Penicillin Allergy Label Research Articles

Delabelling multiple antibiotic allergy: Practical issues.

With the growing incidence of multi-drug resistant organisms, delabelling incorrect antibiotic allergies has become an integral part of antimicrobial stewardship worldwide. For example, around 90% of penicillin allergy labels are found to be inaccurate following a full allergy work-up, which deprive patients the use of effective first-line penicillin antibiotics and increase the risk of antimicrobial resistance with the use of other extended spectrum non-penicillin antimicrobials. Significant numbers of adult and paediatric patients over time are labelled with multiple penicillin and non-penicillin antibiotic allergies often during inappropriate antimicrobial use, resulting in a label of "multiple antibiotic allergy". In contrast to delabelling penicillin allergy where oral direct provocation tests can be used for low-risk, mild reactions, and sensitivity/specificity/positive and negative predictive values of skin tests have been demonstrated, diagnostic tests for multiple antibiotic allergy often require the use of a combination of in-vivo and in-vitro tests across different antimicrobial classes for evaluation. Shared decision making with patients and informed consent are also needed when prioritising which drugs to delabel first, balancing the risks, benefits of testing vs. interim use of alternative antibiotics. Similar to delabelling penicillin allergy, the cost-effectiveness of delabelling multiple drug allergies is unknown.

Health outcomes of penicillin allergy testing in children: a systematic review.

Penicillin allergy labels are commonly acquired in childhood and lead to avoidance of first-line penicillin antibiotics. Understanding the health outcomes of penicillin allergy testing (PAT) can strengthen its place in antimicrobial stewardship efforts. To identify and summarize the health outcomes of PAT in children. Embase, MEDLINE, Web of Science, Cochrane Library, SCOPUS and CINAHL were searched from inception to 11 Oct 2021 (Embase and MEDLINE updated April 2022). Studies that utilized in vivo PAT in children (≤18 years old) and reported outcomes relevant to the study objectives were included. Thirty-seven studies were included in the review, with a total of 8411 participants. The most commonly reported outcomes were delabelling, subsequent penicillin courses, and tolerability to penicillin courses. Ten studies had patient-reported tolerability to subsequent penicillin use, with a median 93.6% (IQR 90.3%-97.8%) of children tolerating a subsequent course of penicillins. In eight studies, a median 97.3% (IQR 96.4%-99.0%) of children were reported as 'delabelled' after a negative PAT without further definition. Three separate studies verified delabelling by checking electronic or primary care medical records, where 48.0%-68.3% children were delabelled. No studies reported on outcomes relating to disease burden such as antibiotic resistance, mortality, infection rates or cure rates. Safety and efficacy of PAT and subsequent penicillin use was the focus of existing literature. Further research is required to determine the long-term impact of delabelling penicillin allergies on disease burden.

Penicillin-allergy delabelling resources for clinicians practicing in resource-limited settings: a full educational resource review of the grey literature.

The clinical and financial consequences associated with a penicillin-allergy label are increasingly evident and have garnered support from international organizations to prioritize penicillin-allergy delabelling programmes. Most settings lack access to resources including drug allergy specialists and rely on general practitioners (GPs) and pharmacists. The aim of this scoping review was to identify and describe freely available penicillin-allergy delabelling materials to guide clinicians practising in resource-limited settings with initiative application. This scoping review searched two grey literature databases, six targeted websites and consulted content experts to identify freely available materials in the English language that provided evidence-based and actionable penicillin-allergy delabelling strategies. Study investigators ranked and voted on which screened resources should be included in the final review. Characteristics of resources were evaluated and compared. Out of 1191 total citations, 6 open-access resources were included. Penicillin-allergy toolkits featuring various delabelling strategies were identified in four resources. The toolkits supported a broad range of downloadable and adaptable materials, predominantly targeted towards GPs. Patient educational materials were also provided. Another resource highlighted a point-of-care penicillin-allergy risk assessment calculator via a free mobile app that quickly and accurately identified low-risk penicillin-allergic patients. The final resource, a supplemental instructional video, presented impactful and standardized delabelling strategies that clinicians can adopt into daily practices. Limited penicillin-allergy delabelling materials are available in the grey literature but existing resources provide broad and diverse opportunities. Additional support from health protection agencies is critical to augment ongoing delabelling efforts.

