Oral Amoxicillin Challenges in Low-Risk Children During a Pediatric Emergency Department Visit

To evaluate feasibility of completing penicillin (PCN) allergy risk categorization followed by direct amoxicillin challenge in low-risk children during a pediatric emergency department (PED) visit and the effect on length of stay (LOS).

This study included a convenience sample of children (age 2–16 years) with parent-reported penicillin allergy presenting to the PED between December 1, 2017, and December 1, 2018.

Families of eligible patients completed a PCN allergy risk stratifying questionnaire. Those interested in pursuing amoxicillin oral challenge who had low-risk symptoms of allergy and lack of exclusionary conditions were randomized via permutated block randomization to “Oral Challenge” or “No Oral Challenge.” Children randomized to the “Oral Challenge” group received an invariant dose of 500 mg amoxicillin tablet (or 520 mg amoxicillin liquid) followed by a 1-hour observation period and next-day phone follow-up.

Of 376 questionnaires completed, 228 (60.6%) had low-risk symptoms, with 114 (50%) families interested in oral challenge and 82 patients (81.2% of those eligible) ultimately consented for the study. Forty patients were randomized to receive “Oral Challenge” and 42 patients were randomized to the “No Oral Challenge” group. Thirty-seven patients (92.5% of those randomized to challenge) received the challenge and 36 (97.3% of those challenged) tolerated the dose without reaction. One child developed mild urticaria treated with an antihistamine. Twenty-nine children (78.4% of those challenged) completed next-day follow-up and none reported delayed reactions. Compared with controls, the group randomized to oral challenge had increased LOS (216 vs 151 minutes, P < .1).

Addressing PCN allergy in the PED setting is feasible when using direct oral amoxicillin challenge. The health and economic benefits of delabeling PCN allergy offsets the cons associated with increased LOS in the PED.

Given the low prevalence of confirmed PCN allergy in the pediatric population, multiple studies have shown that direct PCN challenge without initial skin testing in low-risk children is safe and effective when performed in a clinical setting prepared to manage adverse events. Previously, the authors found that 100% of children with low-risk symptoms of PCN allergy identified via questionnaire were subsequently able to tolerate amoxicillin oral challenge. In this study, during a PED visit, the authors successfully identified low-risk patients and implemented direct oral amoxicillin challenge. Since ∼30 million children are seen in the PED annually, this strategy would facilitate widespread PCN challenges and delabeling of low-risk patients. Direct oral challenge to penicillin is an effective delabeling strategy for low-risk patients reporting a history of benign rashes who do not have a history of penicillin severe cutaneous adverse reaction, anaphylaxis, or other high-risk features.