Alternatives for broad-spectrum coverage in penicillin allergy?

From the Guidelines

For a patient with a penicillin allergy requiring broad-spectrum coverage, consider using a non-penicillin antibiotic such as cefepime or a fluoroquinolone like levofloxacin, but with caution due to potential cross-reactivity in some cases, as noted in studies 1. Alternatively, aztreonam can be used for gram-negative coverage, and vancomycin or linezolid for gram-positive coverage.

Key Considerations

• The choice of antibiotic and dosage should be tailored to the specific infection being treated and the patient's renal function, as emphasized in 1.
• It's crucial to assess the severity of the penicillin allergy and consider consulting an allergist or infectious disease specialist for guidance, especially if the patient has a history of severe allergic reactions, as recommended in 1.
• For example, cefepime can be given at a dose of 1-2 grams every 8-12 hours, levofloxacin at 500-750 mg every 24 hours, aztreonam at 1-2 grams every 8-12 hours, vancomycin at 1 gram every 12 hours, and linezolid at 600 mg every 12 hours.

Additional Options

• Other alternatives for broad-spectrum coverage in penicillin allergy include:
  • Cefdinir, cefuroxime, or cefpodoxime, which are highly unlikely to be associated with cross-reactivity with penicillin allergy, as noted in 1.
  • Ciprofloxacin plus clindamycin or aztreonam plus vancomycin, which can be used in patients with a history of immediate-type hypersensitivity reaction to penicillin, as recommended in 1.

From the FDA Drug Label

Vancomycin Hydrochloride for Injection, USP is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant (β-lactam-resistant) staphylococci It is indicated for penicillin-allergic patients, for patients who cannot receive or who have failed to respond to other drugs, including the penicillins or cephalosporins, and for infections caused by vancomycin-susceptible organisms that are resistant to other antimicrobial drugs

• Vancomycin is an alternative for broad-spectrum coverage in penicillin allergy, as it is effective against methicillin-resistant staphylococci and other vancomycin-susceptible organisms 2.
• Cefepime should be used with caution in patients with a history of penicillin allergy, as cross-hypersensitivity among beta-lactam antibiotics has been clearly documented and may occur in up to 10% of patients with a history of penicillin allergy 3 3.

From the Research

Alternatives for Broad-Spectrum Coverage in Penicillin Allergy

• Patients with a reported penicillin allergy often receive broad-spectrum antibiotics, which can increase the risk of antimicrobial resistance and adverse events 4.
• Clinicians should be familiar with which antibiotics are safe to use for different types of penicillin-allergic reactions, and consider antimicrobial therapy with an antibiotic that does not cross-react with penicillins or beta-lactams 5.
• For patients with a low-risk allergy history, a direct amoxicillin challenge may be appropriate, while moderate-risk patients can be evaluated with penicillin skin testing 4.
• The use of a penicillin allergy history algorithm and subsequent penicillin skin testing can be a safe and effective way to transition hospitalized patients from second- to first-line antibiotic therapy 6.
• Meropenem allergy testing can be performed at the bedside of hospitalized patients labeled with a penicillin allergy, and has been shown to be a safe and effective procedure for avoiding the use of second-line antimicrobial agents 7.

Antibiotic Options for Penicillin-Allergic Patients

• Cephalosporins, vancomycin, and fluoroquinolones are commonly used as alternative antibiotics for patients with a penicillin allergy 8.
• However, the use of these broad-spectrum antibiotics can contribute to the development of antimicrobial resistance and increase the risk of adverse events 4, 8.
• Beta-lactam antibiotics may be used safely for patients with unknown or possible penicillin allergy, or those with a drug fever or rash 5.
• Penicillins or beta-lactams should not be used for patients with a history of hives or anaphylactic reactions 5.

Importance of Penicillin Allergy Evaluation

• Evaluation of penicillin allergy before deciding not to use penicillin or other beta-lactam antibiotics is an important tool for antimicrobial stewardship 4.
• Many patients report a penicillin allergy, but few have clinically significant reactions, and the rate of IgE-mediated penicillin allergies is decreasing 4.
• A penicillin allergy evaluation can help to identify patients who can safely receive beta-lactam antibiotics, and reduce the use of broad-spectrum antibiotics 6, 7.