Recommendations for the management of beta-lactam intolerance

Beta-lactam intolerance, most of which is not IgE or even immunologically mediated even though it is commonly called an "allergy," can be safely managed using the following seven steps: 1. Avoid testing, re-challenging, or desensitizing individuals with histories of beta-lactam associated toxic epidermal necrolysis, Stevens-Johnson syndrome, drug reaction with eosinophilia and systemic symptoms syndrome, severe hepatitis, interstitial nephritis, or hemolytic anemia. 2. Avoid unnecessary antibiotic use, especially in the setting of viral infections. 3. Expect new intolerances to be reported after 0.5 to 4% of all antibiotic utilizations, dependent on gender and the specific antibiotic used. 4. Expect a higher incidence of new intolerances in individuals with three or more medication intolerances already noted in their medical records. 5. For individuals with an appropriate penicillin class antibiotic intolerance based on a history of anaphylaxis, urticaria, macular papular rashes, unknown symptoms, or symptoms not excluded in step one, proceed with penicillin skin testing. Skin test with penicilloyl-poly-lysine and native penicillin. If skin test is negative, proceed with an oral amoxicillin challenge. If skin test and oral challenge are negative, penicillin class antibiotics may be used. If skin test or oral challenge is positive, avoid penicillin class antibiotics. If skin test or oral challenge is positive, non-penicillin-beta-lactams may be used, unless there is a history of intolerance to a specific non-penicillin-beta-lactam, then avoid that specific non-penicillin-beta-lactam. If there is life-threatening infection that can only be treated with a penicillin class antibiotic, proceed with oral penicillin desensitization prior to any oral or parenteral penicillin use. 6. For individuals with an appropriate non-penicillin-beta-lactam intolerance, avoid re-exposure to the beta-lactam implicated. An alternative beta-lactam may be used, ideally with different side chains. Penicillin allergy testing is not useful in the management of non-penicillin-beta-lactam intolerance. Non-penicillin-beta-lactam skin testing is not clinically useful and should not be done outside of a research setting. If the non-penicillin-beta-lactam implicated is needed to treat a life-threatening infection, proceed with desensitization. 7. Be ready to treat anaphylaxis with all parenteral beta-lactam use.