Penicillin and Beta-Lactam Allergy Management

Notes

This guideline applies to BC Children's Hospital and BC Women's Hospital + Health Centre

This is a tool to aid identifying which beta lactam antibiotics have high and low risk of cross reactivity

Beta-lactam Cross Reactivity

This document can only be used to evaluate the risk of cross reactivity between beta lactams in patients with type I IgE mediated hypersensitivity reactions. This does NOT apply to type II, III, and IV hypersensitivity reactions. Please see below for information on other types of hypersensitivity reactions and their management

Coombs and Gell Classification of Hypersensitivity Reactions

Description: IgE mediated, immediate type hypersensitivity
Mediator: IgE antibodies
Onset: 0-1 hr
Clinical Reactions: Anaphylaxis, urticaria, angioedema, hypotension, bronchospasm, stridor, pruritis
Management: Avoid offending agent and cross reacting agents

Description: Antibody dependent cytotoxicity
Mediator: IgG and IgM antibodies
Onset: >72 hr
Clinical Reactions: Hemolytic anemia, thrombocytopenia, neutropenia
Management: Drug specific, avoid offending agent

Description: Antibody complex mediated hypersensitivity
Mediator: Antigen-antibody complexes
Onset: >72 hr
Clinical Reactions: Serum sickness, vasculitis, drug fever, glomerulonephritis
Management: Avoid beta lactams, consult AMS or ID for alternative antibiotic

Description: Delayed type hypersensitivity
Mediator: T cells
Onset: >72 hr
Clinical Reactions: Contact dermatitis, some morbilliform reactions, severe exfoliative dermatoses (e.g. SJS/TEN), AGEP, DRESS/DiHS, interstitial nephritis, drug-induced hepatitis
Management: Avoid beta lactams, consult AMS or ID for alternative antibiotic

More Information

  1. Macy E. and Contreras R. Health care use and serious infection prevalence associated with penicillin “allergy” in hospitalized patients: A cohort study. J Allergy Clin Immunol 2014;133:790-796
  2. Charneski, L., Deshpande, G. & Smith, S.W. (2011). Impact of an antimicrobial allergy label in the medical record on clinical outcomes in hospitalized patients. Pharmacotherapy, 31(8): 742-747.
  3. Pichichero ME and Casey JR. Safe use of selected cephalosporins in penicillin-allergic patients: A meta- analysis. Otolaryngology-Head and Neck Surgery 2007; 136:340-347
  4. Macy E and Ngor E. Recommendations for the Management of Beta-Lactam Intolerance. Clinic Rev Allerg Immunol 2014; 47:46-55.
  5. PL Detailed-document, Allergic Cross-reactivity Among Beta-lactam Antibiotics: An Update. Pharmacist’s Letter/Prescriber’s Letter. October 2013
  6. Terico AT and Gallagher JC. Beta-lactam allergy and cross-reactivity. J Pharm Pract. 2014 Dec;27(6):530-44.
  7. Pichichero, Michael E. A review of evidence supporting the American Academy of Pediatrics recommendations for prescribing cephalosporin antibiotics in penicillin allergic patients. Pediatrics. 2005(115):1048-55.
  8. Pichichero ME. Use of selected cephalosporins in penicillin allergic patients. A paradigm shift. Diagnostic Microbiology and Infectious Disease. 2007(52):13-18.
  9. Romano A et al. IgE-mediated hypersensitivity to cephalosporins: Cross-reactivity and tolerability of alternative cephalosporins. J Allergy Clin Immunol. 2015; 136 (3); 685-691
  10. Campagna JD, Bond MC, Schabelman E, Hayes BD. 2012. The use of cephalosporins in penicillin-allergic patients: a literature review. J Emerg Med 42:612-620.
  11. DePestel DD, Benninger MS, Danziger L, LaPlante KL, May C, et al. Cephalosporin use in treatment of patients with penicillin allergies. J Am Pharm Assoc. 2008; 48:530-540
  12. Novalbos A, Sastre J, Cuesta J et al. Lack of allergic cross-reactivity to cephalosporins among patients allergic to penicillins. Clin Exp Allergy. 2001;31(3):438-443
  13. Kula B, Djordjevic G, and Robinson JL. A Systematic Review: Can one Prescribe Carbapenems to Patients with IgE-Mediated Allergy to Penicillins or Cephalosporins? CID 2014;59(8):1113-1122
  14. Kula B, Djordjevic G, and Robinson JL. A Systematic Review: Can one Prescribe Carbapenems to Patients with IgE-Mediated Allergy to Penicillins or Cephalosporins? CID 2014;59(8):1113-1122
  15. Pichichero ME and Zagursky R. Penicillin and Cephalosporin Allergy. Ann Allergy Asthma Immunol 112(2014):404-412
  16. Frumin J and Gallagher JC. Allergic Cross-Sensitivity Between Penicillin, Carbapenem and Monobactam Antibiotics: What are the Chances? The Annals of Pharmacotherapy 2009 Feb; 43:304-315
  17. NB Provincial Health Authorities Anti-Infective Stewardship Committee. Management of Penicillin and Beta-Lactam Allergy 2017. http://en.horizonnb.ca/media/927867/managementofpenicillinandbetalactamallergy.pdf (accessed December 3, 2018).
  18. Coombs P GP. Classification of allergic reactions responsible for clinical hypersensitivity and disease. Clinical aspects of immunology, 1968 Oxford, UK Oxford University Press (pg 575-96).
  19. Solensky R. and Khan DA. (Editors) Joint Task Force on Practice Parameters. Drug Allergy: an Updated Practice Parameter. Ann Allergy Asthma Immunol 2010; 105:259-273

This document is intended for use within BC Children's and BC Women's Hospitals only. Any other use of reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA