Penicillin Allergy Label Research Articles

Alergia a la penicilina: una etiqueta que no es para siempre

Self-reported penicillin allergy is highly prevalent. Different studies estimate that 10% of the population is labeled as such.This label, confirmed or suspected, forces us to take precautions and replace the antibiotic treatment of choice (frequently beta-lactams) with other 2nd or 3rd choice alternatives with worse overall results: side effects, resistance, costs, etc.The penicillin allergy label, once placed, remains in the medical record. It is only confirmed in less than 5% of patients, either because it has been placed inappropriately or because over time the sensitivity decreases and may disappear.Penicillin Allergy Decision Rule –PEN-FAST– is a validated and simple clinical prediction rule that estimates the risk of presenting an allergic reaction. Its use, together with algorithms that involve primary care in the study and delabeling of low-risk patients, can change our clinical practice.

Adult penicillin allergy programmes in Australian hospitals: a practical guide from the National Antibiotic Allergy Network.

Penicillin allergy is a significant burden on patient, prescribing and hospital outcomes. There has been increasing interest in the incorporation of penicillin allergy testing (i.e. delabelling) into antimicrobial stewardship (AMS) programmes to reduce the burden of penicillin allergy labels and improve prescribing. In particular, there has been a focus on point-of-care penicillin allergy assessment and direct oral challenge for low-risk phenotypes. The National Antibiotic Allergy Network has provided a guide to assist AMS clinicians with the incorporation of penicillin allergy programmes, in particular direct oral challenge, into Australian hospitals.

Delabeling of allergy to beta-lactam antibiotics in hospitalized patients: a prospective study evaluating cost savings.

Patients with a penicillin allergy label are at risk of an associated increase in adverse antibiotic events and hospitalization costs. We aimed to study the economic savings derived from the correct diagnosis and delabeling inpatients with suspected beta-lactam allergy, considering the acquisition cost of antimicrobials prescribed during a patient's hospital stay. We prospectively evaluated patients admitted to the University Hospital of Salamanca who had been labeled as allergic to beta-lactams and performed a delabeling study. Subsequently, cost differences between antibiotics administered before and after the allergy study and those derived from those patients who received alternative antibiotics during admission and those who switched to beta-lactams after the allergy study were calculated. One hundred seventy-seven inpatients labeled as allergic to beta-lactams underwent a delabeling study; 34 (19.2%) were confirmed to have allergy to beta-lactams. Of the total number of patients, 136 (76.8%) received antibiotics during their hospitalization, involving a mean (SD) cost of €203.07 (318.42) and a median (IQR) cost of €88.97 (48.86-233.56). After delabeling in 85 (62.5%) patients, the antibiotic treatment was changed to beta-lactams. In this group of patients, the mean cost (SD) decreased from €188.91 (351.09) before the change to 91.31 (136.07) afterward, and the median cost (IQR) decreased from €72.92 (45.82-211.99) to €19.24 (11.66-168). The reduction was significant compared to the median cost of patients whose treatment was not changed to beta-lactams (p<0.001). Delabeling hospitalized patients represents a cost-saving measure for treating patients labeled as allergic to beta-lactams.

Global differences and risk factors influencing drug hypersensitivity quality of life: A multicenter, multiethnic study of drug allergy across 3 continents

BackgroundPenicillin allergy labels are associated with many adverse outcomes. Fear and restriction of future medication use also impact health-related quality of life (HR-QoL). However, the impact of a drug allergy on HR-QoL and its associated factors remain unknown. ObjectiveTo investigate the impact of penicillin allergy labels and compare the factors associated with HR-QoL impairment among an international multi-center and multi-ethnic cohort. MethodsHR-QoL was measured using the 6-item Drug Hypersensitivity Quality of Life Questionnaire (DrHy-Q) and compared among patients labelled with penicillin allergy, before their allergy evaluation, from eight adult allergy/immunology clinics across Asia, Australasia, and North America. ResultsWe recruited 643 patients labelled with penicillin allergy (median age: 56 [IQR 39-67] years, male: female ratio: 1:2.2), with 273 (42.5%), 186 (28.9%) and 184 (28.6%) from Asia, North America and Australia; respectively. The median DrHy-Q score was 8.3 (IQR 0.0–29.2). All patients underwent penicillin allergy evaluation, and 96.0% (617/643) were delabelled following negative provocation tests. Patients who were female (8.3 vs. 4.2, p=0.003), had other concomitant antimicrobial allergy labels (20.8 vs. 4.2, p=0.004), and from Asia (33.3 vs. 4.2 [North America] vs. 0 [Australia], p<0.001) had significantly higher DrHy-Q scores, reflecting a reduced HR-QoL. Ethnicity, as well as other allergy variables, were not significant in multivariate analysis. ConclusionRegional differences, ethnicity, and other risk factors influence HR-QoL impairment among patients labelled with penicillin allergy. Future studies are needed to understand the contributions of regional socio-demographic factors and identify interventions to improve HR-QoL.

