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Comment & Response
June 18, 2019

Evaluation of Patients With a History of Penicillin Allergy—Reply

Author Affiliations
  • 1Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
  • 2Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts
JAMA. 2019;321(23):2367. doi:10.1001/jama.2019.4542

In Reply Drs Faitelson and Beigelman raise 2 important issues regarding our review1 related to the use of extended penicillin challenges and the role of penicillin skin testing for patients with low-risk or moderate-risk allergy histories in the context of disseminating these evaluations beyond the realm of allergy specialists.

The first issue concerns the utility of extended oral penicillin challenge (ie, administering a course rather than a dose of penicillin antibiotic) to identify patients who have delayed reactions. While tolerating 1 full penicillin dose excludes IgE-mediated penicillin allergy and is often adequate to trigger a delayed hypersensitivity reaction,2 an extended oral challenge would identify about 5% more reactive patients. This is the same frequency with which patients react on their next indicated penicillin course in the absence of extended challenges after a negative penicillin allergy evaluation result.3 Given that the reactions identified with extended courses are benign and cutaneous and that penicillin antibiotics can increase the risk of Clostridium difficile (also known as Clostridioides difficile) infection4 and antibiotic resistance,5 the authors and professional societies that endorsed the review (the American Academy of Allergy, Asthma, and Immunology, Infectious Diseases Society of America, and Society of Healthcare Epidemiology of America) preferred that these benign reactions occur naturally when penicillin is prescribed for active infections rather than expose so many patients to days of unnecessary antibiotics. Although limited evidence supports the idea that longer courses of antibiotics may improve compliance with future penicillin use in children,6 this idea has been insufficiently evaluated on a scale to justify long, unnecessary antibiotic exposures in millions of individuals.