What is the treatment for an allergic rash to cefuroxime (cefuROXime), considering hydrocortisone 200mg?

Treatment of Allergic Rash to Cefuroxime

For a non-severe allergic rash to cefuroxime without systemic symptoms, hydrocortisone 200mg is not the primary treatment—immediate discontinuation of cefuroxime and administration of antihistamines with supportive care is the appropriate management. 1

Immediate Management Steps

Discontinue the Offending Agent

• Stop cefuroxime immediately upon recognition of the allergic rash 1
• The severity and timing of the reaction determines subsequent management—document whether this is an immediate-type reaction (within 1-6 hours) or delayed-type reaction (after 1 hour) 2

Acute Treatment Based on Reaction Severity

For mild to moderate rash (maculopapular, urticarial without systemic symptoms):

• Administer oral antihistamines (H1-blockers) as first-line treatment 1
• Topical corticosteroids may be used for symptomatic relief of localized rash 1
• Systemic corticosteroids like hydrocortisone 200mg are not routinely indicated for isolated cutaneous reactions without systemic involvement 1

For severe reactions with systemic symptoms (anaphylaxis):

• Epinephrine is the first-line treatment for anaphylaxis, not corticosteroids 3, 4
• Cefuroxime can cause anaphylactic reactions with prominent neurologic manifestations (dizziness, altered mental status) even without cutaneous symptoms 3
• Hydrocortisone may be used as adjunctive therapy in anaphylaxis (typically 100-200mg IV) but only after epinephrine administration 4
• Monitor for cardiovascular involvement including hypotension, tachycardia, and even cardiac ischemia, which has been reported with cefuroxime anaphylaxis 5

Important Clinical Pitfalls

Corticosteroid Misuse

• High-dose systemic corticosteroids (like hydrocortisone 200mg) are not indicated as primary treatment for simple drug rashes 1
• Corticosteroids do not prevent progression of IgE-mediated reactions and should never delay epinephrine in anaphylaxis 4

Recognition of Severe Reactions

• Be alert for anaphylaxis presenting primarily with neurologic symptoms (dizziness, confusion) rather than typical cutaneous findings 3
• Cefuroxime-induced anaphylaxis can occur even in patients who previously tolerated the drug 4
• Patients with known penicillin allergy are at higher risk for cefuroxime reactions, though cross-reactivity is not universal 6

Future Antibiotic Selection

Avoid Specific Cross-Reactive Agents

• If the reaction was immediate-type (IgE-mediated), avoid cephalosporins with identical R2 side chains: cefotaxime, cefotetan, cefaclor, ceftibuten, cefadroxil, cephalothin, cefoxitin, cefamandole 1
• The cross-reactivity is based on R1 and R2 side chain similarity, not the beta-lactam ring itself 1

Safe Alternative Cephalosporins

• For non-anaphylactic reactions, cephalosporins with dissimilar side chains (such as ceftriaxone, cefepime) can be administered via direct drug challenge 1
• For anaphylactic histories, negative skin testing should be confirmed prior to administration of any parenteral cephalosporin with a nonidentical R1 side chain 1

Non-Beta-Lactam Alternatives

• Consider fluoroquinolones, macrolides, or other non-beta-lactam antibiotics depending on the indication 1
• These alternatives may result in added patient morbidity, mortality, and cost of care compared to beta-lactams, so careful consideration is warranted 1

Documentation and Follow-up

• Document the exact nature of the reaction (type, timing, severity) in all medical records 1
• Refer to allergy/immunology for skin testing if future cephalosporin use may be necessary 1, 5
• Skin-prick testing is a safe and useful diagnostic tool to confirm immediate drug hypersensitivity to cefuroxime 3
• Structure-activity relationship analysis through skin testing can predict cross-reactivity and guide selection of safe alternative antibiotics 5