Direct Drug Provocation Testing for the Diagnosis of Low-Risk Pediatric Beta-Lactam Allergy: A Risk-Stratified Retrospective Study

Direct Drug Provocation Testing for the Diagnosis of Low-Risk Pediatric Beta-Lactam Allergy: A Risk-Stratified Retrospective Study | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL Pediatric Allergy and Immunology This is a preprint and has not been peer reviewed. Data may be preliminary. 26 December 2025 V1 Latest version Share on Direct Drug Provocation Testing for the Diagnosis of Low-Risk Pediatric Beta-Lactam Allergy: A Risk-Stratified Retrospective Study Authors : Ozlem Sancakli 0000-0003-2489-4021 [email protected] , Soner GÜNDER 0000-0002-0953-1380 , Aymen HİŞMİOĞULLARI 0009-0005-4516-2948 , Figen Çelebi Çelik 0000-0002-1100-4117 , Canan Ünsal Karkıner , and Demet Can Authors Info & Affiliations https://doi.org/10.22541/au.176674155.59559952/v1 Published Pediatric Allergy and Immunology Version of record Peer review timeline 225 views 94 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background Beta-lactam antibiotics remain the most commonly reported cause of drug allergy in children. Skin testing often shows limited sensitivity and logistical challenges, particularly for non-immediate reactions, leading to the adoption of risk-stratified diagnostic algorithms. This retrospective study evaluated the safety and diagnostic performance of a risk-stratified approach in children with suspected beta-lactam hypersensitivity, focusing on low-risk non-immediate phenotypes. Methods Medical records of 180 children (aged 3–18 years) evaluated for suspected beta-lactam allergy were reviewed. Patients were stratified based on reaction timing and clinical phenotype. Moderate-to-high-risk cases (history of anaphylaxis or immediate reactions) underwent skin testing followed by drug provocation test (DPT) if skin tests were negative. Low-risk cases (mild maculopapular exanthema [MPE] or benign delayed-onset urticaria occurring >6 hours after dosing and lasting >24 hours) underwent direct oral DPT without prior skin testing. Results Beta-lactam hypersensitivity was confirmed in 15.6% (28/180) of patients, with higher confirmation rates in immediate reactions (21.1%) compared to non-immediate reactions (3.5%). Among 57 low-risk non-immediate patients who underwent direct DPT, only 2 (3.5%) experienced mild, self-resolving cutaneous reactions; no systemic or severe reactions were observed. No positive reactions occurred in patients with delayed-onset urticaria (>6 hours post-dose). Conclusion Risk stratification based on detailed clinical history provides a safe and effective strategy for evaluating suspected beta-lactam hypersensitivity in children. Direct oral DPT without preceding skin testing is safe and efficient for low-risk non-immediate phenotypes, including mild MPE and benign delayed-onset urticaria, and should be more widely implemented to facilitate timely delabeling. Direct Drug Provocation Testing for the Diagnosis of Low-Risk Pediatric Beta-Lactam Allergy: A Risk-Stratified Retrospective Study Background Beta-lactam antibiotics remain the most commonly reported cause of drug allergy in children. Skin testing often shows limited sensitivity and logistical challenges, particularly for non-immediate reactions, leading to the adoption of risk-stratified diagnostic algorithms. This retrospective study evaluated the safety and diagnostic performance of a risk-stratified approach in children with suspected beta-lactam hypersensitivity, focusing on low-risk non-immediate phenotypes. Methods Medical records of 180 children (aged 3–18 years) evaluated for suspected beta-lactam allergy were reviewed. Patients were stratified based on reaction timing and clinical phenotype. Moderate-to-high-risk cases (history of anaphylaxis or immediate reactions) underwent skin testing followed by drug provocation test (DPT) if skin tests were negative. Low-risk cases (mild maculopapular exanthema [MPE] or benign delayed-onset urticaria occurring >6 hours after dosing and lasting >24 hours) underwent direct oral DPT without prior skin testing. Results Beta-lactam hypersensitivity was confirmed in 15.6% (28/180) of patients, with higher confirmation rates in immediate reactions (21.1%) compared to non-immediate