Patients carrying the label of “penicillin allergy” or “cephalosporin allergy” are likely to receive suboptimal antibiotics, leading to decreased efficacy and increased toxicity. This is a major problem, as these labels are common.
Emerging evidence shows that there is no such thing as a “penicillin allergy” or “cephalosporin allergy.” Instead, cross-allergic reactions are restricted to much smaller groups of antibiotics that share greater structural similarity. This opens the door to using beta-lactam antibiotics safely in patients who have had an allergic reaction to one or more of these drugs.
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The IBCC chapter is located here.
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Question: your blumenthal table does not have a gray or red box where Penicllin G and Ampicillin cross, yet further down under “why there is no such thing as a penicillin allergy” you have a red outline around a picture of their two side chains to show how similar they are. Shouldn’t penicillin and ampicillin be listed as cross-reactive or potentially cross reactive in the blumenthal table, then?
Ben D.
Excellent point!! Thank you.
I think the Blumenthal table is correct and my (initial) figure is wrong – I’ve corrected the figure.
This is a very interesting point. Fairly minor structural differences between Penicillin G and Ampicillin (the presence of a single amine group) may render these drugs non-cross-allergic. This suggests that cross-allergy may be very limited, to drugs which are extremely similar in structure.
Another excellent chapter in your IBCC book! I have collaborated with Blumenthal on the graded test dose protocol on both medical and surgical patients at our institution, and many of the patient’s with reported allergies (often from memory of what may have happened as children) are in fact not present. We have published the abstract with the data and will hopefully have the manuscript out. Thanks for your fantastic effort as always as you have done an fantastic review of the literature. I hoping this is adopted nation and world wide as it is very easy to implement. It will… Read more »
Fantastic! Thanks to you, Dr. Blumenthal, and all your coworkers on doing groundbreaking work. Would love it if you could send me the manuscript when its out and also please let me know if there are any errors you find in the chapter. My goal is to keep this up-dated and reflective of the best available research.
Hello Josh,
I have made a kind of summary on this subject in french. Your work has taught me a lot in a short chapter. I don”t even remember having learnt so many new things in a single article.
I would like to say that I have borrowed one of your pic, hope it’s ok
Here it is http://www.nfkb0.com/2019/05/17/lallergie-a-la-penicilline/
Bye
PS now I dream of testing all the penicillin allergy labeled patients, I have to think about it !
Fantastic!! Thank you and feel free to use as many pictures as you would like – spread the word.
The concept of skin-testing everyone with a penicillin allergy is a good one, but not one I can implement in the ICU.
cheers, Josh
Hello Josh, great chapter, I learned a ton. I plan to implement the graded challenge at our hospital.
One question: Where did you get the Blumenthal matrix? The cited PMID 28483315 has a slightly different topic (“Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation.”) and doesn’t contain the matrix.
@Johannes Ammon
PMID 28483315 is the right article. The PMC full text has omitted the matrix for some reason… but the original article has it. If you get it via the DOI 10.1016/j.jaip.2017.02.019 you should be good.
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Amazing article, as usual. There seems to be some new recent evidence on the cross-reactivity patterns between Piperacillin-Tazobactam and other penicillins. Gallardo et al (PMID: 32320796), define 3 different phenotypes: A – cross-reactive with all penicillins, B – cross-reacting with amino-penicillins, C – specific to pip/tazo. A subsequent article by Casimir-Brown et al (PMID: 33444815) reports cross-sensitization to other penicillins in 33%. Still no great amount of evidence, but there might be more cross-reactivity than your article suggests.