Immediate Hypersensitivity Skin Testing for Penicillin Allergy

ABSTRACT Cholinergic urticaria is a common disorder that has been associated with anaphylaxis. We report the events, workup, and eventual second dose vaccination of a patient at the Walter Reed National Military Medical Center, who had immediate anaphylaxis after administration of the first Pfizer-BioNTech Covid-19 (BNT162b2) vaccine dose. During the initial evaluation after anaphylaxis, the patient described a history of symptoms suspicious for cholinergic urticaria but had never had this condition confirmed with standardized testing. After the episode of anaphylaxis, we performed several studies including immediate hypersensitivity skin testing, which did not demonstrate vaccine or component sensitization. We then performed an exercise provocation challenge and confirmed the diagnosis of cholinergic urticaria. These results, combined with the patient history, suggested that the episode of anaphylaxis was most likely driven by a severe flare of cholinergic urticaria. After obtaining the patient’s consent, she received and tolerated her second dose without any objective findings of anaphylaxis. We conclude that patients with mast cell disorders or anaphylaxis after their first Covid-19 immunization will benefit from referral to an allergist since receipt of their second Covid-19 immunization may be possible.

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Faculty Opinions recommendation of Radiocontrast media hypersensitivity: skin testing differentiates allergy from nonallergic reactions and identifies a safe alternative as proven by intravenous provocation.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.735543706.793566285 ◽

2019 ◽

Author(s):

Timothy Craig ◽

Aparna Daley

Keyword(s):

Skin Testing ◽

Safe Alternative ◽

Radiocontrast Media ◽

Hypersensitivity Skin

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Penicillin Allergy Skin Testing as an Antibiotic Stewardship Intervention in Hematopoietic Cell Transplant Recipients

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.588 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S266-S267 ◽

Cited By ~ 1

Author(s):

Christopher Kovacs ◽

Vasilios Athans ◽

David Lang ◽

Ronald Sobecks ◽

Lisa Rybicki ◽

...

Keyword(s):

Antibiotic Stewardship ◽

Skin Testing ◽

Hematopoietic Cell ◽

Penicillin Allergy ◽

Cell Transplant ◽

Transplant Recipients ◽

Hematopoietic Cell Transplant ◽

Allergy Skin Testing

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162. Assessment of Beta-lactam Allergies as Rationale for Receipt of Vancomycin for Surgical Prophylaxis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.207 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S90-S90

Author(s):

Kendall J Tucker ◽

YoungYoon Ham ◽

Haley K Holmer ◽

Caitlin M McCracken ◽

Ellie Sukerman ◽

...

Keyword(s):

Antimicrobial Prophylaxis ◽

Skin Testing ◽

Cross Reactivity ◽

Penicillin Allergy ◽

Beta Lactam ◽

First Line ◽

Surgical Prophylaxis ◽

Inappropriate Use ◽

Oral Amoxicillin ◽

Ige Mediated

Abstract Background Beta-lactam (BL) antibiotics are first-line agents for most patients receiving antimicrobial prophylaxis in surgical procedures. Despite evidence showing low cross-reactivity between classes of BLs, patients with allergies commonly receive vancomycin as an alternative to avoid allergic reaction. The objective of this study was to identify potentially inappropriate use of vancomycin surgical prophylaxis among patients with reported BL allergies. Methods Adult patients (≥18 years) receiving vancomycin for surgical prophylaxis with a reported penicillin and/or cephalosporin allergy at our institution between August 2017 to July 2018 were retrospectively evaluated for potential eligibility for penicillin allergy testing and/or receipt of standard prophylaxis. Surgery type and allergy history were extracted from the electronic medical record. Per our institution’s penicillin-testing protocol, patients with IgE-mediated reactions < 10 years ago were eligible for penicillin skin testing (PST), mild reactions or IgE-mediated reaction > 10 years ago were eligible for direct oral amoxicillin challenge, and severe non-IgE mediated allergies were ineligible for penicillin allergy evaluation or BL prophylaxis. Results Among 830 patients who received vancomycin for surgical prophylaxis, 196 reported BL allergy and were included in the analysis (155 with penicillin allergy alone; 21 with cephalosporin allergy; 20 with both cephalosporin and penicillin allergy). Approximately 40% of surgeries were orthopedic. Six patients were ineligible for BL prophylaxis. Per institutional protocol, 73 of 155 patients (48%) may have qualified for PST; 81 of 155 (52%) patients may have received a direct oral amoxicillin challenge. Only 3 of 22 patients with history of methicillin-resistant Staphylococcus aureus appropriately received additional prophylaxis with vancomycin and a BL. Conclusion Patients with BL allergies often qualify for receipt of a first-line BL antibiotic. An opportunity exists for improved BL allergy assessment as an antimicrobial stewardship intervention. Future studies should evaluate outcomes associated with BL allergy evaluation and delabeling in patients receiving surgical prophylaxis. Disclosures All Authors: No reported disclosures

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