reactions (3.5%). Among 57 low-risk non-immediate patients who underwent direct DPT, only 2 (3.5%) experienced mild, self-resolving cutaneous reactions; no systemic or severe reactions were observed. No positive reactions occurred in patients with delayed-onset urticaria (>6 hours post-dose). Conclusion Risk stratification based on detailed clinical history provides a safe and effective strategy for evaluating suspected beta-lactam hypersensitivity in children. Direct oral DPT without preceding skin testing is safe and efficient for low-risk non-immediate phenotypes, including mild MPE and benign delayed-onset urticaria, and should be more widely implemented to facilitate timely delabeling. Keywords: beta-lactam allergy; children; drug provocation test; risk stratification; delayed urticaria; penicillin allergy; non-immediate hypersensitivity INTRODUCTION Beta-lactam antibiotics are among the most commonly prescribed medications in children and the leading cause of suspected drug hypersensitivity reactions (DHRs) in this population. 1 In routine clinical practice, benign skin rashes—often linked to concurrent viral infections or drug–virus interactions—are frequently misattributed to drug allergy. 2 Consequently, approximately 10% of children carry a “penicillin allergy” label, although true hypersensitivity is confirmed in fewer than 10% of cases upon proper evaluation. 3,4 This widespread mislabeling results in avoidance of first-line antibiotics, greater use of broad-spectrum alternatives, increased healthcare costs, and accelerated antimicrobial resistance. 5,6 Accurate diagnosis and delabeling are therefore essential elements of effective antimicrobial stewardship. 6 Conventional diagnostic pathways rely on a stepwise approach starting with skin testing followed by drug provocation tests (DPTs). 7-9 However, skin testing in children is painful, time-consuming, technically demanding, and often constrained by the limited availability of commercial reagents. Recent international guidelines recommend risk-stratified protocols based on reaction phenotype and timing, 10 while emerging diagnostic perspectives support simplified strategies such as direct DPT in low-risk pediatric cases. 11 Accumulating evidence confirms the safety and diagnostic utility of direct DPT—without prior skin testing—in non-immediate reactions, particularly mild-to-moderate maculopapular exanthema (MPE). 12,13 The management of delayed-onset urticaria remains less clearly defined, but emerging evidence suggests that direct DPT is safe in benign cases with onset >6 hours after dosing and duration >24 hours. 14 Recent systematic reviews and meta-analyses have confirmed the overall low risk of reaction during direct DPT, although further phenotype-specific validation in pediatric populations is still needed. 14 This study evaluated a risk-stratified diagnostic algorithm in children referred for suspected beta-lactam hypersensitivity, with particular focus on the safety and diagnostic performance of direct DPT in low-risk groups: mild-to-moderate MPE and delayed-onset benign urticaria (onset hours). MATERIALS AND METHODS Study Design This retrospective study was conducted at the Pediatric Immunology and Allergy Outpatient Clinic from January 1, 2022, to December 1, 2025. We reviewed the medical records of children aged 3–18 years who were referred for suspected drug hypersensitivity reactions to beta-lactam antibiotics. The study protocol complied with the ethical principles of the Declaration of Helsinki and was approved by the Institutional Review Board. Written informed consent was obtained from parents or legal guardians before any diagnostic procedures. Study Population Children who underwent a complete diagnostic evaluation—including in vitro assays, skin prick tests (SPT), intradermal tests (IDT), and/or DPT—were included. Exclusion criteria were: uncontrolled asthma, chronic urticaria, or active infection at the time of evaluation; use of interfering medications (e.g., antihistamines or systemic corticosteroids); history of severe cutaneous adverse reactions (SCARs) such as Stevens-Johnson syndrome, toxic epidermal necrolysis, or DRESS; and incomplete medical records (Figure 1). Definitions and Risk Stratification Index reactions were classified according to EAACI recommendations: Immediate reactions: onset within 1 hour (extended to 6 hours for analytical purposes). Non-immediate (delayed) reactions : onset >1 hour (typically >6 hours) after the last dose. 1 A risk-stratified diagnostic algorithm was applied in line with current pediatric guidelines and published evidence: Low-risk group: Non-immediate mild-to-moderate MPE or benign delayed-onset urticaria (>6 hours after dose, duration patients underwent direct DPT without prior skin testing. 