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Penicillin Drug Allergy Clinical Pathway – All Settings

Clinical Pathway for the Management of Children
with a Reported Penicillin (PCN) Drug Allergy

Child with a reported Penicillin (PCN) Allergy
Excluded: cephalosporin allergy
Only 5%–10% of children with a PCN allergy label are truly allergic
 
 
 
 
History of Severe Cutaneous
Adverse Reaction
 
  • Steven Johnson Syndrome (SJS)
  • Toxic Epidermal Necrolysis (TEN)
  • Drug Reaction w/Eosinophilia and Systemic Symptoms (DRESS)
 
 
Avoid PCN and cephalosporin
 
 
 
 
 
 
Low Risk for PCN Allergy
(benign delayed rash)
History of
All Other Reactions
  • Family history only
  • GI symptoms only
  • Child tolerated drug since initial reaction
  • Maculopapular rash onset ≥ 3 days into course
  • No hives, pruritus or other symptoms
  • Well-appearing
  • Including, but not limited to:
    • Anaphylaxis
    • Wheezing, respiratory distress
    • Angioedema
    • Hives
    • Rash < 3 days after first dose
    • Erythema multiforme
    • Serum sickness like reaction
 
 
 
 
 
 
Remove PCN Allergy label
  • Remove PCN allergy label
  • Give PCN antibiotic if indicated
  • Refer to allergy if team or family has additional questions
  • For inpatients requiring penicillin antibiotics, consult allergy
  • Provide Family with PCN PFE
Severe Cutaneous Reactions
SJS/TEN
  • Severe reaction with fever, malaise
  • Significant rash follows, ultimately sloughing of the skin
  • Mucosal and ocular involvement ultimately sloughing of the skin
DRESS
  • Rash
  • Hematologic abnormalities (eosinophilia, atypical lymphocytosis)
  • Lymphadenopathy
  • Internal organ involvement (liver, kidney, lung).
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