Single-step direct drug provocation testing is safe for de-labelling selected “non-low-risk” penicillin allergy labels

AbstractBackgroundDirect drug provocation testing (DPT) in patients with low-risk penicillin allergy labels would allow population-level ‘de-labelling’. We sought to determine the incidence and nature of penicillin allergy labels in a large UK surgical cohort and to define patient and anaesthetist attitudes towards penicillin allergy testing.MethodsA prospective cross-sectional study was performed in 213 UK hospitals. ‘Penicillin allergic’ patients were interviewed and risk-stratified. Knowledge and attitudes around penicillin allergy were defined in patients and anaesthetists, determining potential barriers to widespread testing.FindingsOf 21,281 patients 12% self-reported penicillin allergy and 67% of these were potentially suitable for direct DPT (stratified low or intermediate risk). Irrespective of risk category 62% wanted allergy testing. Of 4,978 anaesthetists 40% claimed to routinely administer penicillin when they judge the label to be low-risk; 64% would then tell the patient they had received penicillin. Only 47% of all anaesthetists would be happy to administer penicillin to a patient previously de-labelled by an allergy specialist using direct DPT; the commonest reason not to administer penicillin was perceived lack of support from their hospital. On the study days, 13% of low-risk patients requiring penicillin received it, and 6 patients with high-risk labels received it. There were no adverse events in any of this group. However, 1 patient who received an alternative antibiotic suffered suspected anaphylaxis to this.InterpretationThe majority of patients with a penicillin allergy label may be suitable for direct DPT and demand for testing is high among patients. Anaesthetists demonstrate inconsistent, potentially unsafe prescribing in patients labelled as penicillin allergic. More than half of anaesthetists are not reassured by a negative DPT undertaken by a specialist. Significant knowledge gaps may prevent widespread de-labelling being effectively implemented in surgical patients.FundingThe National Institute of Academic Anaesthesia.

Download Full-text

The Penicillin Allergy Delabeling Program: A Multicenter Whole-of-Hospital Health Services Intervention and Comparative Effectiveness Study

Clinical Infectious Diseases ◽

10.1093/cid/ciaa653 ◽

2020 ◽

Cited By ~ 3

Author(s):

Kyra Y L Chua ◽

Sara Vogrin ◽

Susan Bury ◽

Abby Douglas ◽

Natasha E Holmes ◽

...

Keyword(s):

Health Services ◽

Propensity Score Analysis ◽

Antibiotic Use ◽

Low Risk ◽

Penicillin Allergy ◽

Index Admission ◽

Relative Risk Ratio ◽

Antibiotic Prescribing ◽

Narrow Spectrum ◽

Oral Penicillin

Abstract Background Penicillin allergies are associated with inferior patient and antimicrobial stewardship outcomes. We implemented a whole-of-hospital program to assess the efficacy of inpatient delabeling for low-risk penicillin allergies in hospitalized inpatients. Methods Patients ≥ 18 years of age with a low-risk penicillin allergy were offered a single-dose oral penicillin challenge or direct label removal based on history (direct delabeling). The primary endpoint was the proportion of patients delabeled. Key secondary endpoints were antibiotic utilization pre- (index admission) and post-delabeling (index admission and 90 days). Results Between 21 January 2019 and 31 August 2019, we assessed 1791 patients reporting 2315 antibiotic allergies, 1225 with a penicillin allergy. Three hundred fifty-five patients were delabeled: 161 by direct delabeling and 194 via oral penicillin challenge. Ninety-seven percent (194/200) of patients were negative upon oral penicillin challenge. In the delabeled patients, we observed an increase in narrow-spectrum penicillin usage (adjusted odds ratio [OR], 10.51 [95% confidence interval {CI}, 5.39–20.48]), improved appropriate antibiotic prescribing (adjusted OR, 2.13 [95% CI, 1.45–3.13]), and a reduction in restricted antibiotic usage (adjusted OR, 0.38 [95% CI, .27–.54]). In the propensity score analysis, there was an increase in narrow-spectrum penicillins (OR, 10.89 [95% CI, 5.09–23.31]) and β-lactam/β-lactamase inhibitors (OR, 6.68 [95% CI, 3.94–11.35]) and a reduction in restricted antibiotic use (OR, 0.52 [95% CI, .36–.74]) and inappropriate prescriptions (relative risk ratio, 0.43 [95% CI, .26–.72]) in the delabeled group compared with the group who retained their allergy label. Conclusions This health services program using a combination of direct delabeling and oral penicillin challenge resulted in significant impacts on the use of preferred antibiotics and appropriate prescribing.