Impact of penicillin allergy labels among pneumonia admissions at an academic children's center

Background: Pneumonia is the most common reason for pediatric hospitalizations. The impact of penicillin allergy labels among children with pneumonia has not been well studied. Objective: This study assessed the prevalence and impact of penicillin allergy labels among children admitted with pneumonia over a 3-year period at a large academic children's center. Methods: Inpatient charts of pneumonia admissions with a documented allergy to a type of penicillin from January to March in 2017, 2018, and 2019 were reviewed and compared with pneumonia admissions without the label over the same time with regard to days of antimicrobial treatment, route of antimicrobial therapy, and days of hospitalization. Results: There were 470 admissions for pneumonia during this time period, of which 48 patients (10.2%) carried a penicillin allergy label. Hives and/or swelling comprised 20.8% of the allergy labels. Other labels included nonpruritic rashes, gastrointestinal GI symptoms, unknown/undocumented reactions, or other reasons. There were no significant differences between those with a penicillin allergy label to those without regarding days of antimicrobial treatment (inpatient and outpatient), route of antimicrobial therapy, and days of hospitalization. Those with a penicillin allergy label were less likely to be prescribed a penicillin product (p < 0.002). Of the 48 patients who were allergy labeled, 23% (11/48) were given a penicillin medication without adverse reaction. Conclusion: Ten percent of pediatric admissions for pneumonia had a label of penicillin allergy, similar to the overall population. The hospital course and clinical outcome were not significantly affected by the penicillin allergy label. The majority of documented reactions were of low risk for immediate allergic reactions.

Artificial intelligence and the potential for perioperative delabeling of penicillin allergies for neurosurgery inpatients

Purpose of the article Patients with penicillin allergy labels are more likely to have postoperative wound infections. When penicillin allergy labels are interrogated, a significant number of individuals do not have penicillin allergies and may be delabeled. This study was conducted to gain preliminary evidence into the potential role of artificial intelligence in assisting with perioperative penicillin adverse reaction (AR) evaluation. Material and methods A single-centre retrospective cohort study of consecutive emergency and elective neurosurgery admissions was conducted over a two-year period. Previously derived artificial intelligence algorithms for the classification of penicillin AR were applied to the data. Results There were 2063 individual admissions included in the study. The number of individuals with penicillin allergy labels was 124; one patient had a penicillin intolerance label. Of these labels, 22.4% were not consistent with classifications using expert criteria. When the artificial intelligence algorithm was applied to the cohort, the algorithm maintained a high level of classification performance (classification accuracy 98.1% for allergy versus intolerance classification). Conclusions Penicillin allergy labels are common among neurosurgery inpatients. Artificial intelligence can accurately classify penicillin AR in this cohort, and may assist in identifying patients suitable for delabeling.

Impact of a Documented Penicillin Allergy on Antibiotic Selection in Pediatric Patients With Osteomyelitis.

Penicillin allergy labels are common in hospitalized patients, and there is a frequent misconception that these patients cannot receive cephalosporins. Through retrospective review, we found that patients with reported penicillin allergies were significantly less likely to receive first-line therapy for acute hematogenous osteomyelitis.

The Quality and Management of Penicillin Allergy Labels in Pediatric Primary Care.

Penicillin allergy labels are the most common drug allergy label. The objective of this study was to describe the quality and management of penicillin allergy labels in the pediatric primary care setting. Retrospective chart review of 500 of 18 015 children with penicillin allergy labels born from January 1, 2010 to June 30, 2020 randomly selected from an outpatient birth cohort from Texas Children's Pediatrics and Children's Hospital of Philadelphia networks. Penicillin allergy risk classification ("not allergy," "low risk," "moderate or high risk," "severe risk," "unable to classify") was determined based on documentation within (1) the allergy tab and (2) electronic healthcare notes. Outcomes of allergy referrals and penicillin re-exposure were noted. Half of penicillin allergy labels were "unable to classify" based on allergy tab documentation. Risk classification agreement between allergy tabs and healthcare notes was fair (Cohen's ĸ = 0.35 ± 0.02). Primary care physicians referred 84 of 500 (16.8%) children to an allergist, but only 54 (10.8%) were seen in allergy clinic. All children who were challenged (25 of 25) passed skin testing. Removal of allergy labels was uncommon (69 of 500, 13.8%) but occurred more often following allergy appointments (26 of 54, 48%) than not (43 of 446, 9.6%, P < .001). Children delabeled by primary care physicians were as likely to tolerate subsequent penicillin-class antibiotics as those delabeled by an allergist (94% vs 93%, P = .87). Penicillin allergy documentation within the allergy tab was uninformative, and children were infrequently referred to allergists. Future quality improvement studies should improve penicillin allergy documentation and expand access to allergy services.

