Survey of Obstetric Providers to Assess the Knowledge and Management of a Reported Penicillin Allergy in Pregnant Women

Abstract

Background: Penicillin allergy is the most commonly reported drug allergy in the United States, however less than 10% of individuals labeled with a penicillin allergy are truly allergic. A reported penicillin allergy in pregnancy is associated with adverse maternal and perinatal outcomes. Despite recommendations for penicillin allergy testing in pregnancy, limited literature regarding obstetric providers’ comfort and knowledge in addressing penicillin allergy and referral patterns exists. Objective: To survey obstetric providers to assess their clinical practice patterns and baseline penicillin allergy knowledge, identify potential knowledge gaps in management of pregnant patients with reported penicillin allergy, and measure the impact of an educational intervention on provider knowledge and practice patterns. Study Design: An anonymous, electronic 23 question survey administered to all obstetric providers at a single academic medical center assessed obstetric provider characteristics, self-reported antibiotic practice patterns, and antibiotic allergy knowledge before (June 19, 2020) and after (September 16, 2020) a penicillin allergy educational intervention, which consisted of multiple small-group educational sessions and a culminating departmental educational session. Discrete knowledge comparison by provider type and experience level was performed using chi square tests pre and post-intervention. Results: Of 277 obstetric providers invited, 124(45%) responded pre-intervention and 62(22%) post-intervention. 27% correctly identified the percentage of patients labeled penicillin allergic who would tolerate penicillins, 45% identified cephalosporin cross-reactivity, 59% understood penicillin allergies can wane, and 54% identified penicillin skin testing(PST) as a valid allergy verification tool. Among 48 respondents who attended educational sessions and responded post-intervention, their knowledge of penicillin allergy waning (79% pre-education vs 98% post-education, p<0.01) and PST as a valid tool for penicillin allergy verification (50% pre-education vs 83% post-education, p<0.01) improved. Conclusions: Knowledge gaps related to penicillin allergy exist among obstetric providers. Educational initiatives may improve provider knowledge, identification of patients requiring penicillin allergy evaluation, and reduce referral barriers.

The Cost of Developing and Implementing an Antepartum Referral Program for Penicillin Allergy Evaluation at a Single Academic Tertiary Care Hospital

“…We found that this component of the cost was a critical component of the program given a preintervention survey, which demonstrated a provider knowledge gap related to penicillin allergy in pregnancy. 10 The median cost of penicillin allergy evaluation for referred patients was $397 (IQR: $303-$663). When considering only patients who completed their allergy evaluation, this cost ranged from $299 to $663.…”

“…8,9 Despite this, most patients labeled with a penicillin allergy do not undergo evaluation to determine the persistence or accuracy of their allergy and instead, alternative, nonbeta-lactam, antibiotics are often prescribed. 10 Reporting a penicillin allergy in pregnancy, and consequent alternative antibiotic use, is associated with significant maternal and neonatal morbidity. Penicillin allergy has been associated with increased risk for cesarean delivery, endometritis, wound complications, length of delivery hospitalization and neonatal Group B Streptococcus (GBS) sepsis.…”

“…8 9 Despite this, most patients labeled with a penicillin allergy do not undergo evaluation to determine the persistence or accuracy of their allergy and instead, alternative, non-β-lactam, antibiotics are often prescribed. 10…”

Appropriate Antibiotic Use for Group B Streptococcus Prophylaxis Among Penicillin-Allergic Patients in Academic and Nonacademic Hospitals

“…Factors that may contribute to inappropriate antibiotic use include the lack of detailed allergy history and lack of GBS susceptibility testing. In a survey of obstetric providers at an academic medical center, though 70% always asked about symptoms of the index penicillin allergy reaction, 25%–34% asked detailed questions about allergy history [ 16 ]. Among patients with severe IgE-mediated hypersensitivity reactions, guidelines recommend GBS susceptibility testing for clindamycin, with vancomycin administration if the isolate is not susceptible or results are unavailable [ 1 ].…”

“…Outpatient penicillin allergy testing during pregnancy has shown promise in reducing the use of broad-spectrum antibiotics [ 7 , 17 ]. In addition, cross-reactivity of cephalosporins to penicillins is overestimated [ 16 ], and quality improvement studies to encourage cefazolin use for surgical prophylaxis in penicillin-allergic patients found no cases of anaphylaxis [ 18 , 19 ], including in 1 study that used cefazolin even for patients with histories of severe IgE-mediated hypersensitivity reactions to penicillin [ 20 ]. For GBS prophylaxis in patients with penicillin or cephalosporin allergies, a standardized allergy-guided order set increased appropriate antibiotic use from 47% to 85% [ 21 ].…”