4,10 Moderate-to-high-risk group: History of anaphylaxis, immediate urticaria/angioedema, or respiratory/cardiovascular involvement. These patients underwent stepwise evaluation beginning with in vitro and/or skin tests, followed by DPT if preliminary tests were negative. 1,4 Diagnostic Evaluation In Vitro Tests Specific IgE (sIgE) to Penicillin G and Penicillin V was measured in patients with high-risk immediate reactions using a chemiluminescent enzyme immunoassay (Immulite 2000 XPi; Siemens Healthcare Diagnostics, Tarrytown, NY, USA). A level >0.35 kU/L was considered positive, in accordance with the manufacturer’s instructions and validation studies. 15 Skin Tests Skin tests were performed at least 4–6 weeks after the index reaction, following ENDA/EAACI guidelines. 7,16 Commercially available major (penicilloyl-polylysine, PPL) and minor (MDM) determinants (DAP® test, Diater, Spain) were used when available, supplemented by native drugs (e.g., amoxicillin, ampicillin, ceftriaxone) at non-irritating concentrations. Histamine (10 mg/mL) served as the positive control and saline as the negative control. A wheal >3 mm larger than the negative control was considered positive for SPT. For negative SPT results, intradermal testing was performed (0.02–0.05 mL, 3-mm bleb), with a wheal increase considered positive. Drug Provocation Tests (DPT) DPT was conducted as the diagnostic gold standard in a hospital setting equipped with full emergency facilities. 1,16 For immediate or high-risk cases, graded challenges consisted of four incremental doses (1%, 10%, 40%, 50% of the therapeutic dose) administered at 30-minute intervals. For non-immediate or low-risk cases, a two-step protocol (10%, 90%) was used with 30–60 minute intervals. Patients with immediate reactions were observed for at least 2 hours after the final dose; those with non-immediate reactions underwent home monitoring for 3 days (up to 5 days in selected cases), with clear instructions to report any symptoms. 17 A positive DPT required objective signs (urticaria, angioedema, bronchospasm, hypotension, or exanthema); subjective symptoms alone were not considered diagnostic. Statistical Analysis Data were analyzed using IBM SPSS Statistics version 25.0 (IBM Corp., Armonk, NY, USA). Normality was assessed using the Kolmogorov-Smirnov test. Continuous variables are presented as mean ± standard deviation or median (interquartile range), and categorical variables as frequencies and percentages. Group comparisons were performed using the Chi-square or Fisher’s exact test for categorical data and the Student’s t-test or Mann-Whitney U test for continuous data. Potential risk factors for confirmed drug allergy were evaluated using multivariable logistic regression. Variables with a p-value ≤0.20 in univariate analysis were included in the multivariable model. Results are expressed as odds ratios (OR) (Exp[B]) with 95% confidence intervals (CI). A two-sided p-value <0.05 was considered statistically significant for all analyses. RESULTS A total of 180 children evaluated for suspected beta-lactam hypersensitivity were included (90 males [50.0%], 90 females [50.0%]). The mean age at evaluation was 89.5 ± 44.8 months, the mean age at the index reaction was 68.3 ± 44.8 months (median 60 months), and the median interval between the index reaction and evaluation was 21.2 ± 25.2 months. Aminopenicillins were the most frequently implicated agents (81.1%), followed by cephalosporins (13.3%) and penicillins (5.6%). Oral administration predominated (85.0%). Index reactions by timing were distributed as follows: 24.4% within 1 hour, 24.4% between 1 and 6 hours, and 51.1% after 6 hours. The most common clinical manifestations were urticaria (67.2%), MPE (31.7%), and angioedema (10.0%). Anaphylaxis