Removing “penicillin allergy” in hospitalized patients to optimize antibiotic therapy

Published in issue: February 2017

Penicillin allergy is the most commonly reported antibiotic allergy, yet over 90% of patients with reported penicillin allergy will tolerate penicillin. Penicillin skin testing is available, but underutilized, to rule out penicillin allergy in appropriate patients. The use of second-line antibiotics in patients with reported penicillin allergy has been associated with increased length of hospital stay, decreased infection cure rates, increased costs, increased rates of Clostridium difficile infection (antibiotic associated diarrhea), and an increased risk of antibiotic resistance. There are evolving strategies to address the penicillin allergy label in hospitalized patients.

In The Journal of Allergy and Clinical Immunology: In Practice, Ramsey et al. report the results of their multidisciplinary study at a 527-bed tertiary care medical center targeting hospitalized patients with penicillin allergy who were receiving certain second line antibiotics. Patients receiving vancomycin, aztreonam, moxifloxacin, daptomycin, and linezolid were screened through the electronic medical record, and identified to undergo penicillin skin testing through the use of a penicillin allergy history algorithm. Patients with negative penicillin skin testing were transitioned to optimal antibiotics.

A total of 50 patients receiving the targeted antibiotics were consented to undergo penicillin skin testing. The majority were receiving either vancomycin (82%) or aztreonam (22%). Forty-seven patients (94%) had negative penicillin skin testing and were transitioned to optimal antibiotics. None of the patients experienced any adverse reaction during the penicillin skin testing, and one patient experienced a mild rash after the introduction of a penicillin-based antibiotic. A total of 982 days of second line antibiotics were saved, and at least 23 hospital days were avoided. The authors also demonstrated a conservative $70 direct cost savings per patient.

This study provides a real-world, multidisciplinary approach for triaging patients for penicillin skin testing based on second line antibiotic use, with appropriate patients identified for skin testing through the use of a penicillin allergy history algorithm. The results support the safety and cost effectiveness of this approach.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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