Appendices
Table A1:
Non-irritating test concentrations for beta-lactam antibiotics (reproduced with
permission from Brockow et al. 2013)
Drug
SPT
IDT
PT
Penicilloyl-poly-L-lysine
5 x 10-5 mM
5 x 10-5 mM
NA
Minor determinant mixture
2 x 10-2 mM
2 x 10-2 mM
NA
Benzylpenicillin
10.000 UI
10.000 UI
5%
Amoxicillin
20 mg/ml
20 mg/ml
5%
Ampicillin
20 mg/ml
20 mg/ml
5%
Cephalosporins
2 mg/ml
2 mg/ml
5%
SPT, skin prick test; IDT, intradermal test; PT, patch test
Table A2:
Examples of increasing drug doses during provocation, modified from
Messaad and colleagues [150]
Drug
Doses1
Route
Usual daily dose for
adults
Amoxicillin
25,100,500,1000
Oral
1000 to 2000mg
Ampicillin
25,100,500,1000
Oral
2000mg
Cefaclor
25,125,500
Oral
750mg
Cefadroxil
25,100,500,1000
Oral
2000mg
Cefuroxime
20,80,400
Oral
500mg
Ceftazidime
25,100,500,2000
IV
3000mg
Cefixime
25,100,225
Oral
400mg
Ceftriaxone
25,100,500,1000
IV
1000-2000mg
1
Messaad and colleagues give a starting dose of 1 and 5 mg, however, current practice is to
start at the higher dose as given in the table.
Table A3: Penicillin oral desensitisation protocol (Adapted from Sullivan [210])
Step
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Penicillin stock
concentration
(mg/ml)
0.5
0.5
0.5
0.5
0.5
0.5
0.5
5
5
5
50
50
50
50
Amount (ml)
Dose (mg)
Cumulative dose
(mg)
0.1
0.2
0.4
0.8
1.6
3.2
6.4
1.2
2.4
5
1
2
4
8
0.05
0.1
0.2
0.4
0.8
1.6
3.2
6
12
25
50
100
200
400
0.05
0.15
0.35
0.75
1.55
3.15
6.35
12.35
24.25
49.35
100
200
400
800
Intervals between doses was 15min
Appendix B: Clinical Audit: Assessment of penicillin allergy
1. Do you undertake beta-lactam allergy testing in your centre?
a. Yes
b. No
2. Which statement(s) best describe why beta-lactam testing is not performed in your
centre?
a. An accurate history is adequate to make a diagnosis
b. Skin testing is inaccurate and therefore not a useful tool
c. Our centre does not have the time or facilities
d. Our centre does not have the financial support
e. Numerous other antibiotics are available
3. How many patients are seen for penicillin testing in an average year?
a. 0-5
b. 6-10
c. 11-20
d. >20
4. What category of patients do you review for penicillin allergy?
a. Adults only
b. Paediatrics
c. Adults and paediatrics
5. Which circumstance best describes why a RAST test would be performed?
a. At all initial consultations
b. Only if history is supportive of allergy
c. Only if history is inconclusive
d. Only if skin testing is negative
e. Only if skin testing is positive
6. Which of the following RAST tests do you perform in your centre? (Please tick as
many choices as appropriate)
a. Penicillin V
b. Penicillin G
c. Amoxycillin
d. Ampicillin
e. Other (please specify)
7. Does your centre perform skin testing?
a. Yes
b. No
8. Would any of the following conditions preclude your centre from performing skin
testing? (Please check multiple conditions if appropriate)
a. Stevens-Johnson Reaction
b. Toxic epidermal necrolysis syndrome
c. Chronic urticaria
d. Atopic dermatitis
e. Dermographism
f. Mastocytosis
9. Does your centre perform the following skin testing methods? (please check multiple
answers if appropriate).
a. Skin prick testing alone
b. Intra-dermal testing alone
c. Skin prick followed by intra-dermal testing if negative or indeterminate skin
prick test
d. Skin prick followed by intra-dermal testing in all cases
e. Patch testing
10. What reagents does your centre use for skin testing?
a. Diater (DPT) penicillin kit
b. In house kit
c. Whole drugs at known non irritant concentrations
11. Which drugs does your centre routinely use for skin prick testing? (Please check
multiple answers if appropriate)
a. Penicillin PPL (major) determinant
b. Penicillin MDM (minor) determinant mix
c. Amoxycillin
d. Benzylpencillin
e. Flucloxacillin
f. Co-amoxiclav
g. Cephalosporin (please specify in other)
h. Other please specify
12. What drugs and concentrations does your centre use for intra-dermal testing? (Please
check the lowest dilution that most closely applies to your regimen assuming the
stated standard doses).
