Direct oral penicillin challenge for penicillin allergy delabeling as a health services intervention: A multicenter cohort study

Abstract

To the Editor, Some patients with anaphylaxis experience recurrences even when a trigger is identified in the initial reaction. [1][2][3][4][5][6] However, recurrence has received less attention than other epidemiological parameters associated with this condition. [1][2][3][4][5][6] We carried out a systematic review of the international literature to investigate the frequency, severity, and time to onset of recurrence.Details of the methodology of the review are provided in the additional material.After ruling out 3,527 articles, we eventually selected 35 for quantitative analysis (Figure A1).The 35 studies on recurrence covered 34,864 patients. The median percentage of recurrence was 27% (IQR, 12.8-61.43) (Table A1, A2). The median duration of studies was 5 years (range, 1-13 years).Retrospective and prospective cohorts accounted for only 31.43%(Table 1 and Table A2).Studies from Australia reported the highest rates (up to 57.27 recurrences per 100 person-years) (Figure 1, Table A3), with prevalence values higher than 50% for at least 1 recurrence. 3,4 For both prevalence and incidence, differences between continents were statistically significant (p < .01) and heterogeneity was high (I 2 > 99%).Studies carried out in 2 age groups (under 19 years and all ages) did not reveal differences for incidence or prevalence of recurrence rates (p = .88 and .67, respectively) (Table A3), although differences may be diluted because of the inclusion of children and adolescents in the studies covering all age groups. We found no studies that provided data on all causes of recurrence for the >18-year-old group.Given that the review revealed up to 25 different ways of grouping ages, it was impossible to aggregate them into more homogeneous categories.By principal cause of anaphylaxis, the lowest incidence rates were found for recurrences due to drugs and exercise, although only 1 study 3 addressed both causes. The lowest prevalence rates were for drugs, with the differences also being significant for both prevalence and incidence (p < .01) (Figure 1, Table A3).Other potential explanations for the heterogeneity of the metaanalysis include the incorrect classification of anaphylaxis (underand over-diagnosis) in settings other than allergy departments,

The effectiveness of interventions that support penicillin allergy assessment and delabeling of adult and pediatric patients by nonallergy specialists: a systematic review and meta-analysis

“…(Figure 1). Fifty six studies were case series, (Eischens, Wolf et al , Lnumerables and Fischer-Cartlidge , Skibba, Fischer et al , Wrenn, Sarubbi et al 2017, Torney and Tiberg 2018, Blackwell and Khan 2020, Lo, Lacaria et al 2020 , (Harper and Sanchez , Leis, Palmay et al , Adkinson, Thompson et al 1971, Rimawi and Mazer 2014, Jones and Bland 2017, Englert and Weeks 2019, Griffith, Justo et al 2020, Torney and Tiberg 2021 ten were quasi-experimental studies, (Ravindran, Beshir et al 2017 , (Blumenthal, Shenoy et al 2015, Shannon and Krop 2016 two were cohort studies, (Chua, Vogrin et al 2020, Trubiano, Vogrin et al 2022 and one RCT. (Vyles, Chiu et al 2020)…”

“…The 69 included studies reported on the successful PADL of 5019 patients (adults n= 4314; (Eischens, Wolf et al , Harper and Sanchez , Leis, Palmay et al , Lnumerables and Fischer-Cartlidge , Skibba, Fischer et al , Adkinson, Thompson et al 1971, Rimawi and Mazer 2014, Shannon and Krop 2016, Jones and Bland 2017, Torney and Tiberg 2018, Englert and Weeks 2019, Chua, Vogrin et al 2020, Trubiano, Vogrin et al 2022 heamatology (n=9), (Lnumerables and Fischer-Cartlidge , Trubiano, Thursky et al 2017, Lo, Lacaria et al 2020, Trubiano, Vogrin et al 2022 Emergency Department (n=8), (Eischens, Wolf et al , Rimawi, Cook et al 2013) paediatrics (n=6), (Wong, Timberlake et al 2018 obstetrics & gynaecology (n=5), (Rimawi, Cook et al 2013 peri-operative (n=4), (Harris, Sauberman et al 1999 transplant services (n=3), Fischer-Cartlidge , Trubiano, Thursky et al 2017, Lo, Lacaria et al 2020) infectious diseases (n=4), (Trubiano, Thursky et al 2017, Torney and Tiberg 2018) cardiology (n=2), (Blumenthal, Shenoy et al 2015) urology (n=1), (Blumenthal, Shenoy et al 2015) oral maxillofacial surgery (n=1), (Blumenthal, Shenoy et al 2015) neurology (n=1). (Blumenthal, Li et al 2019) Most studies attempted to de-label those patients with a low allergy risk history only (n=26), (Blumenthal, Shenoy et al 2015, Chua, Vogrin et al 2020, Trubiano, Vogrin et al 2022 moderate risk allergy history only (n=21), , Rimawi and Mazer 2014, Shannon and Krop 2016, Jones and Bland 2017, Torney and Tiberg 2018, Englert and Weeks 2019…”

