Is spurious penicillin allergy a major public health concern only in high-income countries?

Krishna, Mamidipudi Thirumala; Vedanthan, P.K.; Vedanthan, Rajesh; Shabrawy, Reham Mohamed El; Ramesh, Madhan; Nguyen, Hoa L.; Kudagammana, Thushara; Williams, Iestyn; Subramanian, Hariharan; Krishnamurthy, Kandamaran; Sumantri, Stevent; Elliott, Rachel; Mahesh, P A; Marriott, John

doi:10.1136/bmjgh-2021-005437

Cited by 13 publications

(13 citation statements)

References 15 publications

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“…A comprehensive framework for incorporation of BLA de-labelling in LMICs/LICs has recently been outlined. [4] The inclusion of several hospitals across different levels of the health system in the present study, and inclusion of private and government-funded hospitals, improved the generalisability of these data. However, the fact that the study was performed in only one SA city is a limitation.…”

Section: Researchmentioning

confidence: 86%

“…[14] The burden of ABR is highest in lowincome countries (LICs). [4,14,15] Western sub-Saharan Africa has the highest all-age death rate attributable to ABR (27.3 deaths per 100 000; 95% confidence interval (CI) 20.9 -35.3). [14] The high mortality due to ABR in sub-Saharan Africa makes de-labelling BLA a public health and antibiotic stewardship priority.…”

Section: Researchmentioning

confidence: 99%

“…[17] The need to establish the true prevalence and incidence of BLA in LMICs is of paramount importance to improve our management of BLA in settings with the highest burden of infectious diseases. [4]…”

Section: Researchmentioning

confidence: 99%

“…[1][2][3] While the epidemiology of BLA in HICs is well described, there are no published epidemiological data available on BLA in Africa or other low-and middle-income countries (LMICs). [4] An HIC is defined by the World Bank as a nation with a gross national income (GNI) per capita of ≥USD12 696 in 2020, whereas an LMIC is defined as one with a GNI of USD1 046 -4 095. [5] South Africa (SA) is classed as an upper middle-income economy, with a GNI per capita of USD4 096 -12 695.…”

mentioning

confidence: 99%

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Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa

Day

Deetlefs²,

O’Brien³

et al. 2023

S Afr Med J

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Background. Up to a quarter of inpatients in high-income countries (HICs) self-report beta-lactam allergy (BLA), which if incorrect,increases the use of alternative antibiotics, worsening individual health outcomes and driving bacterial resistance. In HICs, up to 95% ofself-reported BLAs are incorrect. The epidemiology of BLA in low- and middle-income African countries is unknown.Objectives. To describe the epidemiology and de-labelling outcomes of self-reported BLA in hospitalised South African (SA) patients.Methods. Point-prevalence surveys were conducted at seven hospitals (adult, paediatric, government and privately funded, district andtertiary level) in Cape Town, SA, between April 2019 and June 2021. Ward prescription records and in-person interviews were conductedto identify and risk-stratify BLA patients using the validated PEN-FAST tool. De-labelling was attempted at the tertiary allergy clinic atGroote Schuur Hospital.Results. A total of 1 486 hospital inpatients were surveyed (1 166 adults and 320 children). Only 48 patients (3.2%) self-reported a BLA,with a higher rate in private than in government-funded hospitals (6.3% v. 2.8%; p=0.014). Using the PEN-FAST tool, only 10.4% (n=5/48)of self-reported BLA patients were classified as high risk for true penicillin hypersensitivity. Antibiotics were prescribed to 70.8% (n=34/48)of self-reported BLA patients, with 64.7% (n=22/34) receiving a beta-lactam. Despite three attempts to contact patients for de-labelling atthe allergy clinic, only 3/36 underwent in vivo testing, with no positive results, and 1 patient proceeded to a negative oral challenge.Conclusion. Unlike HICs, self-reported BLA is low among inpatients in SA. The majority of those who self-reported BLA were low risk fortype 1 hypersensitivity, but outpatient de-labelling efforts were largely unsuccessful.

