The Laryngoscope V C 2015 The American Laryngological, Rhinological and Otological Society, Inc. Cephalosporin Use in Penicillin-Allergic Patients: A Survey of Otolaryngologists and Literature Review Michael J. Persky, MD; Scott A. Roof, BA; Yixin Fang, PhD; Daniel Jethanamest, MD; Max M. April, MD Objectives/Hypothesis: This study investigated the differences between the standard guidelines and the practice pat- terns of otolaryngologists in managing “penicillin-allergic” patients. A major goal was to identify factors influencing an otolar- yngologist’s choice of antibiotic. Study Design: Cross-sectional survey. Methods: Four hundred seventy members of the American Society of Pediatric Otolaryngologists (ASPO) and 150 gen- eral otolaryngologists from the Florida Society of Otolaryngology (FSO) were surveyed. Results: Ninety-six ASPO members (20.4%) and 22 members of FSO (14.6%) responded. When asked about the man- agement of a pediatric patient with acute otitis media and a history of a nonsevere immunoglobulin E (IgE)-mediated amoxi- cillin allergy, 54% of ASPO respondents indicated they would initiate guideline-recommended cefdinir, whereas only 27% of FSO respondents chose cefdinir (P 5.02). Otolaryngologists who are fellowship trained in pediatrics or have pediatric-focused practices were significantly more likely to prescribe cefdinir. Overall, 57% of respondents indicated that they were familiar with the literature regarding the cross-reactivity of b-lactams, but only 25% of respondents felt that they could easily differ- entiate a potentially life-threatening IgE-mediated allergy from a non–IgE-mediated drug intolerance. Conclusions: The data show differences between the current recommendations and the behavior of otolaryngologists. Pediatric otolaryngologists were more familiar with the guideline-recommended therapy, likely from their frequent exposure to patients requiring a b-lactam. Nevertheless, most otolaryngologists could benefit from increased awareness of the current literature. Patients may be receiving less than optimal medication management due to a misidentification of those at risk of life- threatening allergic cross-reactions. Key Words: Allergy, penicillin, pen-allergic, antibiotic, immunology, clinical practice guidelines, evidence-based medicine. Level of Evidence: NA Laryngoscope, 00:000–000, 2015 INTRODUCTION The practicing otolaryngologist frequently encoun- ters infections of the head and neck that are susceptible to a family of antibiotics called b-lactams. b-lactams are the most commonly used family of antibiotics, with 247 courses of penicillins and 114 courses of cephalosporins used per 1,000 patients in 2010. 1 This family of antibiot- ics offers excellent coverage with minimal side effects. Penicillins and cephalosporins are two classes of b- lactams. b-lactams are remarkably nontoxic to mammalian cells, with other classes of antibiotics having worse side- effect profiles. 1,2 It is also known that early (and incor- rect) reports of a 10% cross-reactivity between the two most commonly prescribed classes of b-lactam antibiot- ics, penicillins and cephalosporins, still affect the way physicians perceive their shared allergy risks. 1,3 Many physicians will still not offer a cephalosporin to a patient with a reported penicillin allergy and vice versa. This results in prescribing a less optimal antibiotic in terms of ability to cure the infection and side-effect profile. Additionally, the literature describes the difference between a true allergy and intolerance. An allergy is a potentially life-threatening response to an antigen that is caused by an immunoglobulin E (IgE) response and could potentially result in anaphylaxis. It has been shown that a patient’s history can distinguish between a potentially life-threatening allergic reaction that is medi- ated by IgE and a drug intolerance that does not have the potential for life-threatening anaphylaxis. An IgE- mediated allergy will result in at least urticarial hives within 1 hour of exposure. 1 If this did not occur, it is extremely unlikely to be an allergy, but rather an intolerance. 1 Recent studies show that of patients who state they have a history of penicillin allergy, only 5% will test pos- itive with a penicillin allergy skin test. 4 Furthermore, of Additional Supporting Information may be found in the online version of this article. From the Department of Otolaryngology–Head and Neck Surgery (M.J.P ., S.A.R., D.J., M.M.A.), the Department of Population Health (Y.F .), and the Department of Environmental Medicine (Y.F .), New York University School of Medicine, New York, New York, U.S.A. Editor’s Note: This Manuscript was accepted for publication February 3, 2015. Presented at the Triological Society Combined Sections Meeting, San Diego, California, U.S.A., January 23, 2015. This work was funded by the Department of Otolaryngology–Head and Neck Surgery, New York University School of Medicine, New York, New York, U.S.A. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Max M. April, MD, Department of Otolar- yngology–Head and Neck Surgery, NYU School of Medicine, Bellevue Hospital, NBV 5E5 New York, NY 10016. E-mail: max.april@nyumc.org DOI: 10.1002/lary.25227 Laryngoscope 00: Month 2015 Persky et al.: Cephalosporins and Penicillin Allergy 1