Penicillin allergy management strategies relevant for clinical practice – a narrative review
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Mar 31, 2025
About this article
Published Online: Mar 31, 2025
Page range: 28 - 38
Received: Nov 29, 2024
DOI: https://doi.org/10.2478/rjim-2024-0035
Keywords
© 2025 Ileana-Maria Ghiordanescu et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.
Figure 1.
Figure 2.
ENDA, Blumenthal and Schrüfer strategies, classification by risk class and corresponding recommendations
|
High-risk NIR |
SCARs, generalised bullous FDE, severe MPE, linear IgA bullous dermatosis, systemic vasculitides, organ involvement/cytopenia, penicillin-induced autoimmune disease | avoid using Penicillins/Cephalosporins OR use non-BL antibiotics by microbial coverage OR use, upon graded challenge, Aztreonam, Carbapenems, 3rd/4th/5th generation Cephalosporins | |
|
High-risk IR |
anaphylaxis, hypotension, laryngeal oedema, bronchospasm, urticaria or angioedema, generalised angioedema | avoid using Penicillins/Cephalosporins OR use non-BL antibiotics by microbial coverage OR use, upon graded challenge, Aztreonam, Carbapenems, 3rd/4th/5th generation Cephalosporins | |
|
Low-risk IR, NIR, and unknown reactions |
NIR: contact dermatitis, systemic contact dermatitis, local reaction (i.m. administration), exfoliative palmar dermatitis, FDE, delayed urticaria, mild or moderate MPE, symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) OR IR: isolated generalised pruritus which did not require treatment, isolated digestive symptoms, localised urticaria OR unknown reactions | avoid using Penicillins/Cephalosporins OR use full-dose Aztreonam, Carbapenems, 3rd/4th/5th generation Cephalosporins OR use non-BL antibiotics by microbial coverage | |
|
High-risk NIR |
Stevens-Johnsons syndrome, Toxic Epidermal Necrolysis, Acute interstitial Nephritis, Drug Rash Eosinophilia with Systemic Symptoms (DRESS), haemolytic anaemia | avoid using Penicillins/Cephalosporins, and Carbapenems AND use alternative agents by microbial coverage; | |
|
High-risk IR and unknown reactions |
anaphylaxis, angioedema, wheezing, laryngeal oedema, hypotension, hives/urticaria OR unknown reactions with no further details available from patient/proxy | avoid using the penicillin subclass OR use 3rd/4th/5th generation Cephalosporins by test dose procedure OR use alternative agent by microbial coverage OR use Aztreonam or Carbapenems | |
|
Low-risk NIR, EHR and unknown reactions without severity elements |
MPE, or minor rash (not hives), EHR mention but patient denies, unknown reaction, but patient denies mucosal involvement, skin desquamation, organ involvement, or need for medical evaluation | use full dose Cephalosporins OR use Penicillin by test dose procedure OR use Carbapenems | |
|
High-risk IR and NIR and reaction during general anaesthesia |
chronology of up to 30 minutes from exposure to reaction and a semiology of urticaria or anaphylaxis. signs and symptoms of anaphylaxis occurrence during general anaesthesia mucous membrane erosions/skin bullae hepatic or renal involvement or cytopenia | If answer is Yes/Uncertain – USE ALTERNATIVE ANTIBIOTIC | |
|
MPE |
measles-like rash or MPE occurring during or within one week of penicillin exposure? | If answer is Yes – USE ALTERNATIVE ANTIBIOTIC (as for high-risk subjects) | |
|
Recurrent acute urticaria |
acute urticaria with or without angioedema during penicillin exposure which reoccurs for several days after treatment is stopped? | If answer is Yes – DELABEL | |
|
Skin involvement during childhood/adolescence |
skin symptoms such as urticaria and MPE only developed during or immediately after stopping penicillin exposure occurring during childhood or adolescence (less than 16 years)? | If answer is Yes – DELABEL | |
|
Complaints and timing not compatible with hypersensitivity |
symptoms reported are not compatible with a hypersensitivity reaction – gastrointestinal symptoms, cephalea, palpitation? chronology between exposure and symptom onset not suggestive of hypersensitivity – urticaria >2 days after the last dose; MPE >7 days after the last dose? | If answer is Yes – DELABEL |