![]() In summary, most patients who report penicillin allergy are not allergic and most patients with documented specific-IgE to penicillin can tolerate cephalosporin, since the majority of cephalosporin immunologic reactions are to the side-chain (Ledford). This is consistent with the British guidelines (Mirakian). Most of the evidence is opinion or consensus but the highest level of evidence for administration of cephalosporin to a patient with penicillin allergy is “minimal concern” if the penicillin and major determinant skin test are negative and if graded challenge is used with the cephalosporin following a negative skin test with the same drug. (B) Summary Statement 103: If penicillin and cephalosporin skin testing is unavailable, depending on the reaction history, cephalosporins may need to be given via graded challenge or rapid induction of drug tolerance. (E) Summary Statement 102: Skin testing to the cephalosporin followed by graded challenge appears to be a safe method for administration of some cephalosporins in penicillin allergic patients. (B) Summary Statement 101: Treatment options for penicillin skin test–positive patients include (1) administration of an alternate (non–beta-lactam) antibiotic, (2) administration of cephalosporin via graded challenge, or (3) administration of cephalosporin via rapid induction of drug tolerance. (E) Summary Statement 100: Patients who have a history of a possible IgE-mediated reaction to penicillin, regardless of the severity of the reaction, may receive cephalosporins with minimal concern about an immediate reaction if skin test results for penicillin major and minor determinants are negative. (C) Summary Statement 99: Penicillin skin testing, when available, should be considered before administration of cephalosporins in patients with a history of penicillin allergy. (C) Summary Statement 98: Without preceding penicillin skin testing, cephalosporin treatment of patients with a history of penicillin allergy, selecting out those with severe reaction histories, show a reaction rate of 0.1% based on recent studies. Summary Statement 97: Since 1980, studies show that approximately 2% of penicillin skin test–positive patients react to treatment with cephalosporins, but some of these reactions may be anaphylactic reactions. Cephalosporin administration to patients with a history of penicillin allergy (D) Summary Statement 96: Cephalosporins and penicillins share a common beta-lactam ring structure and moderate crossreactivity has been documented in vitro. (D) Treatment with cephalosporins with dissimilar side chains may be considered, but the first dose should be given via graded challenge or induction of drug tolerance, depending on the severity of the previous reaction. (D) Summary Statement 95: Patients with a history of an immediate-type reaction to 1 cephalosporin should avoid cephalosporins with similar R-group side chains. (D) A negative skin test result does not rule out an allergy because the negative predictive value is unknown. (D) Summary Statement 94: Skin testing with native cephalosporins is not standardized, but a positive skin test result using a nonirritating concentration suggests the presence of drug specific IgE antibodies. (C) Summary Statement 93: Most hypersensitivity reactions to cephalosporins are probably directed at the R-group side chains rather than the core beta-lactam portion of the molecule. Summary Statement 92: The overall reaction rate to cephalosporins is approximately 10-fold lower than it is for penicillin. Summary Statement 71: Approximately 10% of patients report a history of penicillin allergy, but after complete evaluation, up to 90% of these individuals are able to tolerate penicillins. Some quotes from the 2010 Practice Parameter for Drug Allergy with evidence basis provided in parenthesis are: (Annè, Macy) Finally there is evidence of increased risk for any medication, irrespective of structure similarities or cross-reactivity, if there is history of prior drug reaction (Strom). (Romano Kelkar Mirakian) However, other analyses minimize risk. The medical literature suggests there is greater risk in giving cephalosporin, particularly first generation cephalosporin, to a patient with a history of penicillin allergy than to a patient without penicillin allergy (2-4 fold increased risk). The difficulty in answering your question is the meaning of “safe” and the meaning of “penicillin allergic patient”. ![]()
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