Cross-Reactivity and Tolerability of Cephalosporins in Patients with Immediate Hypersensitivity to Penicillins

6 July 2004 | Volume 141 Issue 1 | Pages 16-22

Background: In patients with documented IgE-mediated hypersensitivity to penicillins, data on sensitization to cephalosporins vary. Administering cephalosporins to such patients is often deferred because of the risk for cross-reactivity.

Objective: To assess the cross-reactivity with cephalosporins and its potential determinants in patients with documented penicillin allergy.

Design: Prospective study in patients without clinical indications for cephalosporin treatment.

Setting: Italy.

Patients: 128 consecutive patients who sustained anaphylactic shock (n = 81) or urticaria (n = 47) and had positive results on skin tests for at least 1 of the penicillin reagents tested.

Measurements: All patients were skin tested with cephalothin, cefamandole, cefuroxime, ceftazidime, ceftriaxone, and cefotaxime. Patients with negative results for the last 4 cephalosporins were challenged with cefuroxime axetil and ceftriaxone.

Results: 14 patients (10.9% [95% CI, 6.1% to 17.7%]) had positive results on skin tests for cephalosporins, mostly for cephalothin or cefamandole. Skin test results for the minor determinant mixture were positive in 10 of 14 patients (71.4%) with cross-reactivity and 44 of 114 patients (38.6%) without cross-reactivity (odds ratio, 3.90 [CI, 1.17 to 13.40]; P = 0.0189). All 101 patients with negative results on skin tests for cefuroxime, ceftazidime, ceftriaxone, and cefotaxime tolerated cefuroxime axetil and ceftriaxone (tolerability rate, 100% [CI, 96.4% to 100%]).

Limitations: Challenges were not followed by full therapeutic courses. Twenty-two patients declined challenges; positive responses in those patients would have decreased the tolerability rate to 82.1% (CI, 74.2% to 88.4%).

Conclusions: These data confirm the advisability of avoiding cephalosporin treatment in patients with positive results on skin tests for penicillin. In patients who especially require cephalosporin treatment, we recommend skin tests with cephalosporins before assessing the tolerability of the cephalosporin with a graded challenge.

Editors' Notes Context The usefulness of cephalosporin skin tests is not well-defined in patients with a history of penicillin allergy. Contribution These investigators performed cephalosporin skin tests of 128 patients with a history of documented penicillin allergy. About 11% of patients had positive skin test results. Patients with negative skin test results tolerated subsequent challenge doses of cephalosporin without an allergic reaction. Implications Since 10% of patients with documented penicillin allergy also had positive results on skin tests for cephalosporin, physicians should avoid using cephalosporins in such patients unless they have tested these patients for cephalosporin allergy. –The Editors

 

Author and Article Information

From Università Cattolica del Sacro Cuore, Complesso Integrato Columbus, Rome, Italy; Istituto di Ricovero e Cura a Carattere Scientifico, Oasi Maria Santissima, Troina, Italy; Laboratoire de Pathologie Cellulaire et Moléculaire en Nutrition, Institut National de la Santé et de la Recherche Médicale, Vandoeuvre, France; and Centre Hospitalier Universitaire de Nancy-Brabois, Vandoeuvre, France.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Antonino Romano, MD, Unità di Allergologia, Complesso Integrato Columbus, Via G. Moscati, 31-00168 Rome, Italy; e-mail, columbus.romano{at}linet.it.

Current Author Addresses: Professor Romano and Dr. Viola: Unità di Allergologia, Complesso Integrato Columbus, Via G. Moscati, 31-00168 Rome, Italy.

Dr. Guéant-Rodriguez and Professor Guéant: Laboratoire de Pathologie Cellulaire et Moléculaire en Nutrition, Institut National de la Santé et de la Recherche Médicale 0014, Faculté de Médecine, BP 184, F-54500 Vandoeuvre, France and Service de Cardiologie, Centre Hospitalier Universitaire de Nancy-Brabois, F-54500 Vandoeuvre, France.

Dr. Pettinato: Istituto di Ricovero e Cura a Carattere Scientifico, Oasi Maria Santissima, Via Conte Ruggero, 73–94018 Troina, Italy.

Author Contributions: Conception and design: A. Romano, J.-L. Guéant.

Analysis and interpretation of the data: A. Romano, R.-M. Guéant-Rodriguez, M. Viola, R. Pettinato, J.-L. Guéant.

Drafting of the article: A. Romano, R.-M. Guéant-Rodriguez, J.-L. Guéant.

Critical revision of the article for important intellectual content: A. Romano, R.-M. Guéant-Rodriguez, J.-L. Guéant.

Final approval of the article: A. Romano, R.-M. Guéant-Rodriguez, J.-L. Guéant.

Provision of study materials or patients: A. Romano, M. Viola, R. Pettinato.

Statistical expertise: R.-M. Guéant-Rodriguez, J.-L. Guéant.

Administrative, technical, or logistic support: A. Romano.

Collection and assembly of data: A. Romano, M. Viola, R. Pettinato.