Ceftriaxone-Induced Anaphylaxis in a Pediatric Patient: Challenges and Management

Abstract

Background: Cephalosporin-induced anaphylaxis is uncommon (6.1/10,000 exposures), and the diagnosis in pediatrics entails challenges due to nonspecific clinical histories and lack of standardized diagnostic tests. G-Penicillin has demonstrated diagnostic utility in the absence of penicilloilpolylisin, with a negative predictive value up to 95.2% when combined with controlled oral challenge. The basophil activation test (BAT) has a variable sensitivity (38–75%), depending on the assessed biomarker.

Case report: A 13-year-old male presented anaphylaxis two minutes after receiving intramuscular ceftriaxone. He presented with pharyngeal pruritus, facial angioedema, dyspnea, vomiting, and altered alertness. The condition resolved with intramuscular adrenaline and intravenous crystalloid administration. Test results: BAT for ceftriaxone and cefuroxime were negative. Skin tests were negative for penicillin and cefuroxime and positive for ceftriaxone. Outcome: Oral challenge with amoxicillin was tolerated. The use of ceftriaxone and cephalosporins with an identical R1 side chain were contraindicated.

Conclusions: When dealing with a patient with drug allergy, clinicians should implement diagnostic tools that include skin testing with specific antibiotics and oral challenge. It is important to reconsider unconfirmed allergy labels, as it is estimated that between 58% and 75% of pediatric patients diagnosed with “cephalosporin allergy” present low-risk symptoms and could be delabeled with appropriate protocols. Cephalosporin anaphylaxis requires a combined evaluation. Penicillin G skin testing and oral challenge are key tools to guide safe antibiotic treatment.

Keywords: Drug allergy; Beta-lactams; Skin testing; Basophil activation test.