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Lim PPC, Moore LN, Minich NM, Wessell KR, Desai AP. Inpatient allergy delabeling of pediatric patients with low-risk penicillin allergy status through direct oral amoxicillin challenge. Allergy Asthma Proc 2024; 45:61-69. [PMID: 38151739 DOI: 10.2500/aap.2024.45.230069] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Background: Less than 5% of children who report penicillin allergy have clinically pertinent type 1 immunoglobulin E mediated hypersensitivity reaction by using direct oral amoxicillin challenge. Several pathways have been developed to delabel penicillin allergy by using direct oral amoxicillin challenge, mostly in the outpatient settings, but there is relative scarcity on published outcomes of these pathways, especially in the inpatient pediatric settings. Objective: This study aimed to evaluate the performance of an institutionally derived inpatient penicillin allergy screening tool. Methods: Patients were stratified into three penicillin allergy risk categories by using an institutional screening questionnaire. Patients with a no-risk status were delabeled without challenge testing. Patients with low-risk status underwent direct graded oral amoxicillin challenge and delabeled based on their response. Patients with high-risk status were referred to allergy service. Results: Ninety-two patients were identified with penicillin allergy. Forty of the 92 patients (43%) were screened. Of the 40 patients screened, 6 (15%) were identified as no risk, 28 (70%) were identified as low risk, and 6 (15%) were identified as high risk. Twenty-four of the 28 patients at low risk (86%) were eligible for direct amoxicillin oral challenge. Seventeen of the 24 (71%) consented to oral challenge but only 12 (71%) underwent direct amoxicillin oral challenge. Eleven of the 12 who underwent oral challenge (92%) were successfully delabeled. Five of the six patients at no risk (83%) were successfully delabeled. Three of the six patients at high risk (50%) were referred for further allergy evaluation. Overall, 16 of the 40 patients screened (40%) were successfully delabeled. Conclusion: In this small pediatric inpatient study, our institutional risk stratification screening tool identified patients at low risk for penicillin allergy and direct graded oral amoxicillin challenge was safely administered to delabel penicillin allergy in these patients.Clinical trial NCT05020327, www.clinicaltrials.gov.
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Affiliation(s)
- Peter Paul C Lim
- From the Division of Infectious Diseases, Department of Pediatrics, Avera McKennan University Health Center and Sanford University of South Dakota School of Medicine, Sioux Falls, South Dakota
| | - LeAnne N Moore
- Department of Pediatric Pharmacy, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Nori Mercuri Minich
- Department of Pediatrics, Case Western Reserve University and Rainbow Babies and Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Kathryn Ruda Wessell
- Division of Allergy and Immunology, Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, and
| | - Ankita P Desai
- Division of Infectious Diseases, Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio
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Bellanti JA, Settipane RA. A tribute to allergy and immunology fellowship training program directors and to the fellows they train. Allergy Asthma Proc 2023; 44:155-157. [PMID: 37160753 PMCID: PMC10165681 DOI: 10.2500/aap.2023.44.230017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
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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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Arasaratnam RJ, Chow TG, Liu AY, Khan DA, Blumenthal KG, Wurcel AG. Penicillin Allergy Evaluation and Health Equity: A Call to Action. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:422-428. [PMID: 36521831 DOI: 10.1016/j.jaip.2022.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022]
Abstract
Allergists have been at the forefront of addressing the burden of unverified penicillin allergy labels. Coordinated national efforts with infectious diseases, antimicrobial stewardship experts, and pharmacy societies to advocate for formal evaluation of patient-reported penicillin allergy have resulted in improvements in delabeling efforts. Given the poorer health outcomes associated with the penicillin allergy label and the potential health benefits that can be gained with delabeling, improving access to penicillin allergy evaluation is of the utmost importance. Health disparities are widely recognized to impact all aspects of health care, and multilevel interventions at the patient, clinician, and systems level are required to ensure equitable care delivery. Structural racism underpins many social determinants of health and is a key driver of racial and ethnic health disparities. In this Rostrum, we use a conceptual framework from the 2015 National Academy of Medicine report Improving Diagnosis in Health Care to explore how inequities are related to the evaluation of penicillin allergy. We use the National Institute on Minority Health and Health Disparities Strategies to Advance Health Disparities to elucidate areas of important study. Building upon existing efforts to address disparities in Allergy/Immunology, we highlight the urgent importance of understanding and eliminating health disparities in penicillin allergy evaluation and delabeling.
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Affiliation(s)
- Reuben J Arasaratnam
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center and Veterans Affairs North Texas Health Care System, Dallas, Texas.
