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Safely diagnosing clinically significant penicillin allergy using only penicilloyl-poly-lysine, penicillin, and oral amoxicillin.
Open accessAbstract
Background Penicillin skin testing is rarely used to undiagnose penicillin "allergy" in the United States, partially because of concern that commercially available materials are inadequate.Objective We determined whether skin testing with only commercially available penicilloyl-poly-lysine and penicillin followed by an oral amoxicillin challenge, if skin test-negative, can safely identify clinically significant penicillin allergy.Methods Five hundred sequential persons with positive history of penicillin "allergy" were evaluated by skin testing with penicilloyl-poly-lysine and penicillin between June 8, 2010, and March 29, 2012. All persons with negative skin tests were given an oral amoxicillin challenge and observed for 1 hour.Results Persons undergoing penicillin allergy testing were representative of all health plan members with penicillin allergy. Only 4 persons (0.8%; 95% CI, 0.32%-2.03%) had a positive skin test result. Only 4 persons (0.8%; 95% CI, 0.32%-2.03%) had an acute objective oral amoxicillin challenge reaction. Fifteen persons (3.0%; 95% CI, 1.83%-4.98%) had subjective oral challenge reactions, either acute transient itching or dizziness. All were women and 11 (73.3%) had multiple drug intolerance syndrome. None had severe reactions or objective signs. These were not considered to be positive challenge reactions. Sixty-eight subjects (13.6%) who were negative on testing were exposed to 88 courses of penicillins during 90 days of follow-up. New reactions were reported after 4 courses (4.5%), 3 (75%) occurring in subjects with multiple drug intolerance syndrome.Conclusions Penicillin skin testing, using only penicilloyl-poly-lysine and penicillin, followed by oral amoxicillin challenge, if negative, can safely identify clinically significant IgE-mediated penicillin allergy in patients who use health care in the United States at this time.
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“Penicillin skin testing with a major determinant analog (penicilloyl-polylysine) and minor determinants (benzylpenicilloate, benzylpenilloate, or benzylpenicillin isomers of penicillin) are used for skin test evaluation for IgE-dependent penicillin allergy and can reliably identify persons at high risk for IgE-mediated reactions to penicillin (658,660,676).”
From Sexually Transmitted Infections Treatment Guidelines, 2021 (2021) · cites this paper as [660]
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“Penicillin allergy is often overreported, with the majority of patients who report penicillin allergy able to tolerate the medication (660).”
From Sexually Transmitted Infections Treatment Guidelines, 2021 (2021) · cites this paper as [660]
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Johansson, S. G. O., Hourihane, J. O., Bousquet, J., Bruijnzeel-Koomen, C. A. F. M., Dreborg, S. K. G., Haahtela, T., Kowalski, M. L., Mygind, N., Ring, J., Cauwenberge, P. V., et al. (2001) · Allergy · doi:10.1034/j.1398-9995.2001.t01-1-00001.x · Cited by 1,710
Caubet, J., Kaiser, L., Lemaître, B., Fellay, B., Gervaix, A., & Eigenmann, P. (2010) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2010.08.025 · Cited by 343
Sogn, D. D. (1992) · Archives of Internal Medicine · doi:10.1001/archinte.1992.00400170105020 · Cited by 337
Self-reported antibiotic allergy incidence and prevalence: age and sex effects.
Macy, E., & Poon K-Y, T. (2009) · The American Journal of Medicine · doi:10.1016/j.amjmed.2009.01.034 · Cited by 313
Green, G. R., Rosenblum, A. H., & Sweet, L. C. (1977) · Journal of Allergy and Clinical Immunology · doi:10.1016/0091-6749(77)90064-1 · Cited by 214
Routine elective penicillin allergy skin testing in children and adolescents: study of sensitization
Mendelson, L. M., Ressler, C., Rosen, J. P., & Selcow, J. E. (1984) · Journal of Allergy and Clinical Immunology · doi:10.1016/0091-6749(84)90487-1 · Cited by 183
Multiple drug intolerance syndrome: prevalence, clinical characteristics, and management
Macy, E. M., & Ho, N. J. (2011) · Annals of Allergy Asthma & Immunology · doi:10.1016/j.anai.2011.11.006 · Cited by 171
Oral challenges are needed in the diagnosis of β‐lactam hypersensitivity
Bousquet, P., Pipet, A., Bousquet-Rouanet, L., & Demoly, P. M. (2007) · Clinical & Experimental Allergy · doi:10.1111/j.1365-2222.2007.02867.x · Cited by 125
Routine Use of Penicillin Skin Testing on an Inpatient Service
Adkinson, N. F., Thompson, W. L., Maddrey, W. C., & Lichtenstein, L. M. (1971) · New England Journal of Medicine · doi:10.1056/nejm197107012850104 · Cited by 125
Macy, E. M., Mangat, R., & Burchette, R. J. (2003) · Journal of Allergy and Clinical Immunology · doi:10.1067/mai.2003.1385 · Cited by 120
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Sexually Transmitted Infections Treatment Guidelines, 2021
Workowski, K. A., Bachmann, L. H., Chan, P. A., Johnston, C. M., Muzny, C. A., Park, I., Reno, H., Zenilman, J. M., & Bolan, G. A. (2021) · MMWR. Recommendations and Reports · doi:10.15585/mmwr.rr7004a1 · Cited by 3,018
Sexually Transmitted Diseases Treatment Guidelines, 2010
Workowski, K., & BOLAN, G. A. (2011) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2011.04.006 · Cited by 2,074
Evaluation and Management of Penicillin Allergy: A Review
Shenoy, E. S., Macy, E., Rowe, T., & Blumenthal, K. G. (2019) · JAMA · doi:10.1001/jama.2018.19283 · Cited by 830
Macy, E., & Contreras, R. (2014) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2013.09.021 · Cited by 829
Blumenthal, K. G., Peter, J. G., Trubiano, J. A., & Phillips, E. J. (2019) · The Lancet · doi:10.1016/s0140-6736(18)32218-9 · Cited by 614
Metadata
- Authors
- Macy, E., & Ngor, E. W.
- Affiliations
- Kaiser Permanente (US)
- Corresponding author
- Macy, Eric
- ORCID
- Macy, Eric
- Venue
- The Journal of Allergy and Clinical Immunology In Practice
- Publisher
- Elsevier BV
- Published
- 2013-05
- Volume
- 1
- Issue
- 3
- Pages
- 258-263
- ISSN
- 2213-2198 (ISSN-L)
- OpenAlex
- W2136352256
- Cited by
- 275
- References
- 24
- Citations by year
- 2026: 9 · 2025: 9 · 2024: 16 · 2023: 19 · 2022: 22 · 2021: 18 · 2020: 33 · 2019: 35 · 2018: 25 · 2017: 29 · 2016: 23 · 2015: 14 · 2014: 17 · 2013: 5
- FWCI
- 14.44
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Journal of Allergy and Clinical Immunology In Practice (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Pharmacology (medical) › Drug-Induced Adverse Reactions
- Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Toxicology › Pharmacovigilance and Adverse Drug Reactions
- Health Sciences › Medicine › Dermatology › Contact Dermatitis and Allergies
- Keywords
- penicillin allergy, penicillin skin testing, IgE-mediated drug allergy, drug hypersensitivity testing, health insurance beneficiaries
- MeSH terms
- Administration, Oral, Adolescent, Adult, Aged, Amoxicillin, Female, Humans, Male, Middle Aged, Penicillanic Acid, Penicillins, Polylysine, Prospective Studies, Retrospective Studies, Skin Tests, Benzeneacetamides, Young Adult
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