was reported in 5.6% (n=10) of cases (Table 1). Following risk stratification, moderate-to-high-risk patients underwent stepwise evaluation, while low-risk patients received direct DPT without prior skin testing. Drug allergy was confirmed in 28 patients (15.6%) and ruled out in 152 (84.4%). No significant differences were observed between the confirmed and excluded groups in gender (p=0.100), age at evaluation (p=0.804), age at index reaction (p=0.957), or time to evaluation (p=0.614) (Table 2, Figur 2). Confirmed drug allergy was strongly associated with immediate reactions (92.9% vs 63.8%; p=0.002), symptom onset within 6 hours (92.8% vs 40.8%; p<0.001), earlier onset during treatment (1.3 ± 0.6 vs 2.6 ± 2.1 days; p=0.003), urticaria (92.9% vs 62.5%; p=0.002), and angioedema (14.3% vs 2.6%; p=0.006). MPE was significantly more frequent in excluded cases (36.2% vs 7.1%; p=0.002), and reaction duration was shorter in confirmed cases (78.6% lasting <24 hours; p=0.001). The confirmation rate was markedly higher in immediate reactions (21.1%; n=123) than in non-immediate reactions (3.5%; n=57). Skin tests and specific IgE were primarily diagnostic in the immediate group (positivity rates: sIgE 2.4%, SPT 3.2%, IDT 10.0%). In the low-risk non-immediate subgroup (n=57) undergoing direct DPT, only 2 patients (3.5%) experienced mild cutaneous reactions; no systemic reactions occurred. Notably, all patients with symptom onset >6 hours after dosing (n=35) had negative direct DPT results (0% confirmed allergy) (Table 3). In multivariable logistic regression analysis, the route of administration of the culprit drug (OR = 10.38; 95% CI: 2.34–45.92; p = 0.002) and the presence of angioedema (OR = 13.83; 95% CI: 1.55–123.42; p = 0.019) were identified as independent risk factors for confirmed drug allergy. Conversely, basophil percentage was found to be an independent protective factor (OR = 0.03; 95% CI: 0.001–0.80; p = 0.036). Urticaria and the day of reaction onset during treatment were not retained as significant independent predictors in the final model (Table 4). DISCUSSION Beta-lactam antibiotics remain the most commonly prescribed agents in children and the leading reported cause of drug hypersensitivity reactions. However, many labeled cases result from misattribution to concurrent viral exanthems. 1,2 This widespread mislabeling has significant public health implications, including avoidance of first-line antibiotics, greater reliance on broad-spectrum alternatives, increased healthcare costs, and accelerated antimicrobial resistance. 3,5 Our study demonstrates that a risk-stratified diagnostic strategy—employing direct DPT without prior skin testing in low-risk phenotypes (mild MPE and benign urticaria with onset >6 hours post-dose)—is both safe and diagnostically effective. True hypersensitivity was confirmed in only 15.6% of cases, enabling safe delabeling in 84.4%. These findings align with contemporary international guidelines and recent evidence supporting simplified diagnostic algorithms in pediatric populations, including emerging perspectives that highlight the value of DPT risk-based approaches and the reduction of unnecessary skin testing. 11 Confirmation rates of drug allergy differed markedly depending on reaction timing: 21.1% in immediate reactions versus 3.5% in non-immediate reactions. These figures align with reported pediatric ranges of 2–16%. 18 The higher rate observed in the immediate-reaction group is likely attributable to referral bias at our tertiary center. This pattern is consistent with findings from larger pediatric cohorts, such as those reported by Atanaskovic-Markovic et al. and Ponvert et al. (overall confirmation multicenter real-world studies from 2024–2025 continue to demonstrate that the prevalence of true beta-lactam allergy among labeled children is generally below 10%, underscoring the critical role of systematic delabeling in supporting antimicrobial stewardship. 