\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,greek,english]{babel}



\usepackage{float}








\begin{document}

\title{PATTERNS OF RESPONSE AND DRUGS INVOLVED IN HYPERSENSITIVITY REACTIONS TO
BETA-LACTAMS IN CHILDREN.}



\author[1]{Isabel Torres-Rojas}%
\author[1]{Diana Perez}%
\author[1]{Maria Luisa Somoza-Alvarez}%
\author[1]{Elisa Haroun Diaz}%
\author[1]{Ana María Prieto-Moreno Pfeifer}%
\author[2]{Teodorikez Jimenez-Rodriguez}%
\author[3]{Javier Fernandez}%
\author[1]{Miguel Blanca}%
\author[4]{Gabriela Canto}%
\author[1]{Natalia Blanca-Lopez}%
\affil[1]{Hospital Universitario Infanta Leonor}%
\affil[2]{Alicante General University Hospital}%
\affil[3]{Universidad Miguel Hernández}%
\affil[4]{Infanta Leonor Hospital}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Background Beta-lactams generate different allergenic determinants that
induce selective or cross-reactive drug hypersensitivity reactions
(DHRs). We aimed to identify the drugs involved, the selectivity of the
response, the mechanism, and the value of the different diagnostic tests
for establishing a diagnosis in children evaluated for DHRs to
beta-lactams. Methods Prospective study evaluating children aged under
16 years reporting DHRs to beta-lactams. Reactions were classified as
immediate and nonimmediate reactions. The work-up included sIgE, skin
testing and drug provocation tests (DPTs) for immediate reactions and
patch testing and DPTs for nonimmediate ones. Results Of the 510
included children, 133 were evaluated for immediate reactions and
confirmed in 8.3\%. Skin test/in vitro IgE contributed to diagnosing
half of the cases. Selective reactions occurred with amoxicillin (63\%),
followed by common penicillin determinants (27\%) and cephalosporins
(0.9\%). Among nonimmediate reactions (11,4\% of the 377 children
evaluated), most required DPTs, 52.7\% of which were positive at 6--7
days of drug challenge. Selective reactions were identified with
amoxicillin (80\%), penicillin G (7.5\%), cephalosporins (7.5\%), and
clavulanic acid (5\%). Urticaria and maculopapular exanthema were the
most frequent entities. Conclusions There were few confirmed cases of
either type of reaction. Skin testing proved less valuable in
nonimmediate reactions, over half of which would also have been lost in
a short DPT protocol. Selective responders to amoxicillin were more
likely to have nonimmediate reactions, while clavulanic acid-selectivity
was exclusive to the nonimmediate typology. Over half the cases with
DPTs required 6-7 days of treatment for DHR confirmation.%
\end{abstract}%



\sloppy


\textbf{Title} : \textbf{Patterns of response and drugs involved in
hypersensitivity reactions to beta-lactams in children.}

\textbf{Conflict of interest statement:}

The authors declare that there are no conflicts of interest.

\textbf{Financial support:}

This work was supported by grants from the ISCIII (PI20/00771), FEDER
funds, and the national network ARADyAL (RD16/0006/0024;
RD16/0006/0032).

\textbf{Statement of Ethics:}

Ethical approval: The study was approved by our Institutional Ethics
Committee.

Informed consent: a written informed consent was obtained from parents
or guardians of all individual participants included in the study.

\textbf{Background}

Beta-lactams generate different allergenic determinants that induce
selective or cross-reactive drug hypersensitivity reactions (DHRs). We
aimed to identify the drugs involved, the selectivity of the response,
the mechanism, and the value of the different diagnostic tests for
establishing a diagnosis in children evaluated for DHRs to beta-lactams.

\textbf{Methods}

Prospective study evaluating children aged under 16 years reporting DHRs
to beta-lactams.~Reactions were classified as immediate and nonimmediate
reactions. The work-up included sIgE, skin testing and drug provocation
tests (DPTs) for immediate reactions and patch testing and DPTs for
nonimmediate ones.

\textbf{Results}Of the 510 included children, 133 were evaluated for
immediate reactions and confirmed in 8.3\%. Skin test/in vitro IgE
contributed to diagnosing half of the cases. Selective reactions
occurred with amoxicillin (63\%), followed by common penicillin
determinants (27\%) and cephalosporins (0.9\%).

Among nonimmediate reactions (11,4\% of the 377 children evaluated),
most required DPTs, 52.7\% of which were positive at 6--7 days of drug
challenge. Selective reactions were identified with amoxicillin (80\%),
penicillin G (7.5\%), cephalosporins (7.5\%), and clavulanic acid (5\%).
Urticaria and maculopapular exanthema were the most frequent entities.

\textbf{Conclusions}

There were few confirmed cases of either type of reaction. Skin testing
proved less valuable in nonimmediate reactions, over half of which would
also have been lost in a short DPT protocol. Selective responders to
amoxicillin were more likely to have nonimmediate reactions, while
clavulanic acid-selectivity was exclusive to the nonimmediate typology.
Over half the cases with DPTs required 6-7 days of treatment for DHR
confirmation.

\textbf{Key words:} hypersensitivity, betalactams, immediate reaction,
nonimmediate reactions, children.

