Infectious Disease

Pediatric primary care clinic challenges amoxicillin allergy labels

February 08, 2023

3 min read

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The staff at a pediatric primary care clinic performed direct graded oral challenges for amoxicillin with indirect allergist guidance, according to a study published in Annals of Allergy, Asthma & Immunology.

This model could be used to increase access to penicillin allergy testing, Timothy G Chow, MD, assistant professor, division of allergy and immunology, department of pediatrics and internal medicine, University of Texas Southwestern Medical Center, and colleagues wrote.

Data were derived from Chow TG, et al. Ann Allergy Asthma Immunol. 2022;doi:10.1016/j.anai.2023.01.034.

“Penicillin allergy is the most common allergy listed in electronic medical records. However, it is a very poor predictor of whether a patient can actually safely take penicillin. Over 95% of patients with a penicillin allergy label can tolerate penicillins,” Chow told Healio.

Timothy G Chow

Patients who unnecessarily avoid penicillin can experience worse infection outcomes, such as increased lengths of stay for hospitalizations, increased readmission rates and increased risks for clostridium difficile infections, Chow said.

“It also has impacts on the public health system, contributing to antimicrobial resistance due to the use of broader spectrum alternative antibiotics and increased health care costs,” Chow said.

Previous studies have recommended evaluations of patients with penicillin allergy labels, Chow said. These evaluations traditionally have been performed in outpatient allergy offices, but many patients do not have access to these specialists, he continued.

“As such, we wanted to study performing these penicillin allergy evaluations through direct amoxicillin challenges without skin testing in the pediatric primary care setting as a novel strategy to decreasing access to these evaluations,” Chow said.

Study design, results

Twenty-three children aged 2 to 17 years (mean age, 9.3 years ± 0.8; 56% girls; 61% white) with a penicillin allergy label completed the graded oral challenge during their routine maintenance visit at a pediatric primary care clinic between December 2021 and October 2022.

A pediatric nurse trained in identifying and managing immediate reactions administered 50 mg of amoxicillin followed by a 200 mg dose 10 minutes later and a 60 minute observation period. The maintenance visit was conducted during the observation period.

Between seven and 10 days later, the researchers contacted families by phone to assess them for delayed reactions.

Within 5 minutes of the first dose, one patient developed an immediate erythematous macule to her ear that was treated with cetirizine and resolved within 30 minutes. About 4 hours after the challenge, another patient developed an isolated, mild maculopapular exanthem that resolved within 48 hours with oral antihistamines.

The researchers calculated an 8.6% reaction rate for amoxicillin among their cohort, which they called consistent with amoxicillin graded oral challenges performed in other settings.

All the caregivers said they were satisfied with the challenge and would recommend it to others if indicated. None of the caregivers said that they had any preference for completing testing at an allergy clinic or at their pediatrician’s office.

The study began with 86 subjects who were eligible, the researchers said, and about 40% were interested in proceeding with the challenge. The researchers said that this baseline acceptability was significant and could be improved with targeted education that addresses the concerns of caregivers.

The researchers also surveyed 21 of the caregivers who were not interested in the challenge and found:

  • 81% (n=17) were worried that a reaction would cause a worse allergy.
  • 43% (n = 9) were worried that the child would still be allergic regardless of testing.
  • 43% (n = 9) said they could avoid penicillin without any adverse health effects.
  • 38% (n = 8) said there was not enough time to schedule the test.
  • 33% (n = 7) said their child was afraid of having a reaction.
  • 10% (n = 2) said their child was too young.

These concerns represent opportunities to provide further educational interventions, the researchers said.

Conclusions, next steps

“This is the first reported experience that direct amoxicillin challenges can be performed in the pediatric primary care clinic here in the United States,” Chow said.

The rates of positive tests were consistent with other studies, and all reactions were mild and resolved with cetirizine, Chow continued.

“Many patients were interested in this testing, and all who completed the challenge with negative testing reported that they would use penicillin if prescribed by a physician in the future,” Chow said.

Chow also encouraged primary care doctors to refer patients with penicillin allergy to local allergists for evaluation.

Despite these findings, the researchers said that further studies into effectively and efficiently identifying patients with appropriate risk in the primary care setting as well as larger studies assessing the safety, acceptability and efficacy of these challenges in the pediatric primary care setting are warranted.

“The next step is to build off the success of this pilot study and study the safety and efficacy of this approach though larger implementation studies,” Chow said.

For more information:

Timothy G Chow, MD, can be reached at [email protected].

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