Reaction Risk to Direct Penicillin Challenges

While direct penicillin challenges might support the expansion of penicillin allergy delabeling efforts, the perceived risk of reactions remains a key barrier. To evaluate the frequency of reactions to direct penicillin challenges in individuals with penicillin allergy labels and to identify factors associated with such reactions. Three electronic databases were searched (MEDLINE, Web of Science, and Scopus) from inception to July 19, 2023, for primary studies assessing patients undergoing direct penicillin challenges. Articles were included regardless of publication year, language, status, or definition of allergy risk. Two reviewers independently selected original studies reporting the frequency of immunologically mediated reactions following a direct penicillin challenge in patients reporting a penicillin allergy. Two reviewers independently extracted data and independently assessed the quality of each primary study using a risk-of-bias tool for prevalence studies. The primary outcome was the frequency of reactions to direct penicillin challenges as calculated using random-effects bayesian meta-analysis of proportions. Secondary outcomes included risk factors for reactions and the frequency of severe reactions. A total of 56 primary studies involving 9225 participants were included. Among participants, 438 experienced reactions to direct penicillin challenges without prior testing, corresponding to an overall meta-analytic frequency of 3.5% (95% credible interval [CrI], 2.5%-4.6%). Meta-regression analyses revealed that studies performed in North America had lower rates of reaction to direct challenges (odds ratio [OR], 0.36; 95% CrI, 0.20-0.61), while studies performed in children (OR, 3.37; 95% CrI, 1.98-5.98), in outpatients (OR, 2.19; 95% CrI, 1.08-4.75), and with a graded (OR, 3.24; 95% CrI, 1.50-7.06) or prolonged (OR, 5.45; 95% CrI, 2.38-13.28) challenge had higher rates of reaction. Only 5 severe reactions (3 anaphylaxis, 1 fever with rash, and 1 acute kidney injury) were reported, none of which were fatal. This systematic review and meta-analysis found that reactions to direct penicillin challenges are infrequent, with rates comparable to indirect challenges after allergy testing. These findings suggest that direct challenges are safe for incorporation into penicillin allergy evaluation efforts across age groups and clinical settings.

“What if the patient has a severe reaction, and it is my fault?” A qualitative study exploring factors for sustainable implementation of penicillin allergy delabelling

BackgroundPenicillin allergy delabelling (PAD), the process of evaluating penicillin allergy labels, is a key target in antibiotic stewardship, but uptake of the procedure outside clinical studies is limited. We aimed to explore factors that need to be addressed to sustainably implement a clinical pathway for PAD.MethodsWe conducted a qualitative study based on semi-structured interviews with focus groups consisting of a purposive sample of twenty-five nurses and physicians working in four different hospitals in Western Norway. Systematic text condensation was applied for analysis.ResultsPsychological safety was reported as crucial for clinicians to perform PAD. A narrative of uncertainty and anticipated negative outcomes were negatively associated with PAD performance. Education, guidelines, and colleague- and leadership support could together create psychological safety and empower health personnel to perform PAD. Key factors for sustainable implementation of PAD were facilitating the informant’s profound motivation for providing optimal health care and for reducing antimicrobial resistance. Informants were motivated by the prospect of a simplified PAD procedure. We identified three main needs for implementation of PAD: (1) creating psychological safety; (2) utilising clinicians’ inherent motivation and (3) optimal organisational structures.ConclusionA planned implementation of PAD must acknowledge clinicians’ need for psychological safety and aid reassurance through training, leadership, and guidelines. To implement PAD as an everyday practice it must be minimally disruptive and provide a contextually adaptive logistic chain. Also, the clinician’s motivation for providing the best possible healthcare should be utilised to aid implementation. The results of this study will aid sustainable implementation of PAD in Norway.EthicsThe study was approved by the Western Norway Regional Committee for Medical Research Ethics (Study No:199210).

