AAAAI Position Statement

Penicillin Allergy Testing Should Be Performed

AAAAI Position Statements, Work Group Reports, and Systematic Reviews are not to be considered to reflect current AAAAI
standards or policy after five years from the date of publication. The statement below is not to be construed as dictating an exclusive
course of action nor is it intended to replace the medical judgment of healthcare professionals. The unique circumstances of individual
patients and environments are to be taken into account in any diagnosis and treatment plan. The statement reflects clinical and
scientific advances as of the date of publication and is subject to change.

For reference only.

Adverse reactions to medications are frequently observed. Systemic reactions have been reported, although rarely; for
Among the drugs associated with IgE-mediated allergic reactions, this reason, penicillin allergy testing should be performed in a
penicillins are most commonly implicated.1 Penicillin allergy is health care setting only by clinicians with the knowledge,
estimated to affect 7% to 10% of community populations and training, and experience to select appropriate patients for this
up to 20% of hospitalized patients.1,2 However, when penicillin procedure, interpret test results, and manage a systemic allergic
allergy testing is performed in individuals who report a history of reaction should it occur.1,2 Patients with negative skin testing to
penicillin allergy, the overwhelming majority do not exhibit penicillin reagents, followed by an oral challenge that is well
positive reactions. The rate of positive skin test results to peni- tolerated, are able to receive penicillins without increased risk of
cillin in recent studies is only 1% to 8%.3-5 The reasons for the IgE-mediated allergic reaction. The negative predictive value of
low rate of confirmed penicillin allergy include mislabeling of a penicillin allergy testing exceeds 99%.9
side effect (eg, gastrointestinal upset) or a coincidental event (eg, Reporting a history of penicillin allergy is associated with a
headache or cutaneous eruption due to underlying infection) as morbidity that has not been widely appreciated until recently.
an allergic reaction, reduced rates of exposure to parenteral Unverified penicillin allergy in hospitalized patients is associated
penicillins, and loss of IgE-mediated allergy with avoidance of with longer hospital stays and increased rates of serious drug-
penicillins over time.2 resistant infections.10 For this reason, the Choosing Wisely
Skin testing was introduced as a diagnostic intervention for program of the American Board of Internal Medicine Founda-
the evaluation and management of patients with a history of tion recommended in 2014 that clinicians not overuse none
penicillin allergy in the late 1950s and early 1960s, indepen- beta-lactam antibiotics in patients with a history of penicillin
dently by Charles Parker and Bernard Levine.6 This procedure is allergy, without an appropriate evaluation.11 The National
commonly performed, and with minimal risk. Penicillin skin Quality Partners’ Antibiotic Stewardship Action Team recom-
testing can be done safely in properly selected patients with mends penicillin allergy skin testing as a component of a
suspected penicillin allergy, even in pregnant women with group comprehensive antibiotic stewardship program.12
B Streptococcal infections7 and in patients who require organ In the absence of appropriate evaluation for penicillin allergy,
transplantation.8 patients providing a history of penicillin allergy must continue to
avoid penicillins. For example, when such patients undergo a
surgical procedure, preoperative antibiotics are commonly
administered prophylactically to safeguard against postoperative
Approved by the AAAAI Board of Directors, July 2016.
infection. Hospitalized patients frequently report allergy to
Conflicts of interest: The authors declare that they have no relevant conflicts of penicillin. Providing this history leads to receiving an alternative
interest. antibiotic (eg, vancomycin, a quinolone, or a carbapenem).
For more information, contact the AAAAI at [email protected]. These alternative therapies can be associated with higher cost
2213-2198
and/or greater risk for untoward effects. More frequent use of
Ó 2016 American Academy of Allergy, Asthma & Immunology
http://dx.doi.org/10.1016/j.jaip.2016.12.010 alternative nonebeta-lactam antibiotics also may lead to greater

333

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334 J ALLERGY CLIN IMMUNOL PRACT
MARCH/APRIL 2017

nosocomial rates of resistant gram-positive (eg, enterococci and David A. Khan, MD, FAAAAI (University of Texas South-
staphylococcus) and gram-negative (eg, klebsiella) strains, which western Medical Center); Eric M. Macy, MD, FAAAAI
are associated with increased costs, poorer patient outcomes, and (SCPMG-Kaiser Permanente San Diego); and Andrew W.
other burdens. Murphy, MD, FAAAAI (Asthma, Allergy and Sinus Center).
In 2015, President Obama released an Executive Order for a
National Action Plan for combating antibiotic-resistant bacte- REFERENCES
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The American Academy of Allergy, Asthma & Immunology Stewardship_in_Acute_Care.aspx?utm_source¼internal&utm_medium¼
Board of Directors acknowledges the contributions of David M. link&utm_term¼ABX&utm_content¼Playbook&utm_campaign¼ABX.
Accessed February 1, 2017.
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on August 23, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.