\textbf{Key Message}

Beta-lactams are the first-line antibiotic to control many bacterial
infections. Traditionally, the most frequently prescribed antibiotic in
children has been amoxicillin, which has been increasingly combined with
clavulanic acid. An accurate diagnosis is essential for avoiding the
prescription of alternative antibiotics which may be less effective,
more toxic. Betalactams drug hypersensitivity reactions are classified
as immediate and nonimmediate, being the last one the most frequent in
children. The aim of our study was to identify the drugs involved, the
selectivity of the response, the mechanism, and the value of the
different diagnostic tests for establishing a diagnosis in children
evaluated for DHRs to BLs. After the allergollogical study we conclude
that only few cases were confirmed of either type of reaction. Skin
testing proved less valuable in nonimmediate reactions, over half of
which would also have been lost in a short DPT protocol. Selective
responders to amoxicillin were more likely to have nonimmediate
reactions, while clavulanic acid-selectivity was exclusive to the
nonimmediate typology. Over half the cases with DPTs required 6-7 days
of treatment for DHR confirmation.

\textbf{Introduction}

Beta-lactams (BLs) are the first-line antibiotic to control many
bacterial infections\textsuperscript{1}. Traditionally, the most
frequently prescribed antibiotic in children has been amoxicillin (AX),
which has been increasingly combined with clavulanic acid (CLAV); in
recent years, this formulation has become the most
dominant\textsuperscript{1-2}. BLs are also the most common inducers of
drug hypersensitivity reactions (DHR) in children. Since systematic
reporting of side-chain-specific reactions to AX were first published in
the late 1980s, diagnosis has required more determinants for evaluating
DHRs\textsuperscript{3}. In many countries, penicillin G
(PG)(benzylpenicillin) is no longer the major determinant, and classical
penicillin determinants yield low sensitivity, making drug provocation
tests (DPTs) necessary for diagnosis\textsuperscript{4}.

The prevalence of DHR in children ranges from 2.5\% to
10.2\%\textsuperscript{5}. More than 10\% of children develop skin
rashes over the course of an antibiotic treatment for a viral infection.
Allergological evaluation confirms that only a few cases are confirmed
allergic\textsuperscript{5,6}, while most skin exanthemas are due to
underlying viral infections or to interactions between drugs and
infectious agents\textsuperscript{5,7,8}.

An accurate diagnosis is essential for avoiding the prescription of
alternative antibiotics which may be less effective, more toxic, and
larger contributors to bacterial resistance. Significant differences
exist between European centers in terms of diagnosing BL
hypersensitivity, particularly in children\textsuperscript{7,9}.
Although consensus protocols have helped to ensure patient safety and
accurate diagnosis, these must be adapted to between-country variations
in both patients' response to BLs and health system capacities for
diagnosis.

BLs DHRs are classified as immediate (IR) and nonimmediate reactions
(NIR)\textsuperscript{10}. IRs usually appear within 1 h after drug
administration and include urticaria, angioedema, rhinitis,
bronchospasm, and anaphylaxis\textsuperscript{11}. NIRs, although
assumed to occur 24-48 h after drug intake\textsuperscript{5}, can
actually occur anytime from 1 h after taking the
medication\textsuperscript{12}. Clinical presentation ranges from mild
reactions, such as nonimmediate urticaria (NIU) and maculopapular
exanthema (MPE), to more severe reactions like acute generalized
exanthematous pustulosis, drug-induced hypersensitivity syndrome,
Stevens-Johnson syndrome, and toxic epidermal necrolysis (13).

The diagnostic approach varies depending on whether the reaction is
immediate (IgE mediated) or nonimmediate (T cell effector response), as
well as the severity, symptoms elicited, and patient risk factors.
Although they have low sensitivity, skin and SIgE testing may have a
role in IR\textsuperscript{12,14}. Several studies support direct DPT
without skin testing (ST), especially in children with mild
NIR\textsuperscript{7,15-17}. However, if the results are positive,
avoidance of the BL involved or all the drug group is controversial
because reactions can be side-chain-specific to AX, cephalosporins, or
another BLs, meaning that a different class of BL could still be
administered\textsuperscript{3,18}.

The aim of our study was to identify the drugs involved, the selectivity
of the response, the mechanism, and the value of the different
diagnostic tests for establishing a diagnosis in children evaluated for
DHRs to BLs.

\textbf{Material and methods}

Patients

This 10-year prospective study (2010-2019) included children aged under
16 years who were referred to our allergy unit for an evaluation of BL
DHR.Reactions were classified as IR or NIR according to established
criteria\textsuperscript{5,10}. For IRs, ST (prick tests and intradermal
tests) were carried out as recommended, with some
modifications\textsuperscript{19}. For NIRs, we also followed the
pediatric adaptation\textsuperscript{5,8,21} of the 2004 general
recommendations made by the European Network for Drug Allergy (ENDA) and
the European Academy of Allergy and Clinical Immunology
(EAACI)\textsuperscript{20}, that is, ST (delayed intradermal tests and
patch tests) followed by DPT when appropriate.

