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From the PresidentLang

October 2019

Dear Colleagues,

One of the AAAAI’s current advocacy priorities is to promote routine penicillin allergy testing as a key component of antibiotic stewardship.

As you know, penicillin is the most commonly reported drug allergy. Approximately 10 percent of the U.S. population reports being allergic to penicillin, yet 9 out of 10 patients reporting a penicillin allergy are not truly allergic when formally evaluated, such that fewer than one percent of the population is truly allergic to penicillin.

For patients who have a label of “penicillin allergy”, healthcare providers will treat infections they develop with alternative antibiotics (e.g., vancomycin, fluoroquinolones, and clindamycin) when a penicillin is the drug of choice. Receiving an alternative non-penicillin antibiotic has been associated with undesirable outcomes: higher costs of care, greater risk for adverse effects, and longer hospital stays. These alternative antibiotics also have been associated with higher rates of Clostridium difficile, and can encourage emergence of antibiotic-resistant bacteria including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus infections.

How much of a threat is antibiotic resistance? According to the Centers for Disease Control and Prevention (CDC), each year at least two million illnesses and 23,000 deaths are caused by antibiotic-resistant bacteria in the United States alone.

Correctly identifying if patients are penicillin-allergic is crucial to decreasing the unnecessary use of broad-spectrum antibiotics. This is why the AAAAI has an official position statement that supports more widespread and routine use of penicillin skin testing for patients with a self-reported history of allergy to penicillin. Such testing can accurately identify the approximately 9 of 10 patients who, despite reporting a history of penicillin allergy, can safely receive penicillin.

The AAAAI has been working on advocacy efforts surrounding penicillin allergy for a number of years. Our efforts go back to 2014, when we participated in the American Board of Internal Medicine Foundation’s Choosing Wisely® campaign. This initiative was introduced to foster conversations between patients and healthcare providers—more specifically, to empower patients to ask questions about the tests and procedures that are most appropriate and necessary based on best evidence, and to encourage patients to more effectively participate in the medical decision making process via a partnership with their healthcare provider. Among our 10 recommendations (which can be found here), we advised physicians to not overuse non-beta-lactam antibiotics in patients with a history of penicillin allergy without an appropriate evaluation.

I’m pleased to report that in recent weeks we’ve had several advocacy wins from our efforts to take our penicillin allergy messages directly to Capitol Hill. These significant wins would not be possible without the work of the AAAAI Advocacy Committee, the Office of Practice Management, and our expert consultants on legislative and regulatory advocacy at Hart Health Strategies.

Senate Appropriations Report Language Supports Penicillin Allergy Testing
First, we learned in late September that the Senate Appropriations Committee included language to encourage the Department of Health and Human Services to educate the public and healthcare providers on the importance of penicillin allergy testing in the fight against antimicrobial resistance in its report to the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriation bill for 2020. The AAAAI was extremely pleased to see report language addressing the issue directly, as requested by AAAAI leaders during our visits on Capitol Hill in May and vigorously pursued with the Senate Appropriations Committee since then. Additional details on this and other important AAAAI appropriations efforts can be found here.

AAAAI Op-Ed on Penicillin Allergy Published in The Hill
Second, we hit a major media milestone last week when an op-ed titled “Don't overlook penicillin to combat antimicrobial resistance” was published in The Hill. The Hill is one of the most important media outlets targeting national policy issues and politics, making the publication of this op-ed a noteworthy achievement. I invite you to read the op-ed here.

AAAAI to Present Congressional Briefing on Penicillin Allergy
And last, I am thrilled to announce that the AAAAI is presenting a penicillin allergy Congressional briefing on November 1. Representatives of the Peggy Lillis Foundation and the Infectious Diseases Society of America will be joining me as speakers. We also invited the CDC to describe its efforts related to penicillin allergy and antibiotic stewardship.

The briefing is an excellent opportunity to build on the momentum of the aforementioned Senate Appropriations language directing the Department of Health and Human Services to do public outreach on penicillin allergy and antibiotic stewardship, as well as the op-ed in The Hill.

The message we want to convey during the briefing is that the public has a role to play in the fight against antimicrobial resistance, and that role is: Don’t be complacent. If you have penicillin allergy, then make arrangements for penicillin allergy testing. The label of penicillin allergy is often given in childhood, when common infections may themselves contribute to or be confused with a true allergy. And even for those who may have a true allergy, over 80% will lose this tendency with avoidance of penicillins over a 10 year period.

It’s vitally important for patients with unverified penicillin allergy to understand that undergoing appropriate diagnostic evaluation in the overwhelming majority of cases will lead to removal of the label of penicillin allergy. Evidence from multiple studies clearly demonstrates that when this “delabeling” happens, it’s associated with improved outcomes over time and reduces the spread of antibiotic resistance. As health care transitions to a system of value-based reimbursement, this is another opportunity for our specialty to demonstrate that we bring value to the table.

Sincerely,

David M. Lang, MD, FAAAAI
AAAAI President
president@aaaai.org

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