RHSC

Protocol 8.13

ANTIBIOTIC SKIN TEST AND

CHALLENGE

Antibiotic skin test and challenge

Author(s):Dr Rosie Hague, Maureen
Lilley, Jenny Macdonald
Review: December 2008

Version: 1.2
Authorised by:

Page 1 of 4
Issue Date:

Q-Pulse:

Reviewed: December 2006

RHSC
PROTOCOL 8.13

Women & Childrens Service

Yorkhill Site
Nursing and Midwifery Policy Committee
Protocol No: 8.13
Protocol: Antibiotic Skin Test and Challenge
Statement
As a registered nurse the nurse practitioner is personally accountable for his/her practice and in exercising
accountability may therefore enhance his/her skills by performing antibiotic skin testing and challenge.
The nurse practitioner will work in partnership with medical staff, seeking their co-operation when
necessary to ensure patient needs are met.

Characteristics of the nurse performing antibiotic skin testing and challenge

The nurse practitioner will be deemed competent by:
Demonstrating capabilities with regards to safe and competent practice
Receiving recognised practical training
Having completed the Paediatric Advanced Life Support Course
The nurse practitioner must adhere to the following:
Yorkhill Division Policy on The Scope of Professional Practice
Yorkhill Division Protocol on Management of Anaphylaxis
Yorkhill Division Nursing and Midwifery Medicine Policy
Yorkhill Division Protocol Skin Prick Testing
Nursing and Midwifery Council Standards for Administration of Medicines (2002)

1.

Conditions Under Which Protocol can be used

1.1

No antihistamine should be given 48 hours before. No antibiotic should be given in the 2 weeks
before the test date 2-4 weeks prior to the test date.

1.2

The procedure should be fully explained to the child and parent(s) by the nurse practitioner
carrying out the procedure.

1.3

A named doctor must be informed that the procedure is being carried out.
Medical advice must be sought when necessary.

2
3 1.4
4
5 1.5
6
1.6
7
8 1.7

The child must be well and have no need of antibiotics at the time of testing.
Consent must be obtained by the nurse practitioner/doctor if an oral antibiotic challenge
is indicated.
Medication and resuscitation equipment must be readily available as per Anaphylaxis Protocol.
The referring medical practitioner must prescribe the antibiotics used for testing on a drug kardex.

Practical guidelines are attached for reference and to standardise the quality

Antibiotic skin test and challenge

Author(s):Dr Rosie Hague, Maureen
Lilley, Jenny Macdonald
Review: December 2008

Version: 1.2
Authorised by:

Page 2 of 4
Issue Date:

Q-Pulse:

Reviewed: December 2006

RHSC Protocol 8.13

2.

Antibiotic Skin Testing and Oral Challenge Practice Guidelines

2.1

Principle:

The response provoked by skin prick testing is an IgE mediated response. A positive
skin prick tests results in a wheal, which occurs within 15 minutes after the skin is prick
tested. The resulting weal (size dependent) can help identify whether a child has the
potential to react to an antibiotic and whether or not an oral challenge is indicated.
2.2

Precautions:

The likelihood of systemic manifestations are low however intramuscular Epinephrine

(1:1000) together with other supportive measures must be readily available.
2.3
Equipment required
As per Yorkhill Division Skin Prick Testing Protocol (Protocol 8.2)
2.4

Procedure
The selected site for the test should be either on the forearm or the back of the child being
tested
A ballpoint pen should be used to mark the site(s) were the antibiotic allergen(s) will be placed
together with sites for positive and negative controls.
One drop of the prepared antibiotic solution is placed on the skin using a dropper. If more
than one antibiotic is to be tested they should be placed at least 3mm apart. A positive and
negative control should also be used.
A sterile blood lancet is placed on the skin with the tip in the drop of solution. The tip of the
lancet is then pushed gently into the skin, just enough to make an indent without breaking the
skin. Excess solution should be blotted off with a tissue.
After 15 minutes the results are interpreted

3.

Interpretation of Results

Both weal and erythema are measured and recorded. The reactions are graded according to the Bencard
grading system.
3.1

Results of Skin Prick Testing:

Erythema and Weal Response 5x5mm (>25mm) positive no further testing indicated.
Erythema and Weal Response <5x5mm (25mm) proceed to intradermal test dose
3.2

General Guidelines for Intradermal Test Dose:

Administer an intradermal test dose of 0.02ml of the antibiotic to be tested (1mg/1ml).
After 15 minutes the results are interpreted.

3.3

Results of Intradermal Test Dose:

Erythema and Weal at Injection Site

Erythema and Weal at Injection Site

5x5mm (.25mm) positive allergy to antibiotic tested.

>3x3mm (>9mm) but <5x5mm
(<25mm) borderline positive

If intradermal skin test negative oral challenge indicated

Antibiotic skin test and challenge

Author(s):Dr Rosie Hague, Maureen
Lilley, Jenny Macdonald
Review: December 2008

Version: 1.2
Authorised by:

Page 3 of 4
Issue Date:

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Reviewed: December 2006

RHSC Protocol 8.13

4. Oral challenge following negative Intradermal skin test:
(FOLLOW PROTOCOLS FOR SPECIFIC ANTIBIOTICS)

Weight < Than 40lbs (< 16kgs)

Weight > Than 40lbs (> 16kgs)

125mg of antibiotic tablet orally

250mg antibiotic tablet orally .

*This might not always be the case and depends on the antibiotic. The dose listed above is
used for penicillin V, ampicillin, and erythromycin.

Monitor for 2 hour post challenge. If no reaction, a 5 to 10 day course of the same antibiotic is
administered at home. The child should have an antihistamine to use if symptoms develop
during this time.

References:
Duff, A. L., et al The Relevance of Sensitivity to Allergy Paediatric Clinics
of North America 39:1277 (1992).
Pichichero, M. E., Pichichero, D. Diagnosis of penicillin, amoxicillin and cephalosporin allergy: Reliability of
examination assessed by skin testing and oral challenge The Journal of Paediatrics Jan, 1998, 137-143.
The Scope of Professional Practice UKCC 1992.
Tipton, W. R. Evaluation of Skin Testing in the Diagnosis of IgE-Mediated Disease Paediatric Clinics of
North America 30:785 (1983)

Authors:
Dr Rosie Hague, Consultant in Infectious Diseases and Immunology
Maureen Lilley, Paediatric Advanced Nurse Practitioner
Jenny Macdonald, Pharmacist Medicines Information

Names of Nurses authorised under protocol:

Maureen Lilley, Paediatric Advances Nurse Practitioner
Allison McLaughlin, Paediatric Nurse Practitioner
Ratified:
Head of Nursing
Date:

Review Date: December 2008

Reviewed December 2006
Review December 2008
Antibiotic skin test and challenge
Author(s):Dr Rosie Hague, Maureen
Lilley, Jenny Macdonald
Review: December 2008

Version: 1.2
Authorised by:

Page 4 of 4
Issue Date:

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Reviewed: December 2006