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Stul F, Heytens S, Ebo DG, Sabato V, Piessens V. Safe Penicillin Allergy Delabeling in Primary Care: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00640-8. [PMID: 38901618 DOI: 10.1016/j.jaip.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 06/02/2024] [Accepted: 06/07/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Ten percent of the population is labeled as allergic to penicillin(s), when in fact 90% of these labels are inappropriate. Recent studies have shown that inpatient delabeling by a direct drug challenge (dDC) is safe in low-risk patients. However, there is a need for outpatient and nonallergist delabeling. OBJECTIVE To assess the safety of delabeling low-risk adults by means of dDC in primary care. METHODS We searched the MEDLINE, Embase, and Cochrane Library databases from inception to March 15, 2022 (updated June 5, 2023) for studies performing dDC in adults in primary care or other outpatient settings. Two researchers independently screened studies for eligibility. The data extraction and critical appraisal were performed by 1 reviewer, and we pooled the results in a meta-analysis. RESULTS Of 2138 results, 12 studies (1070 participants) were eligible for inclusion. Three studies evaluated delabeling in primary care and 9 studies in an outpatient hospital setting. There were no critical adverse events during dDC. No reaction occurred in 97.13% of the 1070 patients, who previously labeled as penicillin-allergic, and were safely delabeled. Ten patients (<1%) developed an immediate reaction: 3 had self-limiting reactions and 7 needed antihistaminics, steroids, epinephrine, and/or salbutamol. CONCLUSIONS No serious allergic reactions are observed during direct amoxicillin challenge in adults in an outpatient setting. However, with the exception of 1 recent report, these studies are of low to moderate quality. Nonspecialist delabeling is promising, but further research is required on correct risk stratification and safety assessment in large cohort studies evaluating dDC in primary care.
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Affiliation(s)
- Florian Stul
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
| | - Stefan Heytens
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Didier Gaston Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Vito Sabato
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Veerle Piessens
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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Grant Day W, DeNora AB, Shields D, Otto A, Banks T, Dore MM. Clearance of Penicillin Allergy Through Direct Oral Challenge by Primary Care Physicians. J Gen Intern Med 2023; 38:3651-3653. [PMID: 37783980 PMCID: PMC10713884 DOI: 10.1007/s11606-023-08425-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/12/2023] [Indexed: 10/04/2023]
Affiliation(s)
- W Grant Day
- Department of Medicine, Naval Medical Readiness Training Command Portsmouth, Portsmouth, VA, USA.
| | - Allyson Burkhart DeNora
- Department of Medicine, Naval Medical Readiness Training Command Portsmouth, Portsmouth, VA, USA
| | - Daniel Shields
- Department of Medicine, Naval Medical Readiness Training Command Portsmouth, Portsmouth, VA, USA
| | - Ashley Otto
- Department of Medicine, Naval Medical Readiness Training Command Portsmouth, Portsmouth, VA, USA
| | - Taylor Banks
- Department of Allergy and Immunology, Naval Medical Readiness Training Command Portsmouth, Portsmouth, VA, USA
| | - Michael M Dore
- Department of Medicine, Duke University Medical Center, Durham, USA
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Samarakoon U, Accarino J, Wurcel AG, Jaggers J, Judd A, Blumenthal KG. Penicillin allergy delabeling: Opportunities for implementation and dissemination. Ann Allergy Asthma Immunol 2023; 130:554-564. [PMID: 36563744 DOI: 10.1016/j.anai.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/01/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Although existing as a safety measure to prevent iatrogenic harm, unconfirmed penicillin allergy labels have a negative impact on personal and public health. One downstream effect of unconfirmed penicillin allergy is the continued emergence and transmission of resistant bacteria and their associated health care costs. Recognizing the consequences of inaccurate penicillin allergy labels, professional and public health organizations have started promoting the adoption of proactive penicillin allergy evaluations, with the ultimate goal of removing the penicillin allergy label when the allergy is disproved, also known as penicillin allergy "delabeling." A penicillin allergy evaluation includes a comprehensive allergy history often followed by drug challenge, sometimes with preceding skin testing. Currently, penicillin allergy delabeling is largely carried out by allergy specialists in outpatient settings. Penicillin allergy delabeling is performed on inpatients, albeit rarely, often at the time of need, as a point-of-care procedure. Access to penicillin allergy evaluation services is limited. Recent studies demonstrate the feasibility of expanding penicillin allergy evaluations and delabeling to internists, pediatricians, emergency medicine physicians, infectious diseases specialists, and clinical pharmacists. However, reducing the impact of mislabeled penicillin allergy will require comprehensive efforts and new investments. In this review, we summarize the current practices of penicillin allergy delabeling and discuss expansion opportunities for penicillin allergy delabeling as quality improvement.
