Direct Challenges for the Evaluation of Beta-Lactam Allergy: Evidence and Conditions for Not Performing Skin Testing

Melissa Iammatteo, Guillaume Lezmi, Ronit Confino-Cohen, Mark Tucker, Moshe Ben-Shoshan, Jean Christoph Caubet*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


In the western world, up to 10% of the general population and more than 15% of hospitalized patients report penicillin allergy. After a comprehensive evaluation, more than 95% of patients who report a penicillin allergy can subsequently tolerate this antibiotic. Traditionally, the most widely accepted protocol to evaluate beta-lactam (BL) allergy consisted of skin testing (ST) followed by a drug provocation test (DPT) in ST-negative patients. DPT is the gold standard for proving or excluding BL allergy and is considered the final and definitive step in the evaluation. Recently, studies have been published that support the use of direct DPTs without preceding ST for both pediatric and adult patients who report a low-risk historical reaction to BLs. However, these studies use various risk-stratification criteria to determine eligibility for a direct DPT. A standardized protocol for DPT is also lacking. In this review, we assess the current literature and evidence for performing direct DPT in the pediatric and adult populations. On the basis of this evidence, we also present risk-based algorithms for the evaluation of BL allergy in pediatric and adult populations based on a description of the historical reaction.

Original languageEnglish
Pages (from-to)2947-2956
Number of pages10
JournalJournal of Allergy and Clinical Immunology: In Practice
Issue number8
StatePublished - Aug 2021


FundersFunder number
Food Allergy Canada Healthcare Advisory Board
Aimmune Therapeutics


    • Beta-lactam allergy
    • Drug challenge
    • Drug provocation test
    • Penicillin allergy
    • Skin test


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