Outcome of drug provocation testing in children with suspected beta-lactam hypersensitivity

Si Hui Goh; Kok Wee Chong; Wen Chin Chiang; Anne Goh; Wenyin Loh

doi:10.5415/apallergy.2021.11.e3

Outcome of drug provocation testing in children with suspected beta-lactam hypersensitivity

Asia Pac Allergy. 2021 Jan 14;11(1):e3. doi: 10.5415/apallergy.2021.11.e3. eCollection 2021 Jan.

Authors

Si Hui Goh¹, Kok Wee Chong¹, Wen Chin Chiang¹, Anne Goh¹, Wenyin Loh¹

Affiliation

¹ Allergy Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore.

Abstract

Background: Suspicion of beta-lactam (BL) hypersensitivity is often based on parental report. Evaluation is important as incorrect labelling has clinical consequence.

Objective: To describe the outcomes of drug provocation test (DPT) in children with suspected hypersensitivity.

Methods: A retrospective study of patients who completed BL DPT from 1 August 2016 to 31 December 2017 at a paediatric allergy centre in Singapore. Suspected hypersensitivity reactions were classified as immediate (onset ≤1 hour) or delayed (onset > 1 hour). Patients with immediate reactions underwent skin prick test (SPT) followed by DPT if SPT was negative. Patients with delayed reactions underwent DPT directly.

Results: We identified 120 children who reported 121 suspected hypersensitivity reactions. The median age at reaction was 2.0 years (interquartile range [IQR], 1.0-5.0 years) and the median age at DPT was 7.4 years (IQR, 4.2-11.1 years). The timing of suspected hypersensitivity reaction was immediate in 21% (25 of 121), delayed in 66% (80 of 121), and uncertain in 13% (16 of 121). Commonly implicated drugs were amoxicillin in 45% (54 of 121), amoxicillin-clavulanate in 37% (45 of 121), and cephalexin in 8% (10 of 121). Commonly reported symptoms were maculopapular rash 44% (53 of 121), urticaria 34% (41 of 121), and angioedema 22% (27 of 121). All SPTs (n = 26) were negative. There were 118 diagnostic DPTs to index drug and 3 DPTs to alternative drug. A negative challenge result was obtained in 93% (110 of 118) of diagnostic DPTs: 92% (96 of 104) and 100% (14 of 14) of DPTs to penicillin group and cephalosporins respectively. All challenge reactions were mild.

Conclusion: Our study supports the opinion that prior skin tests may not be necessary for children who report nonsevere reactions and directly performing diagnostic DPT is a safe approach in the evaluation of suspected childhood BL hypersensitivity.

Keywords: Antibiotic allergy; Child; Drug allergy; Drug hypersensitivity; Oral provocation test.