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The Role of Skin Testing for Penicillin Allergy

The Role of Skin Testing for Penicillin Allergy Abstract • Skin testing for penicillin allergy is an imperfect predictor of severe allergic reactions. We used decision analysis to identify the types of allergy history for which skin testing should alter management. The treatment threshold, the probability of a serious allergic reaction at which point one should switch from penicillin to another antibiotic, depends on the quality of life associated with the clinical outcomes. We measured 12 physicians' attitudes toward the outcomes of treatment with penicillin or vancomycin for Streptococcus viridans endocarditis in patients with a history of penicillin allergy. The clinicians' threshold probabilities ranged from.00010 to.00210 (median,.00013). Given the sensitivity (89% to 96%) and specificity (89% to 96%) of skin testing and our clinicians' median threshold, test results could alter the choice of antibiotic when the probability of a severe allergic reaction is between.00001 and.001. This range corresponds to a weak history of penicillin allergy. Although the decision should be individualized, our study suggests that skin testing is unnecessary when the patient has a convincing history of a severe allergic reaction to penicillin. (Arch Intern Med. 1990;150:1939-1946) References 1. Idsoe O, Guthe T, Wilcox RR, De Weck AL. Nature and extent of penicillin side-reactions with particular reference to fatalities from anaphylactic shock . Bull WORLD Health Organ . 1968;38:159-188. 2. Erffmeyer JE. Adverse reactions to penicillin . Ann Allergy . 1981;47:288-300. 3. ER Barnhart. Physicians' Desk Reference . Oradell, NJ: Medical Economics Co Inc; 1987. 4. Rosenblum AH. Penicillin allergy . J Allergy . 1968;42:309-318.Crossref 5. Sussman GL, Davis K, Kohler PF. Penicillin allergy: a practical approach to management . Can Med Assoc J . 1986;134:1353-1356. 6. Saxon A. Immediate hypersensitivity reactions to β-lactam antibiotics . Rev Infect Dis . 1983;5( (suppl 2) ):s368-s379.Crossref 7. Winterbauer RH, Ronald AR, Belcher DW, Turck M. Antimicrobial therapy in patients sensitive to penicillin . J Chron Dis . 1967;20:407-428.Crossref 8. Green GR, Peters GA, Geraci JE. Treatment of bacterial endocarditis in patients with penicillin hypersensitivity . Ann Intern Med . 1967;67:235-249.Crossref 9. Brown BC, Price EV, Moore MB. Penicilloyl-polylysine as an intradermal test of penicillin sensitivity . JAMA . 1964;189:599-604.Crossref 10. Sarti W. Routine use of skin testing for immediate penicillin allergy to 6,764 patients in an outpatient clinic . Ann Allergy . 1985;55:157-161. 11. Oswald NTA. Penicillin allergy: a suspect label . BMJ . 1983;287:265-266.Crossref 12. Sher TH. Penicillin hypersensitivity: a review . Pediatr Clin North Am . 1983;30:161-176. 13. Brown BC, Price EV, Moore MB. Penicillin-polylysine as an intradermal test of penicillin allergy . JAMA . 1964;189:599-604.Crossref 14. Beeley L. Allergy to penicillin . BMJ . 1984;288:511-512.Crossref 15. VanArsdel PP, Martonick GJ, Johnson LE, Sprenger JD, Altman LC, Henderson WR. The value of skin testing for penicillin allergy diagnosis . West J Med . 1986;144:311-314. 16. Green GR, Rosenblum AH, Sweet LC. Evaluation of penicillin hypersensitivity: value of clinical history and skin testing with penicilloyl-polylysine and penicillin G . J Allergy Clin Immunol . 1977;60:339-345.Crossref 17. Sogn DD, Casale TB, Condemi JJ, et al. Interim results of the NIAID collaborative clinical trial of skin testing with major and minor penicillin derivatives in hospitalized adults . J Allergy Clin Immunol . 1983;71:147.Crossref 18. Warrington RJ, Simons FER, Ho HW, Gorski BA, Tse KS. Diagnosis of penicillin allergy by skin testing: the Manitoba experience . Can Med Assoc J . 1978;118:787-791. 19. Bierman CW, VanArsdel PP, Hemphill B. Penicillin allergy in children: the role of immunological tests in its diagnosis . J Allergy . 