Pediatric Allergies to Non-Beta-Lactam-Antibiotics Are Over-Reported

By Will Boggs MD

December 05, 2019

NEW YORK (Reuters Health) - Most children with reported hypersensitivity reactions to non-beta-lactam antibiotics (NBLAs) have negative allergy tests, researchers in Australia report.

"Our study has shown that all children who report hypersensitivity reactions to NBLAs should be referred for formal allergy evaluation, given that the large majority of children can have their allergy label removed," Dr. Lisa Grinlington of The Royal Children's Hospital Melbourne and the University of Melbourne, in Parkville, told Reuters Health by email. "Prompt evaluation of drug allergies is required to minimise the health and socioeconomic impacts of these labels."

As many as a third of the pediatric population has reported adverse drug reactions to anti-infective agents, but there are few data on drug hypersensitivity reactions to NBLAs.

Dr. Grinlington and colleagues reviewed the clinical presentation and results of allergy evaluation procedures for 141 children with 150 suspected NBLA allergies who were evaluated between 2011 and 2018.

Allergies were most commonly reported for macrolides (51.3%) and trimethoprim-sulfamethoxazole, or TMP-SMX (30.7%). Most patients reported non-immediate reactions (50.7%); 46.7% reported immediate reactions.

Challenge results for NBLAs were positive in 17.4% of cases (26/149) and negative in 82.6% of cases, with the highest frequency of positive reactions for TMP-SMX (32.6%) and macrolides (10.4%).

Of the 26 positive challenge results, 10 were classified as IgE-mediated hypersensitivity reactions (four severe, six nonsevere), the researchers report in Pediatrics, online December 3.

Most children with positive challenge results had symptoms similar to those that were initially reported.

Four children reported initial anaphylactic reactions, but no patients had severe symptoms on rechallenge or required epinephrine.

"The most interesting result from our study was that 8 out of 10 children with a NBLA allergy were successfully delabeled using an oral or intravenous challenge test," Dr. Grinlington said. "This is important, because by removing an allergy label we can prevent lifelong, unnecessary avoidance of certain antibiotic classes and potentially prevent the use of broader spectrum antibiotics."

"Improved access to standardized and reliable allergy testing protocols to delabel children is needed," she said.

Dr. Elizabeth J. Phillips of Vanderbilt University Medical Center, in Nashville, Tennessee, who recently reviewed antibiotic allergy, told Reuters Health by email that the study "reaffirms that children with low-risk cutaneous symptoms are unlikely to reproduce these on rechallenge and that they can be safely delabeled with oral challenge to drugs."

"Readers should be mindful of antibiotic stewardship here," said Dr. Phillips, who was not involved in the new work. "The best approach is still to try and avoid treating children with viral infections with antibiotics. One has to question why many of these younger children have been exposed to so many classes of antibiotics so early in their life, and this is perhaps a call for action for more education of providers and patients."

Dr. Eric M. Macy of Kaiser Permanente, in San Diego, California, has reviewed the practical management of patients with a history of immediate hypersensitivity to common NBLAs. He told Reuters Health by email, "An evaluation to confirm current hypersensitivity, or current tolerance, to needed non-beta-lactam anti-bacterial antibiotics can be safely performed in children using rechallenge as the primary method. Recurrent challenge reactions are typically no more severe than the index reactions."

"In general, skin testing is not useful in evaluating suspected immediate-onset IgE-mediated hypersensitivity or delayed onset T-cell mediated hypersensitivity," said Dr. Macy, who also was not involved in the study. "Rechallenge with therapeutic doses is required to confirm current tolerance or continued hypersensitivity."


Pediatrics 2019.