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Bjørbak Alnæs M, Skodvin B, Anker Jahnsen J, Kalleklev Velure G, Oppegaard O, Reiakvam Kittang B, Storaas T, Aase Schaufel M. "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. Antimicrob Resist Infect Control 2024; 13:97. [PMID: 39218954 PMCID: PMC11368001 DOI: 10.1186/s13756-024-01456-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 08/24/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Penicillin 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. METHODS We 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. RESULTS Psychological 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. CONCLUSION A 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. ETHICS The study was approved by the Western Norway Regional Committee for Medical Research Ethics (Study No:199210).
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Affiliation(s)
- Marie Bjørbak Alnæs
- Section of Clinical Allergy, Department of Occupational Medicine, Haukeland University Hospital, Bergen, 5020, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway.
| | - Brita Skodvin
- The Norwegian Advisory Unit for Antibiotic use in Hospitals, 5020, Bergen, Norway
| | - Jan Anker Jahnsen
- Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway
- Regional Medicines Information and Pharmacovigilance Centre (RELIS Vest), University Hospital, Haukeland, Bergen, Norway
| | - Grete Kalleklev Velure
- Section of Clinical Allergy, Department of Occupational Medicine, Haukeland University Hospital, Bergen, 5020, Norway
| | - Oddvar Oppegaard
- Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, 5020, Norway
| | - Bård Reiakvam Kittang
- Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway
- Haraldsplass Deaconess Hospital, Bergen, 5009, Norway
- Department of Nursing Home Medicine, Fyllingsdalen, 5145, Norway
| | - Torgeir Storaas
- Section of Clinical Allergy, Department of Occupational Medicine, Haukeland University Hospital, Bergen, 5020, Norway
| | - Margrethe Aase Schaufel
- Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, 5020, Norway
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Lee HJ, Hart M, Chow TG. Caregiver perceptions on pediatric penicillin allergy delabeling in a primary care setting. Ann Allergy Asthma Immunol 2024; 133:349-351. [PMID: 38879164 DOI: 10.1016/j.anai.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 07/01/2024]
Affiliation(s)
- Hannah J Lee
- Department of Internal Medicine and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Margaret Hart
- Pediatric Health Care Associates, Boston Children's Primary Care Alliance, Peabody, Massachusetts
| | - Timothy G Chow
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard F04.206, Dallas 75390, Texas
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Alagoz E, Saucke M, Balasubramanian P, Liebenstein T, Kakumanu S. Leveraging implementation science theories to develop and expand the use of a penicillin allergy de-labeling intervention. BMC Health Serv Res 2024; 24:987. [PMID: 39187854 PMCID: PMC11348780 DOI: 10.1186/s12913-024-11364-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/25/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Penicillin allergy is the most frequently reported drug allergy, yet most patients can tolerate the drug if challenged. Despite this discrepancy, large scale penicillin allergy de-labeling interventions have not been widely implemented in many health care systems. The application of a multi-method implementation science approach can provide key tools to study this evidence to practice gap and provide insight to successfully operationalize penicillin allergy evaluation in real-world clinical settings. METHODS We followed a four-step process that leverages qualitative analysis to design evidence-based, actionable strategies to develop an intervention. First, we specified the clinician-perceived barriers to penicillin allergy de-labeling (intervention targets). We then mapped intervention targets onto Theoretical Domains Framework (domains and constructs) and found the root causes of behavior. Next, we linked root causes of behavior with intervention functions (BCW). In the final step, we synthesized participants' suggestions for process improvement with implementation strategies aligning with the intervention functions. RESULTS Evidence-based strategies such as focused education and training in penicillin allergy evaluation can address knowledge and confidence barriers reported by frontline clinicians. Other key strategies involve developing a system of champions, improving communications systems, and restructuring the healthcare team. Implementation mapping can provide a powerful multi-method framework to study, design, and customize intervention strategies. CONCLUSION Empowering clinicians beyond allergy specialists to conduct penicillin allergy assessments requires designing new workflows and systems and providing additional knowledge to those clinicians.