Evaluation of IR

Before ST, SIgE testing was carried out by fluoroimmunoassay (CAP
system, Thermofisher Diagnosis, Uppsala, Sweden R). Results of 0.35
kUA/l or more were considered positive\textsuperscript{11}.

The determinants used for ST were penicilloyl-polylysine (PPL)
(5x10\textsuperscript{-5}mol/l), minor determinant mixture
(2x10\textsuperscript{-2}mol/l), and PG (10\textsuperscript{4}UI/ml). If
negative, we proceeded to the graded administration of penicillin V
until achieving the therapeutic dose\textsuperscript{5,19}. If tolerated
well, we evaluated the response to AX if this drug was involved alone or
in combination with CLAV; if tolerance was still good, we proceeded to
ST with CLAV to test if this was the culprit, and then finally to a DPT
with AX-CLAV. If a cephalosporin was involved, we tested first with
common determinants of PG, and if negative, we proceeded to
cephalosporin (first ST and if negative, DPT when indicated).

DPT was performed in a single-blind, placebo-controlled way as described
elsewhere\textsuperscript{18}, under strict hospital surveillance with
emergency room facilities. We gave escalating doses of the drug at
intervals of 30 min to 60 min until reaching the weight-adjusted
therapeutic dose\textsuperscript{5}. BLs were administered orally at the
following doses: 5 mg, 25 mg, 50 mg, 75 mg, 100 mg, and 250 mg, with a
final observation period of at least 1 h after the last dose
administered.

Evaluation of NIR

Patch testing was performed on the patient's back, as described
elsewhere\textsuperscript{22}. Drugs were mixed in petrolatum 50\% w/w
at a final concentration of 20 mg. Readings were done at 48h and 72h
after patch application, and if negative, patients were recommended to
monitor the patch site to detect any eventual reaction. Due to the very
low sensitivity of the test and the lack of systemic effects in cases
with mild reactions\textsuperscript{5-10}, in most instances all BLs
were tested on the same day. In case of negative results, we proceeded
to DPT as described\textsuperscript{5}. DPT was considered positive if
any objective symptoms indicative of an allergic reaction appeared
during the treatment or within 48h after the last
dose\textsuperscript{5}.

Statistical analysis

A descriptive analysis of clinical characteristics was undertaken, and
mean age, age range, gender distribution, and mean time between reaction
and workup were calculated. The chi-square test was used to compare
qualitative variables between patients with IR versus NIR. P values of
less than 0.05 were considered significant. Mean age was compared using
the Mann-Whitney U test.

\textbf{Results}

A total of 510 children (229 {[}45\%{]} girls; median age 4.3 years
{[}range 0.5 to 16{]}) with a clinical history indicative of BL DHR were
evaluated. Based on clinical history, AX was involved in 349 (68.5\%)
cases, AX-CLAV in 123 (24.1\%), penicillin in 23 (4.5\%), and different
cephalosporins in 15 (2.9\%).

After the allergological workup, 54 cases (10.6\%) were finally
confirmed as allergic. The median time between the reaction and the
allergological study was 30 days (range 1 to 1095). Of the 54 allergic
patients, 30 (55.5\%) were girls, with an age range of 0.5 to 16 years
(mean 6.2), and 42.6\% were atopic. AX produced reactions in 72\% of the
positive cases, AX-CLAV acid in 20.4\%, and cephalosporins in 7.6\%.
When comparing cases finally diagnosed as allergic versus non-allergic,
we did not observe differences in gender or the BL involved, but we
found differences in the mean age (p \textless{} 0.001), which was
higher in cases confirmed as allergic.

Among positive cases, 20.4\% were classified as IRs and the 79.6\% as
NIRs. Figure 1 shows the allergological algorithm with the evaluation of
all cases.

Immediate reactions

Diagnosis of IR was established in 11 of the 133 cases evaluated
(8.3\%), nearly three-quarters (72.7\%) of whom were girls. Reactions
were induced by AX (72.7\%), AX-CLAV (18.2\%), and cephalosporins
(9.1\%).

SIgE was detected in two cases. One patient presented values of sIgE to
AX of 0.37 kU/l; to ampicillin, 0.37 kU/l; to PG, 0.36 kU/l; and to PV,
0.35 kU/l. Another showed sIgE to AX of 0.52kU/l; to ampicillin,
0.49kU/l; to PG, 0.37 kU/l; and to PV, 0.35 kU/l.

Different ST were positive in 4 out of 131 children, all to AX: by prick
test at 20 mg/ml (n = 1), intradermal test at 2 mg/ml (n = 1), and
intradermal test at 20 mg/ml (n = 2).

DPTs were performed in the remaining 127 patients, yielding positive
results in 5 (Table 1), in all cases within 45 minutes or less. Three
cases were positive to AX but showed good tolerance to PG and PV; one
case was positive to PV; and one to cefaclor. Most of the reactions
observed during the DPT were mild (urticaria in 1 case and angioedema in
3 cases), with only one child developing skin involvement plus
bronchospasm and good recovery after treatment. The remaining 122 cases
presented good tolerance to AX or another culprit BL until reaching
therapeutic doses.

