Clinical history as a predictor of penicillin skin test outcome

Division of Allergy and Clinical Immunology, Department of Medicine, McMaster University, Ontario, Canada.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology (Impact Factor: 2.6). 09/2006; 97(2):169-74. DOI: 10.1016/S1081-1206(10)60008-7
Source: PubMed


Up to 10% of the population reports an "allergy" to penicillin, whereas approximately 1.1% has positive penicillin skin test results. Where penicillin skin tests are unavailable, some have advocated using history to decide whether to use a penicillin-related antibiotic.
To determine if clinical history predicts penicillin skin test results.
Retrospective medical record review of 94 consecutive patients who had previously taken penicillin referred for penicillin allergy. Case histories were taken, penicillin skin tests performed, and an oral challenge recommended if skin test results were negative.
Of 91 cases studied, the average patient age was 27 years (range, 6 months to 82 years; 36% female). Fifty-two (57%) experienced hives as their main adverse reaction. Sixteen (18%) had at least 1 positive test result. Of this group, 9 had hives as their main symptom, whereas 1 had respiratory problems and 1 had angioedema. Most patients with positive skin test results had experienced their reaction at least 3 years ago. Regression analysis showed that age, sex, and clinical history, including type of reaction, time of reaction after penicillin ingestion, or time since the last reaction, were not associated with skin test positivity. Seventy-two (96%) of the 75 patients who had negative skin test results underwent oral challenge. Seventy had negative challenge results. The negative predictive value of a negative penicillin skin test result was 97%.
Clinical history was not predictive of subsequent penicillin skin test results.

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    • "Furthermore, we have demonstrated that using only a history of minor acute Type 1 mediated symptoms may not be adequate to diagnose antibiotic allergy. In penicillin testing, the history has been found to be poorly predictive of subsequent skin test results [3,6-8]. Symptoms such as urticaria may be triggered by other causes such as the underlying infection itself [9]. "
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    ABSTRACT: Background Diagnostic testing to antibiotics other than to penicillin has not been widely available, making the diagnosis of antibiotic allergy difficult and often erroneous. There is often reluctance in performing challenges to antibiotics when standardized testing is lacking. However, while the immunogenic determinants are not known for most antibiotics, a skin reaction at a non-irritating concentration (NIC) may mean that antibodies to the native form are present in the circulation. While the NIC’s for many non penicillin antibiotics have been determined in adults, the use of these concentrations for skin testing pediatric subjects prior to provocative challenge has not been done. Our objective was to determine if we could successfully uncover the true nature of antibiotic allergy in children using these concentrations for testing. Methods Children were included between 2003–2009 upon being referred to the Drug and Adverse Reaction/Toxicology (DART) clinic of the Hospital for Sick Children in Toronto, Ontario Canada. The referral needed to demonstrate that clinical care was being compromised by the limitation in antibiotic options or there was a significant medical condition for which the label of antibiotic allergy may prove detrimental. Patients were not seen if there was a suggestion of serum like sickness, Stevens Johnson Syndrome or Toxic Epidermal Necrolysis. Patients were excluded from testing if there was objective evidence of anaphylaxis. All other patients were consented to receive testing and/or challenges. A retrospective chart review was then performed of the results. Results We were able to exclude an antibiotic allergy in the majority of our patients who had a negative intradermal test result and were then challenged (>90%). Only one patient was challenged with a positive intradermal test to Cotrimoxazole because of a questionable history and this patient failed the provocative challenge. While we did not challenge more patients with positive testing, we did note that 10/11 (91%) patients with positive intradermal testing had some aspect of a Type 1 reaction in their history. Conclusions Through testing with NIC’s of various antibiotics in children and providing provocative challenges based on negative skin testing results, we were able to advance the medical care of the majority of our patients by increasing their antibiotic options in order to successfully treat future infections. While challenging patients with positive testing was not deemed ethically appropriate at this stage of our study, it would be a useful future step to reaching statistical validity of testing to these antibiotics.
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    ABSTRACT: Individual approaches to the diagnosis and management of penicillin allergy are practiced by clinicians. This cross-sectional survey of physicians was aimed at exploring their ways of dealing with diagnosis and management of penicillin G allergy. Of the 235 respondents, 63% believed patients' self-reported history of penicillin allergy and avoided using penicillin G; 97% do so for patients whose allergic status was confirmed with positive skin test results. Researchers insist on skin testing for patients claiming penicillin allergy and for those whose allergic status was confirmed with positive skin test results, before considering antibiotic substitution, in an attempt to minimize the development of multi drug resistant pathogens. Undue concern about penicillin allergy may negatively influence the therapeutic outcome of rheumatic fever and syphilis. Repeated skin testing is recommended before each subsequent course of penicillin G, even in patients who have tolerated it before which was practiced by an appreciable number (89%) of our respondents. Epi cutaneous followed by intra dermal routes with major and minor determinants have been recommended for penicillin G skin testing. 100% of our respondents skin tested by intra dermal route alone, using penicillin G and its repository preparations before injecting the respective full dose preparations. Legal problems arising from serious clinical outcomes of penicillin allergy may pose a threat to the physician of losing self esteem in the society forcing him to be overcautious with its use. Educating both the public and health care providers is necessary in this regard.
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