevalence of penicillin allergy is secondary to imprecise use of the term “allergy” by families and clinicians and lack of clarity to differentiate between immunoglobulin E (IgE)-mediated hypersensitivity reactions, drug intolerances, and other idiosyncratic reactions that can occur days after exposure. Approximately 80% of patients with a true IgE-mediated allergic reaction to penicillin have lost the sensitivity after 10 years (658). Thus, patients with recent reactions are more likely to be allergic than patients with remote reactions, and patients who had allergic reactions in the distant past might no longer be reactive.
In a Baltimore, Maryland, STI clinic study, only 7.1% of the patients who reported allergy to penicillin or to another ß-lactam antibiotic had an objective positive test for penicillin allergy (659). Moreover, in studies that have incorporated penicillin skin testing and graded oral challenge among persons with reported penicillin allergy, the true rates of allergy are low, ranging from 1.5% to 6.1% (665–667). Studies in preoperative surgical patients with reported penicillin allergy, evaluated for cardiovascular surgery (668) or orthopedics (669), have rates of skin test positivity <8.5%. However, when patients with high-risk penicillin allergy histories are excluded, 99% of patients could receive ß-lactams. In hospitalized patients and other populations with comorbidities, the typical rates of validated penicillin allergy among patients who report a history of penicillin allergy are 2.5%–9.0% (670–673).
Cross-Reactivity with Cephalosporins
Penicillin and cephalosporins both contain a ß-lactam ring. This structural similarity has led to considerable confusion regarding cross-reactivity of these drugs and the risks for allergic reactions from cephalosporins among penicillin-allergic patients. In most clinical settings, patients with reported penicillin allergy are precluded from treatment with such cephalosporin antibiotics as ceftriaxone. Third-generation cephalosporins (e.g., ceftriaxone and cefixime) have lower cross-reactivity with IgE-mediated penicillin-allergic patients (<1%) compared with first- and second-generation cephalosporins (range: 1%–8%). Moreover, anaphylaxis secondary to cephalosporins is extremely rare among persons who report a penicillin allergy and is estimated to occur at a rate of one per 52,000 persons (652). Data from the Kaiser health care system reported that among 3,313 patients with self-reported cephalosporin allergy who received a cephalosporin (mostly first generation), no cases of anaphylaxis were reported (652). Use of third- and fourth-generation cephalosporins and carbapenems is safe for patients without a history of any IgE-mediated symptoms (e.g., anaphylaxis or urticaria) from penicillin during the preceding 10 years.
Validating Penicillin or Another ß-Lactam Antibiotic Allergy
Evaluating a patient who reports a penicillin or another ß-lactam antibiotic allergy involves three steps: 1) obtaining a thorough medical history, including previous exposures to penicillin or other ß-lactam antibiotics (658); 2) performing a skin test evaluation by using the penicillin major and minor determinants; and 3) among those who have a negative penicillin skin test, performing an observed oral challenge with 250 mg amoxicillin before proceeding directly to treatment with the indicated ß-lactam therapy (667,675).
For persons who have a positive skin test reactive to penicillin (either to the major or minor determinants), treatment with a ß-lactam antibiotic is not usually advised, and other effective antimicrobials should be used (656,658). For persons among whom the only therapy option is a penicillin antibiotic (e.g., a patient with neurosyphilis or a pregnant woman with syphilis) and among whom a penicillin skin test is positive, induction of penicillin tolerance (also referred to as desensitization) is required (675). Desensitization protocols to penicillin should be performed by allergists, and they require a monitored inpatient environment.
