Should a 10-month-old female child with a mild allergic reaction to the fifth dose of amoxicillin (amoxicillin) continue the remaining doses of her 10-day treatment course, currently dosed at 400mg/5ml twice daily?

From the Guidelines

For a 10-month-old female child experiencing a mild allergic reaction to amoxicillin, I recommend continuing the medication under close supervision, as the reaction is likely a benign cutaneous eruption, which is common in pediatric patients treated with amoxicillin 1.

The current dosing schedule of 400mg/5ml two times a day can be continued for the full 10 days, as the risk of a severe allergic reaction is low, and the benefits of completing the antibiotic course outweigh the risks of a mild allergic reaction. According to the 2022 practice parameter update on drug allergy, a direct amoxicillin challenge without preceding skin tests is recommended for pediatric patients with a history of benign cutaneous reactions, such as maculopapular exanthem or urticarial eruption, not accompanied by systemic symptoms 1.

Key points to consider:

• The reaction is mild and likely a benign cutaneous eruption, which is common in pediatric patients treated with amoxicillin 1.
• The risk of a severe allergic reaction, such as anaphylaxis, is low, and the benefits of completing the antibiotic course outweigh the risks of a mild allergic reaction.
• The healthcare provider should closely monitor the child for any signs of worsening allergic reaction and adjust the treatment plan as needed.
• Formal allergy testing may be considered once the current infection is resolved, but it is not necessary in this case, as the reaction is likely a benign cutaneous eruption 1.

From the FDA Drug Label

If an allergic reaction occurs, amoxicillin should be discontinued, and appropriate therapy instituted. The patient is experiencing a mild allergic reaction to amoxicillin.

• The FDA drug label advises that if an allergic reaction occurs, amoxicillin should be discontinued.
• Therefore, the remaining doses of amoxicillin should not be continued for the full 10 days.
• Appropriate therapy should be instituted instead 2, 2, 2.

From the Research

Allergic Reaction to Amoxicillin

• A 10-month-old female child experienced a mild allergic reaction to the fifth dose of amoxicillin, prompting the question of whether to continue the remaining doses for the full 10 days 3.
• The current dosing schedule is 400mg/5ml two times a day, which is a common regimen for pediatric patients.

Diagnostic Challenges

• Allergic reactions to amoxicillin can present a diagnostic dilemma, as the onset of symptoms can vary and may not always be immediately apparent 3.
• A case series study highlighted the challenges of diagnosing allergic reactions to amoxicillin, particularly in pediatric patients, and emphasized the importance of thorough clinical history and diagnostic testing 3.

Evaluation and Management of Penicillin Allergy

• Approximately 10% of the US population reports an allergy to penicillin, but clinically significant IgE-mediated or T lymphocyte-mediated penicillin hypersensitivity is uncommon (<5%) 4.
• The evaluation and management of penicillin allergy involve assessing the patient's medical history, performing penicillin skin testing, and considering amoxicillin challenge for patients with low-risk allergy histories 4.
• Moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95% and approaches 100% when combined with amoxicillin challenge 4.

Management of Allergic Reactions

• An acute allergic reaction is a rapid-onset, IgE-mediated hypersensitivity reaction that can range from mild urticaria and swelling to respiratory collapse 5.
• The management of allergic reactions and anaphylaxis in the emergency department involves epinephrine, corticosteroids, antihistamines, and other adjunctive therapies, as well as grading of symptoms to determine treatment and disposition 5.

Diagnosis of Non-Immediate Hypersensitivity to Amoxicillin

• Non-immediate hypersensitivity to amoxicillin can be diagnosed using skin tests and drug provocation tests, with a retrospective case-series study showing that 52% of children with suspected non-immediate hypersensitivity to amoxicillin had a definitive diagnosis 6.
• The study highlighted the importance of examining children with mild or moderate reactions, as positive cases may not have significant features and half of the suspected cases may be negative 6.

Implications for Clinical Practice

• Inaccurate reporting of antibiotic hypersensitivities can limit treatment options and result in the use of more expensive antibiotics, contributing to resistance 7.
• A retrospective cohort chart review demonstrated a high prevalence of reported antibiotic sensitivity, with penicillins and sulfonamides being the top two reported adverse reactions 7.
• The study emphasized the need for increased awareness among medical professionals about the importance of detailed history taking and management of self-reported antibiotic allergies to combat unnecessary use of antibiotics 7.