Breaking the Mold: Safely Delabeling Penicillin Allergies in Hospitalized Children

Abstract

Children are often reported to have antibiotics allergies, with up to 35 million people, or 10% of the US population, labeled as allergic to an antibiotic. 1 In fact, 75% of children with reported antibiotic allergies are identified before the age of 3 years. 2 Recent studies have revealed that the majority of symptoms reported as an allergy by parents are non-immunoglobulin E-mediated adverse reactions or symptoms of a viral illness, such as rash, abdominal pain, vomiting, diarrhea, or other benign symptoms. 3,4 Additionally, .90% of patients with a reported penicillin allergy have negative skin testing results. 1,5,6 Several studies in adults and children reveal risk-stratified management, wherein those at low risk for a true allergy skip skin testing in favor of direct oral challenge, is safe and effective. 7 Delabeling penicillin allergies in children without true allergies is critical because penicillin allergy labels are associated with worse clinical outcomes, increased adverse drug events, more multidrug-resistant infections, and increased health care costs. [7][8][9] Although risk-stratified management of drug allergies is now standard of care, 7,8 implementation of this best practice in the hospital setting is lacking.In this issue of Hospital Pediatrics, researchers report a single-center, hospital-based quality improvement (QI) project aimed at performing risk stratification of penicillin allergies, with subsequent delabeling of children who do not have a true allergy. They used a multidisciplinary clinical care pathway, with several important interventions, including provider incentives, education initiatives, electronic health record (EHR) support, and oversight team encouragement of allergy evaluation at the provider level. The QI project achieved their preset goal, and the proportion of penicillin-allergy delabeling increased almost fivefold.In addition to the overall increased proportion of penicillin-allergy delabeling, the authors present several interesting findings. First, of those deemed low risk for true allergy, .50% received a penicillin antibiotic before discharge. Although this is likely due to the prioritization of delabeling efforts by providers in patients with immediate antibiotic selection needs, the high rate of penicillin prescribing in those admitted with a penicillin allergy is striking and emphasizes the short-term benefits of allergy delabeling programs. Second, 38% of delabeling occurred without an oral challenge. Many children are unnecessarily deemed "allergic" due to

Barriers to paediatric penicillin allergy de-labelling in UK secondary care: a regional survey

“…This can be achieved in collaboration with pharmacists and infectious disease specialists to incorporate antibiotic allergy testing guidelines into AS programmes 9–11. Local projects comprising antibiotic allergy education and multidisciplinary clinical care pathway have been successful in improving penicillin allergy knowledge, de-labelling and prescribing practices 12–14…”