# Challenging the Efficacy of Routine Antibiotic Skin Testing: Insights From Two Cases of Anaphylaxis

## TL;DR

Two patients had severe allergic reactions to antibiotics despite negative skin tests, suggesting current testing methods may be unreliable.

## Contribution

Highlights limitations of unstandardized antibiotic skin testing and advocates for adopting international guidelines in resource-limited settings.

## Key findings

- Two patients experienced anaphylaxis after negative skin tests for beta-lactam antibiotics.
- Unstandardized skin testing in India has poor sensitivity and cannot reliably predict anaphylaxis.
- International guidelines suggest skin testing should be used selectively, but this is not widely followed in some regions.

## Abstract

This series presents two cases of anaphylaxis following the administration of beta-lactam antibiotics, piperacillin-tazobactam, and cefotaxime in patients who had previously shown negative skin test results. A 32-year-old woman with no history of allergies developed anaphylaxis 15 minutes after receiving piperacillin-tazobactam, despite a negative intradermal test. Similarly, a 48-year-old woman with no prior allergic response experienced anaphylaxis within 10 minutes of cefotaxime administration even after a negative intradermal test. Both patients were successfully treated with epinephrine, fluids, and corticosteroids with close monitoring of further complications. These cases highlight the limitations of preemptive skin testing for antibiotics, a practice still commonly followed in certain healthcare settings in India, despite growing concerns about its predictive reliability and lack of standardization. Unstandardized methods of skin testing, as commonly practiced in India, have poor sensitivity and are unreliable for predicting drug-related anaphylaxis. Furthermore, even small intravenous test doses can trigger severe anaphylactic reactions, underscoring the need for caution during antibiotic allergy testing. According to the European Academy of Allergy and Clinical Immunology (EAACI) and the American Academy of Allergy, Asthma, and Immunology (AAAAI) guidelines, skin testing is recommended only in suspected cases of antibiotic allergy, with diagnostic algorithms tailored to the nature of the reaction. However, these guidelines are not universally followed, particularly in regions where standardized testing resources and training are limited. These cases emphasize the need for standardized indications and protocols for skin testing in India, along with the adaptation of international guidelines to suit India’s unique clinical and healthcare context, potentially serving as a model for other resource-limited countries that face similar challenges.