Delabeling penicillin allergy in a pediatric primary care clinic

Reported adverse drug reactions to penicillins are common, affecting between 10-20% of the North American population; however, more than 90% of patients with a penicillin allergy label can safely tolerate penicillins 1, 2. Numerous adverse outcomes are associated with labeled penicillin allergy 1, 2. In light of this, appropriate diagnosis and verification of a penicillin allergy label is crucial to achieving optimal health outcomes and has been recommended by the Centers for Disease Control and Prevention, the American College of Allergy, Asthma, and Immunology, and the American Academy of Allergy, Asthma, and Immunology 3.

Low frequency of allergy referral for penicillin allergy evaluation in an urban Boston primary care setting.

A key strategy to combat the public health crisis of antimicrobial resistance is to use appropriate antibiotics, which is difficult in patients with a penicillin allergy label. Our aim was to investigate racial and ethnic differences related to penicillin allergy labeling and referral to allergy/immunology in primary care. This was a retrospective study of Tufts Medical Center's Boston-based primary care patients in 2019. Univariable and multivariable logistic regression models were used to examine demographic associations with (1) penicillin allergy label and (2) allergist referral. Of 21,918 primary care patients, 2,391 (11%) had a penicillin allergy label; of these, 249 (10%) had an allergist referral. In multivariable logistic regression models, older age (adjusted odds ratio [aOR]= 1.06 [95% CI= 1.04-1.09]) and female sex (aOR= 1.58 [95% CI = 1.44-1.74]) were associated with higher odds of penicillin allergy label carriage. Black race (aOR= 0.77 [95% CI= 0.69-0.87]) and Asian race (aOR= 0.47 [95%CI = 0.41-0.53]) were associated with lower odds of penicillin allergy label carriage. In multivariable regression, allergist referral was associated with female sex (aOR= 1.52 [95% CI= 1.10-2.10]) and Black race (aOR= 1.74 [95% CI= 1.25-2.45]). Of 93 patients (37%) who completed their allergy visit, 26 (28%) had received penicillin allergy evaluation or were scheduled to receive a penicillin allergy evaluation at a future visit. There were racial differences in penicillin allergy labeling and referral. Allergy referral for penicillin allergy assessment was rare. Larger studies are needed to assess penicillin allergy labeling and delabeling with an equity focus on optimizing patient health outcomes.

A Quality Improvement Initiative to Increase Access to Penicillin Allergy Evaluations in Pediatric Surgical Patients

Surgical patients with a penicillin allergy label have worse clinical outcomes and increased healthcare costs compared to patients without a penicillin allergy label. Our aim is to decrease the number of pediatric patients presenting to surgery with a penicillin allergy label by increasing access to pre-operative penicillin allergy evaluation.

Few Patients "Re-Labeled" Allergic to Penicillin After Removal of Inappropriate Penicillin Allergy Label

Penicillin allergy is reported in up to 10% of the general population; however, more than 90% of “penicillin allergic” patients can tolerate penicillin without incident. There is limited evidence whether efforts to remove inappropriate penicillin allergies are sustainable since it is unknown how often penicillin allergy labels are “resurrected” in the electronic medical record (EMR).

Pilot Program utilizes telemedicine to expedite penicillin allergy de-labeling

Approximately 5% of children carry a penicillin (PCN) allergy label. Less than 10% of reported reactions are estimated to be IgE-mediated. Current guidelines recommend formal evaluation of all patients with unconfirmed PCN allergy labels, and dedicated PCN allergy clinics have proved to be effective for de-labeling. We piloted a new PCN allergy clinic utilizing telemedicine services to provide prompt PCN allergy evaluation.

Persistent Penicillin Allergy Label in Pharmacies after Penicillin Allergy De-labeling

Persistent Penicillin Allergy Label in Pharmacies after Penicillin Allergy De-labeling

Pharmacist-led improvement in perioperative antibiotic selection for patients with a penicillin allergy label.

