Penicillin Drug Allergy Clinical Pathway — All Settings

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Goals and Metrics

Patient Education

Provider Resources

Patient with a reported PCN Allergy
Excluded: Cephalosporin allergy

Only 10% of patients labeled with PCN allergy are actually allergic.
80% of patients that are truly allergic will outgrow this allergy within 10 years.

History & Physical Exam
- Details, Timing of Reaction
- Signs and Symptoms of Possible PCN Allergy

History Not Consistent with PCN Allergy

Family History Only
GI Symptoms
Patient Tolerated Drug Since Initial Reaction

Remove PCN allergy label

History of Severe Cutaneous
Adverse Reaction

History of
All Other Reactions

Low risk for PCN Allergy (benign delayed rash)

Remove PCN allergy label
Give penicillin antibiotic if indicated
Refer to allergy if team or family has additional questions

Steven Johnson Syndrome (SJS)
Toxic Epidermal Necrolysis (TEN)
Drug Reaction w/Eosinophilia and Systemic Symptoms (DRESS)
Erythema Multiforme
Serum Sickness Like Reaction

Including, but not limited to:
- Anaphylaxis
- Wheezing, respiratory distress
- Angioedema
- Hives
- Rash < 3 days after first dose

Maculopapular rash onset ≥ 3 days into course
No hives, pruritus, or other symptoms
Well appearing

Avoid Penicillin

Allergy Clinic Referral

Patients with PCN allergy do not need to avoid most cephalosporins

For inpatients requiring antibiotics, consult allergy
Provide Family with PCN PFE
- Challenge as Clinically Indicated

Severe Cutaneous Reactions
SJS/TEN	Severe reaction with fever, malaise Significant rash follows, ultimately sloughing of the skin Mucosal and ocular involvement ultimately sloughing of the skin
DRESS	Rash Hematologic abnormalities (eosinophilia, atypical lymphocytosis) Lymphadenopathy Internal organ involvement (liver, kidney, lung).
Erythema Multiforme	Rash with target-like lesions, often accompanied by erosions or bullae Involves mucosal surfaces
Serum-Sickness Like Reaction	Rash, fever Polyarthralgias or polyarthritis May appear ill, uncomfortable during the acute febrile stag Self-limited, excellent prognosis once the responsible drug stopped

Posted: February 2019
Revised: September 2021
Authors: J. Lee, MD; S. Swami, MD; R. Grundmeier MD; R. Saltzman MD;C. Tucker MD; R. Tenney-Soeiro, MD;
J. Lavelle MD; J. Gerber MD; R. Stinson, CRNP; T. Brown-Whitehorn, MD; J. Cockerham, RN; M. Russo, MD;
M. Hayes, Pharm.D; V. Scheid, MD; L. Biggs, MD

Evidence

CHOP Programs

Division of Allergy

Related Links

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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