Patient Perceptions of Penicillin Allergy Testing in a Public Health System

Documented penicillin allergies are associated with increased morbidity, increased hospital stay, and an increase in resistant infections. Penicillin allergy evaluations using a direct oral challenge with or without skin testing has been recommended as a delabeling strategy for patients with penicillin reaction histories. Barriers for achieving equitable access, however, exist. Understanding patient perceptions regarding their penicillin allergy across diverse populations is crucial to mitigate potential obstacles to penicillin allergy testing (PAT) and the use of penicillin-like antibiotics after delabeling. The objective of this study was to gather perceptions of patients delabeled of their penicillin allergy after testing through a PAT program. Patients who underwent PAT and had a subsequent allergy removal due to a negative result were interviewed using closed and open-ended questions. A total of 100 patient interviews were completed. Awareness of the risks associated with unnecessary penicillin avoidance and PAT was low. Initial concerns regarding PAT were common but were frequently alleviated with targeted education. Most patients undergoing testing reported a positive experience and would recommend PAT to others. A minority of patients continued to have discordant perceptions regarding their penicillin allergy label with mistrust in the negative result being a critical theme identified. Future interventions increasing the awareness of penicillin allergy labels and the risks and benefits of PAT in the general population are needed and must consider health literacy levels, languages, and cultural contexts. Measures to offer PAT within a clinical setting that has built high levels of patient trust will likely achieve the greatest long-term success.

Retrospective study on penicillin allergy delabeling and evaluation of an antibiotic allergy assessment tool

BackgroundIt has been reported that 95 % of patients labeled as penicillin-allergic may be mislabeled. However, the process of delabeling has not advanced due to a shortage of allergy specialists capable of conducting accurate assessments. To address this issue, The Antibiotics Allergy Assessment Tool (AAAT) has been proposed as a tool to evaluate patients who can be delabeled by non-specialists. ObjectiveThis study aims to identify patients who can be delabeled and to evaluate patients who are likely to be delabeled using AAAT. MethodsPatients admitted to the hospital between January 1, 2017, and December 31, 2021, with documented penicillin allergy labels were included in the study. Patients who demonstrated tolerance to labeled antibiotics or were labeled without explicit allergy declarations were defined as delabeling. Subsequently, patients who did not meet the criteria for delabeling were evaluated for their potential to be delabeled using the AAAT, retrospectively. Results530 patients were selected, of which 62 (11.7 %) were delabeled. The AAAT evaluation of the remaining patients indicated that at least an additional 137 (25.8 %) patients could potentially be delabeled. ConclusionThe use of AAAT demonstrated the potential to delabel approximately third as many patients without the need for specialist evaluation. To promote broader delabeling efforts in the future, prospective studies should investigate the safety and effectiveness of evaluation tools such as the AAAT.

Sulfonamide allergy label and the risk of opportunistic infections in solid organ transplant recipients - A retrospective matched cohort study.

While a penicillin allergy label has been linked to various negative clinical outcomes, limited studies have specifically characterized the implication of sulfonamide allergy labels (SAL) on clinical outcomes. We examined the impact of SAL on clinical outcomes of solid organ transplant recipients. In this retrospective matched cohort study, we utilized the TriNetX US collaborative Network, a multicenter de-identified US database, and identified solid organ transplant recipients with and without SAL. The 1-year probability of developing Pneumocystis jirovecii pneumonia (PJP), toxoplasmosis, and nocardiosis was estimated and contrasted between the two study groups. The hazard ratio (HR) and the 95% confidence interval (CI) quantified the strength and direction of the association between SAL and these outcomes. When comparing 1571 solid organ transplant recipients with SAL to an equal number of matched controls, patients with SAL had a higher probability of developing nocardiosis (HR 3.85; 95% CI, 1.44-10.30; p=.004; corrected p=.04), and toxoplasmosis (HR, 1.87; 95% CI, 1.10-3.17; p=.019; corrected p=.19), but no difference in the risk of developing PJP (HR, 1.64; 95% CI, 0.68-3.95; p=.27). There was no mortality difference (HR, 1.31; 95% CI, 0.99-1.75; p=.061; corrected p=.6). SAL influenced antibiotic prescription with overutilization of dapsone, atovaquone, and pentamidine and underutilization of trimethoprim and sulfamethoxazole. SAL is associated with an increased risk of opportunistic infections following solid organ transplantation. Measures to evaluate and de-label sulfonamide allergy prior to transplantation or desensitizing shortly after transplantation are advisable.

