BSACIguideline for the set‐up of penicillin allergy de‐labelling services by non‐allergists working in a hospital setting

Abstract

The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and a committee of experts and key stakeholders have developed this guideline for the evaluation and testing of patients with an unsubstantiated label of penicillin allergy. The guideline is intended for UK clinicians who are not trained in allergy or immunology, but who wish to develop a penicillin allergy de‐labelling service for their patients. It is intended to supplement the BSACI 2015 guideline “Management of allergy to penicillin and other beta‐lactams” and therefore does not detail the epidemiology or aetiology of penicillin allergy, as this is covered extensively in the 2015 guideline (1). The guideline is intended for use only in patients with a label of penicillin allergy and does not apply to other beta‐lactam allergies. The recommendations include a checklist to identify patients at low risk of allergy and a framework for the conduct of drug provocation testing by non‐allergists. There are separate sections for adults and paediatrics within the guideline, in recognition of the common differences in reported allergy history and likelihood of true allergy.

Towards a safe and efficient de‐labelling penicillin allergy service by non‐allergists

“…The first five points in Savic et al Table 1 describe unambiguous non-allergic manifestations, patients with no personal history of penicillin allergy or patients who have tolerated penicillin after the presumed allergic reaction. 1 These patients do not warrant further allergy work-up, [2][3][4] and the penicillin allergy label can and should be removed without further investigations. The patients should be advised that their risk of an allergic reaction to penicillin is the same as that of the general population.…”

“…Table 3 from Savic et al suggests a graded DPT protocol for amoxicillin with three doses: 50 mg (10%), 250 mg (50%) and finally 200 mg (40%) of the full 500 mg dose. 1 This is against common clinical practice based on the basic principle for allergy provocation testing, during which gradually increasing drug doses are administered, as supported by the BSACI guideline (which this publication by Savic et al is written to complement) and the EAACI guidelines for betalactam allergy. 2,6 Deviating away from common clinical practice introduces potential confusion for no benefit.…”

“…However, Savic et al in Table 3 recommend checking the vital signs immediately after each penicillin dose is administered. 1 We are concerned that this would be too soon to pick up any change after oral drug administration. The BSACI guideline, 6 which this guideline was written to complement, does not mention timings for observations.…”

Is penicillin allergy de-labelling about to find its place in UK antimicrobial stewardship strategy?

“…However, there have been recent developments in the UK, with Scotland publishing their nonallergist de-label toolkit aimed at hospital physicians in 2021 10 and BSACI publishing guidelines for non-allergist de-labelling in hospitals. 11 Both these publications provide toolkits for non-allergy healthcare workers to undertake penicillin allergy de-labelling in the UK. 10,11 Although behind in guidance, the UK's National Institute for Health and Care Research has recognised the importance of this topic and funded several studies exploring how to embed penicillin allergy assessment into the NHS, exploring the resource implications and the potential barriers and enablers to implementing penicillin allergy de-labelling patient pathways, as well as quantifying the patient and healthcare benefits of penicillin allergy de-labelling.…”

“…11 Both these publications provide toolkits for non-allergy healthcare workers to undertake penicillin allergy de-labelling in the UK. 10,11 Although behind in guidance, the UK's National Institute for Health and Care Research has recognised the importance of this topic and funded several studies exploring how to embed penicillin allergy assessment into the NHS, exploring the resource implications and the potential barriers and enablers to implementing penicillin allergy de-labelling patient pathways, as well as quantifying the patient and healthcare benefits of penicillin allergy de-labelling. [12][13][14][15] The early adoption of penicillin allergy assessment by nonallergists in the USA, Australia and New Zealand and the provision of toolkits to enable non-allergists to deliver this service has facilitated early adoption in these countries.…”