Distinct Characteristics and Chronology of Amoxicillin-Associated Reactions in Pediatric Acute Care Settings

Katharine M Guarnieri; Susan S Xie; Joshua D Courter; Chunyan Liu; Richard M Ruddy; Kimberly A Risma

doi:10.1016/j.jaip.2022.07.002

Distinct Characteristics and Chronology of Amoxicillin-Associated Reactions in Pediatric Acute Care Settings

J Allergy Clin Immunol Pract. 2022 Nov;10(11):2951-2957.e3. doi: 10.1016/j.jaip.2022.07.002. Epub 2022 Jul 22.

Authors

Katharine M Guarnieri¹, Susan S Xie¹, Joshua D Courter², Chunyan Liu³, Richard M Ruddy⁴, Kimberly A Risma⁵

Affiliations

¹ Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
² Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³ Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
⁴ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
⁵ Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio. Electronic address: kimberly.risma@cchmc.org.

PMID: 35872212
DOI: 10.1016/j.jaip.2022.07.002

Abstract

Background: Amoxicillin-associated reactions (AARs) in children presenting as rashes are common, and recent data suggest that >90% tolerate amoxicillin on re-exposure. However, additional data would help pediatricians and allergists gain confidence in referring and testing children who experienced systemic symptoms perceived as "worrisome," thus leading to urgent medical evaluations. By characterizing the entire spectrum of AAR symptoms in pediatric patients presenting to emergency department (ED)/urgent care (UC) settings, we sought to increase our diagnostic acumen to guide subsequent allergy evaluations.

Objective: To fully characterize clinical features of rash and systemic symptoms in children presenting to the ED/UC with AARs.

Methods: A retrospective chart review of children seen in the ED/UC from July 1, 2015, to June 30, 2017, was conducted. Clinical features, chronology, and seasonality were detailed, and cases were classified into 3 previously described AAR phenotypes: maculopapular exanthem (MPE), urticaria, and serum sickness-like reactions (SSLRs), if they experienced joint symptoms.

Results: Children (n = 668; median age: 1.8 years) presented to the ED/UC with urticaria (44%), MPE (36%), and SSLRs (11%) typically on days 7 to 10 of amoxicillin. Although children with SSLRs were more frequently treated with corticosteroids (28%, P < .0001) and exhibited higher rates of "worrisome" features (fever, angioedema, or gastrointestinal symptoms; 73%, P < .0001), delayed-onset systemic symptoms were identified frequently in all 3 groups. ED/UC reutilization was unexpectedly high with 66 children (10%) returning to the ED/UC for re-evaluation.

Conclusion: "Worrisome" symptoms are common in children presenting to the ED/UC with AARs. Future studies are needed to determine the impact on subsequent referral and allergy testing.

Keywords: Amoxicillin; Drug allergy; Drug rash; Emergency department; Pediatric; Penicillin; Urgent care.

MeSH terms

Amoxicillin / adverse effects
Drug Eruptions* / diagnosis
Emergency Service, Hospital
Humans
Retrospective Studies
Urticaria*

Substances

Amoxicillin