12,13 Among patients with a reported history of anaphylaxis (n=10), the confirmation rate of drug allergy was notably low (20%). Several factors may contribute to this finding, including potential diagnostic confusion with vasovagal syncope and infection-triggered urticaria (which can present with bronchospasm or vomiting) mimicking anaphylaxis. Serum tryptase measurement plays a critical role in confirming anaphylaxis, and it is routinely performed in our center for suspected cases. However, tryptase assessment was not always available in patients referred from other institutions. Upon re-evaluation of the patients initially diagnosed with anaphylaxis but ultimately excluded from drug allergy, two cases were found to have been labeled as anaphylaxis based solely on syncope and hypotension at an external center, where epinephrine was administered without tryptase confirmation. The low confirmation rate in our anaphylaxis cohort may also be partly explained by the natural waning of drug-specific IgE sensitivity over time, as supported by prospective studies (e.g., Ibáñez et al.) and earlier observations (e.g., Blanca et al.). 20,21 In our series, patients with reported anaphylaxis had relatively long intervals between the index event and evaluation. To minimize the risk of false-negative results due to time-dependent loss of sensitization, skin tests were repeated one month after initial negative results in all cases to confirm the absence of drug allergy. Urticaria was the most common clinical presentation (67.2%) and is frequently attributed to antibiotics during concurrent viral illnesses. Caubet et al. have shown that viral–antibiotic interactions or the virus itself are responsible for the majority of benign rashes in this setting, rather than true drug hypersensitivity. 2 In our subgroup of patients with delayed-onset benign urticaria (onset DPT without prior skin testing yielded no reactions, indicating a negligible risk. The conservative >6-hour cutoff was deliberately selected to exclude possible accelerated IgE-mediated reactions (onset 1–6 hours), thereby maximizing safety. These findings are supported by Vyles et al. and recent meta-analyses, which demonstrate that direct challenges are safe in low-risk presentations, with reaction rates below 5% and exclusively mild in nature. 14,17 Our results are further corroborated by 2024–2025 multicenter real-world evidence confirming the safety of direct oral provocation in both low-risk immediate and non-immediate pediatric cases. 13 Direct DPT was well tolerated in patients with mild-to-moderate MPE. In the non-immediate group, only 3.5% of cases developed mild, self-limited cutaneous reactions, with no systemic or anaphylactic events observed. Avoiding skin testing—which is painful, time-consuming, and often resource-intensive in children—improves patient comfort and cost-effectiveness while maintaining both safety and diagnostic accuracy. This approach is supported by Mill et al.’s landmark trial 23 and guideline recommendations from Moral et al. 24 and Pouessel et al. 25 . An increasing number of pediatric studies report DPT positivity rates of 3.4–14% in mild non-immediate reactions—all of which were mild—further positioning direct DPT as the emerging standard for safe and efficient delabeling in low-risk cases. 26 Emerging evidence is increasingly challenging the necessity of traditional stepwise testing, even in cases of mild immediate reactions. While current guidelines still recommend initial skin testing for patients with histories suggestive of immediate-type hypersensitivity, paradigm-shifting studies—such as that by Labrosse et al.—have demonstrated the safety of direct DPT in children with non-severe amoxicillin allergy, with a reaction rate of 20% (all reactions mild). 26 Multicenter data from Ibáñez et al. and Mill et al. report tolerance rates exceeding 94%, with no severe reactions observed; however, the proportion of true immediate-reaction cases in these cohorts remains limited (~10%), warranting continued caution. 20,23 Current EAACI position papers and updated diagnostic algorithms continue to endorse skin testing as the preferred initial step for immediate reactions. Nevertheless, they increasingly acknowledge the potential role of direct challenges in carefully selected low-risk immediate presentations, particularly in light of the progressive decline in skin test sensitivity over time. 7,13,14 In the multivariable logistic regression analysis, parenteral administration of the culprit drug (OR = 10.38; 95% CI: 2.34–45.92; p = 0.002) and the presence of angioedema (OR = 13.83; 95% CI: 1.55–123.42; p = 0.019) were identified as independent risk factors for confirmed beta-lactam allergy. These results are consistent with existing literature. Angioedema is recognized as a high-risk feature in immediate hypersensitivity reactions and is associated with increased likelihood of confirmed allergy in children. 