1969;43:267-272.Crossref 20. Levine BB, Zolov DM. Prediction of penicillin allergy by immunological tests . J Allergy . 1969;43:231-244.Crossref 21. Adkinson NF, Thompson WL, Maddrey WC, Lichtenstein LM. Routine use of penicillin skin testing on an inpatient service . N Engl J Med . 1971;285:22-24.Crossref 22. Solley GO, Gleich GJ, Van Dellen RG. Penicillin allergy: clinical experience with a battery of skin-test reagents . J Allergy Clin Immunol . 1982;69:238-244.Crossref 23. Sullivan TJ, Wedner J, Shatz GS, Yecies LD, Parker CW. Skin testing to detect penicillin allergy . J Allergy Clin Immunol . 1981;68:171-180.Crossref 24. Van Dellen RG, Gleich GJ. Penicillin skin tests as predictive and diagnostic aids in penicillin allergy . Med Clin North Am . 1970;54:997-1007. 25. Mendelson LM, Ressler C, Rosen JP, Selcow JE. Routine elective penicillin allergy skin testing in children and adolescents: study of sensitization . J Allergy Clin Immunol . 1984;73:76-81.Crossref 26. Pauker SG, Kassirer JP. The threshold approach to clinical decision making . N Engl J Med . 1980;302:1109-1117.Crossref 27. Sox HC, Blatt MA, Higgins MC, Marton KI. Medical Decision Making . Woburn, Mass: Butterworths; 1988. 28. Sackett DL, Torrance GW. The utility of different health states as perceived by the general public . J Chron Dis . 1978;31:697-704.Crossref 29. Eraker SA, Sox HC. Assessment of patient's preferences for therapeutic outcomes . Med Decis Making . 1981;1:29-39.Crossref 30. Lane DA. Utility, decision, and quality of life . J Chron Dis . 1987;40:585-591.Crossref 31. Torrance GW. Utility approach to measuring health-related quality of life . J Chron Dis . 1987;40;593-600.Crossref 32. Geraci JE, Hermans PE. Vancomycin . Mayo Clin Proc . 1983;58:88-91. 33. Plante DA, Pauker SG. Enterococcal endocarditis and penicillin allergy . Med Decis Making . 1983;3:81-109.Crossref 34. Wilson WR, Geraci JE. Treatment of streptococcal infective endocarditis . Am J Med . 1985;78( (suppl 6b) ):128-137.Crossref 35. Hook EW, Roberts RB, Sande MA. Antimicrobial therapy of experimental enterococcal endocarditis . Antimicrob Agents Chemother . 1975;8:564-570.Crossref 36. Vasquez GJ, Archer GL. Antimicrobial therapy in experimental Staphylococcus epidermidis endocarditis . Antimicrob Agents Chemother . 1980; 17:280-285.Crossref 37. Richardson JV, Karp RB, Kirklin JW, Dismukes WE. Treatment of infective endocarditis: a ten year comparative analysis . Circulation . 1978;58:589-597.Crossref 38. Green GR, Peters GA, Geraci JE. Treatment of bacterial endocarditis in patients with penicillin hypersensitivity . Ann Intern Med . 1967;67:235-249.Crossref 39. L'Abbé KA, Detsky AS, O'Rourke K. Meta-analysis in clinical research . Ann Intern Med . 1987;107:224-233.Crossref 40. Eisenberg JM, Hershey JC. Derived thresholds, determining the diagnostic probabilities at which clinicians initiate testing and treatment . Med Decis Making . 1983;3:155-167.Crossref 41. Levine BB. Skin rashes with penicillin therapy: current management . N Engl J Med . 1972;286:42-43.Crossref 42. Cooper GL, Given DB. Vancomycin: A Comprehensive Review of 30 Years of Clinical Experience . Indianapolis, Ind: Park Row Publishers Inc; 1986. 43. Sorrell TC, Collington PJ. A prospective study of adverse reactions associated with vancomycin therapy . J Antimicrob Chemother . 1985;16:235-241.Crossref 44. Farber BF, Moellering RC. Retrospective study of the toxicity of vancomycin from 1974 to 1981 . Antimicrob Agents Chemother . 1982;23:138-141.Crossref 45. Cheung RPF, DiPiro JT. Vancomycin: an update . Pharmacotherapy . 1986;6:153-169. 46. Cook FV, Farrar WE. Vancomycin revisited . Ann Intern Med . 1978;88:813-818.Crossref 47. Mellor JA, Kingdom J, Cafferky M, Keane CT. Vancomycin toxicity: a prospective study . J Antimicrob Chemother . 1985;15:773-780.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

The Role of Skin Testing for Penicillin Allergy

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Publisher
