Does ceftriaxone (Ceftriaxone) injection require a skin sensitivity test?

From the Guidelines

Ceftriaxone injections typically do not require a skin sensitivity test before administration. This third-generation cephalosporin antibiotic can be given intramuscularly or intravenously without prior skin testing in most patients, as supported by the 2022 practice parameter update on drug allergy 1. However, caution is warranted in patients with a documented history of severe allergic reactions to penicillins or other beta-lactam antibiotics due to potential cross-reactivity.

Key Considerations

• The cross-reactivity rate between penicillins and cephalosporins is estimated to be around 2-4.8% 1, which is lower than previously thought.
• A thorough allergy history should be obtained in patients with suspected beta-lactam allergy, and alternative antibiotics may be considered.
• If ceftriaxone must be used in a patient with suspected but unconfirmed beta-lactam allergy, consultation with an allergist might be appropriate.
• The standard adult dose of ceftriaxone ranges from 1-2 grams once or twice daily depending on the severity and type of infection being treated.
• Healthcare providers should monitor all patients for signs of hypersensitivity reactions during administration, particularly during the first dose, even without prior skin testing.

Skin Testing

• Skin testing may be useful for patients with anaphylactic or convincing histories of IgE-mediated reactions, but its validity and sensitivity are unknown 1.
• The recommended concentrations for skin testing with ceftriaxone are 100 mg/mL for epicutaneous testing and 1 mg/mL and 10 mg/mL for intradermal testing 1.
• A positive cephalosporin skin test suggests drug-specific IgE antibodies, and the patient should receive a skin test–negative alternative cephalosporin or alternate antibiotic, or undergo desensitization 1.

From the Research

Ceftriaxone Injections and Skin Sensitivity Tests

• Ceftriaxone is a third-generation cephalosporin antibiotic, and its use in patients with penicillin allergy has been studied extensively 2, 3, 4.
• According to the available evidence, ceftriaxone has a negligible risk of cross-allergy with penicillins, especially when compared to first-generation cephalosporins 2, 3.
• Studies have shown that the risk of allergic reactions to ceftriaxone in penicillin-allergic patients is low, and it can be prescribed safely for these patients 3, 4.
• The use of skin testing for cephalosporins, including ceftriaxone, has not been well validated, and its predictive value for immediate hypersensitivity is low 5, 6.
• In fact, one study found that the intradermal skin test for cephalosporins had a sensitivity of 0% and a positive predictive value of 0% when challenged with the same drugs that were positive in the skin test 5.

Key Findings

• Ceftriaxone is a safe option for penicillin-allergic patients, with a low risk of cross-allergy 2, 3, 4.
• Skin testing for cephalosporins, including ceftriaxone, is not a reliable predictor of immediate hypersensitivity 5, 6.
• The use of ceftriaxone in penicillin-allergic patients does not require a skin sensitivity test, given its low risk of cross-allergy and the limited predictive value of skin testing 5, 6, 2, 3, 4.