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Affiliation(s)
- Esra Alagoz
- Department of Surgery, University of Wisconsin-Madison, 600 Highland Avenue, Madison, 53792-7375, WI, USA.
| | - Megan Saucke
- Department of Surgery, University of Wisconsin-Madison, 600 Highland Avenue, Madison, 53792-7375, WI, USA
| | | | - Tyler Liebenstein
- William S. Middleton Veterans Memorial Hospital Madison, Madison, WI, USA
| | - Sujani Kakumanu
- William S. Middleton Veterans Memorial Hospital Madison, Madison, WI, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care, University of Wisconsin-Madison, Madison, WI, USA
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Kakumanu S, Szefler S, Pappalardo AA, Sales AE, Baptist AP, Stern J, Nyenhuis SM. Applying the dissemination and implementation sciences to allergy and immunology: A Work Group Report from the AAAAI Quality, Adherence, and Outcomes Committee. J Allergy Clin Immunol 2024:S0091-6749(24)00745-0. [PMID: 39162669 DOI: 10.1016/j.jaci.2024.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 06/04/2024] [Accepted: 07/18/2024] [Indexed: 08/21/2024]
Abstract
Translating evidence-based practice (EBP) into real-world clinical settings often takes a considerable amount of time and resources. In allergy and immunology, the dissemination and implementation (D&I) sciences facilitate the study of how variations in knowledge, resources, patient populations, and staffing models lead to differences in the clinical care of asthma, allergic disease, and primary immunodeficiency. Despite the need for validated approaches to study how to best apply EBP in the real world, the D&I sciences are underutilized. To address this gap, an American Academy of Allergy, Asthma & Immunology (AAAAI) work group was convened to provide an overview for the role of the D&I sciences in clinical care and future research within the field. For the D&I sciences to be leveraged effectively, teams should be multidisciplinary and inclusive of community and clinical partners, and multimethods approaches to data collection and analyses should be used. Used appropriately, the D&I sciences provide important tools to promote EBP and health equity as well as optimization of clinical practice in allergy and immunology.
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Affiliation(s)
- Sujani Kakumanu
- University of Wisconsin School of Medicine and Public Health, Madison, Wis; William S. Middleton Veterans Memorial Hospital, Madison, Wis.
| | - Stanley Szefler
- Department of Pediatrics, Section of Pediatric Pulmonary and Sleep Medicine, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, Colo; Breathing Institute, Children's Hospital Colorado, Aurora, Colo
| | - Andrea A Pappalardo
- Departments of Medicine and Pediatrics, Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois, Chicago, Ill
| | - Anne E Sales
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, Mo; Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Mich
| | - Alan P Baptist
- Division of Allergy and Clinical Immunology, Henry Ford Health, Detroit, Mich
| | - Jessica Stern
- Division of Allergy, Immunology, and Rheumatology, Division of Pediatric Allergy and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sharmilee M Nyenhuis
- Department of Pediatrics, Section of Allergy, Immunology, and Pulmonology, University of Chicago, Chicago, Ill
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Arasaratnam RJ, Guastadisegni JM, Kouma MA, Maxwell D, Yang L, Storey DF. Rising to the Challenge: An ID Provider-Led Initiative to Address Penicillin Allergy Labels at a Large Veterans Affairs Medical Center. Open Forum Infect Dis 2024; 11:ofae396. [PMID: 39130085 PMCID: PMC11310584 DOI: 10.1093/ofid/ofae396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/09/2024] [Indexed: 08/13/2024] Open
Abstract
Background 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. Methods 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. Results 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. Conclusions 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.
