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Penicillin allergy – recommendations for diagnostic work up and patient management

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Abstract

Background

Allergy to penicillins or cephalosporins manifests either within a few minutes after intake or infusion in the form of acute anaphylaxis symptoms, or several hours to days later as exanthematous skin reactions. Exanthematous skin eruptions caused by amoxicillin or ampicillin are currently the most frequently diagnosed clinical reaction pattern within the spectrum of penicillin allergy. Certain single cephalosporins such as cefazolin, ceftriaxone, and cefuroxime are gaining in relevance as triggers of β‑lactam antibiotic-induced IgE(Immunglobulin E)-mediated anaphylaxis reactions.

Methods

This article provides an overview of selected scientific articles and is based on research in PubMed, studies, and specialist databases.

Results

Penicillin allergy work-up is based on patient history and documented medical findings; serological IgE determinations, as well as skin and provocation testing, are routinely performed. While the determination of IgE directed to certain penicillin determinants is one of the few reliable laboratory tests for the diagnosis of drug hypersensitivity, the basophil activation test or the lymphocyte transformation test are reserved for experienced laboratories which are able to critically evaluate their test results. Wheal-and-flare reactions in skin prick and intradermal testing suggest IgE-mediated allergy, while infiltrated erythematous or exanthematous plaques in patch or intradermal testing point to delayed-type hypersensitivity.

Conclusion

The overall predictive value of combined in vitro and in vivo allergy testing with β‑lactam antibiotics is approximately 90%. However, subsequent controlled provocation testing is recommended in order to reliably exclude allergic hypersensitivity.

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Abbreviations

AGEP:

Acute generalized exanthematous pustulosis

BAT:

Basophil activation test

BP-OL:

Benzylpenicilloyl octa-L-lysine

DRESS:

Drug rash with eosinophilia and systemic symptoms

GPT:

Glutamic pyruvic transaminase

IgE:

Immunglobulin E

i. v.:

Intravenous

LTT:

Lymphocyte transformation test

MD:

Minor determinant

SDRIFE:

Symmetrical drug-related intertriginous and flexural exanthema

SJS:

Stevens–Johnson syndrome

TEN:

Toxic epidermal necrolysis

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Authors and Affiliations

  1. Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, Josef-Schneider-Straße 2, 97080, Würzburg, Germany

    Axel Trautmann MD

  2. Department of Dermatology and Allergy, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany

    Gerda Wurpts

Authors
  1. Axel Trautmann MD
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Correspondence to Axel Trautmann MD.

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A. Trautmann and G. Wurpts declare that they have no competing interests.

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Trautmann, A., Wurpts, G. Penicillin allergy – recommendations for diagnostic work up and patient management. Allergo J Int 27, 107–113 (2018). https://doi.org/10.1007/s40629-018-0068-9

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