Penicillin Skin Testing
Penicillin skin testing with a major determinant analog (penicilloyl-polylysine) and minor determinants (benzylpenicilloate, benzylpenilloate, or benzylpenicillin isomers of penicillin) are used for skin test evaluation for IgE-dependent penicillin allergy and can reliably identify persons at high risk for IgE-mediated reactions to penicillin (658,660,676). Until recently, penicillin skin testing in the United States only included the major determinant benzyl penicillin poly-L-lysine (Pre-Pen) in addition to penicillin G. This test identifies approximately 90%–99% of the IgE-mediated penicillin-allergic patients. Because the remaining 1%–10% of penicillin-allergic patients who are not captured by this penicillin skin test are due to minor determinants IgE antibodies, the standard practice is to follow skin testing with an observed oral challenge of amoxicillin 250 mg with 1 hour of observation. If the skin test and oral challenge are both negative, the risk for IgE-mediated anaphylaxis approaches zero and is equivalent to that of a person who has never reported an allergy to penicillin.
A revised version of the penicillin skin test kit, which includes the major determinant reagent Pre-Pen, minor determinants, and amoxicillin, is being evaluated by FDA. This penicillin skin test kit has been evaluated among 455 patients (677) with previous allergy history and has a negative predictive value of 98%. If approved, this kit might eliminate the need for oral challenge.
Penicillin skin testing has become a clinically significant element in antibiotic stewardship programs, and the procedure has been increasingly used by hospital-based pharmacists, hospitalists, and infectious disease physicians (670,672,673,678,679) as part of overall antibiotic stewardship interventions. When integrated into stewardship, the rates of ß-lactam antibiotic use increased substantially (670).
Persons with a history of severe adverse cutaneous reaction (e.g., Stevens-Johnson syndrome or toxic epidermal necrolysis) and other severe non-IgE-mediated reactions (e.g., interstitial nephritis, and hemolytic anemia) are not candidates for penicillin skin testing or challenge. Penicillin and any other ß-lactam antibiotics should be avoided indefinitely among these patients, and they should be referred to an allergy center for further evaluation. Similarly, patients who deny penicillin allergy, but who report previous IgE type reactions to cephalosporins, should be referred to an allergist for specific cephalosporin testing.
In a time of increasing antimicrobial resistance, following recommended use of antibiotic treatments is crucial. STI programs and clinicians should promote increased access to penicillin allergy testing. Allergy testing is being provided by clinicians in primary care and hospital settings. If appropriate, STI programs and ambulatory settings should consider developing expanded access to penicillin or ß-lactam allergy assessment.
Persons with high-risk symptom histories (e.g., anaphylaxis within the previous 10 years) should not be administered penicillin or a ß-lactam antibiotic in an ambulatory setting. Furthermore, these persons with high-risk symptoms should not receive penicillin skin testing or amoxicillin oral challenge in an ambulatory STI setting and should be referred to an allergist for further evaluation.
High-risk symptom histories include development of the following after penicillin or ß-lactam administration: anaphylaxis within 6 hours or severe adverse cutaneous reaction (e.g., eosinophilia and systemic symptoms, Stevens-Johnson syndrome, toxic epidermal necrolysis, or acute generalized exanthematous pustulosis), and other severe non-IgE-mediated reactions (e.g., kidney or hepatic injury, hemolytic anemia, or thrombocytopenia).
Direct Treatment Approach for Ceftriaxone
Among persons with confirmed IgE-mediated penicillin allergy, the level of cross-reactivity with third-generation cephalosporins is low (652,680,681). If a patient has a low-risk history for an IgE-mediated penicillin allergy, ambulatory settings often treat with third-generation cephalosporins without further testing. Low-risk history includes one nonspecific symptom (e.g., gastrointestinal intolerance, headache, fatigue, or nonurticarial rash) (Box 2). In addition, a family history of penicillin or ß-lactam allergy alone is not a contraindication for treatment with ß-lactam antibiotics. This practice is increasingly being used in ambulatory settings and for preoperative prophylaxis (658,663,680,682–684).
Patients at Low Risk for Oral Challenge
If the patient gives only a low-risk history of IgE-mediated penicillin allergy that includes symptoms such gastrointestinal intolerance, headache, fatigue, or nonspecific pruritus, or gives a family history only, an oral challenge can be administered to document the absence of allergy (Box 2). If the reaction occurred in the distant past (>10 years), the likelihood is reduced even further (653,658,663,682,683,685,686). The risk for severe amoxicillin-mediated anaphylaxis has decreased over time and is rare. In the United Kingdom during 1972–2007, one fatal case of amoxicillin-medicated anaphylaxis was reported (684).