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Affiliation(s)
- Reuben J Arasaratnam
- Veterans Affairs North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Marcus A Kouma
- Pharmacy Department, Veterans Affairs North Texas Health Care System, Dallas, Texas, USA
| | - Daniel Maxwell
- Veterans Affairs North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Linda Yang
- Pharmacy Department, Veterans Affairs North Texas Health Care System, Dallas, Texas, USA
| | - Donald F Storey
- Veterans Affairs North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Hanniet A, Puyraveau M, Castelain F, Pelletier F, Aubin F. Efficacy of the PEN-FAST score in a French cohort of patients with reported allergy to penicillins. FRONTIERS IN ALLERGY 2024; 5:1439698. [PMID: 39139756 PMCID: PMC11319814 DOI: 10.3389/falgy.2024.1439698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 07/10/2024] [Indexed: 08/15/2024] Open
Abstract
Introduction Various clinical decision-making tools for penicillin allergy have been developed to guide delabeling strategies. Objective To evaluate the penicillin allergy PEN-FAST decision score in a retrospective cohort of patients, adults and children, with penicillin-reported allergy. Methods This monocentric retrospective cohort included patients with penicillin-reported allergy. All patients underwent penicillin allergy testing using skin tests and/or drug challenge. The PEN-FAST score sensitivity, specificity, negative (NPV) and positive (PPV) predictive values, and the area under the receiver operating characteristics curve (AUC) were calculated. Results Two hundred and fourteen patients were included (64 children and 150 adults). Allergy was confirmed in 52 cases (24%). A PEN-FAST score <3 points showed a poor discrimination capacity for the whole population (AUC = 0.66; 95% CI: 0.58-0.75), while it demonstrated a better discrimination capacity in the adults group (AUC = 0.71; 95% CI: 0.63-0.80). The sensitivity to identify penicillin allergy using this cutoff of less than 3 points was 0.67 (95% CI: 0.52-0.80); specificity, 0.58 (95% CI: 0.48-0.68); PPV, 0.43 (95% CI: 0.32-0.55); and NPV, 0.78 (95% CI: 0.68-0.87). Conclusions Although our data confirm a rather good discrimination value of a PEN-FAST score <3 points, its low negative predictive value (78%) did not advocate for its use as an accurate, simple and cost-effective clinical decision-making tool to effectively reduce the number of penicillin skin tests required before direct oral challenge. Further studies are required to improve the predictive capacity of the PEN-FAST score.
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Affiliation(s)
- Anatole Hanniet
- Allergology Unit, Departement of Dermatology, University Hospital, Besançon, France
| | - Marc Puyraveau
- Methodology and Statistics Unit, University Hospital, Besançon, France
| | - Florence Castelain
- Allergology Unit, Departement of Dermatology, University Hospital, Besançon, France
| | - Fabien Pelletier
- Allergology Unit, Departement of Dermatology, University Hospital, Besançon, France
| | - François Aubin
- Allergology Unit, Departement of Dermatology, University Hospital, Besançon, France
- INSERM UMR 1098 RIGHT, University of Besançon, Besançon, France
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Shi W, Liu N, Huang JX, Xiao H, Meng J, Li PH. Penicillin Allergy in China: Consequences of Inappropriate Skin Testing Practices and Policies. Clin Exp Allergy 2024. [PMID: 39053914 DOI: 10.1111/cea.14546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/23/2024] [Accepted: 07/09/2024] [Indexed: 07/27/2024]
Abstract
Penicillins are the most frequently prescribed class of medications worldwide and first-line antibiotic of choice for most bacterial infections. They are also commonly labelled as the culprit of drug 'allergy'; leading to obligatory use of second-line antibiotics, suboptimal antibiotic therapy and increased antimicrobial resistance. However, the majority of reported penicillin 'allergy' labels are found to be incorrect after allergy testing, emphasising the importance of proper drug allergy testing and evaluation. Penicillin skin testing (PST) remains an important component of drug allergy diagnosis; however, its practice and policies significantly differ across the world. Inappropriate and non-evidence-based PST practices can lead to consequences associated with allergy mislabelling. Even within different regions of China, with a population exceeding 1.4 billion, there are marked differences in the implementation, execution and interpretation of PST. This review aims to examine the differences in PST between Mainland China, Hong Kong and the rest of the world. We critically analyse the current practice of 'pre-emptive' PST in Mainland China, which has a significant false-positive rate leading to high levels of penicillin allergy mislabelling. Non-evidence-based practices further compound the high false-positive rates of indiscriminatory PST. We postulate that inappropriate PST policies and practices may exacerbate the mislabelling of penicillin allergy, leading to unnecessary overuse of inappropriate second-line antibiotics, increasing antimicrobial resistance and healthcare costs. We advocate for the importance of more collaborative research to improve the contemporary workflow of penicillin allergy diagnosis, reduce mislabelling and promote the dissemination of evidence-based methods for allergy diagnosis.