A call to address penicillin allergy labels in patients with hematopoietic stem cell transplants: How to avoid rash decisions.

Among patients with hematopoietic stem cell transplants, infections, particularly multidrug-resistant infections, pose a grave threat. In this setting, penicillin allergy labels are both common and harmful. Though the majority of patients who report penicillin allergy can actually tolerate penicillin, penicillin allergy labels are associated with use of alternative antibiotics, which are often more broad spectrum, less effective, and more toxic. In turn, they are associated with more severe infections, multidrug-resistant infections, Clostridium difficile, and increased mortality. Evaluating penicillin allergy labels can immediately expand access to preferred therapeutic options, which are critical to care in patients with recent hematopoietic stem cell transplants. Point-of-care assessment and clinical decision tools now exist to aid the nonallergist in assessment of penicillin allergy. This can aid in expanding use of other beta-lactam antibiotics and assist in risk-stratifying patients to determine a testing strategy. In patients with low-risk reaction histories, direct oral challenges can be employed to efficiently delabel patients across clinical care settings. We advocate for multidisciplinary efforts to evaluate patients with penicillin allergy labels prior to transplantation.

Risk of Self-Reported Penicillin Allergy Despite Removal of Penicillin Allergy Label

Risk of Self-Reported Penicillin Allergy Despite Removal of Penicillin Allergy Label

Effectiveness of direct delabelling of allergy labels in type A adverse drug reactions to penicillin: a multicentre hospitalwide prospective cohort study.

Patient-reported penicillin allergy labels (PALs) are associated with adverse patient outcomes and inappropriate antibiotic prescribing. Removal of PALs via direct oral challenge (DOC) is associated with increased penicillin utilization post removal. To assess the impact of direct delabelling (allergy label removal via medical reconciliation alone) of type A adverse drug reaction (ADR) PALs on inpatient prescribing. From January 2019 to December 2022 at two tertiary hospitals in Melbourne, patients aged ≥18 years with type A ADR PALs, as defined by the validated Antibiotic Allergy Assessment Tool, were offered direct delabelling or single-dose DOC. The primary endpoint was antibiotic use pre- and post-assessment (during index admission and 90 days post assessment). The secondary endpoint was the proportion of patients delabelled in the direct delabelling and DOC cohorts in the electronic medical record at 90 days post assessment. Allergy labels (n = 4108) were assessed for 488 participants, with 490 individual type A ADR PAL assessments included. Three hundred and thirty-seven patients were directly delabelled, 69 underwent DOC and 84 were not delabelled. There was increased use of any penicillin following direct delabelling (OR 19.19, 95% CI 2.48-148.36) and DOC (OR 56.98, 95% CI 6.82-476.19) during the index admission, higher in the DOC group compared with direct delabelling (OR 2.97, 95% CI 1.39-6.37). Relabelling at 90 days was low with no statistically significant difference between direct delabelling (5/337; 1.5%) and DOC (0/69; 0%). Both direct delabelling and DOC of type A ADR PALs increased penicillin usage; however, the impact was greatest with DOC. Most patients remain delabelled at 90 days.

First-line treatment with ceftriaxone for Neisseria gonorrhoeae infection less likely to be prescribed to patients with a penicillin allergy label: a retrospective audit of medical records.

Background Gonorrhoea notifications have increased substantially in Australia over the past decade. Neisseria gonorrhoeae is already highly resistant to several antibiotics and so, alternatives to first-line treatment are generally strongly discouraged. The penicillin allergy label (AL) on patient medical records has previously been shown to influence prescribing practices, to the detriment of best-practice management and antimicrobial stewardship. This study aimed to understand how the penicillin AL influences antibiotic selection for gonorrhoea treatment at Canberra Sexual Health Centre. Methods A retrospective chart audit of gonorrhoea cases treated at Canberra Sexual Health Centre between January 2020 and October 2023 (n =619 patients, n =728 cases). Antibiotic selection was assessed according to penicillin AL status. Ceftriaxone selection was assessed according to penicillin allergy severity reported in the medical records and as determined using a validated antibiotic allergy assessment tool. Results Cases with a penicillin AL were more likely to receive antibiotics other than ceftriaxone (n =7/41, 17.1%) than cases without the label (n =8/687, 1.2%, P n =28/41, 68.3%) to apply the assessment tool. Those reported as low-severity in the records were more likely to receive ceftriaxone (n =21/22, 95.5%) than those reported as moderate-high (n =7/11, 63.6%) or unreported (n =6/8, 0.75%). Conclusions Treatment of gonorrhoea in outpatient settings requires an understanding of penicillin allergy, and the ability to quickly and accurately identify penicillin-AL patients who can safely tolerate ceftriaxone. Institutionally endorsed penicillin allergy de-labelling protocols and access to easy-to-navigate prescribing advice within national sexually transmitted infection management guidelines would support this.

