The Journal of pediatrics | 2019
The Importance of Delabeling β-Lactam Allergy in Children.
Abstract
A n 11-month-old, previously healthy male infant was diagnosed by his primary care provider with acute otitis media after 2 days of fever and irritability. He was prescribed amoxicillin 90 mg/kg/day for a 10-day course.This course of antibiotics was his first. On day 4, the child developed maculopapular exanthem approximately 5 hours after a dose of amoxicillin (Figure 1; available at www.jpeds.com). There was no associated angioedema, vomiting, diarrhea, or respiratory symptoms. There was no associated high fever, skin sloughing, joint swelling, hematuria, or other systemic symptoms. He was otherwise well with no change in appetite or disposition. The child was taken to his physician who advised that amoxicillin be discontinued. The rash resolved over the course of a week, leaving no bruising or pigmentary changes of the skin. This infant was subsequently labeled as penicillin allergic and avoided all b-lactam antibiotics into toddlerhood. When he was 5 years old, it was suggested that he be evaluated by an allergist because of the reaction that occurred in infancy. After intradermal testing to penicilloyl-polylysine, benzyl penicillin, and ampicillin, which were negative, the allergist performed an oral drug provocation test (DPT). The toddler received a dose of amoxicillin (250 mg orally) and was observed for 1 hour afterward. There were no signs or symptoms of an allergic reaction. The rash in infancy was diagnosed as likely a viral exanthem or a virus–drug interaction of no consequence. He subsequently has received amoxicillin for otitis media with no further reactions. Most children who are labeled as b-lactam allergic are not allergic to the antibiotic. For example, viral exanthems often are mislabeled as antibiotic reactions. Mislabeling of b-lactam allergy has significant consequences related to use of broader spectrum or less effective agents, as well as leading to increased rates of antibiotic resistance. As a result, evaluation of b-lactam allergy, of which the gold standard is a DPT, is an important public health goal. Our goal is to review each of these key points, providing an approach to the child who is labeled as b-lactam allergic, as well as offering salient examples of the importance of delabeling b-lactam allergy in the pediatric population.