Version July 2025
IgE: immunoglobulin E; IM: intramuscular.
* Examples of mild, non-IgE-mediated reactions include maculopapular rashes. Examples of IgE-mediated reactions include hives, wheezing, angioedema, and anaphylaxis. Examples of severe, delayed reactions include Steven-Johnson syndrome, toxic epidermal necrolysis, acute interstitial nephritis, drug-induced hepatitis, and serum sickness.
¶ Approach to selecting among cephalosporins varies among experts. Some prefer to use a first-generation cephalosporin (eg, cephalexin) because of its narrow spectrum and low likelihood of cross reactivity. Others select a third-generation cephalosporin with a side chain that is dissimilar to penicillin (eg, cefpodoxime, cefdinir), although these agents have a broader spectrum.
Δ Macrolide resistance varies considerably by region, with higher rates observed in Asia and Europe when compared with the United States. Knowledge of local resistance patterns should guide antibiotic selection.
◊ Selection among these agents should be based on drug availability and patient preference. For patients with a history of acute rheumatic fever and penicillin allergy, antibiotic selection should be individualized.
§ Many patients with IgE-mediated reactions can tolerate cephalosporins. These patients should be referred for allergy consultation following treatment for streptococcal pharyngitis.
¥ Approach to selecting among these agents varies among experts. Some prefer cephalosporins due their high efficacy and low risk of cross-reactivity, while others favor selecting a non-cephalosporin alternative to avoid any possibility of cross-reactivity.
‡ Rates of resistance to clindamycin are high and can be higher than rates of resistance to macrolides. Therefore, when beta-lactams and macrolides cannot be used, knowledge of local resistance rates should guide antibiotic selection or culture with susceptibility testing should be obtained.