Low self-reported penicillin allergy in South Africa—implications for global public health response

Abstract

Objectives In high-income countries, up to 25% of inpatients have a self-reported penicillin allergy (PA). After testing, 95% of these self-reported PAs are incorrect. These incorrectly labelled PAs increase the use of broad-spectrum antibiotics, and drive bacterial resistance. The epidemiology of PA in low- and middle-income countries is unknown. We aimed to describe the epidemiology and delabelling outcomes of self-reported PA in South African (SA) inpatients. Methods We conducted point prevalence surveys between April 2019 and June 2021 at seven hospitals in Cape Town, South Africa. A team trained in the PEN-FAST allergy decision tool conducted in-person interviews, and reviewed patient notes to identify and risk stratify inpatients with a self-reported PA. These patients were referred to the Groote Schuur Hospital (GSH) allergy clinic for delabelling. Results A total of 1486 hospital inpatients were surveyed and 3.2% (n = 48) carried a PA label. Importantly, 64.6% (n = 31) were classified by PEN-FAST as low risk for true penicillin hypersensitivity. Overall, 25% of the self-reported PAs received a β-lactam antibiotic in hospital and were directly delabelled. Delabelling attrition was very high, with 6.3% (3/48) of the self-reported PAs attending the GSH allergy clinic, and only one patient proceeding to a negative oral penicillin challenge. Conclusions Inpatient self-reported PA was lower in South Africa hospitals compared with other upper-middle-income countries, and the majority of patients carried a low-risk PA label. Linkage for delabelling with the allergy clinic was very poor, and thus strategies to improve access and delivery of delabelling remains an urgent public health issue.

Oral challenge vs routine care to assess low-risk penicillin allergy in critically ill hospital patients (ORACLE): a pilot safety and feasibility randomised controlled trial

“…The performance of this study in a high-income setting with relatively low rates of multi-resistant bacterial infections may limit the generalisability of these findings. Furthermore, whilst the prevalence of penicillin allergy labels may be lower in some low/middle-income settings, point-of-care delabelling could still play an important role in settings with limited ambulatory allergy clinic access [ 21 ].…”

Efficacy of a Clinical Decision Rule to Enable Direct Oral Challenge in Patients With Low-Risk Penicillin Allergy

“…PEN-FAST is a tool to facilitate the identification of low-risk patients labeled as penicillin allergic. A recent survey from South African hospitals demonstrated that PEN-FAST could also be deployed in a low- and middle-income setting; 65% of hospital-admitted patients presented with a low-risk allergy, making them eligible for a direct penicillin oral challenge . The PALACE trial is an important strategy to improve global access to care and allow safe, fast, and cheap penicillin delabeling strategies to address this important public health issue.…”

“…Specialized allergy skin testing is a labor-intensive, expensive, and resource-rich intervention not currently available to large populations of high-income and low-and middleincome countries. 20,21 Furthermore, a penicillin allergy label cannot be removed based on skin testing alone, and the oral challenge remains the gold standard. PEN-FAST is a tool to facilitate the identification of low-risk patients labeled as penicillin allergic.…”

“…A recent survey from South African hospitals demonstrated that PEN-FAST could also be deployed in a lowand middle-income setting; 65% of hospital-admitted patients presented with a low-risk allergy, making them eligible for a direct penicillin oral challenge. 21 The PALACE trial is an important strategy to improve global access to care and allow safe, fast, and cheap penicillin delabeling strategies to address this important public health issue. The PALACE trial demonstrates that PEN-FAST is now an internationally validated clinical decision rule that can accurately risk assess penicillin allergy and that 2-stage skin testing followed by oral challenge no longer needs to be the standard of care in low-risk phenotypes.…”

Southern African HIV Clinicians Society Guideline for the clinical management of syphilis

“…However, true penicillin allergy is uncommon in our region, therefore the majority of patients who report having a penicillin allergy are actually not at high risk of a severe allergic reaction. 66 Importantly, alternative therapeutic options are available in most cases. It is therefore important to take a good history and work-up of anyone reporting penicillin allergy; penicillin desensitisation before syphilis treatment can be attempted in those with a confirmed severe allergy, although this is generally only necessary for cases of neurosyphilis and syphilis in pregnancy, where the efficacy of non-beta-lactam drug options is not well-established.…”