Penicillin PPL (major)
determinant (manufacturer's
instructions)
Penicillin MDM (minor)
determinant
(manufacturer's
instructions)
Amoxycillin 250mg/ml
Benzylpenicillin 100,000
Mu/ml (60mg/ml)
Yes
No
Specify Dose
Yes
No
Specify Dose
Yes
No
Yes
No
Specify Dose
Specify Dose
Other please specify
13. Which of the following questions are true of your intra-dermal test (IDT) practice?
a. IDT performed at one dilution only
b. IDT performed at increasing concentrations, once lower dilution shown to be
negative
c. IDT performed at one dilution and repeated at a lower dilution if positive
14. Has a systemic allergic reaction occurred following skin testing at your centre?
a. Yes
b. No
15. What method of skin testing have reactions occurred to? (please check more than one
choice if appropriate)
a. Skin prick test
b. Intra-dermal test
c. Uncertain
16. How many patients have experienced systemic reactions in the last five years
following skin testing?
a. 0
b. 1-5
c. 6-10
d. >10
17. Which set of symptoms best describe the worst reaction to skin testing in your centre?
a. Grade I: generalized urticaria, mild lip and periorbital swelling, pruritus,
nausea, anxiety
b. Grade II: any grade I symptom plus angioedema, or two or more of the
following: tightness, vomiting, diarrhoea, abdominal cramps, and dizziness
c. Grade III: any grade I or II symptom plus dyspnoea, wheezing, or stridor or
two or more of the following: dysphagia, dysarthria, hoarseness, general
weakness, numbness, or fear of death
d. Grade IV: any grade I, II, or III symptom plus two or more of the following: a
drop in blood pressure, collapse, syncope, incontinence, or cyanosis
e. Death
18. Does your centre perform drug provocation testing (DPT)?
a. Yes, in all patients with no demonstrable specific IgE
b. Yes, but only in 'selected patients' (please briefly describe criteria below)
c. No, I am happy to reassure on the basis of absence of detectable specific IgE
d. No, facilities and resources are not available
Briefly describe criteria:
19. Do you have specific criteria for stopping a direct provocation test?
a. Yes
b. No
20. How does your centre monitor for delayed reactions?
a. Patients are not routinely monitored
b. Routinely review patients in clinic at 48/72 hours
c. Ask the patient to contact clinic if there is a reaction to DPT or IDT
d. Ask the patient to photographically record any reaction to DPT or IDT
e. Patch testing is performed
f. The patient is prescribed a course of drug
g. Other (please specify)
21. Does your centre provide emergency treatment to be taken home in case of an allergic
reaction?
a. Yes
b. No
22. After completing all investigations do you invite patients to return to check for resensitisation?
a. Yes
b. No
23. What procedure(s) do you perform to check for re-sensitisation?
a. Skin prick test
b. Intra-dermal test
c. Drug provocation test
24. What is the interval between initial testing and retesting?
a. <1 month
b. 1-2 months
c. 2-4 months
d. 4-6 months
e. > 6 months
f. Other (please specify)
25. Why does your centre not assess for re-sensitisation?
a. It is unnecessary
b. Resources do not permit re-evaluation
c. Other (please specify)
26. Which drugs do you advise avoiding following a positive test during beta-lactam
testing?
a. All penicillins
b. 1st and 2nd generation cephalosporins
c. All cephalosporins
d. Carbopenems
e. Monobactams
f. Other (please specify)
27. If sensitisation to amoxicillin is demonstrated without specific IgE to penicillin
determinants do you test for tolerance to penicillin by direct provocation testing? (to
determine side chain reactors).
a. Yes
b. No