Antibiotic Skin Testing in Children: A Risk-Stratified Approach

Introduction to Risk-Stratified Approach

The American Academy of Allergy, Asthma, and Immunology recommends that pediatric patients with a history of benign cutaneous reactions to penicillins proceed directly to a single-dose oral amoxicillin challenge without prior skin testing, based on a strong recommendation from the 2022 practice parameter 1, 2

Most children labeled as "penicillin allergic" are not truly allergic, with only 1.98% of children with reported β-lactam allergy having confirmed reactions upon testing, which is substantially lower than the 7.78% rate seen in adults 3, 4, 5
The American Academy of Pediatrics suggests that mild cutaneous reactions only, such as maculopapular exanthem or urticaria without systemic involvement, are low-risk criteria for direct challenge without skin testing 1, 2
Remote reactions, defined as reactions occurring >1 year ago, have a 98.4% negative predictive value for true IgE-mediated allergy, according to the Clinical Microbiology and Infection guidelines 3, 5

The American College of Allergy, Asthma, and Immunology recommends skin testing before challenge in children with severe index reactions, such as anaphylaxis, angioedema, serum sickness-like reactions, or severe cutaneous adverse reactions (SCAR) 3, 5
Recent severe reactions, particularly if <1 year ago and involved systemic symptoms, require skin testing before challenge, as per the Clinical Microbiology and Infection guidelines 3, 4

The Journal of Allergy and Clinical Immunology suggests that for low-risk patients, a single-dose challenge with full therapeutic dose of amoxicillin (or culprit antibiotic) is sufficient, with observation for 60-90 minutes post-administration 1, 2, 7
For moderate-risk patients, a two-step challenge with 1/10 dose followed by full dose, with 30-minute observation between doses, is recommended by the Clinical Reviews in Allergy and Immunology 8

The Clinical Microbiology and Infection guidelines state that a shorter interval since reaction (<1 year) increases odds of true allergy, with cephalosporin reactions having 2.96-fold higher odds of confirmed allergy versus penicillin reactions 3, 4, 5
Severe reactions (anaphylaxis, angioedema) are independently associated with true hypersensitivity, and healthcare-observed reactions are more likely to be confirmed as true allergies, according to the Clinical Microbiology and Infection guidelines 3, 5

After negative testing/challenge, the British Journal of Anaesthesia recommends informing families that the child has the same baseline risk as the general population for developing new penicillin allergy, and removing the "penicillin allergy" label from medical records 9
No routine repeat testing is needed unless a new reaction occurs, and the child can safely receive penicillins orally or intravenously in the future, as per the Journal of Allergy and Clinical Immunology guidelines 1, 2