Is summary, of the total 8.3 \% positives cases within this group SIgE
contributed to the diagnosis in the 1.5\%, ST with all the determinants
in the 3\% and DPT in the 3.7\%. Selective reactions occurred with AX
(63\%), followed by common penicillin determinants (27\%) and
cephalosporins (0.9\%).

Nonimmediate reactions

Of 377 patients evaluated for NIRs, diagnoses were confirmed in 43
(11.4\%). Half (51\%) were girls, and 39.5\% atopic. The BLs involved
were AX (72\%), AX-CLAV (21\%) and cephalosporins (7\%).

Severe reactions were reported in three cases (one acute generalized
exanthematous pustulosis, one exudative erythema multiforme, and one
drug-induced hypersensitivity syndrome). Patients were diagnosed based
on their clinical history; neither ST nor DPT were carried out because
of the risks.

Except for the three patients with severe reactions, patch testing was
carried out in all other children evaluated (n = 374). Two were positive
to AX, one to PG, and one to cefotaxime.

A controlled DPT was performed in 370 children, yielding positive
results in 36 cases (9.7\%) (Table 2). Thirty cases were positive to AX,
all with good tolerance to PV; two were positive to CLAV, with good
tolerance to PV and AX; two were positive to PV; one to cefaclor, and
one to cefixime. These latter two cases both showed good tolerance to PV
and to AX.

Clinical entities induced by DPT included NIU in 21 (58.3\%) cases (plus
angioedema in 5), and MPE in 15 ( 41.6\%)(See table 2). In all cases a
full therapeutic dose was required to elicit a response. However, when
we analyzed the interval from drug administration to reaction, there was
a clear divergence: 30\% of the positive cases presented a reaction
within 24 h, while 52.7\% responded only at day 6 or 7 (Figure 2). Less
than 10\% of positives started showing symptoms between days 2 and 5.

Is summary, of the total 11.4\% positives cases within this group ST
contributed to the diagnosis in the 1.1\% and DPT in the 9.5\%.
Selective reactions were identified with AX (80\%), PG (7.5\%),
cephalosporins (7.5\%), and CLAV (5\%). NIU and MPE were the most
frequent entities.

\textbf{Discussion}

This study included a large cohort of children referred to our center
for BL allergy evaluation. We followed the classification of IR versus
NIR, as initially reported by Terrados et al.\textsuperscript{10} and
used extensively in the literature\textsuperscript{8,16,18,21-25}.

Of the total patients evaluated, 10.6\% were confirmed as allergic, most
of whom were diagnosed by DPT. This proportion is lower than that
reported by Ponvert et al.\textsuperscript{21}, but consistent with
other studies\textsuperscript{8,16,18,24}.

Regarding the drugs involved, AX was implicated in 68.5\% of the cases
and AX-CLAV in 24\%, very similar to results reported
elsewhere\textsuperscript{16}. Penicillin and cephalosporins accounted
for 4.5\% and 3\% of the positive cases, respectively. Of interest is
the important role of AX-CLAV, coherent with the high pattern of
prescription\textsuperscript{1,2}. The reported involvement of this
formulation in DHR has changed from 12\%\textsuperscript{8} to over 70\%
in recent years\textsuperscript{15,22,23}. Considered less immunogenic
than other BLs\textsuperscript{26}, its contribution to both IR and NIR
in adults has been reported\textsuperscript{27}.

The proportion of confirmed IRs was 8.3\%, with positive ST or SIgE
contributing in the 5.4\%. These values are lower than the 17\% reported
by Iba\selectlanguage{ngerman}ñez et al.\textsuperscript{16} but higher than the results
observed by Mill et al.\textsuperscript{28} One study even reported a
proportion of 86\% positive ST\textsuperscript{21}, but these data have
not been supported by other studies\textsuperscript{8,16,23}.

Regarding the different BLs, 63\% of cases were selective reactors to
AX, with no contribution from CLAV. This result contrasts with other
studies published in adults, where 22\% of participants were selective
responders to CLAV\textsuperscript{27}.

Although AX was involved in 92.5\% of the cases initially evaluated,
27\% of the confirmed responders belonged to the common group of
penicillin reactor. The contribution of cephalosporins was less than
1\%.

Symptoms suggestive of a NIR were reported in 377 cases, nearly 80\% of
the cases evaluated. Three cases with a severe reaction were diagnosed
based on the clinical history. ST were positive in 1\% of cases (2 cases
to AX, 1 to PG and 1 to a cefotaxime). CLAV did not induce any positive
ST. DPT was needed for confirmation in 36 of the 43 cases (83\%) finally
classified as positive. In total, considering all cases diagnosed based
on clinical history, ST or DPT, the final proportion of positive NIRs
was 11.4\%. In our study, 52\% of positive DPTs induced urticaria, with
or without angioedema, while this reaction occurred in 72\% of positive
cases in the study by Ibañez et al.\textsuperscript{16} and 64\% of
cases included in Mori et al.'s report\textsuperscript{25}. Data on the
frequency of MPE versus NIU are variable in the literature. In large
series like ours, the proportion of MPE reactions ranges anywhere from
18\% to 80\%\textsuperscript{15,18,22} which is in line with the 41.6\%
we observed in our study.

