Penicillin Allergy
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The How and Why of Penicillin Allergy Testing

The Bottom Line

  • Patient-reported penicillin allergies are frequent but often inaccurate
  • Inaccurate labels lead to poor antibiotic choice and worse patient outcomes
  • There are not enough Allergy-Immunology subspecialists to assess and validate patients with query penicillin allergies
  • Therefore, we have developed an accessible online tool and protocol to risk-stratify patients for oral challenges versus referral to an allergist

Why should healthcare providers care about penicillin allergy labelling?

Why should healthcare providers care about penicillin allergy labelling?

Why should healthcare providers care about penicillin allergy labelling?

  • Penicillin is the most frequently encountered drug allergy (1-2); however, most patient-reported penicillin allergies are inaccurate (3-6) 
    • There is often omission of details or inclusion of incomplete or misleading information when drug allergies are recorded (24-26). Unfortunately, the presence of an allergy label is sufficient to influence prescribing habits of healthcare providers (27). 
  • Inaccurately labelled penicillin allergies are associated with:
    • poor antimicrobial stewardship prescribing with increased use of second line and restricted antibiotics (7-8), leading to more resistant organisms
    • worse patient outcomes, increased hospital stay, greater drug costs, and higher patient mortality (9-12)
  • De-labeling of inaccurate allergies can improve both inpatient care and public health

It is a logistical issue.

Why should healthcare providers care about penicillin allergy labelling?

Why should healthcare providers care about penicillin allergy labelling?

  • The vast majority of patients with reported penicillin allergies are not evaluated by Allergy and Immunology subspecialists given the relative paucity of Allergy-Immunology subspecialists 
  • Physicians without special training in allergy frequently feel uncomfortable evaluating allergy validity (13)
  • Oral penicillin challenge is a safe and acessable method of penicillin allergy testing that can be done by primary care providers (27, 28).

Ontario primary care physician trial

Real-world data.

How do you know your patient's risk for true allergy?

How do you know your patient's risk for true allergy?

  • Prior studies have shown that oral allergy challenges are as safe and efficacious without skin testing (14-17). 
  • Pharmacist based interventions have been effective in identifying low risk penicillin allergies in past projects (18-20). 
  • We know that pharmacist-led penicillin allergy de-labelling ward rounds reduced penicillin allergy labels and the prescribing of restricted antibiotics (21). 
  • This not only makes a difference during the index hospitalization but also in the future. Over a mean follow-up of just under 5 years, 70.7% of de-labeled patients were dispensed a penicillin antibiotic (22). 
  • There is significant support for incorporating penicillin allergy assessment in all patients by major stewardship organizations (23). 

How do you know your patient's risk for true allergy?

How do you know your patient's risk for true allergy?

How do you know your patient's risk for true allergy?

  • Evidence based tools including the PEN-FAST rule help risk stratify these patients. (13) Depending on risk stratification, patients may be more appropriate for skin testing, oral challenge or desensitization. (2)
  • We have developed a tool incorpotating existing evidence to assist you in this process. 

Access our tool here

Our Solution.

  • Implement an accessible and timely penicillin de-labeling program that can be utilized by non-specialist healthcare providers to significantly decrease penicillin allergy labels of both inpatients and outpatients
  • We anticipate both immediate impacts on patient care, as well as downstream effects:
    • improved antibiotic prescribing
    • reduced hospitalization costs
    • improved patient outcomes. 

Looking for resources for your patient?