Rising to the Challenge: An ID Provider-Led Initiative to Address Penicillin Allergy Labels at a Large Veterans Affairs Medical Center.

Given the negative consequences associated with a penicillin allergy label, broader penicillin allergy delabeling initiatives are highly desirable but hindered by the shortage of allergists in the United States. To address this problem at our facility, the infectious diseases section introduced a quality improvement initiative to evaluate and remove allergy labels among inpatient veterans. Between 15 November 2022 and 15 December 2023, we identified inpatients with a penicillin allergy label. We subsequently interviewed eligible candidates to stratify penicillin allergy risk and attempt to remove the allergy label directly via chart review, following inpatient oral amoxicillin challenge or outpatient community care allergy referral. Delabeling outcomes, subsequent penicillin-class prescriptions, and relabeling were tracked after successful allergy label removal. We screened 272 veterans, of whom 154 were interviewed for this intervention. A total of 53 patients were delabeled: 26 directly, 23 following oral amoxicillin challenge, and 4 following outpatient allergy referrals. Of the patients who were delabeled, 25 received subsequent penicillin-class prescriptions. No adverse reactions occurred following inpatient oral amoxicillin challenges. Patients with a low-risk penicillin allergy history were more likely to undergo a challenge if admitted with an infectious diseases-related condition. Only 1 inappropriate relabeling event occurred during the study period, which was subsequently corrected. An infectious diseases provider-led initiative resulted in penicillin allergy label removal in more than one third of inpatients evaluated using direct removal or oral amoxicillin challenge. Efforts focused on patients who had been admitted for infections were particularly successful.

True Rate of Allergy among Pediatric Inpatients with Penicillin Allergy Labels (TRIAL).

Penicillin allergy is a common drug allergy diagnosis in pediatric patients; however, upon appropriate allergy testing, many of these patients are found not to have a true allergy. For patients with a reported allergy, alternative antibiotics are prescribed, which are less effective, more toxic, or more expensive. There is a lack of data evaluating allergies in hospitalized children and comparing allergy assessments conducted by pediatric allergists and pharmacists. To estimate the percentage of pediatric patients admitted with reported penicillin allergy who did not have a true penicillin allergy. This single-centre prospective cohort study included inpatients between 6 months and 17 years of age, with a documented penicillin allergy, who were admitted to the general pediatric and oncology units of a tertiary care children's hospital between November 2019 and March 2023. The allergy history, evaluation, and risk categorization were performed by pharmacists. The history was reviewed with the allergist, and the patient was then referred, underwent skin testing, or received oral amoxicillin challenge with monitoring for 1 hour. Thirty patients were included, of whom 29 (97%) had delabelling of their penicillin allergy. Four patients (13%) had delabelling on the basis of history alone, without risk assessment. Twenty-five (83%) of the patients were assessed as having low risk; 24 of these had delabelling following oral challenge, and 1 did not complete the oral challenge because of transfer to another hospital. One patient (3%) was assessed as having moderate risk, with delabelling on the basis of results of skin testing and oral challenge. The pharmacist's and allergist's risk assessments were in agreement in 29 (97%) of the 30 cases. Pediatric patients, including those with oncologic malignancies, are often mislabelled as having a penicillin allergy. Pharmacists are able to accurately determine true allergy risk and delabel penicillin allergies for pediatric patients in the hospital setting.