The interval between drug administration and symptoms onset was under an
hour in IR, similar to what occurs in adults, although the dose required
for eliciting a response was higher in children after correcting it for
body weight\textsuperscript{29}.

In NIRs, the analysis of the time required for inducing a positive DPT
showed two response patterns. Up to a third of the cases were diagnosed
on the first day, but over half the diagnoses required 6 or 7 days,
which suggests that a 5-day protocol, as reported by some
groups\textsuperscript{13,17,24}, will miss an important number of
positive cases. Other studies have also supported periods longer than 5
days\textsuperscript{26,27}. In order to reconcile results from the
different groups, responders with NIRs may fall into two broad groups,
those responding early and those with a later response. This time
interval is independent of the clinical entity induced (MPE or NIU), as
shown in our work.

In NIRs, the role of selective responders to AX seems more relevant than
in IRs, since 83\% of cases with NIRs were selective in contrast with
63\% of cases in IR. These data are similar to those reported in
adults\textsuperscript{10}.

One limitation of this study, as in other similar ones, is the lack of
comparison between children showing a reaction at 2-3 days versus 5 days
or longer. The low prevalence of allergy to BLs in children complicates
this analysis. Also, we used patch testing, as done by other
authors\textsuperscript{30,31} although there are studies suggesting
that intradermal testing is more sensitive\textsuperscript{8,26}.

Summarizing, after prospectively evaluating a large series of children
with DHRs to BLs, we confirmed the diagnosis in 8.3\% of the children
assessed for IRs and 11,4\% of those assessed for NIRs. Overall, NIRs
were more frequent and had a higher proportion of selective responders.
Moreover, reactions to CLAV were exclusively NIRs.

\textbf{References}

1. Rossignoli A, Clavenna A, Bonati M. Antibiotic prescription and
prevalence rate in the outpatient paediatric population: analysis of
surveys published during 2000-2005. European journal of clinical
pharmacology. 2007;63(12):1099-106.

2. Blanca M, Mayorga C, Torres MJ, Warrington R, Romano A, Demoly P, et
al. Side-chain-specific reactions to betalactams: 14 years later. Clin
Exp Allergy. 2002;32(2):192-7.

3. Ceelie I, van der Starre C, Tibboel D, Stol K, Koren G, de Wildt SN.
Evaluation of drug formularies for pediatric intensive care. Pediatric
critical care medicine : a journal of the Society of Critical Care
Medicine and the World Federation of Pediatric Intensive and Critical
Care Societies. 2011;12(1):e14-9.

4. Blumenthal KG, Li Y, Banerji A, Yun BJ, Long AA, Walensky RP. The
Cost of Penicillin Allergy Evaluation. J Allergy Clin Immunol Pract.
2018;6(3):1019-27.e2.

5. Gomes ER, Brockow K, Kuyucu S, Saretta F, Mori F, Blanca-Lopez N, 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.

6. Caubet JC, Frossard C, Fellay B, Eigenmann PA. Skin tests and in
vitro allergy tests have a poor diagnostic value for benign skin rashes
due to \selectlanguage{greek}β-\selectlanguage{english}lactams in children. Pediatric allergy and immunology :
official publication of the European Society of Pediatric Allergy and
Immunology. 2015;26(1):80-2.

7. Tonson la Tour A, Michelet M, Eigenmann PA, Caubet JC. Natural
History of Benign Nonimmediate Allergy to Beta-Lactams in Children: A
Prospective Study in Retreated Patients After a Positive and a Negative
Provocation Test. J Allergy Clin Immunol Pract. 2018;6(4):1321-6.

8. Atanaskovic-Markovic M, Gaeta F, Medjo B, Gavrovic-Jankulovic M,
Cirkovic Velickovic T, Tmusic V, et al. Non-immediate hypersensitivity
reactions to beta-lactam antibiotics in children - our 10-year
experience in allergy work-up. Pediatric allergy and immunology :
official publication of the European Society of Pediatric Allergy and
Immunology. 2016;27(5):533-8.

9. Torres MJ, Celik GE, Whitaker P, Atanaskovic-Markovic M, Barbaud A,
Bircher A, et al. A EAACI drug allergy interest group survey on how
European allergy specialists deal with \selectlanguage{greek}β-\selectlanguage{english}lactam allergy. Allergy.
2019;74(6):1052-62.

10. Terrados S, Blanca M, Garcia J, Vega J, Torres MJ, Carmona MJ, et
al. Nonimmediate reactions to betalactams: prevalence and role of the
different penicillins. Allergy. 1995;50(7):563-7.

11. Blanca-Lopez N, Jimenez-Rodriguez TW, Somoza ML, Gomez E, Al-Ahmad
M, Perez-Sala D, et al. Allergic reactions to penicillins and
cephalosporins: diagnosis, assessment of cross-reactivity and
management. Expert review of clinical immunology. 2019;15(7):707-21.

12. Blanca M, Torres MJ, Mayorga C, Perez-Inestrosa E, Suau R, Monta\selectlanguage{ngerman}ñez
MI, et al. Immediate allergic reactions to betalactams: facts and
controversies. Current opinion in allergy and clinical immunology.
2004;4(4):261-6.

