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Drug allergy

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Updated 2023 SWAB guidelines for the management of antibiotic allergy.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of drug allergy are prepared by our editorial team based on guidelines from the Dutch Working Party on Antibiotic Policy (SWAB 2023), the American Academy of Allergy, Asthma & Immunology (AAAAI 2022), the British Society for Allergy and Clinical Immunology (BSACI 2015), and the European Academy of Allergy and Clinical Immunology ...
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Diagnostic investigations

Medical history: as per SWAB 2023 guidelines, take into account the time that has elapsed since the index reaction in the estimation of the probability of allergy upon re-exposure to the culprit β-lactam antibiotic. Recognize that the chances of allergic reactions decrease over time.
B
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More topics in this section

  • Drug challenge testing

  • Evaluation of penicillin allergy

  • Evaluation of sulfonamide allergy

  • Evaluation of fluoroquinolone allergy

  • Evaluation of macrolide allergy

  • Evaluation of aspirin allergy

  • Evaluation of abacavir allergy

  • Evaluation of excipient allergy

  • Evaluation of contrast media allergy

Medical management

Re-administration of the culprit drug, penicillins: as per SWAB 2023 guidelines, consider administering the culprit β-lactam antibiotic at a therapeutic dose in a controlled setting in patients with suspected non-severe, immediate-type index reaction that occurred > 5 years ago.
C
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  • Re-administration of the culprit drug (cephalosporins)

  • Re-administration of the culprit drug (non-beta-lactam antibiotics)

  • Drug desensitization (beta-lactams)

  • Drug desensitization (aspirin)

  • Choice of an alternative agent (testing)

  • Choice of an alternative agent (penicillins-cephalosporins)

  • Choice of an alternative agent (penicillins-monobactams/carbapenems)

  • Choice of an alternative agent (cephalosporins-penicillins)

  • Choice of an alternative agent (cephalosporins-monobactams/carbapenems)

  • Choice of an alternative agent (monobactams/carbapenems-penicillins)

  • Choice of an alternative agent (monobactams/carbapenems-cephalosporins)

  • Choice of an alternative agent (analgesics)

Nonpharmacologic interventions

Delabeling drug allergy
As per SWAB 2023 guidelines:
Consider removing the antibiotic allergy label directly without allergy testing in case of any of the following:
the culprit drug has been used since the index reaction without the occurrence of an allergic reaction
the allergy label was solely based on a positive family history of allergy or on fear of allergy
the reported symptoms are not compatible with an allergic reaction (gastrointestinal complaints only, palpitations, and blurred vision)
there was no temporal association between exposure and the onset of symptoms
B
Consider removing the antibiotic allergy label directly without allergy testing in case of any of the following:
the index reaction was not severe, confined to the skin, and occurred in remote adolescence or remote childhood
the patient is not aware of the antibiotic allergy label or cannot recollect clinical signs and symptoms of a reaction at all
C

Preventative measures

Avoidance of the drug, general principles
As per AAAAI/ACAAI/EAACI/iCAALL/ICON/WAO 2014 guidelines:
Advise lifelong avoidance of the drug and cross-reactive drugs in patients with a history of drug-induced anaphylaxis.
B
Provide an indicative, regularly updated list of drugs to avoid and the list of possible alternatives in patients with a history of drug hypersensitivity reaction.
B

More topics in this section

  • Avoidance of the drug (beta-lactams)

  • Avoidance of the drug (cross-reactivity with beta-lactams)

  • Avoidance of the drug (non-beta-lactam antibiotics)

  • Premedication