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Affiliation(s)
- Weihong Shi
- Division of Rheumatology & Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Ning Liu
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Jin-Xian Huang
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Hao Xiao
- Allergy Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Juan Meng
- Allergy Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Philip H Li
- Division of Rheumatology & Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
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Kwan N, Kang K, Carr RR, Mak R, Roberts A, Jin F, Bone JN, Rassekh SR, Wong T. True Rate of Allergy among Pediatric Inpatients with Penicillin Allergy Labels (TRIAL). Can J Hosp Pharm 2024; 77:e3531. [PMID: 38988874 PMCID: PMC11210598 DOI: 10.4212/cjhp.3531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/25/2024] [Indexed: 07/12/2024]
Abstract
Background 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. Objective To estimate the percentage of pediatric patients admitted with reported penicillin allergy who did not have a true penicillin allergy. Methods 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. Results 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. Conclusions 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.
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Affiliation(s)
- Natasha Kwan
- BSc(Pharm), ACPR, PharmD, is with the Department of Pharmacy, Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia
| | - Kristopher Kang
- MD, FRCPC, is with the Division of General Pediatrics, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia
| | - Roxane R Carr
- BSc, BSc(Pharm), ACPR, PharmD, FCSHP, BCPS, is with the Department of Pharmacy, Children's and Women's Health Centre of British Columbia, and the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Raymond Mak
- BSc, MD, FRCPC, is with the Division of Allergy and Immunology, Department of Pediatrics, and the Division of Allergy and Immunology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia
| | - Ashley Roberts
- MD, MEd, FRCPC, is with the Division of Infectious Diseases, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia
| | - Falla Jin
- BA, is with the BC Children's Hospital Research Institute, Vancouver, British Columbia
| | - Jeffrey N Bone
- MSc, is with the BC Children's Hospital Research Institute, Vancouver, British Columbia
| | - S Rod Rassekh
- , BSc, MD, MHSc, is with the Division of Hematology, Oncology and Bone Marrow Transplant, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia
| | - Tiffany Wong
- MD, FRCPC, is with the Division of Allergy and Immunology, Department of Pediatrics, and the BC Children's Hospital Research Institute, The University of British Columbia, Vancouver, British Columbia
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Wong JCY, Kan AKC, Chik TSH, Chu MY, Li TCM, Mak HWF, Chiang V, Li PH. Prospective, Multicenter, Head-to-Head Comparison Between Allergists Versus Nonallergists in Low-Risk Penicillin Allergy Delabeling: Effectiveness, Safety, and Quality of Life (HK-DADI2). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1801-1808.e2. [PMID: 38631522 DOI: 10.1016/j.jaip.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/03/2024] [Accepted: 04/06/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Penicillin "allergy" labels are prevalent but frequently misdiagnosed. Mislabelled allergies are associated with adverse outcomes and increased antimicrobial resistance. With an urgent need to delabel the overwhelming number of mislabeled allergies, nonallergist evaluations have been advocated for low-risk individuals. Despite growing interest in non-allergist-led initiatives, evidence on their effectiveness, safety, and impact by direct comparisons is lacking. OBJECTIVE To assess the comparative outcomes of penicillin allergy evaluations conducted by allergists versus nonallergists. METHODS A prospective, multicenter, pragmatic study was conducted at 4 tertiary hospitals (1 allergist- vs 3 non-allergist-led) for low-risk penicillin allergy patients in Hong Kong-the Hong Kong Drug Allergy Delabelling Initiative 2 (HK-DADI2). RESULTS Among 228 low-risk patients who underwent testing (32.9% by allergists, 67.1% by nonallergists), only 14 (6.1%) had positive penicillin allergy testing results. Delabeling rates (94.1% vs 93.3%; P = .777), positive skin test results (2.6% vs 2.7%; P > .99), and drug provocation test results (3.3% vs 2.7%; P = 1.000) were similar between allergists and nonallergists. There were no systemic reactions in either cohort. All patients had significant improvements in health-related quality of life (Drug Hypersensitivity Quality of Life Questionnaire scores -5.00 vs -8.33; P = .072). Nonallergist evaluations had shorter waiting times (0.57 vs 15.7 months; P < .001), whereas allergists required fewer consultations with higher rate of completing evaluations within a single visit (odds ratio, 0.04; P < .001). CONCLUSIONS With training and support, nonallergists can independently evaluate low-risk penicillin allergies. Compared with allergists, evaluation of low-risk penicillin allergy by nonallergists can be comparably effective, safe, and impactful on quality of life. More multidisciplinary partnerships to empower nonallergists to conduct allergy evaluations should be encouraged.