American Medical Association
Copyright
Copyright © 1990 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1990.00390200117022
Publisher site
See Article on Publisher Site

Abstract

Abstract • Skin testing for penicillin allergy is an imperfect predictor of severe allergic reactions. We used decision analysis to identify the types of allergy history for which skin testing should alter management. The treatment threshold, the probability of a serious allergic reaction at which point one should switch from penicillin to another antibiotic, depends on the quality of life associated with the clinical outcomes. We measured 12 physicians' attitudes toward the outcomes of treatment with penicillin or vancomycin for Streptococcus viridans endocarditis in patients with a history of penicillin allergy. The clinicians' threshold probabilities ranged from.00010 to.00210 (median,.00013). Given the sensitivity (89% to 96%) and specificity (89% to 96%) of skin testing and our clinicians' median threshold, test results could alter the choice of antibiotic when the probability of a severe allergic reaction is between.00001 and.001. This range corresponds to a weak history of penicillin allergy. Although the decision should be individualized, our study suggests that skin testing is unnecessary when the patient has a convincing history of a severe allergic reaction to penicillin. (Arch Intern Med. 1990;150:1939-1946) References 1. Idsoe O, Guthe T, Wilcox RR, De Weck AL. Nature and extent of penicillin side-reactions with particular reference to fatalities from anaphylactic shock . Bull WORLD Health Organ . 1968;38:159-188. 2. Erffmeyer JE. Adverse reactions to penicillin . Ann Allergy . 1981;47:288-300. 3. ER Barnhart. Physicians' Desk Reference . Oradell, NJ: Medical Economics Co Inc; 1987. 4. Rosenblum AH. Penicillin allergy . J Allergy . 1968;42:309-318.Crossref 5. Sussman GL, Davis K, Kohler PF. Penicillin allergy: a practical approach to management . Can Med Assoc J . 1986;134:1353-1356. 6. Saxon A. Immediate hypersensitivity reactions to β-lactam antibiotics . Rev Infect Dis . 1983;5( (suppl 2) ):s368-s379.Crossref 7. Winterbauer RH, Ronald AR, Belcher DW, Turck M. Antimicrobial therapy in patients sensitive to penicillin . J Chron Dis . 1967;20:407-428.Crossref 8. Green GR, Peters GA, Geraci JE. Treatment of bacterial endocarditis in patients with penicillin hypersensitivity . Ann Intern Med . 1967;67:235-249.Crossref 9. Brown BC, Price EV, Moore MB. Penicilloyl-polylysine as an intradermal test of penicillin sensitivity . JAMA . 1964;189:599-604.Crossref 10. Sarti W. Routine use of skin testing for immediate penicillin allergy to 6,764 patients in an outpatient clinic . Ann Allergy . 1985;55:157-161. 11. Oswald NTA. Penicillin allergy: a suspect label . BMJ . 1983;287:265-266.Crossref 12. Sher TH. Penicillin hypersensitivity: a review . Pediatr Clin North Am . 1983;30:161-176. 13. Brown BC, Price EV, Moore MB. Penicillin-polylysine as an intradermal test of penicillin allergy . JAMA . 1964;189:599-604.Crossref 14. Beeley L. Allergy to penicillin . BMJ . 1984;288:511-512.Crossref 15. VanArsdel PP, Martonick GJ, Johnson LE, Sprenger JD, Altman LC, Henderson WR. The value of skin testing for penicillin allergy diagnosis . West J Med . 1986;144:311-314. 16. Green GR, Rosenblum AH, Sweet LC. Evaluation of penicillin hypersensitivity: value of clinical history and skin testing with penicilloyl-polylysine and penicillin G . J Allergy Clin Immunol . 1977;60:339-345.Crossref 17. Sogn DD, Casale TB, Condemi JJ, et al. Interim results of the NIAID collaborative clinical trial of skin testing with major and minor penicillin derivatives in hospitalized adults . J Allergy Clin Immunol . 1983;71:147.Crossref 18. Warrington RJ, Simons FER, Ho HW, Gorski BA, Tse KS. Diagnosis of penicillin allergy by skin testing: the Manitoba experience . Can Med Assoc J . 1978;118:787-791. 