Is It Safe to Use

Cephalosporin in a Patient
with Penicillin Allergy??

Joe Lex, MD, FAAEM

Temple University School of Medicine
Philadelphia, PA

Emergency Medicine
Disclosure

Emergency Medicine
Emergency Medicine
 Common Wisdom

“About 10% of patients

who are allergic to
penicillin will have a
cross-reactivity to
cephalosporin.”
Physician’s Desk Reference, 57thth ed.
Emergency 2003
Medicine
 Penicillin Allergy – Kids?
• 298 children with “history of adverse
reaction to oral penicillin”
• Given oral challenge with penicillin
• No severe reactions
• 30 (10%) had slight to moderate
skin rash on 7th to 10th day of
treatment

Graff-Lonnevig V, et al. ArchEmergency

Dis Child. 1988
Medicine
Nov;63(11):1342-6.
 Penicillin Allergy – Kids?
• One to four years after oral
challenge, 222 children
reinvestigated by interview
• 103 / 110 (94%) tolerated penicillin
treatment without adverse reactions
• Conclusion: the term “penicillin
allergy” is often misused

Graff-Lonnevig V, et al. ArchEmergency

Dis Child. 1988
Medicine
Nov;63(11):1342-6.
 Penicillin Allergy – Adults?
• 132 patients who gave history of
immediate reaction to penicillin
• Four patients confirmed to have
penicillin allergy by the radio-
allergosorbent test
• Other 128 had oral penicillin
challenge without ill effect

Surtees SJ, et al. BMJ. 1991 May

Emergency Medicine
4;302(6784):1051-2.
 Meta-Analysis
• History of penicillin allergy: +LR =
1.9 (95% CI, 1.5-2.5)
• No history of penicillin allergy: -LR =
0.5 (95% CI, 0.4-0.6)
• ~ 10% - 20% of patients reporting
history of allergy are truly allergic

Salkind AR, et al. JAMA. 2001 May

Emergency Medicine
16;285(19):2498-505.
 First Conclusion:

Maybe 10% of patients

who say, “I’m allergic to
penicillin” are really
allergic to penicillin
Emergency Medicine
 Is It Important??
• 101 inpatients who claimed
penicillin allergy had skin testing
 92 negative, 5 positive, 4 unsure
• 49% with negative results given
penicillin-based drug
• 48% with negative results given
cephalosporin

Nadarajah K, et al. AnnEmergency

AllergyMedicine
Asthma
Immunol. 2005 Dec;95(6):541-5.
 Is It Important??
• Reduced use of vancomycin by
95% (67/70)
• Reduced use of fluoroquinolones
by 96% (23/24)
• No serious reactions to skin test
• No reaction to penicillin or
cephalosporin if skin test negative

Nadarajah K, et al. AnnEmergency

AllergyMedicine
Asthma
Immunol. 2005 Dec;95(6):541-5.
Is It Safe??

Emergency Medicine
We Don’t Do Skin Testing

You have GOT toEmergency

be jokingMedicine
 But That’s Okay Because…
• Incidence of adverse reactions from
cephalosporins: also 1% to 10%
• Anaphylaxis: fewer than 2 in 10,000
• Post-marketing studies of 2nd and 3rd
generation cephalosporins: no
increase allergic reactions in
patients with penicillin allergy

Anne S, et al. Ann Allergy Asthma Immunol.

Emergency Medicine
1995 Feb;74(2):167-70.
 But That’s Okay Because…
• Penicillin skin tests do not predict
allergy to cephalosporin in patients
with histories of penicillin allergy
• One reaction occurred in 98
patients (1%) with positive skin test
• Six reactions occurred in 310
patients (2%) with negative skin test

Anne S, et al. Ann Allergy Asthma Immunol.

Emergency Medicine
1995 Feb;74(2):167-70.
 Second Conclusion:

Severe reaction to
cephalosporins are
even less common than
penicillin allergies
Emergency Medicine
 The BIG Study
• Retrospective cohort study of huge
database
• United Kingdom General Practice
Research Database
• 3,375,162 patients got penicillin
• 534,810 patients also got
cephalosporin within 60 days

Apter AJ, et al. Am J Med. 2006

Emergency Medicine
Apr;119(4):354.e11.
 3,375,162 got penicillin
534,810 also got cephalosporin within 60 days

ALE within 30 days of No ALE within 30 days

penicillin: 3920 (0.001%) of penicillin: 530,890
Given
Cephalosporin

ALE within 30 ALE within 30

days: 43 (1.1%) days: 581 (0.1%)

ALE = Allergic-like event Emergency Medicine

 Penicillin Cephalo. Same ALE
Reaction type (N=3920) (N=624) after both
Anaphylaxis 25 13 1
Angioedema 106 15 3
Laryngospasm 19 2 0
Urticaria 2904 (74.1%) 461 (73.9%) 30
Erythema
174 24 1
multiforme
TEN 2 1 0
Other derm 13 1 0
Unspecified 677 107 2
 The BIG Study
• Anaphylaxis after penicillin: 25
• Anaphylaxis after cephalosporin: 13
• Anaphylaxis to penicillin followed by
anaphylaxis to cephalosporin: 1
• ALE to penicillin followed by ALE to
cephalosporin: 43
• Number that were urticaria: 30
Apter AJ, et al. Am J Med. 2006
Emergency Medicine
Apr;119(4):354.e11.
 The BIG Study
• 1.1% of the patients who had an
event after penicillin also had an
event after the cephalosporin
BUT…
• 1.6% of the patients who had an
event after penicillin also had an
event after a sulfonamide

Apter AJ, et al. Am J Med. 2006

Emergency Medicine
Apr;119(4):354.e11.
 Final Conclusion:
Any cephalosporin can
safely be given to a
penicillin-allergic patient
who did not have
anaphylaxis
Emergency Medicine