Download Full-text

Allergy Testing in Children With Low-Risk Penicillin Allergy Symptoms

PEDIATRICS ◽

10.1542/peds.2017-0471 ◽

2017 ◽

Vol 140 (2) ◽

pp. e20170471 ◽

Cited By ~ 38

Author(s):

David Vyles ◽

Juan Adams ◽

Asriani Chiu ◽

Pippa Simpson ◽

Mark Nimmer ◽

...

Keyword(s):

Low Risk ◽

Penicillin Allergy ◽

Allergy Testing

Download Full-text

Risk-Stratified Management Offers a Safe Approach to Removing Low-Risk Penicillin Allergy Labels in the Intensive Care Unit

Journal of Allergy and Clinical Immunology ◽

10.1016/j.jaci.2019.12.592 ◽

2020 ◽

Vol 145 (2) ◽

pp. AB94 ◽

Cited By ~ 2

Author(s):

Cosby Stone ◽

Christopher Lindsell ◽

Joanna Stollings ◽

Mary Lynn Dear ◽

Reagan Buie ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Low Risk ◽

Penicillin Allergy ◽

Safe Approach

Download Full-text

First pediatric electronic algorithm to stratify risk of penicillin allergy

Allergy Asthma & Clinical Immunology ◽

10.1186/s13223-020-00501-6 ◽

2020 ◽

Vol 16 (1) ◽

Author(s):

Hannah Roberts ◽

Lianne Soller ◽

Karen Ng ◽

Edmond S. Chan ◽

Ashley Roberts ◽

...

Keyword(s):

Health Care Professionals ◽

Pediatric Population ◽

Skin Testing ◽

Low Risk ◽

Penicillin Allergy ◽

Oral Drug ◽

Beta Lactam ◽

Paper Version ◽

Pediatric Study ◽

Risk Patients

AbstractBeta-lactam allergy is reported in 5–10% of children in North America, but up to 94–97% of patients are deemed not allergic after allergist assessment. The utility of standardized skin testing for penicillin allergy in the pediatric population has been recently questioned. Oral drug challenges when appropriate, are preferred over skin testing, and can definitively rule out immediate, IgE-mediated drug allergy. To our knowledge, this is the only pediatric study to assess the reliability of a penicillin allergy stratification tool using a paper and electronic clinical algorithm. By using an electronic algorithm, we identified 61 patients (of 95 deemed not allergic by gold standard allergist decision) as low risk for penicillin allergy, with no false negatives and without the need for allergist assessment or skin testing. In this study, we demonstrate that an electronic algorithm can be used by various pediatric clinicians when evaluating possible penicillin allergy to reliably identify low risk patients. We identified the electronic algorithm was superior to the paper version, capturing an even higher percentage of low risk patients than the paper version. By developing an electronic algorithm to accurately assess penicillin allergy risk based on appropriate history, without the need for diagnostic testing or allergist assessment, we can empower non-allergist health care professionals to safely de-label low risk pediatric patients and assist in alleviating subspecialty wait times for penicillin allergy assessment.

Download Full-text

Risk-stratified Management to Remove Low-Risk Penicillin Allergy Labels in the ICU

American Journal of Respiratory and Critical Care Medicine ◽

10.1164/rccm.202001-0089le ◽

2020 ◽

Vol 201 (12) ◽

pp. 1572-1575 ◽

Cited By ~ 1

Author(s):

Cosby A. Stone ◽

Joanna L. Stollings ◽

Christopher J. Lindsell ◽

Mary Lynn Dear ◽

Reagan B. Buie ◽

...

