Makindo Medical Notes

Background

🧪 Penicillin allergy is often reported but rarely true: Around 10% of patients claim an allergy, yet <1% are truly allergic. Mislabeling leads to use of broader-spectrum, more toxic, and more expensive antibiotics, increasing risks of antimicrobial resistance and Clostridioides difficile infection.

• 🤔 Many “allergies” are side effects (e.g., nausea, vomiting) or viral rashes (e.g., amoxicillin + EBV infection) — not true allergies.
• ⌛ Sensitivity wanes: 50% lose penicillin allergy in 5 years, 80% in 10 years.
• 👶 Childhood penicillin “allergy” rarely persists into adulthood.
• 🔄 Cross-reactivity with cephalosporins is low (1–2%); most patients tolerate them.
• 🧪 Patients with mild, delayed reactions >10 years ago may be candidates for oral rechallenge under supervision.
• ✅ Careful assessment can often safely remove the penicillin allergy label.
• 💊 β-lactam allergies are the most common immune-mediated drug reactions encountered in clinical practice.

Taking a History of Penicillin Allergy

When a patient reports penicillin allergy, key questions include:

• 📜 Previous Reactions: Which antibiotics caused problems?
• 💊 Tolerated Antibiotics: Any β-lactams tolerated since?
• 🕒 Timing: How long ago did the reaction occur?
• ⚠️ Nature of Reaction: Was it diarrhoea, rash, swelling, breathing difficulty?
• 🎨 Rash Details: What type (maculopapular, urticarial, bullous)? Could it have been viral?
• ⏳ Onset: Minutes/hours (immediate IgE-mediated) vs days (delayed).
• 📍 Reason for antibiotic: Was it for a throat infection, skin infection, etc.?
• 🏥 Severity: Did it need hospitalisation or ICU?
• ✅ Resolution: Did it stop once the drug was discontinued?
• 📚 Sources: Ask patient, carers, GP, and check records.

Risk Stratification

• 🚨 Immediate reactions (minutes–hours, IgE-mediated): urticaria, angioedema, bronchospasm, hypotension, anaphylaxis.
• 📆 Delayed reactions (days–weeks, T-cell mediated): morbilliform rash, serum sickness, Stevens-Johnson syndrome.
• 🔑 Differentiation matters: delayed mild rashes often allow safe future use under supervision.

📝 Exam pearl: Only 1 in 10 patients labelled as penicillin allergic are truly allergic. Always clarify the history before defaulting to alternatives.

Assessment and Management

Understanding β-lactam classification helps guide safe prescribing:

• 🔴 Penicillins: Avoid in true allergy.
• 🟠 Other β-lactams (cephalosporins, carbapenems): Usually tolerated in mild allergy; caution in severe IgE-mediated cases.
• 🟢 Non-β-lactams: Always safe regardless of allergy history.

🌟 Delabelling strategies: Allergy testing (skin/IgE) and supervised oral challenge can safely remove false penicillin allergy labels, improving antibiotic stewardship.

Clinical Consequences of a False Allergy Label

• 💷 More expensive antibiotic prescriptions
• 🦠 Broader-spectrum antibiotics → antimicrobial resistance
• ⚠️ Higher rates of C. difficile infection
• ⏱️ Longer hospital stays & higher complication rates

References

• Penicillin Allergy: A Practical Guide for Clinicians
• Leeds Teaching Hospitals: Assessment and Management of Penicillin Allergy
• NICE CKS: Drug Allergy