Evaluation of diagnostic approach and clinical outcomes in children with suspected beta-lactam allergy

Wang Chin Eileen Ng, Marcus Wing Choy Loe, John Zhong Heng Low, Si Hui Goh, Kok Wee Chong

Affiliations:
¹ Ministry of Health Holdings, Singapore 139691
² Allergy Service, Department of Paediatrics, KK Women’s and Children’s Hospital, Singapore 229899

Abstract

Background: Beta-lactams (BLs) are commonly implicated in hypersensitivity reactions among children. However, majority of self-reported BL allergies may be viral exanthems and antibiotics side effects. International guidelines have recommended de-labelling BL allergies in children with delayed mild hypersensitivity reactions via direct drug provocation tests (DPTs) without prior skin testing. However, studies on the safety of direct DPTs in Asia remain limited.
Objective: Our study aims to describe the diagnostic approach and clinical outcomes in children with suspected BL allergies and evaluate the safety of direct DPTs for children with immediate and delayed mild BL hypersensitivity reactions.
Methods: This is a retrospective cohort study involving 395 children who underwent 425 BL DPTs for suspected BL hypersensitivity reactions, with or without skin testing.
Results: Median age of children at the time of DPT was 8.0 years, with 47.3% being males. The onset of hypersensitivity symptoms was immediate (within one hour from last BL dose) in 21.3% of children, delayed in 30.1% while the remaining had unknown onset. Of the diagnostic direct oral DPTs to index BLs, 89.3% passed and were successfully de-labelled. Majority (88.9%) of challenge reactions in diagnostic direct oral DPTs were mild cutaneous symptoms, except for three cases (8.3%) of cytokine release syndrome and one case of anaphylaxis (2.8%). A younger age at index reaction was the only statistically significant factor associated with passing diagnostic direct oral DPTs.
Conclusion: Direct oral DPT is a safe method for de-labelling BL allergies in children for both immediate and delayed mild hypersensitivity reactions.
Key words: Beta-lactams, anti-bacterial agents, drug hypersensitivity, child, retrospective studies