Surgical patients with a penicillin allergy label (PAL) are less likely to receive β-lactams for surgical site infection (SSI) prophylaxis and more likely to receive second-line antibiotics, which may increase the risk of SSI, drug toxicities, and associated costs. We assessed the impact of implementing a pharmacist-led quality improvement project to increase the use of cefazolin as a first-line agent in this population. After implementation of a pilot project in December 2021, all patients with a PAL and orders for preoperative antibiotics were risk stratified into high- or low-risk categories by a pharmacist. For the low-risk group, cefazolin was recommended. For the high-risk group, cefazolin was avoided and a second-line agent was administered. Our analysis compared 422 preintervention patients (August 15 to November 15, 2021) to 492 postintervention patients (December 15 to March 15, 2022). During the postintervention period, β-lactam usage increased (from 12.6% to 37.8%, P < 0.001), while usage of vancomycin (45.5% vs 29.5%, P < 0.001) and other second-line antibiotics (87.4% vs 62.2%, P < 0.001) declined. There were no adverse reactions reported in the preintervention cohort, with 2 potential adverse reactions reported after the intervention (0% vs 0.4%, P = 0.190). Medication costs based on claims data were 50% to 80% lower for patients receiving cefazolin. In our cohort, a pharmacy-led antibiotic selection algorithm for patients with a PAL receiving perioperative antimicrobial prophylaxis resulted in increased use of β-lactam antibiotics, decreased use of second-line antibiotics, and decreased costs without a significant change in the incidence of adverse reactions.

The epidemiology of cephalosporin allergy labels in pediatric primary care.

Recent studies have sought to understand the epidemiology and impact of beta-lactam allergy labels on children; however, most of these studies have focused on penicillin allergy labels. Fewer studies assess cephalosporin antibiotic allergy labels in children. The objective of this study was to determine the prevalence, factors associated with, and impact of cephalosporin allergy labels in children cared for in the primary care setting. Cephalosporin allergy labels were reviewed among children in a dual center, retrospective, birth cohort who were born between 2010 and 2020 and followed in 90 pediatric primary care practices. Antibiotic prescriptions for acute otitis media were compared in children with and without cephalosporin allergies. 334,465 children comprised the birth cohort and 2,877 (0.9%) were labeled as cephalosporin allergic during the study period at a median age of 1.6 years. Third-generation cephalosporins were the most common class of cephalosporin allergy (83.0%). Cephalosporin allergy labels were more common in children with penicillin allergy labels than those without (5.8% vs. 0.6%). Other factors associated with a cephalosporin allergy label included white race, private insurance, presence of a chronic condition, and increased health care utilization. Children with third-generation cephalosporin allergy labels received more amoxicillin/clavulanate (28.8% vs. 10.2%) and macrolides (10.4% vs. 1.9%) and less amoxicillin (55.8% vs. 70.9%) for treatment of acute otitis media than non-allergic peers p < 0.001. One in 100 children is labeled as cephalosporin allergic, and these children receive different antibiotics for the treatment of acute otitis media compared to non-allergic peers.

Challenges and opportunities related to penicillin allergy in the Veterans Health Administration: a narrative review.

The presence of a penicillin allergy label in a patient's medical chart is associated with negative clinical and economic outcomes. Given that less than 10% of reported reactions are truly immunoglobulin E-mediated, removal of unverified penicillin allergy labels is a public health priority and an area of ongoing implementation research. The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States, with almost 9 million veterans currently enrolled. However, studies analyzing the impact of the penicillin allergy label in this population are limited to single facilities and largely focus on short-term outcomes of allergy documentation correction, usage of β-lactams, and avoidance of antibiotic-related side effects. Broader, national VHA studies focusing on health outcomes and costs are lacking. As with non-VHA facilities, penicillin allergy evaluations are limited owing to the absence of formal allergy/immunology services at most VHA facilities. Pharmacy-driven screening and referral for clinic-based penicillin skin testing is a promising and frequently discussed modality in the literature, but its scalability within the VHA is not yet proven. Broader, evidence-based strategies that can be adapted to the available resources of individual VHA facilities, including those without on-site access to allergy providers, are needed.

Increasing cefazolin use for surgical prophylaxis in penicillin-allergy-labeled patients.

Penicillin (PCN) allergy labels affect antimicrobial selection for surgical prophylaxis. We aimed to increase the percentage of cefazolin usage in patients with PCN allergy labels undergoing orthopedic surgery from 50% to 80%. Quality improvement initiative. Children's Mercy Kansas City (CMKC), a freestanding children's hospital. Children scheduled for an orthopedic surgery (excluding spinal surgery) at CMKC who had a PCN allergy label and received a perioperative antibiotic. No standardized process existed to identify and clarify PCN-allergic-labeled patients preoperatively. We developed a process for patient identification combined with a pharmacist phone interview for PCN allergy clarification. In plan-do-study-act (PDSA) part 1, we implemented a computer-generated patient list. In PDSA part 2, we combined automated identification with a phone interview. In PDSA part 3, we enhanced the patient list, making it timely and concise. In PDSA part 4, we included a PCN allergy clarification electronic survey to caregivers via the electronic medical record. Cefazolin use in PCN-allergic surgical patients increased from 50% to 74% following interventions. Patients who had their PCN allergy label clarified were 4 times more likely to receive cefazolin compared to those whose allergy labels were not clarified (OR, 4.21; 95% CI, 1.68-11.61; P = 0.003). Moreover, 90% of patients received cefazolin when their PCN allergy was clarified and cefazolin was recommended. When a PCN allergy label was not clarified, only 59% of patients received cefazolin. Appropriate clarification and documentation of PCN allergy labels increases the use of cefazolin for surgical prophylaxis.