19. Bierman CW, VanArsdel PP, Hemphill B. Penicillin allergy in children: the role of immunological tests in its diagnosis . J Allergy . 1969;43:267-272.Crossref 20. Levine BB, Zolov DM. Prediction of penicillin allergy by immunological tests . J Allergy . 1969;43:231-244.Crossref 21. Adkinson NF, Thompson WL, Maddrey WC, Lichtenstein LM. Routine use of penicillin skin testing on an inpatient service . N Engl J Med . 1971;285:22-24.Crossref 22. Solley GO, Gleich GJ, Van Dellen RG. Penicillin allergy: clinical experience with a battery of skin-test reagents . J Allergy Clin Immunol . 1982;69:238-244.Crossref 23. Sullivan TJ, Wedner J, Shatz GS, Yecies LD, Parker CW. Skin testing to detect penicillin allergy . J Allergy Clin Immunol . 1981;68:171-180.Crossref 24. Van Dellen RG, Gleich GJ. Penicillin skin tests as predictive and diagnostic aids in penicillin allergy . Med Clin North Am . 1970;54:997-1007. 25. Mendelson LM, Ressler C, Rosen JP, Selcow JE. Routine elective penicillin allergy skin testing in children and adolescents: study of sensitization . J Allergy Clin Immunol . 1984;73:76-81.Crossref 26. Pauker SG, Kassirer JP. The threshold approach to clinical decision making . N Engl J Med . 1980;302:1109-1117.Crossref 27. Sox HC, Blatt MA, Higgins MC, Marton KI. Medical Decision Making . Woburn, Mass: Butterworths; 1988. 28. Sackett DL, Torrance GW. The utility of different health states as perceived by the general public . J Chron Dis . 1978;31:697-704.Crossref 29. Eraker SA, Sox HC. Assessment of patient's preferences for therapeutic outcomes . Med Decis Making . 1981;1:29-39.Crossref 30. Lane DA. Utility, decision, and quality of life . J Chron Dis . 1987;40:585-591.Crossref 31. Torrance GW. Utility approach to measuring health-related quality of life . J Chron Dis . 1987;40;593-600.Crossref 32. Geraci JE, Hermans PE. Vancomycin . Mayo Clin Proc . 1983;58:88-91. 33. Plante DA, Pauker SG. Enterococcal endocarditis and penicillin allergy . Med Decis Making . 1983;3:81-109.Crossref 34. Wilson WR, Geraci JE. Treatment of streptococcal infective endocarditis . Am J Med . 1985;78( (suppl 6b) ):128-137.Crossref 35. Hook EW, Roberts RB, Sande MA. Antimicrobial therapy of experimental enterococcal endocarditis . Antimicrob Agents Chemother . 1975;8:564-570.Crossref 36. Vasquez GJ, Archer GL. Antimicrobial therapy in experimental Staphylococcus epidermidis endocarditis . Antimicrob Agents Chemother . 1980; 17:280-285.Crossref 37. Richardson JV, Karp RB, Kirklin JW, Dismukes WE. Treatment of infective endocarditis: a ten year comparative analysis . Circulation . 1978;58:589-597.Crossref 38. Green GR, Peters GA, Geraci JE. Treatment of bacterial endocarditis in patients with penicillin hypersensitivity . Ann Intern Med . 1967;67:235-249.Crossref 39. L'Abbé KA, Detsky AS, O'Rourke K. Meta-analysis in clinical research . Ann Intern Med . 1987;107:224-233.Crossref 40. Eisenberg JM, Hershey JC. Derived thresholds, determining the diagnostic probabilities at which clinicians initiate testing and treatment . Med Decis Making . 1983;3:155-167.Crossref 41. Levine BB. Skin rashes with penicillin therapy: current management . N Engl J Med . 1972;286:42-43.Crossref 42. Cooper GL, Given DB. Vancomycin: A Comprehensive Review of 30 Years of Clinical Experience . Indianapolis, Ind: Park Row Publishers Inc; 1986. 43. Sorrell TC, Collington PJ. A prospective study of adverse reactions associated with vancomycin therapy . J Antimicrob Chemother . 1985;16:235-241.Crossref 44. Farber BF, Moellering RC. Retrospective study of the toxicity of vancomycin from 1974 to 1981 . Antimicrob Agents Chemother . 1982;23:138-141.Crossref 45. Cheung RPF, DiPiro JT. Vancomycin: an update . Pharmacotherapy . 1986;6:153-169. 46. Cook FV, Farrar WE. Vancomycin revisited . Ann Intern Med . 1978;88:813-818.Crossref 47. Mellor JA, Kingdom J, Cafferky M, Keane CT. Vancomycin toxicity: a prospective study . J Antimicrob Chemother . 1985;15:773-780.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Sep 1, 1990

References