A guide to The Penicillin Oral Challenge

Settings should be equipped with antihistamines to manage mild reactions and IM epinephrine to manage anaphylactic reactions, as well as standard resuscitation medications and equipment

Our protocol:

For adult patients >10kg, administer 250mg PO amoxicillin followed by 1 hour of monitoring (1)
Monitoring consists of being in the vicinity of the patient such that should they develop symptoms, prompt assessment is possible
If the patient has any immediate reaction suggestive of Type 1 allergy (immediate hives, wheeze, diarrhea, hypotension), epinephrine 0.3mg IM is to be administered to the lateral thigh. If the patient does not improve immediately, another 0.3mg of IM epinephrine should be administered and 911 should be called to arrange transportation to the emergency room
If the patient has mild non-specific symptoms not suggestive of Type 1 allergic reaction (headache, tingling of fingers, nausea), the patient’s observation period will be extended to 2 hours or until resolution of symptoms. If symptoms progress the patient should be treated with epinephrine 0.3mg IM

*This protocol is strictly for use by licensed healthcare providers*

Reference:

Banks TA, Tucker M, Macy E. Evaluating penicillin allergies without skin testing. Curr Allergy Asthma Rep 2019; 19:27.

Next Steps

If no reactions to the amoxicillin is noted, the patient should:

Have their allergy label removed from the hospital and clinic EMR
Have a note added to their EMR indicating successful completion of a penicillin challenge
Receive a note explaining their successful completion of an amoxicillin challenge virtually excludes IgE-mediated allergies, but patients may experience other, benign skin rashes at an incidence similar to the general population
Ensure they notify their home pharmacy of the challenge to remove the allergy
Be provided with an action plan for a possible delayed cutaneous reaction. In these cases, penicillin antibiotics are advised to continue being avoided and the allergy label is to be re-instated on the EMR

Management of Delayed Cutaneous Reaction

Management surrounds re-assurance and symptom control

Typical management includes regular use of non-irritating topical barrier cream (Eucerin, CeraVe, Lipikar etc.)

Medical management includes cetirizine 10 mg PO daily for itch and betamethasone cream 0.1% bid (to areas of redness) should be considered

Additional cetirizine 10-20 mg/day prn (max 40 mg/day) and prednisone 40mg PO daily x 4 days can be used in severe refractory cases

A guide to The Penicillin Oral Challenge

Should my patient receive a challenge?

Next Steps

Management of Delayed Cutaneous Reaction

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