Perceptions on Penicillin Allergy Labels among Nurses and Prescribers in Three Pediatric Urgent Care Sites

Background: National guidelines recommend penicillins (PCN) as first-line treatment for many common pediatric infections in the outpatient setting. Although less than 1% of the United States population has a true, IgE-mediated PCN-allergy, approximately 10% of patients are labeled with a PCN-allergy. Accurate adverse drug reaction (ADR) documentation plays an important role in this over-labeling. We have previously shown that nurses feel assessment and documentation of PCN-allergies are critical to their role. However, additional evidence purports nurse hesitancy to interrogate allergy accuracy or reclassify parent’s response to side effect. Our objective was to explore frontline clinicians’ confidence in assessing, documenting, and responding to PCN-allergy labels. Methods: To expose barriers and prioritize improvement ideas for a multidisciplinary quality improvement (QI) project aimed to improve PCN-allergy labeling in our pediatric urgent care clinics, we deployed this investigator-developed survey to prescribers and nurses. It’s comprised of 14-questions scored on a 5-point Likert scale (4 demographic, 4 PCN/safety, 3 allergy types, 4 allergy documentations, 3 treatment options), and 1 optional free-text. We used descriptive statistics to compare survey responses between prescribers and nurses and evaluated free text comments for themes. Results: Eighty-seven clinicians across 3 sites participated, with a response rate of 35%, with variation by sites (25.3% to 41.4%). Forty-one percent of (n=36) responders have been in practice &gt;15 years and 40.2% (n=35) have worked at our hospital &gt; 15 years (Table 1). Overall, perceived knowledge of PCN-allergies and safety was favorable (Table 2). Prescribers reported higher confidence with: 1) perceiving many patients who believe they are allergic to PCN can safety take PCN (prescribers median=5 [IQR: 4, 5] vs. nurses median=4 [4,4], p = 0.003); and 2) perceiving that time pressures influenced their ability to reconcile allergies and side effects (prescribers median=4 [4, 5] vs. nurses median=3 [2, 4], p = 0.001). Both prescribers and nurses reported lower confidence in continuing to administer or prescribe an antibiotic in the setting of a reported ADR. Thirteen respondents (15%) provided comments with specific requests for additional family education and practice guidance, including the referral process to subspecialty clinics for PCN-allergy testing. Conclusions: Our survey results identified barriers to accurate PCN-allergy labels, including knowledge on documentation, time pressures, hesitancy to challenge parent report, and uncertainty on referral process for PCN-allergy testing. This survey will inform future drivers for our QI. Opportunities include electronic medical record refinement, improving referrals to PCN-allergy de-labeling clinics, and the development of scripted education to guide family discussions.Disclosure: Rana El Feghaly: Merck- grant funding. Amanda Nedved: Contracted Research – Merck

Oral challenge vs routine care to assess low-risk penicillin allergy in critically ill hospital patients (ORACLE): a pilot safety and feasibility randomised controlled trial

PurposeCritically ill patients are vulnerable to penicillin allergy labels that may be incorrect. The validity of skin testing in intensive care units (ICUs) is uncertain. Many penicillin allergy labels are low risk, and validated tools exist to identify those amenable to direct oral challenge. This pilot randomised controlled trial explored the feasibility, safety, and validity of direct enteral challenge for low-risk penicillin allergy labels in critical illness.MethodsConsenting patients with a low-risk penicillin allergy label (PAL) (PEN-FAST risk assessment score < 3) in four ICUs (Melbourne, Australia) were randomised 1:1 to penicillin (250 mg amoxicillin or implicated penicillin) direct enteral challenge versus routine care (2-h post-randomisation observation for each arm). Repeat challenge was performed post -ICU in the intervention arm. Patients were reviewed at 24 h and 5 days after each challenge/observation.ResultsWe screened 533 patients. 130 (24.4%) were eligible and 80/130 (61.5%) enrolled (age median 64.5 years (interquartile range, IQR 53.5, 74), PEN-FAST median 1 (IQR 0,1)), with 40 (50%) randomised to direct enteral challenge. A positive challenge rate of 2.5% was identified. No antibiotic-associated serious adverse events were identified. 32/40 (80%) received a repeat challenge (zero positive). Post-randomisation, 13 (32%) of the intervention arm and 4 (10%) of the control arm received penicillin (odds ratio, OR 4.33 [1.27, 14.78] p = 0.019).ConclusionThese findings support the safety, validity, and feasibility of direct enteral challenge for critically ill patients with PEN-FAST assessed low-risk penicillin allergy. The absence of false negative results was confirmed by subsequent negative repeat challenges. A relatively low recruitment to screened ratio suggests that more inclusive eligibility criteria and integration of allergy assessment into routine ICU processes are needed to optimise allergy delabelling in critical illness.