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Section: Researchmentioning

confidence: 86%

Section: Researchmentioning

confidence: 99%

Section: Researchmentioning

confidence: 99%

mentioning

confidence: 99%

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Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa

Day

Deetlefs²,

O’Brien³

et al. 2023

S Afr Med J

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“…22 More recently, the World Health Organization recommended antibiotic de-labeling as an effective antimicrobial stewardship strategy. 23 However, knowledge of the epidemiology of penicillin allergy labels and their association with antimicrobial resistance in low-and middle-income countries is sparse, as is the evidence for established antibiotic de-labeling pathways, 24 with the majority of studies occurring in high-income countries.…”

Section: Introductionmentioning

confidence: 99%

Effectiveness of interventions that support penicillin allergy assessment and de-labeling of patients by non-allergy specialists: a systematic review protocol

Powell

Kohl

Ahmed

et al. 2021

JBI Evidence Synthesis

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This review will systematically examine and synthesize the evidence evaluating the effectiveness and safety of interventions that enable non-allergy specialist health care workers to assess allergy risk in patients with reported penicillin allergies and subsequently remove erroneous allergy records. Introduction:The potential benefits of removing erroneous penicillin allergy labels (de-labeling) are wide-ranging.Penicillin allergy assessment and de-labeling is an antibiotic stewardship priority. Delivery of such assessment and de-labeling by non-allergy specialists has been reported in several studies, but the effectiveness and safety have not been formally synthesized. This is a necessary step in the upscaling of penicillin allergy assessment services.Inclusion criteria: This review will consider quantitative studies using appropriate designs. The studies will include adults and pediatric patients who have undergone penicillin allergy assessment and de-labeling by non-allergy specialists in any health care setting.Methods: A range of databases will be searched to identify studies published in English, with no date limit applied.Unpublished studies and gray literature will also be searched. Title and abstract screening, and assessment of selected full texts against the inclusion criteria will be conducted by at least two independent reviewers. Identified studies will be assessed for methodological quality using standardized critical appraisal instruments. Data will be extracted and categorized using the EPOC taxonomy, and the effectiveness and safety of the intervention will be determined. Where possible, data will be pooled to facilitate meta-analysis. Data from heterogeneous studies will be reported narratively. The GRADE approach for grading the certainty of evidence will be followed.

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Penicillin Allergy Testing and Delabeling for Patients Who Are Prescribed Penicillin: A Systematic Review for a World Health Organization Guideline

Providencia,

Aali,

Zhu

et al. 2024

Clinic Rev Allerg Immunol

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Secondary prevention with penicillin aims to prevent further episodes of acute rheumatic fever and subsequent development of rheumatic heart disease (RHD). Penicillin allergy, self-reported by 10% of the population, can affect secondary prevention programs. We aimed to assess the role for (i) routine penicillin allergy testing and the (ii) safety of penicillin allergy delabeling approaches in this context. We searched MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, WHO ICTRP, ISRCTN, and CPCI-S to identify the relevant reports. We found 2419 records, but no studies addressed our initial question. Following advice from the WHO-Guideline committee and experts, we identified 6 manuscripts on allergy testing focusing on other populations showing that the prevalence of allergy confirmed by testing was low and the incidence of life-threatening reactions to BPG was very low (< 1–3/1000 individuals treated). A subsequent search addressed penicillin allergy delabeling. This found 516 records, and 5 studies addressing the safety of direct oral drug challenge vs. skin testing followed by drug administration in patients with suspected penicillin allergy. Immediate allergic reactions of minor severity were observed for a minority of patients and occurred less frequently in the direct drug challenge group: 2.3% vs. 11.5%; RR = 0.25, 95%CI 0.15–0.45, P < 0.00001, I2 = 0%. No anaphylaxis or deaths were observed. Severe allergic reactions to penicillin are extremely rare and can be recognized and dealt by trained healthcare workers. Confirmation of penicillin allergy diagnosis or delabeling using direct oral drug challenge or penicillin skin testing seems to be safe and is associated with a low rate of adverse reactions.

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Is spurious penicillin allergy a major public health concern only in high-income countries?

Abstract: Figure 1 A schematic diagram illustrating a systematic multipronged approach to address penicillin allergy delabelling in lowincome, low-middle-income and upper middle-income countries.

Cited by 13 publications

References 15 publications

Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa

Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa

Effectiveness of interventions that support penicillin allergy assessment and de-labeling of patients by non-allergy specialists: a systematic review protocol

Penicillin Allergy Testing and Delabeling for Patients Who Are Prescribed Penicillin: A Systematic Review for a World Health Organization Guideline

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