Is It Safe to Use Cephalosporin in a Patient with Penicillin Allergy

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Is It Safe to Use Cephalosporin in a Patient with
Penicillin Allergy??

• Joe Lex, MD, FAAEM
• Temple University School of Medicine
• Philadelphia, PA

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Disclosure
Nothing to declare
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Common Wisdom

• About 10 of patients who are allergic to
  penicillin will have a cross-reactivity to
  cephalosporin.

Allergy
Physicians Desk Reference, 57th ed. 2003
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Penicillin Allergy Kids?

• 298 children with history of adverse reaction to
  oral penicillin
• Given oral challenge with penicillin
• No severe reactions
• 30 (10) had slight to moderate skin rash on 7th
  to 10th day of treatment

Allergy
Graff-Lonnevig V, et al. Arch Dis Child. 1988
Nov63(11)1342-6.
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Penicillin Allergy Kids?

• One to four years after oral challenge, 222
  children reinvestigated by interview
• 103 / 110 (94) tolerated penicillin treatment
  without adverse reactions
• Conclusion the term penicillin allergy is
  often misused

Allergy
Graff-Lonnevig V, et al. Arch Dis Child. 1988
Nov63(11)1342-6.
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Penicillin Allergy Adults?

• 132 patients who gave history of immediate
  reaction to penicillin
• Four patients confirmed to have penicillin
  allergy by the radio-allergosorbent test
• Other 128 had oral penicillin challenge without
  ill effect

Allergy
Surtees SJ, et al. BMJ. 1991 May
4302(6784)1051-2.
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Meta-Analysis

• History of penicillin allergy LR 1.9 (95 CI,
  1.5-2.5)
• No history of penicillin allergy -LR 0.5 (95
  CI, 0.4-0.6)
• 10 - 20 of patients reporting history of
  allergy are truly allergic

Allergy
Salkind AR, et al. JAMA. 2001 May
16285(19)2498-505.
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First Conclusion

• Maybe 10 of patients who say, Im allergic to
  penicillin are really allergic to penicillin

Allergy
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Is It Important??

• 101 inpatients who claimed penicillin allergy
  had skin testing
• 92 negative, 5 positive, 4 unsure
• 49 with negative results given penicillin-based
  drug
• 48 with negative results given cephalosporin

Allergy
Nadarajah K, et al. Ann Allergy Asthma Immunol.
2005 Dec95(6)541-5.
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Is It Important??

• Reduced use of vancomycin by 95 (67/70)
• Reduced use of fluoroquinolones by 96 (23/24)
• No serious reactions to skin test
• No reaction to penicillin or cephalosporin if
  skin test negative

Allergy
Nadarajah K, et al. Ann Allergy Asthma Immunol.
2005 Dec95(6)541-5.
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Is It Safe??
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We Dont Do Skin Testing
Allergy
You have GOT to be joking
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But Thats Okay Because

• Incidence of adverse reactions from
  cephalosporins also 1 to 10
• Anaphylaxis fewer than 2 in 10,000
• Post-marketing studies of 2nd and 3rd generation
  cephalosporins no increase allergic reactions in
  patients with penicillin allergy

Allergy
Anne S, et al. Ann Allergy Asthma Immunol. 1995
Feb74(2)167-70.
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But Thats Okay Because

• Penicillin skin tests do not predict allergy to
  cephalosporin in patients with histories of
  penicillin allergy
• One reaction occurred in 98 patients (1) with
  positive skin test
• Six reactions occurred in 310 patients (2) with
  negative skin test

Allergy
Anne S, et al. Ann Allergy Asthma Immunol. 1995
Feb74(2)167-70.
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Second Conclusion

• Severe reaction to cephalosporins are even less
  common than penicillin allergies

Allergy
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The BIG Study

• Retrospective cohort study of huge database
• United Kingdom General Practice Research Database
• 3,375,162 patients got penicillin
• 534,810 patients also got cephalosporin within 60
  days

Allergy
Apter AJ, et al. Am J Med. 2006
Apr119(4)354.e11.
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3,375,162 got penicillin
534,810 also got cephalosporin within 60 days
ALE within 30 days of penicillin 3920 (0.001)
No ALE within 30 days of penicillin 530,890
Given Cephalosporin
ALE within 30 days 43 (1.1)
ALE within 30 days 581 (0.1)
ALE Allergic-like event
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The BIG Study

• Anaphylaxis after penicillin 25
• Anaphylaxis after cephalosporin 13
• Anaphylaxis to penicillin followed by anaphylaxis
  to cephalosporin 1
• ALE to penicillin followed by ALE to
  cephalosporin 43
• Number that were urticaria 30

Allergy
Apter AJ, et al. Am J Med. 2006
Apr119(4)354.e11.
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The BIG Study

• 1.1 of the patients who had an event after
  penicillin also had an event after the
  cephalosporin
• BUT
• 1.6 of the patients who had an event after
  penicillin also had an event after a sulfonamide

Allergy
Apter AJ, et al. Am J Med. 2006
Apr119(4)354.e11.
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Final Conclusion

• Any cephalosporin can safely be given to a
  penicillin-allergic patient who did not have
  anaphylaxis

Allergy