4 Parenteral routes have also been consistently identified as a risk factor in position papers and guidelines, likely due to faster systemic absorption, higher antigen load, and greater potential for severe immune responses compared to oral administration. 7,16 Urticaria and the day of reaction onset during treatment were not retained as significant independent predictors in the final model. These findings emphasize the value of incorporating detailed clinical history—particularly route of administration and presence of angioedema—into risk stratification algorithms. Parenteral exposure and angioedema may serve as practical clinical markers for prioritizing stepwise evaluation over direct provocation in higher-risk pediatric cases. Further prospective studies are warranted to confirm these associations and refine risk-based diagnostic pathways. This study has several limitations, including its retrospective design, single-center setting, and occasional reliance on native drug preparations for skin testing due to intermittent unavailability of commercial reagents. Nevertheless, the consistent use of DPT—the diagnostic gold standard—substantially reduces the likelihood of false-negative results. Despite these constraints, our findings provide valuable additional evidence to the literature, particularly regarding the safety of direct provocation in children with delayed-onset benign urticaria occurring more than 6 hours after dosing. Conclusion Risk stratification based on a thorough clinical history remains the foundation of pediatric beta-lactam allergy evaluation. Direct drug provocation testing without preceding skin tests is safe, efficient, and effective in low-risk non-immediate phenotypes, including mild MPE and benign urticaria with onset >6 hours post-exposure. This approach should be more widely implemented to enable timely and large-scale delabeling. KEY MESSAGE Risk-stratified direct oral drug provocation testing without prior skin testing is safe and effective for delabeling low-risk non-immediate beta-lactam hypersensitivity in children, particularly in cases of mild maculopapular exanthema and benign delayed-onset urticaria (>6 hours post-dose), supporting broader implementation to improve antimicrobial stewardship. REFERENCES 1. Gomes ER, Brockow K, Kuyucu S, et al. Drug hypersensitivity in children: report from the pediatric task force of the EAACI Drug Allergy Interest Group. Allergy. 2016;71(2):149-61.2. Caubet JC, Kaiser L, Lemaître B, et al. The role of penicillin in benign skin rashes in childhood: a prospective study based on drug rechallenge. J Allergy Clin Immunol. 2011;127(1):218-222.3. Romano A, Torres MJ, Castells M, et al. Diagnosis and management of drug hypersensitivity reactions. J Allergy Clin Immunol. 2011;127(3 Suppl):S67-73.4. Romano A, Gaeta F, Arribas Penas MP, et al. Towards a more precise diagnosis of hypersensitivity to beta-lactams - an EAACI position paper. Allergy. 2020;75(6):1300-1315.5. Blumenthal KG, Peter JG, Trubiano JA, et al. Antibiotic allergy. Lancet. 2019;393(10167):183-198.6. Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019;321(2):188-199.7. Blanca-Lopez N, Perez-Alzate D, Agundez JA, et al. An EAACI task force report on allergy to beta-lactams in children: clinical entities and diagnostic procedures. Pediatr Allergy Immunol. 2021;32(7):1426-1436.8. Diaferio L, Parisi GF, Brindisi G, et al. Skin tests are important in children with β-lactam hypersensitivity, but may be reduced in number. Pediatr Allergy Immunol. 2019;30(4):462-468.9. Brockow K, Romano A, Blanca M, et al. General considerations for skin test procedures in the diagnosis of drug hypersensitivity. Allergy. 2002;57(8):690-698.10. Arıkoğlu T, Kuyucu S, Caubet JC. New diagnostic perspectives in the management of pediatric beta-lactam allergy. Pediatr Allergy Immunol. 