The beta-lactam antibiotic is commonly used in treating ENT infections in childhood. However, its use can be limited by reported hypersensitivity or allergy to the antibiotic. This is largely attributed to the previous development of skin rashes while being on the course. However, it is important to consider that skin manifestations are not uncommon in many childhood diseases instead of solely being reactionary to the antibiotic. Up to 5% of the general paediatric population is considered as beta-lactam allergic. It is worth noting that not all populations undergo appropriate allergy testing, mainly due to fear of a more severe reaction. In a routine work-up, children with a suspicion of non-severe beta-lactam hypersensitivity (BLH) would undergo intradermal tests (IDL). This is a delayed-reading and if negative, the gold standard oral provocation test (OPT) to the index antibiotic is recommended. This article explored the efficacy of IDL in BLH, demonstrating 50% sensitivity and 91.5% specificity. In children who had both IDL and OPT, the positive predictive value of IDL is only 36%. In terms of practicality, IDL can be difficult to interpret and lack in accuracy as well as be painful for children, thus likely to reduce its clinical uptake.
From a safety perspective, a recent study of 818 children with suspected allergy to amoxicillin were tested with a graded OPT and surprisingly, 94% tolerated the challenge, 2% had an immediate reaction and 4% had a non-immediate reaction.
The risk of death from anaphylactic shock after oral administration of amoxicillin in general population is extremely low and an OPT should always be performed in safe clinical settings. Based on the evidence, this rostrum therefore highlighted the possibility of performing oral provocation test in children with non-severe BLH and circumventing the intradermal test. It also maintained that children with anaphylactic reaction should still be assessed with a classical sequential algorithm.
