Assessment of Antibiotic Allergies

Patient Population: Pediatric

This supplemental section provides guidance on interpreting the "Alternative Therapy" recommendations in the Benioff Children's Hospitals Empiric Antimicrobial Therapy Guidelines for patients with antibiotic allergies, and caring for patients with documented antibiotic allergies: 

  • Many patients report a history of an antibiotic allergic reaction, most commonly to beta-lactam antibiotics (e.g. penicillins or cephalosporins). 
  • In some cases alternative recommendations are provided to help guide therapy when there is concern for a history of allergy that may limit first choice therapy. These alternative recommendations may stratify by characteristics of a patient’s reported previous reaction (“Higher risk” vs “lower risk for allergic reaction”), as well as the class of the labeled antibiotic allergy (penicillin and/or cephalosporin class antibiotics). 
When the guidelines refer to patients with... 
"Higher risk for allergic reaction" "Lower risk for allergic reaction"
This includes patients who report history of reaction including:  This includes patients who report history of reaction limited to: 
  • Hives/urticaria 
  • Angioedema (swelling) 
  • Laryngeal edema 
  • Wheezing / Dyspnea 
  • Hypotension  
  • Treatment with epinephrine  
  • Intubation  
  • Patient unable to give any history due to medical condition (or caregiver unavailable to provide information) 
  • Itching only 
  • Mild, delayed rash (not hives) without internal organ involvement 
  • EMR lists allergy, but patient and/or caregiver do not recall any details about the reaction 

*In addition to the above “higher risk” criteria, patients with the following allergy history suggestive of a Severe Type II-IV Reaction should generally not receive antibiotics of the same class without further evaluation by an allergy or infectious diseases specialist: 

  • Lesions or ulcers involving the mucous membranes; skin desquamation (suggests Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis) 
  • Rash, fever, and lymph node, liver, and/or kidney involvement (suggests Drug Reaction with Eosinophilia and Systemic Symptoms [DRESS] or Drug induced hypersensitivity syndrome [DIHS])
  • Fever, urticarial rash, arthritis (suggests serum sickness) 


While the Empiric Antimicrobial Therapy Guidelines may provide alternative recommendations for antibiotic therapy, it is recommended to evaluate the antibiotic allergy, and take steps to remove the label if appropriate.  

Resources to evaluate beta-lactam antibiotic allergies at UCSF 

The above guidelines are based on the UCSF Inpatient Beta-Lactam Allergy Guideline, which is a comprehensive resource with further guidance for: 

  • Assessing allergy history for level of risk for subsequent reaction 
  • Choosing medications that can be given with or without a test dose procedure, based on prior allergy history.   
  • Guidance for test dose procedure; this is a safe procedure that can be performed on a hospital ward. At BCH, the IP PED Beta Lactam Allergy Test Dose Evaluation orderset should be used 


Referrals and consultations 

  • ​Pediatric ID or Antimicrobial Stewardship teams are available for guidance on addressing a listed allergy vs. choosing alternative therapy 
  • For any patient with a listed antibiotic allergy, consider an outpatient referral to Pediatric Allergy Clinic for delabeling assessment 

Why is assessment of antibiotic allergies important?

Most reactions documented as antibiotic allergies are not true allergies: 

  • Carrying an antibiotic allergy label is common: ~ 10 in 100 people have a labeled beta-lactam allergy (BLA) 
  • The true prevalence of IgE-mediated antibiotic allergy is much lower (estimated ~ 1 in 100 for BLA); most people with a documented BLA could safely receive beta-lactam antibiotics.  
  • Cross-reactivity rates between different beta-lactam antibiotics are low, and patients with true penicillin allergy can still safely receive many cephalosporins and carbapenems (and vice versa) 


Carrying an antibiotic allergy label can be harmful:  

  • For many pediatric infectious conditions, a beta-lactam antibiotic is the first-line therapy. Patients with labeled antibiotic allergies often receive antibiotics that are less effective than first line therapy, and/or have higher toxicity risk and/or cost. 
  • An allergy label placed during childhood may affect care across the lifespan; pediatric clinicians have a special responsibility to apply allergy labels judiciously and remove them when appropriate.  

What can you do to mitigate harm from antibiotic allergy labels?  

Gather careful history on any labeled allergy 

  • Carefully assess the reported reaction to determine consistency with an allergic response. 
  • Ask about and review medication administration history in electronic medical record to see if the patient has tolerated the antibiotic(s) in question in the past.  


Avoid labeling reactions as allergy if not consistent with a true allergic reaction:  

  • Avoid documenting an allergy when signs and/or symptoms are consistent with an anticipated medication side effect such as diarrhea only, nausea only, or a local injection site reaction 
  • Avoid documenting an antibiotic allergy in a patient based on a family history of antibiotic allergy in a relative.  
  • Avoid diagnosing Amoxicillin allergy in patients who develop a delayed maculopapular rash as the only manifestation.


Educate patients and families 


Pediatric Empiric Antimicrobial Therapy Guidelines

This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites. 

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.  

For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK. 

The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.