2022;33(3):e13745.11. Prieto A, Muñoz C, Bogas G, et al. Single-dose prolonged drug provocation test, without previous skin testing, is safe for diagnosing children with mild non-immediate reactions to beta-lactams. Allergy. 2021;76(8):2544-2554.12. Blumenthal KG, Soler AM, Fu X, et al. Reaction Risk to Direct Penicillin Challenges: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2024;184(11):1374-1383.13. Moral L, Toral T, Muñoz C, et al. Direct oral challenge for immediate and non-immediate beta-lactam allergy in children: a real-world multicenter study. Pediatr Allergy Immunol. 2024;35(3):e14096.14. Srisuwatchari W, Phinyo P, Chiriac AM, et al. The safety of the direct drug provocation test in beta-lactam hypersensitivity in children: a systematic review and meta-analysis. J Allergy Clin Immunol Pract. 2023;11(2):506-518.15. Petersen AB, Gudmann P, Mørtz C, et al. Performance evaluation of specific IgE assays on the IMMULITE 2000 system. Clin Chem Lab Med. 2004;42(1):67-7516. Barbaud A, Garvey LH, Chiriac AM, et al. EAACI/ENDA position paper on drug provocation testing. Allergy. 2024;79(3):565-579.17.Vyles D, Adams J, Chiu A, et al. Allergy Testing in Children With Low-Risk Penicillin Allergy Symptoms. Pediatrics. 2017;140(2):e2017047118.Ponvert C, Perrin Y, Bados-Albiero A, et al. Allergy to betalactam antibiotics in children: results of a 20-year study based on clinical history, skin and challenge tests. Pediatr Allergy Immunol. 2011;22(4):411-418.19. Atanaskovic-Markovic M, Gaeta F, Medjo B, et al. Tolerability of cefazolin and ceftibuten in children with IgE-mediated hypersensitivity to penicillins. J Allergy Clin Immunol Pract. 2016;4(5):943-949.20 Ibáñez MD, Rodríguez del Río P, Lasa EM, et al. Prospective assessment of diagnostic tests for pediatric penicillin allergy: from clinical history to challenge tests. Ann Allergy Asthma Immunol. 2018;121(2):235-244.21 Blanca M, Torres MJ, García JJ, et al. Natural evolution of skin test sensitivity in patients allergic to beta-lactam antibiotics. J Allergy Clin Immunol. 1999;103(5 Pt 1):918-924.22. Doña I, Salas M, Bogas G, et al. An algorithm for the diagnosis of beta-lactam allergy, 2024 update. Allergy. 2025;80(2):633-637.23.Mill C, Primeau M-N, Medoff E, et al. Assessing the diagnostic properties of a graded oral provocation challenge for the diagnosis of immediate and nonimmediate reactions to amoxicillin in children. JAMA Pediatr. 2016;170(11):e160033.24. Moral L, Caubet JC. Oral challenge without skin tests in children with non-severe beta-lactam hypersensitivity: time to change the paradigm? Pediatr Allergy Immunol. 2017;28(8):724-727.25. Pouessel G, Winter N, Lejeune S, et al. Oral challenge without skin testing in children with suspected non-severe betalactam hypersensitivity. Pediatr Allergy Immunol. 2019;30(4):488-490.26. Labrosse R, Paradis L, Lacombe-Barrios J, et al. Efficacy and safety of 5-day challenge for the evaluation of nonsevere amoxicillin allergy in children. J Allergy Clin Immunol Pract. 2018;6(5):1673-1680. Table 1. Demographic and Clinical Characteristics of the Study Population (n=180) Gender (Male) 90 (50.0) Age at Evaluation, (months)* 89.5 ± 44.8 Age at Reaction, (months)* 68.3 ± 44.8 Suspected Drug Group Aminopenicillins 146 (81.1) Cephalosporins 24 (13.3) Penicillins 10 (5.6) Route of Administration Oral 153 (85.0) Parenteral 27 (15.0) Clinical Presentation Urticaria 121 (67.2) Maculopapular Exanthema 57 (31.7) Pruritus 44 (24.4) Angioedema 18 (10.0) Anaphylaxis 10 (5.6) Exfoliative Dermatitis 1 (0.6) Time to Reaction Onset 6 hours 92 (51.1) Day of Reaction Onset** 2.0 (1.0.-3.0) Reaction Duration 24 hours 90 (50.0) Reaction Duration ** 1.5 (1.0-3.0) Multiple Antibiotic Use 6 (3.3) Fever at Presentation 49 (27.2) Infection Marker Positivity 21 (11.7) Personal and Family History Atopic Disease 68 (37.8) History of Other Drug Allergy 16 (8.9) Family History of Atopy 61 (33.9) Family History of Drug Allergy 16 (8.9) Laboratory Findings Eosinophils (%)** 2.1 (1.3-4.3) Basophils (%)** 0.5 (0.3-0.6) Total IgE (IU/mL)** 52.7 (19.1-174.0) * Mean ± SD, **Median (IQR) Table 2. Comparison of demographic, clinical, and laboratory characteristics between patients with and without confirmed drug allergy Gender (Male) 72 (47.4) 18 (64.3) 0.100 Age (months)* 88.7 ± 42.7 93.8 ± 55.3 0.804 Age at Reaction (months)* 67.9 ± 43.2 70.4 ± 53.4 0.957 