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Affiliation(s)
- Upeka Samarakoon
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John Accarino
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Alysse G Wurcel
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts; Tufts University School of Medicine, Boston, Massachusetts
| | - Jordon Jaggers
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Allen Judd
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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De-labeling Beta-lactam in Adult Population. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00316-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Penicillin Allergy Delabeling: A Multidisciplinary Opportunity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2858-2868.e16. [PMID: 33039010 DOI: 10.1016/j.jaip.2020.04.059] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022]
Abstract
The penicillin allergy label has been consistently linked with deleterious effects that span the health care spectrum, including suboptimal clinical outcomes, the emergence of bacterial resistance, and increased health care expenditures. These risks have recently motivated professional organizations and public health institutes to advocate for the implementation of penicillin allergy delabeling initiatives; however, the burden of delabeling millions of patients is too expansive for any one discipline to bear alone. This review presents the unique perspectives and roles of various stakeholder groups involved in penicillin allergy diagnosis, assessment, and delabeling; we emphasize opportunities, barriers, and promising areas of innovation. We summarize penicillin allergy methods and tools that have proven successful in delabeling efforts. A multidisciplinary approach to delabeling patients with reported penicillin allergy, bolstered by evidence-based clinical practices, is recommended to reduce the risks that associate with the penicillin allergy label.
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Hall V, Wong M, Munsif M, Stevenson BR, Elliott K, Lucas M, Baird AJ, Athan E, Young M, Pickles R, Cheng AC, Stewardson AJ, Aung AK, Trubiano JA. Antimicrobial anaphylaxis: the changing face of severe antimicrobial allergy. J Antimicrob Chemother 2021; 75:229-235. [PMID: 31637446 DOI: 10.1093/jac/dkz422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/25/2019] [Accepted: 09/10/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES The epidemiology, clinical characteristics and outcomes of antimicrobial-associated anaphylaxis remain ill-defined. We sought to examine antimicrobial anaphylaxis with regard to: (i) the frequency of implicated antimicrobials; (ii) attributable mortality; and (iii) referral for definitive allergy assessment. METHODS This was conducted through a national retrospective multicentre cohort study at five Australian tertiary hospitals (January 2010 to December 2015). Cases of antimicrobial anaphylaxis were identified from ICD-10 coding and adverse drug reaction committee databases. RESULTS There were 293 participants meeting the case definition of antimicrobial anaphylaxis and 310 antimicrobial anaphylaxis episodes. Of 336 implicated antimicrobials, aminopenicillins (62/336, 18.5%) and aminocephalosporins (57/336, 17%) were implicated most frequently. ICU admission occurred in 43/310 (13.9%) episodes; however, attributable mortality was low (3/310, 1%). The rate of anaphylaxis to IV antibiotics was 3.5 (95% CI=2.9-4.3) per 100 000 DDDs and the rate of hospital-acquired anaphylaxis was 1.9 (95% CI=2.1-3.3) per 100 000 occupied bed-days. We observed overall low rates of hospital discharge documentation (222/310, 71.6%) and follow-up by specialist allergy services (73/310, 23.5%), which may compromise medication safety and antimicrobial prescribing in future. CONCLUSIONS This study demonstrated that a high proportion of severe immediate hypersensitivity reactions presenting or acquired in Australian hospitals are secondary to aminopenicillins and aminocephalosporins. Overall rates of hospital-acquired anaphylaxis, predominantly secondary to cephalosporins, are low, and also associated with low inpatient mortality.