Go to patient resources

References

  1. Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Antibiotic allergy. Lancet 2019; 393:183–98. 
  2. David A. Khan, Aleena Banerji, Kimberly G. Blumenthal, Elizabeth J. Phillips, Roland Solensky, Andrew A. White, Jonathan A. Bernstein, Derek K. Chu, Anne K. Ellis, David BK. Golden, Matthew J. Greenhawt, Caroline C. Horner, Dennis Ledford, Jay A. Lieberman, John Oppenheimer, Matthew A. Rank, Marcus S. Shaker, David R. Stukus, Dana Wallace, Julie Wang, Drug Allergy: A 2022 Practice Parameter Update, Journal of Allergy and Clinical Immunology, 2022, https://doi.org/10.1016/j.jaci.2022.08.028
  3. Stone CA Jr, Trubiano J, Coleman DT, Rukasin CRF, Phillips EJ. The challenge of de-labeling penicillin allergy. Allergy. 2020;75(2):273-288. doi:10.1111/all.13848
  4. Trubiano JA, Adkinson NF, Phillips EJ. Penicillin allergy is not necessarily forever. JAMA 2017; 318:82–3.
  5. Trubiano J, Phillips E. Antimicrobial stewardship’s new weapon? A review of antibiotic allergy and pathways to “de-labeling.” Curr Opin Infect Dis 2013; 26:526–37. 
  6. Macy, E. Penicillin allergy: optimizing diagnostic protocols, public health implications, and future research needs. Current opinion in clinical allergy immunology. 2015: 15(4). 308-313. 
  7. Ramsey, A., Mustafa, S., Holly, A., & Staicu, M. (2020). Direct Challenges to Penicillin-Based Antibiotics in the Inpatient Setting. The Journal Of Allergy And Clinical Immunology: In Practice 
  8. Trubiano JA, Chen C, Cheng AC, Grayson ML, Slavin MA, Thursky KA; National Antimicrobial Prescribing Survey (NAPS). Antimicrobial allergy “labels” drive inappropriate antimicrobial prescribing: lessons for stewardship. J Antimicrob Chemother 2016; 71:1715–22. 
  9. Blumenthal KG, Lu N, Zhang Y, Li Y, Walensky RP, Choi HK. Risk of meticillin resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy: population based matched cohort study. BMJ 2018; 361:k2400.
  10. Sousa-Pinto B, Cardoso-Fernandes A, Araujo L, Fonseca JA, Freitas A, Delgado L. Clinical and economic burden of hospitalizations with registration of penicillin allergy. Ann Allergy Asthma Immunol 2018; 120:190–4.e2.
  11. Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin “allergy” in hospitalized patients: a cohort study. J Allergy Clin Immunol 2014; 133:790–6.
  12. Blumenthal KG, Lu N, Zhang Y, Walensky RP, Choi HK. Recorded penicillin allergy and risk of mortality: a population-based matched cohort study. J Gen Intern Med 2019; 34:1685–7. 
  13. Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019;321(2):188–199. doi:10.1001/jama.2018.19283
  14. Ramsey A and Mustafa SS. A penicillin skin testing initiative in an outpatient allergy office. 2018. JACI IP. Epub ahead of print.
  15. Banks TA, Tucker M, Macy E. Evaluating penicillin allergies without skin testing. Curr Allergy Asthma Rep 2019; 19:27.
  16. Mustafa SS, Conn K, Ramsey A. Comparing direct challenge to penicillin skin testing for the outpatient evaluation of penicillin allergy: a randomized controlled trial. J Allergy Clin Immunol Pract 2019; 7:2163–70.
  17. Lanoue D., MacFadden D., Olynych T., Vanwalraven C., Nott C., The Development and Implementation of a Proactive Penicillin Allergy De-Labelling Program for Low Risk Inpatients at The Ottawa Hospital. Accepted for poster presentation at Canadian Society of Allergy and Clinical Immunology Scientific Meeting Oct. 28th 2021
  18. Chen JR, Tarver SA, Alvarez KS et al. A proactive approach to penicillin allergy testing in hospitalized patients. J Allergy Clin Immunol Pract 2017; 5: 686–93.
  19. Vaisman A, McCready J, Hicks S et al. Optimizing preoperative prophylaxis in patients with reported b-lactam allergy: a novel extension of antimicrobial stewardship. J Antimicrob Chemother 2017; 72: 2657–60.
  20. Devchand M, Kirkpatrick CMJ, Stevenson W et al. Evaluation of a pharmacist-led penicillin allergy de-labelling ward round: a novel antimicrobial stewardship intervention. J Antimicrob Chemother 2019; 74: 1725–1730.
  21. Devchand M, Kirkpatrick CMJ, Stevenson W, Garrett K, Perera D, Khumra S, Urbancic K, Grayson ML, Trubiano JA. Evaluation of a pharmacist-led penicillin allergy de-labelling ward round: a novel antimicrobial stewardship intervention. J Antimicrob Chemother. 2019 Jun 1;74(6):1725-1730. doi: 10.1093/jac/dkz082. PMID: 30869124.at inpatient 
  22. Lachover-Roth I, Sharon S, Rosman Y, Meir-Shafrir K, Confino-Cohen R. Long-Term Follow-Up After Penicillin Allergy Delabeling in Ambulatory Patients. J Allergy Clin Immunol Pract. 2019 Jan;7(1):231-235.e1. doi: 10.1016/j.jaip.2018.04.042. Epub 2018 May 22. PMID: 29800754.
  23. (Allergy & Clinical Immunology - Choosing Wisely Canada, 2021) https://choosingwiselycanada.org/allergy-clinical-immunology/ 
  24. Inglis, J. M., Caughey, G. E., Smith, W., & Shakib, S. (2017). Documentation of penicillin adverse drug reactions in electronic health records: inconsistent use of allergy and intolerance labels. Internal medicine journal, 47(11), 1292–1297. https://doi.org/10.1111/imj.13558
  25. Nebeker JR, Barach P, Samore MH. Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting. Ann Intern Med. 2004 May 18;140(10):795-801. doi: 10.7326/0003-4819-140-10-200405180-00009. PMID: 15148066. 
  26. Trubiano JA, Chen C, Cheng AC, et al. Antimicrobial allergy ‘labels’ drive inappropriate antimicrobial prescribing: lessons for stewardship. The Journal of antimicrobial chemotherapy. 2016;71(6):1715–1722.
  27. Stone CA Jr, Trubiano J, Coleman DT, Rukasin CRF, Phillips EJ. The challenge of de-labeling penicillin allergy. Allergy. 2020 Feb;75(2):273-288. doi: 10.1111/all.13848. Epub 2019 May 26. PMID: 31049971; PMCID: PMC6824919.
  28. Savic L, Ardern-Jones M, Avery A, Cook T, Denman S, Farooque S, Garcez T, Gold R, Jay N, Krishna MT, Leech S, McKibben S, Nasser S, Premchand N, Sandoe J, Sneddon J, Warner A. BSACI guideline for the set-up of penicillin allergy de-labelling services by non-allergists working in a hospital setting. Clin Exp Allergy. 2022 Sep 21. doi: 10.1111/cea.14217. Epub ahead of print. PMID: 36128691. 

Learn More

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