13. Brockow K, Ardern-Jones MR, Mockenhaupt M, Aberer W, Barbaud A,
Caubet JC, et al. EAACI position paper on how to classify cutaneous
manifestations of drug hypersensitivity. Allergy. 2019;74(1):14-27.

14. Fontaine C, Mayorga C, Bousquet PJ, Arnoux B, Torres MJ, Blanca M,
et al. Relevance of the determination of serum-specific IgE antibodies
in the diagnosis of immediate beta-lactam allergy. Allergy.
2007;62(1):47-52.

15. Vezir E, Dibek Misirlioglu E, Civelek E, Capanoglu M, Guvenir H,
Ginis T, et al. Direct oral provocation tests in non-immediate mild
cutaneous reactions related to beta-lactam antibiotics. Pediatric
allergy and immunology : official publication of the European Society of
Pediatric Allergy and Immunology. 2016;27(1):50-4.

16. Ibáñez MD, Rodríguez Del Río P, Lasa EM, Joral A, Ruiz-Hornillos J,
Muñoz C, et al. Prospective assessment of diagnostic tests for pediatric
penicillin allergy: From clinical history to challenge tests. Annals of
allergy, asthma \& immunology : official publication of the American
College of Allergy, Asthma, \& Immunology. 2018;121(2):235-44.e3.

17. Caubet JC, Kaiser L, Lemaître B, Fellay B, Gervaix A, Eigenmann PA.
The role of penicillin in benign skin rashes in childhood: a prospective
study based on drug rechallenge. J Allergy Clin Immunol.
2011;127(1):218-22.

18. Zambonino MA, Corzo JL, Muñoz C, Requena G, Ariza A, Mayorga C, et
al. Diagnostic evaluation of hypersensitivity reactions to beta-lactam
antibiotics in a large population of children. Pediatric allergy and
immunology : official publication of the European Society of Pediatric
Allergy and Immunology. 2014;25(1):80-7.

19. Torres MJ, Blanca M, Fernandez J, Romano A, Weck A, Aberer W, et al.
Diagnosis of immediate allergic reactions to beta-lactam antibiotics.
Allergy. 2003;58(10):961-72.

20. Romano A, Blanca M, Torres MJ, Bircher A, Aberer W, Brockow K, et
al. Diagnosis of nonimmediate reactions to beta-lactam antibiotics.
Allergy. 2004;59(11):1153-60.

21. Ponvert C, Perrin Y, Bados-Albiero A, Le Bourgeois M, Karila C,
Delacourt C, et al. Allergy to betalactam antibiotics in children:
results of a 20-year study based on clinical history, skin and challenge
tests. Pediatric allergy and immunology : official publication of the
European Society of Pediatric Allergy and Immunology. 2011;22(4):411-8.

22. Kulhas Celik I, Guvenir H, Hurmuzlu S, Toyran M, Civelek E, Kocabas
CN, et al. The negative predictive value of 5-day drug provocation test
in nonimmediate beta-lactam allergy in children. Annals of allergy,
asthma \& immunology : official publication of the American College of
Allergy, Asthma, \& Immunology. 2020;124(5):494-9.

23. Piccorossi A, Liccioli G, Barni S, Sarti L, Giovannini M, Verrotti
A, et al. Epidemiology and drug allergy results in children investigated
in allergy unit of a tertiary-care paediatric hospital setting. Italian
journal of pediatrics. 2020;46(1):5.

24. Lezmi G, Alrowaishdi F, Bados-Albiero A, Scheinmann P, de Blic J,
Ponvert C. Non-immediate-reading skin tests and prolonged challenges in
non-immediate hypersensitivity to beta-lactams in children. Pediatric
allergy and immunology : official publication of the European Society of
Pediatric Allergy and Immunology. 2018;29(1):84-9.

25. Mori F, Cianferoni A, Barni S, Pucci N, Rossi ME, Novembre E.
Amoxicillin allergy in children: five-day drug provocation test in the
diagnosis of nonimmediate reactions. J Allergy Clin Immunol Pract.
2015;3(3):375-80.e1.

26. Edwards RG, Dewdney JM, Dobrzanski RJ, Lee D. Immunogenicity and
allergenicity studies on two beta-lactam structures, a clavam,
clavulanic acid, and a carbapenem: structure-activity relationships. Int
Arch Allergy Appl Immunol. 1988;85(2):184-9.

27. Blanca-Lopez N, Perez-Alzate D, Ruano F, Garcimartin M, de la Torre
V, Mayorga C, et al. Selective immediate responders to amoxicillin and
clavulanic acid tolerate penicillin derivative administration after
confirming the diagnosis. Allergy. 2015;70(8):1013-9.

28. Mill C, Primeau MN, Medoff E, Lejtenyi C, O'Keefe A, Netchiporouk 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 pediatrics. 2016;170(6):e160033.

29. Torres MJ, Mayorga C, Leyva L, Guzman AE, Cornejo-García JA, Juarez
C, et al. Controlled administration of penicillin to patients with a
positive history but negative skin and specific serum IgE tests. Clin
Exp Allergy. 2002;32(2):270-6.

