JffLactam Antibiotics

Hypersensitivity reactions with ^-lactam antibiotics, especially penicillin, may encompass any of the Type I through IV Gell-Coombs classifications. The most common

reactions are maculopapular and urticarial eruptions. While rare (lesser than

0.05%), anaphylaxis to penicillins cause the greatest concern, as they are responsible for the majority of all drug-induced anaphylaxis deaths in patients, accounting for 75% of all anaphylaxis cases in the United States.5,8 The treatment of anaphylaxis is given in Table 54-3.9

Table 54-2 Problematic Drug Classes

ß-Lactam antibiotics Sulfonamide antibiotics

Aspirin and nonsteroidal anti-inflammatory drugs

Radiocontrast media





Table 54-3 Pharmacologic Management of Anaphylactic Reactions

Immediate Intervention Epinephrine 1:1,000 (1 mg/mL)

• Adults: Give 0.2-0.5 mg intramuscular (IM) or subcutaneous (SC); repeat every 5 minutes as needed

• Pediatrics: 0.01 mg/kg (maximum 0.3 mg) IM or SC, repeat every 5 minutes as needed

Subsequent Interventions

Normal Saline Infusion

• Adults: 1-2 L at a rate of 5-10 mL/kg in the first 5 minutes, followed by slow infusion

• Pediatrics: up to 30 mL/kg in the first hour Epinephrine Infusion

If patient is NOT responding to epinephrine injections and volume resuscitation:

• Adults: epinephrine infusion (1 mg in 250 mL dextrose 5% in water [D5W]): 1-4 mcg/min, titrating based on clinical response or side effects

• Pediatrics: epinephrine 1:10,000 (0.1 mg/mL): 0.01 mg/kg (up to 0.3 mg) over several minutes

Other Considerations after Epinephrine and Fluids Diphenhydramine

• Pediatrics: 1-1.25 mg/kg (maximum of 300 mg/24 hour) Ranitidine

• Pediatrics: 1 mg/kg (up to 50 mg) in D5W 20 mL IV over 5 minutes

Inhaled ^-agonist (bronchospasm resistant to epinephrine) 2-5 mg in 3 mL of normal saline, nebulized, repeat as needed

Dopamine (hypotension refractory to fluids and epinephrine) 2-20 mcg/kg/min titrated to maintain systolic blood pressure greater than 90 mm Hg

Hydrocortisone (severe or prolonged anaphylaxis)

• Adults: 250 mg IV (prednisone 20 mg can be given orally in mild cases)

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