To the Editor:
With great interest we read the article “The role of penicillin in benign skin rashes in childhood: a prospective study based on drug rechallenge” by Caubet et al.1 The authors studied the etiology of delayed-onset rashes in children treated with β-lactam antibiotics. They state that β-lactam allergy is clearly overdiagnosed. They advise oral provocation in all children suspected of antibiotic allergy, a statement in concurrence with the policy of the European Network of Drug Allergy. The few available studies about children with a suspected antibiotic allergy confirm this. They show that intradermal skin testing can be used to demonstrate a direct hypersensitivity reaction, but not a delayed-onset reaction,2, 3 and confirm a high number of false-negative reactions.3 IgE assays show low sensitivity and specificity.4 Oral provocation tests are considered the golden standard in proving antibiotic allergies.3
We completely agree with Caubet et al. We performed a prospective study with open oral provocation from April 2009 to April 2010 in 33 children (43 tests; age range 10 months to 16.3 years).5 In 7 children, more than 1 antibiotic was tested (test protocol in accordance with Demoly and Bousquet2 and Aberer et al6; see Table I ). Thirty-six test results in 29 children were negative; 6 test results in 4 children were positive. In 1 child, the parents failed to show the skin reactions to us that occurred at home. Only mild skin reactions were seen; 2 children used antihistamines for 1 day to alleviate symptoms. Of the 7 children who were tested for more than 1 antibiotic, 4 did not show reactions to any of them.
Table I.
Test protocol
| Oral provocation test | t = 0 min: skin contact (antibiotic suspension on skin) |
| t = 30 min: lip contact (antibiotic suspension on outside lip) | |
| t = 60 min: mucosal contact (licking a spoon dipped in antibiotic suspension) | |
| t = 90 min: administer dose orally (one third of half-day dose) | |
| t =120 min: administer dose orally (two thirds of half-day dose) | |
| t =180 min: physical examination by doctor (no problems: discharge) | |
| If complaints occur during test: immediate physical examination by doctor |
Therefore, allergy was confirmed only in 14% of the cases where it was suspected. Our results confirm those of Caubet et al. Implementation of these findings has important implications: less use of second-choice antibiotics, less prescription costs, possibly fewer side effects, and smaller chance of creating resistant microorganisms.
Footnotes
Disclosure of potential conflict of interest: The authors declare that they have no relevant conflicts of interest.
References
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