The Penicillin Allergy Delabeling Program: A Multicenter Whole-of-Hospital Health Services Intervention and Comparative Effectiveness Study

Abstract

Background Penicillin allergies are associated with inferior patient and antimicrobial stewardship outcomes. We implemented a whole-of-hospital program to assess the efficacy of inpatient delabeling for low-risk penicillin allergies in hospitalized inpatients. Methods Patients ≥ 18 years of age with a low-risk penicillin allergy were offered a single-dose oral penicillin challenge or direct label removal based on history (direct delabeling). The primary endpoint was the proportion of patients delabeled. Key secondary endpoints were antibiotic utilization pre- (index admission) and post-delabeling (index admission and 90 days). Results Between 21 January 2019 and 31 August 2019, we assessed 1791 patients reporting 2315 antibiotic allergies, 1225 with a penicillin allergy. Three hundred fifty-five patients were delabeled: 161 by direct delabeling and 194 via oral penicillin challenge. Ninety-seven percent (194/200) of patients were negative upon oral penicillin challenge. In the delabeled patients, we observed an increase in narrow-spectrum penicillin usage (adjusted odds ratio [OR], 10.51 [95% confidence interval {CI}, 5.39–20.48]), improved appropriate antibiotic prescribing (adjusted OR, 2.13 [95% CI, 1.45–3.13]), and a reduction in restricted antibiotic usage (adjusted OR, 0.38 [95% CI, .27–.54]). In the propensity score analysis, there was an increase in narrow-spectrum penicillins (OR, 10.89 [95% CI, 5.09–23.31]) and β-lactam/β-lactamase inhibitors (OR, 6.68 [95% CI, 3.94–11.35]) and a reduction in restricted antibiotic use (OR, 0.52 [95% CI, .36–.74]) and inappropriate prescriptions (relative risk ratio, 0.43 [95% CI, .26–.72]) in the delabeled group compared with the group who retained their allergy label. Conclusions This health services program using a combination of direct delabeling and oral penicillin challenge resulted in significant impacts on the use of preferred antibiotics and appropriate prescribing.

Co-infections, secondary infections, and antimicrobial use in patients hospitalised with COVID-19 during the first pandemic wave from the ISARIC WHO CCP-UK study: a multicentre, prospective cohort study

“…Many patients can be de-labelled without the need for penicillin challenges, associated with reduced broad-spectrum antimicrobial use, and this strategy should be encouraged in patients admitted to hospital with COVID-19 in advance of a potential need for antimicrobials. 23 Furthermore, we identified frequent use of broad-spectrum empirical therapy (β-lactam–β-lactamase inhibitors) for lower respiratory tract infections, empirical escalation from piperacillin–tazobactam to carbapenems in critical care, and preferential use of carbapenems over carbapenem-sparing alternatives. These findings all represent tractable targets for antimicrobial stewardship.…”

A Baker’s Dozen of Top Antimicrobial Stewardship Intervention Publications in 2020

“…In particular, rates of true allergic reactions to penicillins have been shown to be far less than previously reported [ 32 ]. Chua and colleagues conducted a multicenter, prospective study to evaluate rate of penicillin allergy delabeling following review by trained nursing, pharmacy, or medical staff using a validated assessment tool [ 16 ]. Based on risk stratification, patients were directly delabeled, offered oral penicillin challenge, or referred for outpatient allergy assessment.…”

An algorithm for safe de‐labelling of antibiotic allergy in adult hospital in‐patients

“…This study suggests that there is a population of hospitalized patients in Scotland with a reported penicillin allergy who are suitable for our PADL process delivered via appropriately trained clinical teams. Several larger studies have shown similar success with direct de‐labelling approaches based on allergy history alone 8,9 and/or oral challenge tests 9,10 . Further work is needed to provide a standardized approach for training and to map out the roles of various staff in the process to provide an efficient process utilizing the skills of medical, nursing and pharmacy staff while ensuring professional liability is considered.…”