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Affiliation(s)
- Victoria Hall
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Hospital, VIC, Australia.,Department of Infectious Diseases, Alfred Health, VIC, Australia
| | - Micah Wong
- School of Medicine, University of Melbourne, VIC, Australia
| | - Maitri Munsif
- Department of General Medicine, Alfred Hospital, Monash University, VIC, Australia
| | - Brittany R Stevenson
- Department of Immunology, Sir Charles Gairdner Hospital, WA, Australia.,PathWest Immunology, Nedlands, WA, Australia
| | - Katie Elliott
- School of Medicine, University of Western Australia, WA, Australia
| | - Michaela Lucas
- Department of Immunology, Sir Charles Gairdner Hospital, WA, Australia.,PathWest Immunology, Nedlands, WA, Australia
| | - Ashleigh J Baird
- University Hospital Geelong Barwon Health, Geelong, VIC, Australia
| | - Eugene Athan
- University Hospital Geelong Barwon Health, Geelong, VIC, Australia.,Deakin University, School of Medicine, Geelong, VIC, Australia
| | - Melissa Young
- Hunter New England Local Health District, John Hunter Hospital, NSW, Australia
| | - Robert Pickles
- Departments of Infectious Diseases and General Medicine, John Hunter Hospital, Hunter New England Local Health District, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, NSW, Australia
| | - Allen C Cheng
- Department of Infectious Diseases, Alfred Health, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, VIC, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, Alfred Health, VIC, Australia.,ASID Clinical Research Network, Sydney, NSW, Australia
| | - Ar K Aung
- Department of Infectious Diseases, Alfred Health, VIC, Australia.,Department of General Medicine, Alfred Hospital, Monash University, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Hospital, VIC, Australia.,Department of Medicine, University of Melbourne, VIC, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, VIC, Australia
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Chartois C, Valois A, Paleiron N, Rivière E, Elie B, Pontis J. Alleged Allergy to Penicillin and Isolation Issues: Toward New Practices for French Navy? Mil Med 2021; 187:e906-e914. [PMID: 33861325 DOI: 10.1093/milmed/usab141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/07/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION According to the literature, 8% of the population claim to have an allergy to penicillin. Allergy tests show that 90% of these patients tolerate this molecule. Physicians working in the French Navy are faced with situations of real isolation and only have a limited number of antibiotics on board, the majority of which are penicillins. They must anticipate the risks linked to the prescription of antibiotics before the mission. However, there is no French recommendation, either military or civilian, intended for general practitioners clarifying the management and allergy assessments of patients alleging a history of allergy to penicillin. This study is the first to evaluate the professional practices of French military practitioners taking care of these patients. The main objective was to evaluate the proportion of sailors who reported an allergy to penicillin and who have never been referred for a consultation with an allergist, by studying the medical files of all the submariners working on the submersible ballistic nuclear submarines squadron in Brest. The secondary objective was to compare these data with the practices of Navy doctors by means of questionnaires. MATERIAL AND METHODS Our work is composed of two parts: monocentric study of the digital and paper medical files of Brest submariners (n = 814) looking for allergist consultation reports in cases alleging an allergy to penicillin, then comparison with a multicentric collection of all Navy doctors' practices collected by an anonymized questionnaire (n = 37 out of 53 practicing at the time of the study). RESULTS Forty-seven subjects out of 814 alleged an allergy to penicillin (5.8%). Among them, only 12 (25.5%) had undergone allergy tests, of which 3 (6.4%) were confirmed to be allergic, with no cross-reaction between β-lactam antibiotics. Yet, according to the questionnaire, 25 doctors (67%) report referring their patients to an allergist and 16 (43%) report having had difficulties at sea in connection with the prescription of antibiotics for these patients. CONCLUSIONS A study of medical records shows that the allergic risk is not anticipated for 74.5% of patients labeled allergic, despite the difficulties encountered at sea. Standardization of practices within the French Navy is necessary to avoid the prescription of second-line antibiotics, less effective and sometimes unavailable on board, and to improve patient safety in isolation situations. In agreement with French military allergists, we propose, in this article, guidelines for a systematic exploration of allegations of allergy to penicillin in the French Navy.