“…In the studies with compete data on numbers of patients assessed for PADL (n=47), 11,856 patients were assessed for testing, of which 3720 (31.4%) were de-labelled. (Harper and Sanchez , Leis, Palmay et al , Adkinson, Thompson et al 1971, Rimawi and Mazer 2014, Shannon and Krop 2016, Englert and Weeks 2019, Blackwell and Khan 2020, Chua, Vogrin et al 2020, Griffith, Justo et al 2020, Lo, Lacaria et al 2020, Trubiano, Vogrin et al 2022 In the studies with complete data on the proportion of tested patients' de-labelled (n=60), 5072 were tested, of which 4698 (92.6%) were de-labelled and 76 (1.5%) were harmed; no serious reactions reported (appendix 7). (Harper and Sanchez , Leis, Palmay et al , Lnumerables and Fischer-Cartlidge , Adkinson, Thompson et al 1971, Egger, Smith et al 1997, Rimawi, Griffith, Justo et al 2020, Lo, Lacaria et al 2020 11 by doctors (34%), (Adkinson, Thompson et al 1971, Wood and Wisniewski 1994 and one by nurses (3%).…”

“…(Eischens, Wolf et al , Harper and Sanchez , Leis, Palmay et al , Skibba, Fischer et al , Harris, Sauberman et al 1999, Shannon and Krop 2016, Torney and Tiberg 2018, Englert and Weeks 2019, Chua, Vogrin et al 2020, Griffith, Justo et al 2020, Lo, Lacaria et al 2020, Torney and Tiberg 2021, Trubiano, Vogrin et al 2022 Twenty-five (36%) (Eischens, Wolf et al , Leis, Palmay et al , Harris, Sauberman et al 1999, Jones and Bland 2017, Torney and Tiberg 2018, Englert and Weeks 2019, Chua, Vogrin et al 2020, Griffith, Justo et al 2020, Lo, Lacaria et al 2020, Torney and Tiberg 2021, Trubiano, Vogrin et al 2022 reported increased use of penicillin, of which ten also reported increased cephalosporin or other beta-lactam usage. , Blumenthal KG 2016, Jones and Bland 2017, Englert and Weeks 2019, Trubiano, Vogrin et al 2022 One study reported increased first line antibiotic use. (Eischens, Wolf et al)Twenty-two studies (33%) report reductions in glycopeptides, quinolones, aztreonam, carbapenems, clindamycin, cephalosporins, macrolides, and aminoglycosides.…”

Differences in beta-lactam and penicillin allergy: Beyond the West and focusing on Asia-Pacific

“…BL allergy delabelling has been shown to effectively reduce prescriptions of second-line antibiotics and promote re-uptake of first-line penicillins in delabelled patients ( 16 – 18 ). From Australian experience, antibiotic stewardship was enhanced with increased narrow-spectrum penicillin usage ( 19 ), with a low risk of anaphylaxis recurrence ( 20 ). Economically, delabelling has been shown to generate potential savings of $2000USD per patient-year and switching from other broad-spectrum antibiotics to BL has also been found to lower inpatient and outpatient prescription costs by up to $609USD and $193USD per patient respectively ( 15 , 21 ).…”