30. Blanca-López N, Zapatero L, Alonso E, Torres MJ, Fuentes V,
Martínez-Molero MI, et al. Skin testing and drug provocation in the
diagnosis of nonimmediate reactions to aminopenicillins in children.
Allergy. 2009;64(2):229-33.

31. Vila L, Garcia V, Martinez Azcona O, Pineiro L, Meijide A, Balboa V.
Mild to moderate hypersensitivity reactions to beta-lactams in children:
a single-centre retrospective review. BMJ paediatrics open.
2019;3(1):e000435.

\textbf{Table 1.} Clinical characteristics of cases with confirmed IR by
DPT\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\textbf{Patient} & \textbf{Age (years)} & \textbf{Sex} &
\textbf{Clinical Entity} & \textbf{Clinical characteristics (symptoms
induced, dose, time from DPT to reaction)}\tabularnewline
\midrule
\endhead
1 & 7 & F & ANA & Cough and wheezing, with facial erythema and 20\%
FEV\textsubscript{1} decrease 10 min after a cumulative dose of 55 mg
AX. Good tolerance to PV.\tabularnewline
2 & 3 & F & URT & Facial erythema with eyelid angioedema and wheals on
neck, 20 min after a cumulative dose of 100 mg AX. Good tolerance to
PV.\tabularnewline
3 & 6 & F & URT & Pruritus on face, ears and back, followed by
generalized wheals and lip angioedema 45 min after a cumulative dose of
80 mg AX. Good tolerance to PV.\tabularnewline
4 & 1 & F & URT & Wheals in chest and face with pruritus 45 min after a
cumulative dose of 150 mg PV.\tabularnewline
5 & 3 & F & AE & Eyelid angioedema with pruritus 45 min after a
cumulative dose of 30 mg cefaclor. Good tolerance to PV and
AX.\tabularnewline
\bottomrule
\end{longtable}

F: female; M: male; ANA: anaphylaxis; URT: urticaria; AE: angioedema;
AX: amoxicillin; PV: penicillin V.