Low self-reported penicillin allergy in South Africa-implications for global public health response.

In high-income countries, up to 25% of inpatients have a self-reported penicillin allergy (PA). After testing, 95% of these self-reported PAs are incorrect. These incorrectly labelled PAs increase the use of broad-spectrum antibiotics, and drive bacterial resistance. The epidemiology of PA in low- and middle-income countries is unknown. We aimed to describe the epidemiology and delabelling outcomes of self-reported PA in South African (SA) inpatients. We conducted point prevalence surveys between April 2019 and June 2021 at seven hospitals in Cape Town, South Africa. A team trained in the PEN-FAST allergy decision tool conducted in-person interviews, and reviewed patient notes to identify and risk stratify inpatients with a self-reported PA. These patients were referred to the Groote Schuur Hospital (GSH) allergy clinic for delabelling. A total of 1486 hospital inpatients were surveyed and 3.2% (n = 48) carried a PA label. Importantly, 64.6% (n = 31) were classified by PEN-FAST as low risk for true penicillin hypersensitivity. Overall, 25% of the self-reported PAs received a β-lactam antibiotic in hospital and were directly delabelled. Delabelling attrition was very high, with 6.3% (3/48) of the self-reported PAs attending the GSH allergy clinic, and only one patient proceeding to a negative oral penicillin challenge. Inpatient self-reported PA was lower in South Africa hospitals compared with other upper-middle-income countries, and the majority of patients carried a low-risk PA label. Linkage for delabelling with the allergy clinic was very poor, and thus strategies to improve access and delivery of delabelling remains an urgent public health issue.

Barriers to paediatric penicillin allergy de-labelling in UK secondary care: a regional survey

BackgroundIncorrect penicillin allergy labels result in the use of inappropriately broad-spectrum antibiotics. De-labelling inaccurate penicillin allergy promotes antimicrobial stewardship and optimises prescribing practices. The objectives were to evaluate paediatric clinicians’...

1662. Impact of a Documented Penicillin Allergy on Antibiotic Selection in Patients with Osteomyelitis

Abstract Background Penicillin allergy is the most commonly reported drug allergy, affecting approximately 10% of patients. Although historically there has been concern about administering cephalosporins to patients allergic to penicillin, the rates of cross-reactivity are only approximately 2%. As cephalosporins are the first-line and safest treatment for many infections, unnecessary avoidance of cephalosporins places patients at risk of poor disease outcomes and antibiotic-associated harms. We assessed the relationship between penicillin allergy label and antibiotic selection in pediatric patients with acute osteomyelitis. Methods We performed a retrospective review of inpatients at our quaternary children’s hospital diagnosed with osteomyelitis between 2011 and 2021. During this period, the institutional osteomyelitis clinical pathway recommended clindamycin for patients with cephalosporin but not penicillin allergy. We compared rates of antibiotics used as definitive therapy between patients with and without documented penicillin allergy. Results Of 365 patients hospitalized with a diagnosis of osteomyelitis, 41 (11.2%) had a documented penicillin allergy. First-generation cephalosporins were administered less frequently to penicillin-allergic patients compared with those without documented penicillin allergy (37% vs. 58%, p=.009), while clindamycin was administered more frequently (22% vs. 10%, p=.02). There was no significant difference in vancomycin use (2% vs. 9%, p=.17). Conclusion Patients with osteomyelitis and a penicillin allergy label were significantly less likely to receive a first-generation cephalosporin and significantly more likely to receive clindamycin. Given higher regional resistance rates and more frequent adverse effects, including Clostridioides difficile infection, of clindamycin relative to first-generation cephalosporins, these data support the need for quality improvement work to increase cephalosporin use in patients with penicillin allergy labels. Disclosures Mari M. Nakamura, MD, MPH, Gilead: Grant/Research Support.