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Cephalosporin Use in Penicillin-Allergic Patients: Pros & Cons

OCT 03, 2017 | BRIAN P. DUNLEAVY
Are cephalosporins safe for use in patients allergic to penicillins who haven’t undergone a prior allergy evaluation? Experts debated this very question during the annual meeting of the American Academy of Allergy, Asthma, and Immunology in March, and a summary of the discussion was published on September 22, 2017, in the Journal of Allergy and Clinical Immunology: In Practice.

Currently, there are no widely accepted guidelines regarding the use of cephalosporins in patients allergic to penicillin, which adds to the challenge facing clinicians, given that the most commonly reported drug allergy involves the first-generation antibiotic (and that cephalosporins and penicillin share structural similarities). In general, simply automatically withholding cephalosporins in patients allergic to penicillins would increase the use of broader-spectrum antibiotics, resulting in more adverse events and potential treatment failures.
“Setting standards for cephalosporin use among penicillin-allergic patients… is important to the quality and safety of care we deliver,” Kimberly G. Blumenthal, MD, MSc, Division of Rheumatology, Allergy and Immunology, Department of Medicine and Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, who argued the “con” perspective, told Contagion®.

During the debate, in arguing the pro-cephalosporin position, Eric Macy, MD, MS, FAAAAI, Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, who was unable to respond to a request for comment on deadline, acknowledged that “the literature supports that all individuals, particularly hospitalized individuals, with an unconfirmed penicillin allergy should have the penicillin allergy confirmed or removed for patient safety.” However, he added that, “this does not mean one could not treat a patient with a cephalosporin before removing the penicillin allergy or confirming a penicillin allergy,” and that cephalosporin tolerance testing in patients with a history of penicillin allergy may not improve overall patient safety or clinical outcomes “because of the high number needed to treat, time, expense, and the low likelihood of such testing occurring.”

In making his case, Dr. Macy noted that roughly 1 in 10 Americans has a history of penicillin allergy, and fewer than 2% have a history of any cephalosporin allergy. He added that, even in patients with no history of antibiotic, “there is no such thing as a risk-free antibiotic exposure, even after negative allergy testing.” In general, studies suggest that most reported allergic reactions to cephalosporins are benign rashes, and only “an extremely small minority” of patients experience life-threatening anaphylaxis or a severe cutaneous adverse reaction.


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