Skin Testing for Penicillin Allergy
Skin testing for penicillin allergy should be performed if any indication exists that the symptoms were secondary to an IgE-mediated hypersensitivity. Testing is also indicated as a potential diagnostic procedure to definitively rule out penicillin allergy and document a negative allergy status in the medical record (i.e., delabeling). Because penicillin allergy testing does not test for multiple minor determinants, a person with a negative skin test should follow up with an oral challenge to confirm the negative status.
Persons with negative results of a penicillin skin test, followed by an amoxicillin oral challenge, can receive conventional penicillin therapy safely if needed. Persons with positive skin test results and for whom no other clinical options exist (e.g., neurosyphilis and syphilis in a pregnant woman) should be referred to an allergist and desensitized before initiating treatment.
Penicillin skin testing includes use of skin test reagents for identifying persons at risk for adverse reactions (Box 3), followed by initial pinprick screening with penicillin major determinants (Pre-Pen) and penicillin G, followed by intradermal testing if pinprick results are negative. Penicillin testing procedures are performed in accordance with the Pre-Pen test kit instructions (https://penallergytest.com/wp-content/uploads/PRE-PEN-Package-Insert.pdf). Saline negative controls and histamine positive controls are an integral part of the procedure. Penicillin skin testing should not be performed for patients who have taken antihistamines within the past 7 days.
Skin testing can be safely performed by trained nonallergists and has been implemented as an antimicrobial stewardship intervention by internal medicine physicians, pharmacists, hospitalists, and infectious disease physicians (670,673,678,679). Patients tested should also receive documentation of status, and the results should be entered in the medical record.
Penicillin skin testing during pregnancy is considered safe. For pregnant persons who report a penicillin or ß-lactam allergy, penicillin allergy is an important consideration in treating syphilis during pregnancy and the potential for group B streptococcal infection and preoperative prophylaxis if a cesarean delivery is required. However, oral challenges should not be performed unless in a setting where additional support services are available.
Managing Persons Being Tested
Patients who have a positive skin test should not receive ß-lactam drugs in the ambulatory setting and should be referred to an allergist or penicillin allergy expert for further evaluation. The allergy testing results should be documented in the medical record. Patients who test negative should be informed that their risk for anaphylaxis is extremely low and is equivalent to a person who does not report an allergy history. If treatment with penicillin or ceftriaxone is indicated, it can be administered safely. Documentation of testing results should be provided to the patient.
Desensitization is required for persons who have a documented penicillin allergy and for whom no therapeutic alternatives exist (e.g., syphilis during pregnancy and persons with neurosyphilis). Modified protocols might be considered on the basis of the clinical syndrome, drug of choice, and route of administration (687–690). Patients might require referral to a specialty center where desensitization can be performed.
Allergy Referral Resources
With increased access to skin testing kits and the need to better target therapy for gonorrhea and syphilis, programs should identify local allergy consultant resources.
Pruritis without rash
Delayed onset rash (>24 hours)
Family history of penicillin or other drug allergy
Patient denies allergy, but it is on the medical record
- Benzylpenicilloyl polylysine injection (Pre-Pen) (AllerQuest) (6 × 10-5M)
Minor determinant precursors
- Benzylpenicillin G (10-2M, 3.3 mg/mL, 10,000 units/mL)
- Benzylpenicilloate (10-2M, 3.3 mg/mL)
- Benzylpenicilloate (or penicilloyl propylamine) (10-2M, 3.3 mg/mL)
Aged penicillin is not an adequate source of minor determinants. Penicillin G should either be freshly prepared or come from a fresh-frozen source.
- Commercial histamine for scratch testing (1.0 mg/mL)
- Diluent (usually saline) or allergen diluent
Source: Adapted from Saxon A, Beall GN, Rohr AS, Adelman DC. Immediate hypersensitivity reactions to beta-lactam antibiotics. Ann Intern Med 1987;107:204−15.