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Guidelines
β-lactam Allergy Pathway

β-lactam Allergy Pathway

Guideline Use

Guideline intended for use in patients with a history of β-lactam allergy (penicillins, cephalosporins, carbapenems, monobactams) in whom β-lactam antibiotics are indicated.

Consult ID and/or Allergy & Immunology for allergies to other antibiotic classes.

β-lactam Allergy Pathway

Step 1: Complete Allergy History

Step 2: Triage Patient According to β-lactam Allergy Decision Tree

Inpatient Treatment - β-lactam Allergy Decision Tree

β-Lactam Cross-Reactivity Chart (reference for side chain similarities)

Step 3: Select Appropriate Treatment Pathway

  • If patient qualifies for full dose, administer as with any other antibiotic dose and then update documentation below
  • No special monitoring required

If patient does not qualify for or is unable to receive a β-lactam antibiotic via full or test dose, select an alternative agent based on our local disease specific recommendations

Step 4: Update Documentation

Document via chart note the results of the allergy evaluation and actions taken

Allergy labeling should be updated by the floor pharmacist upon completion of the pathway

Additional Information

The recommendations in this guideline were developed in collaboration between NLEMMC Antimicrobial Stewardship, Infectious Diseases, and Allergy and Immunology

  • Rung-Chi Li, DO, Allergy and Immunology
  • Kyle D. Massey, PharmD
  • Rebekah Gass, MD
  • Kelly Sawyer, PharmD

Allergy Pathway

  1. Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. 2010 Oct;105(4):259-273.
  2. Blumenthal KG, Li Y, Hsu JT, et al. Outcomes from an inpatient beta-lactam allergy guideline across a large US health system. Infect Control Hosp Epidemiol. 2019 May;40(5):528-535. Comment: First large multi-center study evaluating an algorithmic approach to direct oral challenges in an inpatient population
  3. Iammatteo M, Alvarez Arango S, Ferastraoaru D, Akbar N, Lee AY, Cohen HW, Jerschow E. Safety and Outcomes of Oral Graded Challenges to Amoxicillin without Prior Skin Testing. J Allergy Clin Immunol Pract. 2019 Jan;7(1):236-243. Comment: Outpatient study demonstrating the inaccuracy of reported penicillin allergies and the safety of direct oral challenge in select patients.
  4. Trubiano JA, Vogrin S, Chua KYL, Bourke J, Yun J, Douglas A, Stone CA, Yu R, Groenendijk L, Holmes NE, Phillips EJ. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med. 2020 May 1;180(5):745-752. Comment: Validation study for the Pen-Fast Test. The Pen-Fast test is design to predict the likelihood of a (+) PCN skin test in a patient.

Cross-Reactivity Chart

  1. Caruso C, Valluzzi RL, Colantuono S, Gaeta F, Romano A. β-Lactam Allergy and Cross-Reactivity: A Clinician's Guide to Selecting an Alternative Antibiotic. J Asthma Allergy. 2021;14:31-46.
  2. Zagursky RJ, Pichichero ME. Cross-reactivity in β-Lactam Allergy. J Allergy Clin Immunol Pract. 2018 Jan-Feb;6(1):72-81.e1.
  3. Kuruvilla M, Wolf F, Sexton M, Wiley Z, Thomas J. Perioperative use of cefazolin without preliminary skin testing in patients with reported penicillin allergy. Surgery. 2019 Feb;165(2):486-496. Comment: A brief letter to the editor re: use of pre/peri-opertaive cefazolin in patients with reported penicillin allergy. It includes several useful references on the topic.