\textbf{Table 2. Clinical characteristics of cases with confirmed NIR by
DPT}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
Patient & Age (years) & Gender & Clinical entity & Clinical
characteristics (symptoms induced, dose, time from DPT to
reaction)\tabularnewline
\midrule
\endhead
1 & 2 & F & MPE & Generalized MPE 6 h after taking 150 mg AX
(1\textsuperscript{st} day ). Good tolerance to PV\tabularnewline
2 & 4 & F & MPE & MPE on chest and legs with facial and retroarticular
erythema and pruritus after taking 200 mg of AX every 8 h
(6\textsuperscript{th} day). Good tolerance to PV\tabularnewline
3 & 15 & F & MPE & Facial erythema and pruritus followed by MPE on chest
3 h after taking 500 mg of AX every 8 h (6\textsuperscript{th}
day)\tabularnewline
4 & 10 & M & MPE & MPE on chest and abdomen after taking 250 mg of AX
every 8 h (2\textsuperscript{nd} day). Good tolerance to
PV.\tabularnewline
5 & 5 & M & MPE & Isolated wheals on back after taking 250 mg of AX
every 8 h (6\textsuperscript{th} day). Good tolerance to
PV\tabularnewline
6 & 1 & M & MPE & MPE on trunk, abdomen, and legs accompanied with
pruritus 4 h after taking 125 mg of AX (1\textsuperscript{st} day ).
Good tolerance to PV\tabularnewline
7 & 9 & F & MPE & MPE on abdomen, legs, and back accompanied with
pruritus 8 h after taking 250 mg of AX every 8 h (1\textsuperscript{st}
day). Good tolerance to PV\tabularnewline
8 & 12 & F & MPE & Pruritus and generalized MPE after taking 500 mg of
AX every 8 h (4\textsuperscript{th} day). Good tolerance to
PV\tabularnewline
9 & 6 & M & MPE & MPE on chest and neck with pruritus after taking 250
mg of AX every 8 h (7\textsuperscript{th} day). Good tolerance to
PV\tabularnewline
10 & 11 & M & MPE & Wheals on face, abdomen, shoulders and legs with
pruritus 8 h after taking 500 mg of AX (1\textsuperscript{st} day). Good
tolerance to PV\tabularnewline
11 & 1 & M & MPE & Pruritus and MPE on abdomen and chest after taking
125 mg of AX every 8 h (7\textsuperscript{th} day). Good tolerance to
PV\tabularnewline
12 & 1.5 & F & MPE & MPE on neck, back, arms and legs 1.5 h after taking
200 mg of PV (1\textsuperscript{st} day)\tabularnewline
13 & 15 & F & MPE & MPE on chest and back with pruritus 2 h after taking
500 mg of PV (1\textsuperscript{st} day)\tabularnewline
14 & 5 & F & MPE & MPE on abdomen, legs, and chest after taking 200 mg
of cexime every 8 h (2\textsuperscript{nd} day). Good tolerance to PV
and AX.\tabularnewline
15 & 0.5 & M & MPE & Maculopapulae on abdomen and neck with facial
erythema after 100 mg of AX every 8 h (1\textsuperscript{st} day). Good
tolerance to PV\tabularnewline
16 & 4 & F & URT & Wheals with pruritus on chest, abdomen and legs after
250 mg of AX every 8 h (6\textsuperscript{th} day). Good tolerance to
PV\tabularnewline
17 & 3 & F & URT & Generalized wheals with pruritus after taking 150 mg
of AX every 8 h (6\textsuperscript{th} day). Good tolerance to
PV\tabularnewline
18 & 6 & M & URT & Pruritus followed by wheals on legs and buttocks, and
facial erythema after taking 250 mg of AX every 8 h
(6\textsuperscript{th} day). Good tolerance to PV\tabularnewline
19 & 8 & M & URT & Generalized pruritus with wheals on the back after
taking 250 mg of AX every 8 h (7\textsuperscript{th} day). Good
tolerance to PV\tabularnewline
20 & 6 & F & URT & Pruritus and wheals on legs and arms after taking 250
mg of AX every 8 h (6\textsuperscript{th} day). Good tolerance to
PV\tabularnewline
21 & 4 & F & URT & Generalized wheals with pruritus after taking 250 mg
of AX every 8 h (7\textsuperscript{th} day). Good tolerance to
PV\tabularnewline
22 & 1 & F & URT & Wheals on abdomen, back, face and legs after taking
125 mg of AX every 8 h (1\textsuperscript{st} day). Good tolerance to
PV\tabularnewline
23 & 4 & M & URT & Urticaria with pruritus on back that generalized
after taking 250 mg of AX every 8 h (4\textsuperscript{th} day). Good
tolerance to PV\tabularnewline
24 & 7 & F & URT & Generalized wheals on abdomen, buttocks and back
after taking 250 of AX every 8 h (7\textsuperscript{th}
day)\tabularnewline
25 & 12 & F & URT & Systemic pruritus with wheals on abdomen and legs
1.5 h minutes after taking 250 mg of AX (1\textsuperscript{st} day).
Good tolerance to PV\tabularnewline
26 & 5 & M & URT & Skin pruritus followed by wheals on arms that
extended to abdomen, chest and legs taking 250 mg of AX every 8 h
(7\textsuperscript{th} day)\tabularnewline
27 & 4 & F & URT & Facial erythema and wheals on abdomen after taking
250 mg of AX every 8 h (3\textsuperscript{rd} day). Good tolerance to
PV\tabularnewline
28 & 1.5 & M & URT & Wheals on legs and neck, extended to chest 1.5 h
after taking 125 mg of AX (1\textsuperscript{st} day). Good tolerance to
PV\tabularnewline
29 & 2 & F & URT & Generalized wheals on chest, abdomen and legs after
taking 100/12.5 mg of AX-CLAV every 8 h (7\textsuperscript{th} day).
Good tolerance to PV and AX\tabularnewline
30 & 13 & F & URT & Generalized pruritus with wheals on elbows, knees,
and legs after taking 500/125 mg of AX-CLAV every 8 h
(7\textsuperscript{th} day). Good tolerance to PV and AX\tabularnewline
31 & 5 & F & URT & Wheals on abdomen and neck, with joint pain after
taking 250 mg of cefaclor every 8 h (7\textsuperscript{th} day). Good
tolerance to PV and AX\tabularnewline
32 & 2 & M & URT/AE & Facial and eyelid angioedema with wheals on back,
abdomen and arms after taking 125 mg of AX every 8 h
(7\textsuperscript{th} day). Good tolerance to PV\tabularnewline
33 & 3 & F & URT/AE & Generalized erythema and lips angioedema after
taking 125 of AX every 8 h (6\textsuperscript{th} day). Good tolerance
to PV\tabularnewline
34 & 11 & M & URT/AE & Systemic pruritus with facial erythema, eyelid
angioedema and wheals on forehead, chest, and abdomen 6 h after taking
500 mg of AX (1\textsuperscript{st} day). Good tolerance to
PV\tabularnewline
35 & 4 & M & URT/AE & Wheals on abdomen, face, and neck with eyelid
angioedema after taking AX 250 mg every 8 h (7\textsuperscript{th} day).
Good tolerance to PV\tabularnewline
36 & 15 & M & URT/AE & Erythema and pruritus on face followed by wheals
on arms and lips angioedema with pruritus 4 h after taking 875 mg of AX
(1\textsuperscript{st} day). Good tolerance to PV\tabularnewline
\bottomrule
\end{longtable}

F: female; M: male; PV: penicillin V; AX: amoxicillin; AX-CLAV:
amoxicillin-clavulanic acid; MPE: maculopapular exanthema; URT:
urticaria; URT/AE: urticaria/angioedema.

\textbf{FIGURE LEGENDS}

\textbf{Figure 1.} Allergological evaluation algorithm.

\textbf{Figure 2.} Time from drug provocation test (DPT) to reactions in
children with nonimmediate drug hypersensitivity reactions.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1-(Allergological-evaluation-algorithm)/Figure-1-(Allergological-evaluation-algorithm)}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2-BLS-(time-DPT)/Figure-2-BLS-(time-DPT)}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

