PRACTICE NAME
Pediatric and Adult Allergy and Clinical Immunology
ADDRESS
Phone: Fax:
E-Mail
PCN Testing for Immediate and Maculopapular rash, delayed type
Patient:_________________________ Date:__________________ Nurse________
SPIRO: complete at baseline, after 1st prick, 2nd prick, and ID testing. FS= full strength
Testing Item and Concentration and
method
Time
On
Time
Read
Induration
Erythema
BP
Pulse
Resp.
First Prick Testing on back
1
2
3
4
5
6
7
8
PPL (PrePen) 1:10 prick
Minor Det Mix 1000 u prick
Benzyl PCN 1000 IU/ml prick
Ampicillin 1.0 mg/ml prick
HISTAMINE 1 MG/ML
CONTROL
Second Prick testing on back
1
2
3
5
6
7
PPL (Pre-Pen) FS prick
Minor Det Mix FS 10,000u Prick
Benzyl PCN 10,000 IU/ml prick
Ampicillin 10 mg/ml prick
Intradermal Testing use .02 ml of
material on forearm
1
2
3
4
7
8
9
10
PPL (Pre-Pen) 1:10 ID
Minor Det Mix 1000u ID
Benzyl PCN 1000 IU/ml ID
Ampicillin 1 mg/ml ID
HISTAMINE 10MG/ML ID
CONTROL ID
Intradermal Testing use .02 ml of
material on forearm
1.
2
3
4
PPL (Pre-Pen) FS ID
Minor Det Mix FS 10,000 u ID
Benzyl PCN 10,000 IU/ml ID
Ampicillin 10 mg/ml ( note not all
use this strong a strength in research)
ID
5
6
Positive for Prick: Wheal >3 mm than control
Positive for ID: Wheal> 5 mm than control
Positive for 48/72 hours : indurated erythema > 5 mm
If needed, add extra testing agent if patient reacted to another product
For Aztreonam, Cephalosporins, other penicillins use Prick .3 mg/ml and 3 mg/ml and .3 mg/ml and 3 mg/ml for
ID use same concentrations. For Imipenem us Prick .1mg/ml and 1 mg/ml and the same for the ID. For Ancef
use 100 microgram/ml, 1000, and 10,000 for prick and then same for ID if this drug was used or needs to be
used. Use these only if the drug they reacted to was not Ampicillin, amoxicillin, or PCN and seemed to be one of
these or related. Also test for the drug that must be or is planed to be used if not the Augmentin, Ampicillin, or
PCN. Note: in USA Amoxicillin is only available as an oral medication, not IV. If required, could dilute
suspension of Amoxicillin with saline to use the same as ampicillin.
48 hrs
72 hrs
PRACTICE NAME
Pediatric and Adult Allergy and Clinical Immunology
ADDRESS
Phone: Fax:
E-Mail
NOTE: Entire procedure should take approximately 3 hours. Allow 3 ½ for good estimate
Vital signs for testing :
Date
Time
BP
Pulse
Respiration
ORAL CHALLENGE IMMEDIATE TYPE
IF PATIENT REACTED WITH IMMEDIATE REACTION TO A PCN OR RELATED DRUG
BASED ON HISTORY:
If above negative proceed to PCN oral Challenge. Use the PCN product closest to the one to which the
patient reacted.
Give PO Challenge :
#1 1:100 full dose and wait 15 minutes
#2 1: 10 full dose and wait 30 minutes
#3 full dose and wait 1 hour
Record vital signs below and obtain final set of VS and Spiro before patient is discharged.
Drug
Dose
Administration Record
Date and time
Nurse
administered
Administered
Comment
Instructions for home:
Continue taking __________________ ____ mg q ____ hours for ____ (5-10) days.
Advised retesting in 4 weeks.
________________________________________________________________
Vital signs for oral challenge
Date
Time
BP
Pulse
Respiration
PRACTICE NAME
Pediatric and Adult Allergy and Clinical Immunology
ADDRESS
Phone: Fax:
E-Mail
ORAL CHALLENGE DELAYED TYPE
PCN CHALLENGE FOR DELAYED MACULOPAPULAR RASH
Name:______________________________________
Use the PCN product closest to the one to which the patient reacted.
Obtain SPIRO before administering drug and before leaving office only if initial history involved
respiratory symptoms. Vital signs at baseline and before discharge each week.
Before start the 5 daily doses after week 3, we need to wait 3 days to see if any delayed reaction occurred
with the 1st 500 mg dose.
PCN Product
Week 1 (2 days
after skin testing)
Week 2
Week 3
After Week 3 dose
if no reaction after
3 days in office ,
take this dose for 5
days.
Amoxicillin
Ampicillin
Benzyl Penicillin
Benazathine
Penicillin
Piperacillin
5 mg PO
5 mg PO
10,000 units IM
12,000 units IM
50 mg PO
50 mg PO
100,000 units IM
120,000 units IM
500 PO
500 PO
1,000,000 units IM
1,200,000 units IM
500 mg
500 mg
10 mg IM
100 mg IM
WAIT in OFFICE
for 30 minutes
WAIT in OFFICE
for 30 minutes
1000mg = 1 gram
IM
WAIT in OFFICE
for 30 minutes
Week
1
2
3
Drug
Administration Record
Dose
Date and time
administered
Lot #
Nurse
Administered
PRACTICE NAME
Pediatric and Adult Allergy and Clinical Immunology
ADDRESS
Phone: Fax:
E-Mail
Vital signs for testing and oral challenge
Date
Time
BP
Pulse
Respiration
To Make Oral challenge dilutions for Delayed Challenge
Week #1
Drug
Augmentin
Stock solution
600mg/5 cc
Final Dose
5 mg
approximately
Augmentin
125 mg/5 cc
5 mg
approximately
How to make
Add 1cc of 600 mg/5 cc (125 mg/cc) suspension to 9
cc water which will make 12.5 mg/cc. Administer .5
cc= 6.5 mg
Add 1 cc 125 mg/5 cc ( 5 mg/cc) to 4 cc of water
which will make 5 mg/cc. Administer 1 cc=5 mg.
Week #2
Drug
Augmentin
Stock solution
600mg/5 cc
Final Dose
50 mg
approximately
Augmentin
125 mg/5 cc
50 mg
approximately
Drug
Augmentin
Stock solution
600mg/5 cc
Augmentin
125 mg/5 cc
Drug
Stock solution
Final Dose
How to make
Drug
Stock solution
Final Dose
How to make
Week #3
Final Dose
600 mg
approximately
500 mg
approximately
How to make
Add 1cc of 600 mg/5 cc (125 mg/cc) suspension to 4
cc water which will make 25 mg/cc/cc. Administer
2.0 cc= 50 mg
Give 2 cc of 125 mg/5cc (25 mg/cc) = 50 mg.
How to make
Give 1 tsp
Give 4 tsp
PRACTICE NAME
Pediatric and Adult Allergy and Clinical Immunology
ADDRESS
Phone: Fax:
E-Mail
Drug
Stock solution
Final Dose
How to make