Is Safe to Use Cephalosporin in a Patient with Penicillin Allergy

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Slide 1 :

Is It Safe to Use Cephalosporin in a Patient with Penicillin Allergy?? Joe Lex, MD, FAAEM Temple University School of Medicine Philadelphia, PA

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Disclosure Nothing to declare

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Common Wisdom “About 10% of patients who are allergic to penicillin will have a cross-reactivity to cephalosporin.” Physician’s Desk Reference, 57th ed. 2003 Allergy

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Penicillin Allergy – Kids? 298 children with “history of adverse reaction to oral penicillin” Given oral challenge with penicillin No severe reactions 30 (10%) had slight to moderate skin rash on 7th to 10th day of treatment Graff-Lonnevig V, et al. Arch Dis Child. 1988 Nov;63(11):1342-6. Allergy

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Penicillin Allergy – Kids? One to four years after oral challenge, 222 children reinvestigated by interview 103 / 110 (94%) tolerated penicillin treatment without adverse reactions Conclusion: the term “penicillin allergy” is often misused Graff-Lonnevig V, et al. Arch Dis Child. 1988 Nov;63(11):1342-6. Allergy

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Penicillin Allergy – Adults? 132 patients who gave history of immediate reaction to penicillin Four patients confirmed to have penicillin allergy by the radio-allergosorbent test Other 128 had oral penicillin challenge without ill effect Surtees SJ, et al. BMJ. 1991 May 4;302(6784):1051-2. Allergy

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Meta-Analysis History of penicillin allergy: +LR = 1.9 (95% CI, 1.5-2.5) No history of penicillin allergy: -LR = 0.5 (95% CI, 0.4-0.6) ~ 10% - 20% of patients reporting history of allergy are truly allergic Salkind AR, et al. JAMA. 2001 May 16;285(19):2498-505. Allergy

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First Conclusion: Maybe 10% of patients who say, “I’m allergic to penicillin” are really allergic to penicillin Allergy

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Is It Important?? 101 inpatients who claimed penicillin allergy had skin testing 92 negative, 5 positive, 4 unsure 49% with negative results given penicillin-based drug 48% with negative results given cephalosporin Nadarajah K, et al. Ann Allergy Asthma Immunol. 2005 Dec;95(6):541-5. Allergy

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Is It Important?? Reduced use of vancomycin by 95% (67/70) Reduced use of fluoroquinolones by 96% (23/24) No serious reactions to skin test No reaction to penicillin or cephalosporin if skin test negative Nadarajah K, et al. Ann Allergy Asthma Immunol. 2005 Dec;95(6):541-5. Allergy

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Is It Safe??

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We Don’t Do Skin Testing You have GOT to be joking Allergy

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But That’s Okay Because… Incidence of adverse reactions from cephalosporins: also 1% to 10% Anaphylaxis: fewer than 2 in 10,000 Post-marketing studies of 2nd and 3rd generation cephalosporins: no increase allergic reactions in patients with penicillin allergy Anne S, et al. Ann Allergy Asthma Immunol. 1995 Feb;74(2):167-70. Allergy

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But That’s Okay Because… Penicillin skin tests do not predict allergy to cephalosporin in patients with histories of penicillin allergy One reaction occurred in 98 patients (1%) with positive skin test Six reactions occurred in 310 patients (2%) with negative skin test Anne S, et al. Ann Allergy Asthma Immunol. 1995 Feb;74(2):167-70. Allergy

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Second Conclusion: Severe reaction to cephalosporins are even less common than penicillin allergies Allergy

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The BIG Study Retrospective cohort study of huge database United Kingdom General Practice Research Database 3,375,162 patients got penicillin 534,810 patients also got cephalosporin within 60 days Apter AJ, et al. Am J Med. 2006 Apr;119(4):354.e11. Allergy

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3,375,162 got penicillin 534,810 also got cephalosporin within 60 days ALE within 30 days of penicillin: 3920 (0.001%) No ALE within 30 days of penicillin: 530,890 Given Cephalosporin ALE within 30 days: 43 (1.1%) ALE within 30 days: 581 (0.1%) ALE = Allergic-like event

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The BIG Study Anaphylaxis after penicillin: 25 Anaphylaxis after cephalosporin: 13 Anaphylaxis to penicillin followed by anaphylaxis to cephalosporin: 1 ALE to penicillin followed by ALE to cephalosporin: 43 Number that were urticaria: 30 Apter AJ, et al. Am J Med. 2006 Apr;119(4):354.e11. Allergy

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The BIG Study 1.1% of the patients who had an event after penicillin also had an event after the cephalosporin BUT… 1.6% of the patients who had an event after penicillin also had an event after a sulfonamide Apter AJ, et al. Am J Med. 2006 Apr;119(4):354.e11. Allergy

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Final Conclusion: Any cephalosporin can safely be given to a penicillin-allergic patient who did not have anaphylaxis Allergy

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Penicillin skin tests do not predict allergy to cephalosporin in patients with histories of penicil more Penicillin skin tests do not predict allergy to cephalosporin in patients with histories of penicillin allergy; One reaction occurred in 98 patients (1%) ... less
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