Interval, (months)* (Index Rx-Evaluation) 20.8 ± 24.1 23.4 ± 31.0 0.614 Reaction Classification Immediate Reaction 97 (63.8) 26 (92.9) 0.002 Non-immediate Reaction 55 (36.2) 2 (7.1) Time to Reaction Onset < 1 hour 31 (20.4) 13 (46.4) 6 hours 90 (59.2) 2 (7.1) Reaction Day (Culprit Drug)** 2 (1-3) 1 (1-1) 0.003 Reaction Duration (<24h) 68 (44.7) 22 (78.6) 0.001 Reaction Duration (Days)** 2 (1-3) 1 (1-1) 0.001 Route of Administration Oral 134 (88.2) 19 (67.9) 0.060 Parenteral 18 (11.8) 9 (32.1) Suspected Drug Group Penicillin 6 (3.9) 4 (14.3) >0.05 Aminopenicillin 126 (82.9) 20 (71.4) Cephalosporin 20 (13.2) 4 (14.3) Clinical Findings Urticaria 95 (62.5) 26 (92.9) 0.002 Angioedema 4 (2.6) 4 (14.3) 0.006 Maculopapular Exanthema 55 (36.2) 2 (7.1) 0.002 Anaphylaxis 8 (5.3) 2 (7.1) 0.690 Pruritus 39 (25.7) 5 (17.9) 0.377 Medical History, Comorbidities Concomitant Atopic Disease 57 (37.5) 11 (39.3) 0.858 Chronic Diseases 66 (43.4) 13 (46.4) 0.768 Personal History of Drug Allergy 11 (7.2) 5 (17.9) 0.070 Family History of Atopy 49 (32.2) 12 (42.9) 0.275 Family History of Drug Allergy 12 (7.9) 4 (14.3) 0.275 Other Findings Multiple Antibiotic Use 6 (3.9) - 0.285 Fever at Presentation 41 (27.0) 8 (28.6) 0.861 Infection Marker Positivity 17 (11.2) 4 (14.3) 0.639 Laboratory Findings Eosinophils (%)** 2.2 (1.3-4.3) 1.9 (1.1-3.3) 0.426 Basophils (%)** 0.5 (0.3-0.7) 0.4 (0.2-0.5) 0.015 Total IgE (IU/mL)** 55.0 (19.1-170) 52.1 (23.3-185) 0.681 * Mean ± SD, **Median (IQR) Table 3. Comprehensive Diagnostic Results and Provocation Outcomes Stratified by Reaction Timing Total (n=123) 6 hours* (n=35) Total (n=57) Confirmed Drug Allergy, n (%) 26 (21.1%) 13 (22.8%) 13 (29.5%) - 2 (3.5%) In Vivo and In Vitro Tests, n (%) sIgE positive (n=88) 3 (3.4%) 0 (0%) 3 (6.8%) - - SPT positive (n=85) 3 (3.5%) 1 (2.3%) 2 (4.5%) - - IDT positive (n=82) 9 (10.9%) 5 (11.4%) 4 (9.1%) - - DAP Test Performed (PPL/MDM) 58 (47.2%) 38 (66.7%) 20 (45.5%) - - Drug Provocation Test (DPT), n (%) DPT Performed, 108 (87.8%) 38 (66.7%) 35 (79.5%) 35 (100%) 57 (100%) Reaction During DPT 11 (10.1%) 7 (18.4%) 4 (11.4%) - 2 (3.5%) Time to Reaction in DPT, n (%) 6 hours - - - - 2 (100%) DAP : Diater-PPL/Minor Determinant Mix; DPT : Drug Provocation Test. *Subgroup >6 hours (immediate extension) includes patients with clinical features requiring immediate-type evaluation protocols despite late-onset history. Table 4 . Univariate and multivariable analysis of factors predicting drug allergy Urticaria 7.80 (1.78–34.10) 0.006 Route of administration 3.53 (1.39–8.97) 0.008 10.38 (2.34–45.92) 0.002 Day of reaction onset 0.37 (0.15–0.92) 0.032 Angioedema 6.17 (1.44–26.33) 0.014 13.83 (1.55–123.42) 0.019 Basophil percentage 0.09 (0.01–0.66) 0.018 0.03 (0.001–0.80) 0.036 Figur 1. Study Enrollment flowchart Figur 2. Diagnostic algorithm Information & Authors Information Version history V1 Version 1 26 December 2025 Peer review timeline Published Pediatric Allergy and Immunology Version of Record 1 Apr 2026 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Pediatric Allergy and Immunology Authors Affiliations Ozlem Sancakli 0000-0003-2489-4021 [email protected] TC Saglik Bakanligi SBU Dr Behcet Uz Cocuk Hastaliklari Ve Cerrahisi Egitim Ve Arastirma Hastanesi View all articles by this author Soner GÜNDER 0000-0002-0953-1380 TC Saglik Bakanligi SBU Dr Behcet Uz Cocuk Hastaliklari Ve Cerrahisi Egitim Ve Arastirma Hastanesi View all articles by this author Aymen HİŞMİOĞULLARI 0009-0005-4516-2948 TC Saglik Bakanligi SBU Dr Behcet Uz Cocuk Hastaliklari Ve Cerrahisi Egitim Ve Arastirma Hastanesi View all articles by this author Figen Çelebi Çelik 0000-0002-1100-4117 TC Saglik Bakanligi SBU Dr Behcet Uz Cocuk Hastaliklari Ve Cerrahisi Egitim Ve Arastirma Hastanesi View all articles by this author Canan Ünsal Karkıner TC Saglik Bakanligi SBU Dr Behcet Uz Cocuk Hastaliklari Ve Cerrahisi Egitim Ve Arastirma Hastanesi View all articles by this author Demet Can TC Saglik Bakanligi SBU Dr Behcet Uz Cocuk Hastaliklari Ve Cerrahisi Egitim Ve Arastirma Hastanesi View all articles by this author Metrics & Citations Metrics Article Usage 225 views 94 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Ozlem Sancakli, Soner GÜNDER, Aymen HİŞMİOĞULLARI, et al. 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