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Direct challenges to penicillin-based antibiotics in low risk inpatients

Published online: March 7, 2020

Penicillin allergy is the most commonly reported drug allergy and has been linked to poorer outcomes. There are many studies regarding de-labeling of penicillin allergy through penicillin skin testing, with more recent studies examining direct challenges (without preceding penicillin skin testing) in low risk patients. Many of the direct challenge studies have been in the outpatient setting, with less data in the inpatient population.

In a recent issue of The Journal of Allergy and Clinical Immunology: In Practice, Ramsey et al. report their experience with 3-step direct challenges to penicillin-based antibiotics in adult inpatients with cutaneous-only historical reactions occurring >20 years. Patients with higher risk reactions underwent routine penicillin skin testing. The authors collected safety, cost, and antibiotic use data.

A total of 372 inpatients were screened during a 15-month period. Of these, 52 patients underwent penicillin skin testing, and 48 underwent a direct oral challenge to a penicillin-based antibiotic without preceding penicillin skin testing. A total of 56 patients were transitioned to a beta-lactam antibiotic after testing. Direct challenge was less costly than penicillin skin testing ($206.18 per patient versus $419.63 per patient, respectively). The analysis demonstrated direct challenges to have a favorable safety profile, with 1 patient experiencing a mild immediate reaction and 2 patients experiencing a mild delayed reaction to a penicillin-based antibiotic. The authors concluded that direct oral challenge is feasible, less costly, and safe in low risk inpatients with self-reported penicillin allergy.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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