| | - Timothy G Chow
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas; University of Texas Southwestern Medical Center, Dallas, Texas
| | - Anne Y Liu
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, and Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - David A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Alysse G Wurcel
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Mass; Tufts University School of Medicine, Boston, Mass
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Mabilat C, Gros MF, Van Belkum A, Trubiano JA, Blumenthal KG, Romano A, Timbrook TT. Improving antimicrobial stewardship with penicillin allergy testing: a review of current practices and unmet needs. JAC Antimicrob Resist 2022; 4:dlac116. [PMID: 36415507 PMCID: PMC9675589 DOI: 10.1093/jacamr/dlac116] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Penicillin allergy, the most frequently reported drug allergy, has been associated with suboptimal antibiotic therapy, increased antimicrobial resistance, increased rates of Clostridioides difficile colonization and infection, as well as extended hospital length of stay and increased cost. Although up to 10% of all patients may report penicillin allergy, most penicillin allergies are not confirmed. As such, most patients with a penicillin allergy can still safely use penicillin and related drugs following a more precise assessment. Herein, we review the current practices and unmet needs in penicillin allergy testing. The diagnostic algorithm is mostly based on a clinical history assessment followed by in vivo testing, i.e. skin test and/or drug challenge. As these tests are labour and resource intensive, there is increased interest in point-of-care penicillin allergy de-labelling solutions incorporated into Antimicrobial Stewardship Programmes including digital assessment tools. These can be locally parameterized on the basis of characteristics of target populations, incidence of specific allergies and local antibiotic usage to perform clinical risk stratification. Safely ruling out any residual risk remains essential and in vivo drug challenge and/or skin testing should be systematically encouraged. Gradual understanding and convergence of the risk stratification of the clinical presentation of penicillin allergy is enabling a wider implementation of this essential aspect of antimicrobial stewardship through digitalized decision tools and in vivo testing. More research is needed to deliver point of care in vitro diagnostic tools to democratize this de-labelling practice, which would be highly beneficial to patient care. This progress, together with better education of patients and clinicians about the availability, efficacy and safety of penicillin allergy testing, will increase the dissemination of penicillin allergy assessment as an important component of Antimicrobial Stewardship Programmes.
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Affiliation(s)
| | - Marie-Françoise Gros
- bioMérieux, Medical Affairs, 100 Rue Louis Pasteur, F-69280 Marcy l'Etoile, France
| | - Alex Van Belkum
- Current address:BaseClear, Sylviusweg 74, 2333 BE Leiden, The Netherlands
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, 145 Studley Road, Heidelberg, Victoria, 3084Australia
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | | | - Tristan T Timbrook
- bioMérieux, BioFire Diagnostics, Global Medical Affairs, 515 Colorow Drive, Salt Lake City, UT 84108, USA
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Li PH, Wong JCY, Chan JMC, Chik TSH, Chu MY, Ho GCH, Leung WS, Li TCM, Ng YY, Shum R, Sin WWY, Tso EYK, Wu AKL, Au EYL. Hong Kong Drug Allergy Delabelling Initiative (HK-DADI) consensus statements for penicillin allergy testing by nonallergists. FRONTIERS IN ALLERGY 2022; 3:974138. [PMID: 36133403 PMCID: PMC9483020 DOI: 10.3389/falgy.2022.974138] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Penicillin allergy testing has been traditionally performed by allergists, but there remains a huge deficit of specialists. A multidisciplinary effort with nonallergists would be invaluable to overcome the magnitude of penicillin allergy labels via the Hong Kong Drug Allergy Delabelling Initiative (HK-DADI). These consensus statements (CSs) offer recommendations and guidance to enable nonallergists to screen for low-risk (LR) patients and perform penicillin allergy testing. Methods CSs were formulated by the HK-DADI Group using the Delphi method. An agreement was defined as greater than or equal to 80% consensus. Results A total of 26 CSs reached consensus after multiple rounds of Delphi. CSs were categorized into risk assessment, skin testing, drug provocation testing (DPT), and post-testing management. For risk assessment, the essentials of allergy history and exclusion criteria were detailed. Patients with only LR features can proceed with testing by nonallergists. Skin tests should be performed prior to DPT. Details regarding the timing, preparation, and interpretation of skin tests were elaborated. DPT remains the gold standard to diagnose genuine allergy or tolerance and should be performed when there is a low pretest probability following negative skin testing. Details of DPT preparations, dosing protocols, and interpretation were elaborated. For post-testing management, inaccurate allergy labels should be delabeled following negative DPT with proper patient counseling. Conclusion CSs support penicillin allergy testing by nonallergists in Hong Kong. LR cases can be managed by nonallergists at Spoke Clinics, with training and support of an allergist-led Hub.
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Affiliation(s)
- Philip H. Li
- Division of Rheumatology & Clinical Immunology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
- Correspondence: Philip H. Li
| | - Jane C. Y. Wong
- Division of Rheumatology & Clinical Immunology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Jacky M. C. Chan
- Division of Infectious Diseases, Department of Medicine & Geriatrics, Kwong Wah Hospital, Hong Kong SAR, China
| | - Thomas S. H. Chik
- Division of Infectious Diseases, Department of Medicine & Geriatrics, Kwong Wah Hospital, Hong Kong SAR, China
| | - M. Y. Chu
- Division of Infectious Diseases, Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Grace C. H. Ho
- Division of Rheumatology, Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - W. S. Leung
- Division of Infectious Diseases, Department of Medicine & Geriatrics, Kwong Wah Hospital, Hong Kong SAR, China
| | - Timothy C. M. Li
- Division of Infectious Diseases, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Y. Y. Ng
- Division of Infectious Diseases, Department of Medicine & Geriatrics, Tuen Mun Hospital, Hong Kong SAR, China
| | - Rocky Shum
- Division of Microbiology, Department of Clinical Pathology, Tuen Mun Hospital, Hong Kong SAR, China
| | - Winnie W. Y. Sin
- Division of Infectious Diseases, Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR, China
| | - Eugene Y. K. Tso
- Division of Infectious Diseases, Department of Medicine & Geriatrics, United Christian Hospital, Hong Kong SAR, China
| | - Alan K. L. Wu
- Division of Microbiology, Department of Clinical Pathology, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Elaine Y. L. Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China
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Bellanti JA, Settipane RA. Evaluation and management of adverse reactions to the COVID-2019 vaccines. Allergy Asthma Proc 2022; 43:1-4. [PMID: 34983703 DOI: 10.2500/aap.2022.43.210118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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