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Affiliation(s)
- Jane C Y Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Andy K C Kan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Thomas S H Chik
- Division of Infectious Diseases, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | - M Y Chu
- Division of Infectious Diseases, Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Timothy C M Li
- Division of Infectious Diseases, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong
| | - Hugo W F Mak
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
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10
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Brown JF, Kim J, Ham Y, Joshi SR. Updates to penicillin allergy delabeling: Reducing the need for direct testing. Ann Allergy Asthma Immunol 2024; 132:656-657. [PMID: 38219872 DOI: 10.1016/j.anai.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/13/2023] [Accepted: 01/04/2024] [Indexed: 01/16/2024]
Affiliation(s)
| | - Joyce Kim
- Oregon Health and Science University, Portland, Oregon
| | - YoungYoon Ham
- Oregon Health and Science University, Portland, Oregon
| | - Shyam R Joshi
- Oregon Health and Science University, Portland, Oregon
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Powell N, Upton M, Kent B, Sandoe J, Tonkin-Crine S. Non-allergist healthcare workers views on delivering a penicillin allergy de-labelling inpatient pathway: identifying the barriers and enablers. JAC Antimicrob Resist 2024; 6:dlae014. [PMID: 38328264 PMCID: PMC10848892 DOI: 10.1093/jacamr/dlae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/15/2024] [Indexed: 02/09/2024] Open
Abstract
Background Non-allergist delivered PADL is supported by UK and World Health Organization guidelines but is not yet routine in UK hospitals. Understanding the views of healthcare workers (HCWs) on managing patients with penA records and exploring perspectives on delivering a PADL inpatient pathway are required to inform the development of non-allergist delivered PADL pathways. Objective To explore the perspectives of non-allergist HCWs working in medical specialties on managing patients with penA records, and to explore the enablers and barriers to embedding PADL as a standard of care for inpatients. Methods Semi-structured interviews with doctors, nurses, pharmacists and medicines optimization pharmacy technicians working in a district general hospital in the UK. Thematic analysis was used to analyse the data. Results The PADL pathway was considered a shared responsibility of the multidisciplinary team, which needed to be structured and supported by a framework. PADL aligns with HCW roles but time to deliver PADL was a barrier. Training for HCWs on the benefits of PADL and delivering PADL for those patients where a penicillin might be beneficial during the current episode of care would both motivate HCWs to deliver PADL. Discussion and conclusion The PADL pathway was acceptable to HCWs and aligned with their roles and current healthcare processes but their capacity to deliver PADL in a time pressured environment was a significant barrier.
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Affiliation(s)
- Neil Powell
- Pharmacy Department, Royal Cornwall Hospital, Truro, UK TR1 3LJ
- School of Biomedical Sciences, University of Plymouth, Plymouth, UK
| | - Mathew Upton
- School of Biomedical Sciences, University of Plymouth, Plymouth, UK
| | - Bridie Kent
- School of Nursing and Midwifery, University of Plymouth, Plymouth, UK
| | - Jonathan Sandoe
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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