English

Background: Interest in finding efficient ways to remove penicillin allergy alerts has grown as a result of awareness of the considerable excess of false-negative diagnoses in patients with penicillin allergy labels (90%-95%), the poorer course with non–ß-lactam antibiotics, the increase in bacterial resistance, and the fact that these problems can affect up to 20% of the population in some countries. The strategies proposed have generated many publications in countries where the number of allergists to conduct such studies is low. In many cases where delabeling is performed, the risk of ß-lactam allergy is low, and a single penicillin challenge is sufficient to delabel the alert. However, other less “ultrarapid” strategies can be used to administer a ß-lactam during an admission for infection and thus postpone delabeling until traditional drug allergy consultations. However, the definitive withdrawal of ß-lactam alerts is threatened by nonremoval of alerts in electronic health records and by the reactivation or nonsynchronization of alerts between electronic systems at different levels of care. Allergy departments need to reflect on how to implement practices that enable rapid and efficient delabeling of drug allergy alerts, especially in patients with major comorbidities.

Eliciting the barriers and enablers towards anaesthetists giving penicillin-based antibiotic prophylaxis to low-risk patients who have had their penicillin allergy label removed as part of a preoperative delabelling process.

Some penicillin allergy labels can be removed by non-allergy specialists by direct oral challenge, but there is reluctance amongst anaesthetists to give penicillin to these patients. We aimed to assess anaesthetist beliefs about giving penicillin to patients delabelled by direct oral challenge. A survey, developed using the Theoretical Domains Framework, was circulated to anaesthetists within a regional research network in England. Domains were rated using 5-point Likert scales. Overall and group medians were used to dichotomize domains rated by group into 'relatively important/unimportant' and 'relative enabler/barrier'. We received 257 responses from six hospitals (response rate 49.7%). Seven domains were rated as important for all stakeholder groups and hospitals: Knowledge, Skills, Belief in Capabilities, Belief in Consequences, Memory/Attention/Decisions, Environmental Context and Resources, and Emotions. Social and Professional Role was also important to all respondents except those in one hospital. Intentions and Optimism were rated as important for some groups/hospitals and unimportant for others. All four other domains were rated as unimportant for all groups/hospitals. All domains rated as important were enablers for all groups/hospitals, with the exception of Memory/Attention/Decisions and Emotions, which were rated as discordant barriers/enablers between groups. This means they were acting as a barrier for some staff groups/hospitals and an enabler for others. Barrier domains (Reinforcement, Goals, Social Influences, Behavioural Regulation) were all rated unimportant. Behavioural influences on giving penicillin prophylaxis to a delabelled patient are complex and nuanced. These findings could inform targeted interventions, both across and within hospitals and staff groups.

Penicillin or cephalosporin antibiotic allergy label: Influence on length of stay and hospital readmission

A penicillin or cephalosporin antibiotic (PCA) allergy label (PCAAL) has negative implications for both the patient and health care alike. A retrospective study was undertaken to evaluate the influence of a PCAAL on length of stay (LOS) and hospital readmissions. Over 4 weeks, inpatients with a PCAAL who were referred to the allergy service or opportunistically reviewed were grouped in the categories delabeled (group 1a) or advice not followed (ie, label carriage) (group 1b). Comparator groups without a PCAAL were identified, those either on a PCA (the PCA group [group 2]) or on a non-PCA (the non-PCA group [group 3]). The study population comprised 77 patients as follows: group 1a (n= 19), group 1b (n= 6), group 2 (n= 36), and group 3 (n= 16). Those in group 1a were significantly older (median age 78 years) than those in group 1b (median age 53 years [P= .013]) or group 3 (median age 59 years [P= .013]).There was a trend toward lower LOS in group 1a (10 days) than in group 1b (11.5 days [P= not significant]). Group 2 had a significantly lower LOS (6 days) than either both group 1a (10 days [P= .043]) or group 3 (15 days [P= .002]). Group 3 had the highest rate of patients readmitted within 30 days (n= 5 [71.4%]). A PCAAL carries influence on both LOS and readmissions, thus identifying the prompt need for allergy review to provide specific recommendations: delabeling and transition to an appropriate antibiotic. The significantly older group of those with a PCAAL who received a PCA after delabeling (ie, a 20-year age difference) may also be a signal that more elderly and comorbid patients benefit from this intervention the most.