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Affiliation(s)
- Cyprien Chartois
- Military Teaching Hospital, HIA Clermont-Tonnerre, Brest 29240, France
| | - Aude Valois
- Military Teaching Hospital, HIA Sainte Anne, Toulon 83800, France
| | - Nicolas Paleiron
- Military Teaching Hospital, HIA Sainte Anne, Toulon 83800, France
| | - Emilie Rivière
- Military Teaching Hospital, HIA Clermont-Tonnerre, Brest 29240, France
| | - Bertrand Elie
- Medical Service, Submarine Forces, Brest 29200, France
| | - Julien Pontis
- Medical Service, Submarine Forces, Brest 29200, France
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Lee RU. Penicillin Allergy Delabeling Can Decrease Antibiotic Resistance, Reduce Costs, and Optimize Patient Outcomes. Fed Pract 2020; 37:460-465. [PMID: 33132684 DOI: 10.12788/fp.0040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Antibiotics are one of the most frequently prescribed medications. Among all classes of antibiotics, penicillins are prescribed due to their clinical efficacy, cost-effectiveness, and general safety. Unfortunately, penicillins also are the most common drug allergy listed in patient medical records. Increasing evidence shows that > 90% of patients labeled with a penicillin allergy are not allergic to penicillins and associated β-lactams. The health care consequences of penicillin allergy in the setting of military medicine and readiness are important to consider. Observations In the US, 8 to 10% of the population and up to 15% of hospitalized patients have a documented penicillin allergy, limiting the use of these effective antibiotics. When treating a patient with a penicillin allergy, many clinicians avoid prescribing all β-lactam antibiotics and stay away from cephalosporins due to the concern for potential cross-reactivity. The cost of treating those with a documented penicillin allergy is greater than the cost for those who can receive penicillin, as treatment with broad-spectrum antibiotics often results in longer hospitalizations with increased rates of adverse effects (AEs). Despite preventive programs such as vaccinations, hygiene measures, and prophylactic antibiotics, military personnel are at increased risk for infections due to the military's mobile nature and crowded living situations. Conclusions Many patients report an allergy to penicillin, but only a small portion have a true immune-mediated allergy. Given the clinical, public health, and economic costs associated with a penicillin allergy label, evaluation and clearance of penicillin allergies improves clinical outcomes, decreases AEs from higher risk alternative broad-spectrum antibiotics, and prevents the spread of antibiotic resistance. In military personnel, penicillin delabeling improves readiness with optimal antibiotic options and avoidance of unnecessary risks, expediting return to full duty.
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Affiliation(s)
- Rachel U Lee
- is a Staff Allergist and Immunologist in the Division of Allergy, Department of Internal Medicine at the Naval Medical Center in San Diego, California
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Abstract
PURPOSE OF REVIEW As drug allergy research aims to inform clinical practice, implementation of best practices may be influenced by financial resources required to incorporate new interventions and the resulting clinical and economic returns on those resource investments. The present review summarizes new insights into the economics of drug allergy over the past year. RECENT FINDINGS While considering economic implications of recent drug allergy research, many studies have addressed different contextual factors related to the setting, provider, or outcomes. Advances in technology have enabled specialized allergists to support remote settings through telemedicine consultation. Training opportunities and interdisciplinary approaches to address drug allergy challenges have enabled multiple provider types to play a role in screening, diagnosis, and management. Penicillin allergy testing has been a major focus for many institutions, with several studies focused on de-labeling strategies including confirmatory skin testing and direct oral challenges. SUMMARY Studies over the past year provide new opportunities for the field of drug allergy research. The focus of current research to capture direct health costs or savings associated with drug allergy interventions demonstrates opportunity for more cost-effective care delivery and opportunity to explore greater benefits to society.
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Abstract
PURPOSE OF REVIEW An unconfirmed penicillin allergy is known to confer significant risk to patients. Only a small minority of patients labeled with penicillin allergy will be confirmed to be hypersensitive with the current reference standard test, an oral amoxicillin therapeutic dose challenge. Skin testing has been recommended prior to oral challenges to reduce the risk of severe acute challenge reactions. The rate of severe acute anaphylactic reactions with oral amoxicillin is currently extremely low. Unfortunately, penicillin skin testing, as commonly performed, has a high rate of false positive results. RECENT FINDINGS Encouraging skin testing in all individuals with an unconfirmed penicillin allergy, prior to a confirmatory oral challenge, would be technically difficult, make testing all individuals with an unconfirmed penicillin allergy very unlikely, and ultimately increase the risk to patients because of suboptimal antibiotic use. Most patients, who are appropriate candidates for a direct oral amoxicillin challenge, to confirm current penicillin tolerance, can be safely identified by their clinical histories. Higher risk individuals, those with a history of anaphylaxis or other acute onset potentially IgE-mediated reaction such as hives within 6 h of the first dose of the last course of a penicillin, may benefit from properly performed puncture and intradermal skin testing, using commercially available penicilloyl-polylysine, prior to an oral challenge, if skin test negative. Direct oral amoxicillin challenges in low-risk individuals are well accepted by patients and a safe and effective part of penicillin allergy delabeling.
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