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Ask the Expert - Determining Risk of Cephalosporin Use with Remote History PCN-Associated Urticaria (April 2010)

Question (Part 1): An adult patient is referred by his primary care physician to the allergist with the question of determining if he can take cephalosporins.  He has a history (under the care of another physician at the time) that 10 years ago he had a reaction to PCN. He had a generalized rash that was itchy and he thinks that it was diagnosed to be hives but cannot say for sure.  He has been advised to avoid all PCN drugs and to avoid all cephalosporins.  He is not interested in having PCN testing.  In fact he flatly refuses.  What would be your advice and recommendations?

(Part 2): He rethinks the issues and agrees to undergo PCN allergy testing and he has a positive skin testing response.  Again he wants to know if he can take cephalosporins.  Would your advice be any different than in Part 1?

Answer:
In regards to a patient with a pruritic rash to penicillin > 10 years ago who now may need a cephalosporin there are several approaches.  The first approach is to determine if there is an alternative antibiotic.  Most often there is an alternative and then there is no need for any procedure to be done.  A second approach is to perform penicillin skin testing and if negative, he may receive the cephalosporin safely.  Since he refuses penicillin skin testing this option is out.  A third approach would be to perform a graded challenge to a cephalosporin.  Typically one would start with 1/100th or 1/10th of the final dose and administer this orally, and increase the dose as tolerated until a full therapeutic dose is completed.  Skin testing to a cephalosporin could also be performed prior to the graded challenge.(1)  A fourth approach would be to desensitize the patient to a cephalosporin.  In the case presented here, this would not be practical as this is an elective evaluation and the patient does not urgently need a cephalosporin.  The fifth option would be simply to administer a cephalosporin.  In the case presented, this may be the most reasonable option.  In a study by Daulat et al., 606 patients with non-severe reactions attributed to penicillin were administered a cephalosporin and only one patient had a reaction (worsening of eczema).(2)  Another retrospective study of patients with a history of penicillin allergy who were administered a cephalosporin (predominantly cefazolin) had similar reassuring results.(3)

In patients with a history of penicillin allergy and a positive penicillin skin test, the following aforementioned options would be reasonable: find an alternative, perform a graded challenge, or perform a desensitization.  The second option is likely the most attractive in the case presented.  Romano et al, studied a group of 128 history and skin test positive penicillin allergic subjects and performed skin testing to cephalosporins (2 mg/ml concentration) followed by a graded challenge starting with 1/100th of dose, then 1/10th of dose and then the full dose at hourly intervals.(1)  While some patients declined challenges, 101 patients with negative cephalosporin skin tests tolerated graded challenges to oral cefuroxime and intramuscular ceftriaxone. 

1. Romano A, Gueant-Rodriguez RM, Viola M, Pettinato R, Gueant JL. Cross-reactivity and tolerability of cephalosporins in patients with immediate hypersensitivity to penicillins. Ann Intern Med. 2004;141:16-22. IIb.
2. Daulat SB, Solensky R, Earl HS, Casey W, Gruchalla RS. Safety of cephalosporin administration to patients with histories of penicillin allergy. J Allergy Clin Immunol. 2004;113:1220-2. IIb.
3. Goodman EJ, Morgan MJ, Johnson PA, Nichols BA, Denk N, Gold BB. Cephalosporins can be given to penicillin-allergic patients who do not exhibit an anaphylactic response. J Clin Anesth. 2001;13:561-4. IIb. 

 
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