Journal
JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY
Volume 147, Issue 1, Pages 296-308Publisher
MOSBY-ELSEVIER
DOI: 10.1016/j.jaci.2020.04.058
Keywords
Diagnostic accuracy; drug provocation test; IgE quantification; penicillin allergy; skin tests
Categories
Funding
- Portuguese Ministry for Science, Technology and Higher Education (Ministerio da Ciencia, Tecnologia e Ensino Superior), through the Portuguese Foundation for Science and Technology (Fundacao para a Ciencia e a Tecnologia) [PD/BD/129836/2017]
- National Institutes of Health [NIH K01AI125631]
- American Academy of Audiology, Asthma & Immunology Foundation
- Massachusetts General Hospital (MGH) Claflin Distinguished Scholar Award
- Fundação para a Ciência e a Tecnologia [PD/BD/129836/2017] Funding Source: FCT
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The diagnostic accuracy of skin tests and specific IgE quantification in identifying patients reporting a penicillin/B-lactam allergy is low, with low sensitivity and high specificity. More research is needed to assess the role of these tests in stratifying patients for delabeling.
Background: Having a penicillin allergy label associates with a higher risk for antibiotic resistance and increased health care use. Objective: We sought to assess the accuracy of skin tests and specific IgE quantification in the diagnostic evaluation of patients reporting a penicillin/B-lactam allergy. Methods: We performed a systematic review and diagnostic accuracy meta-analysis, searching on MEDLINE, Scopus, and Web of Science. We included studies conducted in patients reporting a penicillin allergy and in whom skin tests and/or specific IgE quantification were performed and compared with drug challenge results. We quantitatively assessed the accuracy of diagnostic tests with bivariate random-effects meta-analyses. Meta-regression and subgroup analyses were performed to explore causes of heterogeneity. Studies' quality was evaluated using QUADAS-2 criteria. Results: We included 105 primary studies, assessing 31,761 participants. Twenty-seven studies were assessed by bivariate meta-analysis. Skin tests had a summary sensitivity of 30.7% (95% CI, 18.9%-45.9%) and a specificity of 96.8% (95% CI, 94.2%-98.3%), with a partial area under the summary receiver operating characteristic curve of 0.686 (I-2 = 38.2%). Similar results were observed for subanalyses restricted to patients reporting nonimmediate maculopapular exanthema or urticaria/angioedema. Specific IgE had a summary sensitivity of 19.3% (95% CI, 12.0%-29.4%) and a specificity of 97.4% (95% CI, 95.2%-98.6%), with a partial area under the summary receiver-operating characteristic curve of 0.420 (I-2 = 8.5%). Projected predictive values mainly reflect the low frequency of true penicillin allergy. Conclusions: Skin tests and specific IgE quantification appear to have low sensitivity and high specificity. Because current evidence is insufficient for assessing the role of these tests in stratifying patients for delabeling, we identified key requirements needed for future studies.
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