DRUG hypersensitivity reactions are often unpredictable and can arise through immune or non-immune pathways. In children, reported drug allergy rates range from 2.8% to 7.8%, with beta-lactam (BL) antibiotics, particularly penicillins, being the most commonly implicated.
However, confirmed cases of true beta-lactam allergy (BLA) are significantly lower than perceived. Mislabelled drug allergies frequently lead to the use of alternative antibiotics, contributing to resistance, increased healthcare costs, and suboptimal treatment outcomes.
Accurate diagnosis is therefore essential. The PEN-FAST scoring system is commonly used to assess suspected penicillin allergy, but its predictive value in children is limited. In this study, researchers evaluated paediatric patients with suspected penicillin allergy using direct drug provocation tests (DPTs), bypassing skin testing due to limited resources and availability of diagnostic reagents.
Among the children evaluated, DPT positivity was observed in only 5.3% of cases. Importantly, none experienced severe reactions, and all confirmed reactions were limited to the skin. The findings align with recent literature suggesting that in selected cases, particularly those with mild, skin-limited symptoms, direct DPT may be a safe and effective diagnostic approach.
The study also highlighted the diagnostic challenges posed by unreliable histories and overlapping symptoms from infection-related exanthems. Nonetheless, the removal of false allergy labels enabled safe reintroduction of beta-lactams in over 90% of patients, supporting more accurate and effective antibiotic use.
Although limited by its small sample size and retrospective design, the study underscores the potential of direct DPT in paediatric allergy assessment, especially in resource-limited settings. By refining diagnostic pathways and reserving skin testing for high-risk cases, this approach offers a patient-friendly and cost-effective alternative.
Larger, multicentre studies are needed to validate these findings and further define safe, simplified diagnostic protocols for suspected beta-lactam allergies in children. In the meantime, this study provides compelling evidence for re-evaluating current practices to improve care and reduce unnecessary antibiotic avoidance.
Reference
Yağmur H et al. Evaluation of drug provocation tests without prior skin testing in children with suspected penicillin allergy and correlation with PEN-FAST: A single-center study. Eur J Pediatr. 2025;184(8):488.