Keyword(s):

Low Risk ◽

Penicillin Allergy

Download Full-text

De-labelling penicillin allergy in acutely hospitalized patients: a pilot study

BMC Infectious Diseases ◽

10.1186/s12879-021-06794-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Linde Steenvoorden ◽

Erik Oeglaend Bjoernestad ◽

Thor-Agne Kvesetmoen ◽

Anne Kristine Gulsvik

Keyword(s):

Antibiotic Use ◽

Hospitalized Patients ◽

Low Risk ◽

Penicillin Allergy ◽

Environmental Benefit ◽

Medical Department ◽

Norwegian Population ◽

Risk Patients ◽

History Of ◽

Clinically Significant

Abstract Background Penicillin allergy prevalence is internationally reported to be around 10%. However, the majority of patients who report a penicillin allergy do not have a clinically significant hypersensitivity. Few patients undergo evaluation, which leads to overuse of broad-spectrum antibiotics. The objective of this study was to monitor prevalence and implement screening and testing of hospitalized patients. Methods All patients admitted to the medical department in a local hospital in Oslo, Norway, with a self-reported penicillin allergy were screened using an interview algorithm to categorize the reported allergy as high-risk or low-risk. Patients with a history of low-risk allergy underwent a direct graded oral amoxicillin challenge to verify absence of a true IgE-type allergy. Results 257 of 5529 inpatients (4.6%) reported a penicillin allergy. 191 (74%) of these patients underwent screening, of which 86 (45%) had an allergy categorized as low-risk. 54 (63%) of the low-risk patients consented to an oral test. 98% of these did not have an immediate reaction to the amoxicillin challenge, and their penicillin allergy label could thus be removed. 42% of the patients under treatment with antibiotics during inclusion could switch to treatment with penicillins immediately after testing, in line with the national recommendations for antibiotic use. Conclusions The prevalence of self-reported penicillin allergy was lower in this Norwegian population, than reported in other studies. Screening and testing of hospitalized patients with self-reported penicillin allergy is a feasible and easy measure to de-label a large proportion of patients, resulting in immediate clinical and environmental benefit. Our findings suggest that non-allergist physicians can safely undertake clinically impactful allergy evaluations.

Download Full-text

30. Implementation of the PEN-FAST Penicillin Allergy Screening Tool in the Emergency Department During Medication Reconciliation

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.232 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S137-S138

Author(s):

Satwinder Sony Kaur ◽

David T Adams ◽

Brittany Parker

Keyword(s):

Emergency Department ◽

Screening Tool ◽

Healthcare Providers ◽

Low Risk ◽

Penicillin Allergy ◽

Secondary Outcome ◽

Beta Lactam ◽

Decision Tool ◽

Allergy Test ◽

Risk Patients

Abstract Background The purpose of this study is to implement the PEN-FAST Penicillin Allergy Screening Tool in the emergency department to identify low risk patients with inappropriate penicillin-related allergies to transition them to a beta-lactam. Newly published, validated, penicillin allergy clinician decision tool (PEN-FAST) allows healthcare providers to identify low risk penicillin allergies with a negative predictive value of 96%. This quick, five question clinical decision tool allows healthcare providers and antimicrobial stewardship programs to identify patients who would also test negative if a formal penicillin allergy test was performed, making the process to confidently identify inappropriately labeled penicillin-related allergies more efficient. Methods During routine medication reconciliations, pharmacists will identify patients who have a documented penicillin-related allergy in the EMR and use the PEN-FAST screening tool. Patients meeting inclusion criteria will have their penicillin-related allergy updated in the EMR based upon their assessed risk of very low, low, moderate, or high. The primary outcomes for this study are the percentage of patients screened that were classified as “very low and low risk” and percentage penicillin-related allergies updated. The secondary outcomes are the percentage of patients that required antibiotic therapy (post-allergy update) that were transitioned to a beta-lactam, inpatient broad-spectrum antibiotic usage before and after allergy update, and time spent interviewing each patient. Results A total of 59 patients were interviewed using the PEN-FAST Tool. The results for the primary outcomes indicate 92% (n=54) of patient allergies updated in the EMR, 24% (n=13) of patients classified as “very low risk” and 34% (n=18) of patients classified as “low risk”. Results for the secondary outcome showed out of the 36 patients that were on non-beta lactams during allergy update, 72% (n=26) of those patients were transitioned to a beta-lactam. The average time to complete the PEN-FAST Tool was 4.2 minutes. Conclusion The results of this study support the use of the PEN-FAST Tool in efficiently updating patient’s allergies in the EMR and identifying low risk patients who may be eligible for beta-lactam therapy. Disclosures All Authors: No reported disclosures

Download Full-text