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Blumenthal KG, Smith LR, Mann JTS, Salciccioli I, Accarino JJO, Shah RJ, Alvi FI, Cardoso-Fernandes A, Ferreira-da-Silva R, Schunemann HJ, Sousa-Pinto B. Reaction Risk to Direct Penicillin Challenges: A Systematic Review and Meta-Analysis. JAMA Intern Med 2024:2823686. [PMID: 39283610 PMCID: PMC11406457 DOI: 10.1001/jamainternmed.2024.4606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2024]
Abstract
Importance While direct penicillin challenges might support the expansion of penicillin allergy delabeling efforts, the perceived risk of reactions remains a key barrier. Objective To evaluate the frequency of reactions to direct penicillin challenges in individuals with penicillin allergy labels and to identify factors associated with such reactions. Data Sources 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. Study Selection Two reviewers independently selected original studies reporting the frequency of immunologically mediated reactions following a direct penicillin challenge in patients reporting a penicillin allergy. Data Extraction and Synthesis Two reviewers independently extracted data and independently assessed the quality of each primary study using a risk-of-bias tool for prevalence studies. Main Outcomes and Measures 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. Results 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. Conclusions and Relevance 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.
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Affiliation(s)
- Kimberly G Blumenthal
- Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology. Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston
- Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Massachusetts General Hospital, Boston
| | - Liam R Smith
- Division of Rheumatology. Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston
- Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Massachusetts General Hospital, Boston
| | | | - Ingrid Salciccioli
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Mount Auburn Hospital, Cambridge, Massachusetts
| | - John J O Accarino
- Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology. Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston
- Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Massachusetts General Hospital, Boston
| | - Ruchi J Shah
- Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology. Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Fatima I Alvi
- Harvard School of Public Health, Boston, Massachusetts
| | - António Cardoso-Fernandes
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Renato Ferreira-da-Silva
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Holger J Schunemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology and Research Center, Humanitas University and Humanitas Research Hospital, Milan, Italy
| | - Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Health Technology and Services Research, Health Research Network, Faculty of Medicine, University of Porto, Porto, Portugal
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Mitri E, Reynolds G, Hornung CJ, Trubiano JA. Low-risk penicillin allergy delabeling: a scoping review of direct oral challenge practice, implementation, and multi-disciplinary approaches. Expert Rev Anti Infect Ther 2024; 22:59-69. [PMID: 38098185 DOI: 10.1080/14787210.2023.2296068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/13/2023] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Penicillin allergy is common, and there is increased clinician interest in direct oral challenge (DOC) as a testing strategy for low-risk penicillin allergy. To aid wider implementation of DOC, consensus definitions of low-risk penicillin allergy phenotypes, and standardized approaches to assessment, DOC procedures, and evaluation, are required. AREAS COVERED This review systematically reviews studies that have utilized penicillin DOC in healthcare settings to identify heterogeneity in implementation approaches and synthesize low-risk definitions, procedures, and evaluation. EXPERT OPINION Opportunity exists to standardize penicillin DOC procedures in patients with a low-risk penicillin allergy to optimize antimicrobial prescribing and reduce the burden of penicillin allergy. Standardizing the definitions of 'low-risk' and 'positive challenge,' and improving the evaluation of patient safety, alongside the development of a unified approach to the structure of undertaking an oral challenge, is likely to increase uptake and confidence among non-allergist clinicians.
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Affiliation(s)
- Elise Mitri
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- National Allergy Centre of Excellence (NACE), Parkville, Victoria, Australia
| | - Gemma Reynolds
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Catherine J Hornung
- National Allergy Centre of Excellence (NACE), Parkville, Victoria, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- National Allergy Centre of Excellence (NACE), Parkville, Victoria, Australia
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
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Wrenn RH, Trubiano JA. Penicillin Allergy Impact and Management. Infect Dis Clin North Am 2023; 37:793-822. [PMID: 37537003 DOI: 10.1016/j.idc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
There is international evidence that penicillin allergies are associated with inferior prescribing and patient outcomes. A host of tools now exist from assessment (risk assessment tools, clinical decision rules) to delabeling (the removal of a beta-lactam allergy via testing or medical reconciliation) to reduce the impact of these "labels" in the hospital and community setting, as a primary antimicrobial stewardship intervention.
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Affiliation(s)
- Rebekah H Wrenn
- Duke University Medical Center, Durham, NC, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA.
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Melbourne, Australia; Department of Infectious Diseases, University of Melbourne, at The Peter Doherty Institute for Infection and Immunity, Victoria 3000, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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