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Proactive inpatient penicillin allergy testing: Old problem, new approach

Published online: November 22, 2016

Penicillin allergy is the most commonly reported drug allergy in the United States, leading to the use of alternatives that are often costlier, more toxic, or limited to intravenous administration.  The vast majority of patients labeled as penicillin-allergic in fact tolerate this drug, but clinicians frequently forgo its use along with other beta-lactams due to a fear of hypersensitivity reactions.  Penicillin allergy testing is well validated for diagnosing IgE-mediated penicillin allergy and has been proposed as a tool for reducing unnecessary broad-spectrum antibiotic use in the inpatient setting, but it remains underutilized and underpublicized by both allergists and inpatient physicians.

A new study by Chen and colleagues published in the The Journal of Allergy and Clinical Immunology: In Practice introduces a multidisciplinary inpatient service dedicated to the preemptive identification, testing, and education regarding penicillin allergy at a large public hospital.  The service utilizes EMR-assisted protocols to stratify admitted patients carrying a penicillin allergy diagnosis and a trained clinical pharmacist to perform penicillin skin testing and challenge.  Prioritization criteria included the cost of the current antibiotic, immunocompromising conditions, and use of medications with the potential to interfere with skin testing.  

Through 18 months 1,203 admitted patients were identified and 252 were directly evaluated.  Of this group, 228 (90.5%) had their allergy removed from the chart by the testing service.  Medication administration records for patients after negative testing showed significant declines in active orders for vancomycin, clindamycin, fluoroquinolones, carbapenems and aztreonam along with over a twenty-fold increase in use of penicillin. Overall,  377 inpatient days of penicillins and 127 days of cephalosporins were administered to patients not previously receiving beta-lactams and 438 days of penicillins and 210 days of cephalosporins were prescribed as outpatient therapy for this group.

In summary, the authors outline a proactive approach to the epidemic of penicillin allergy in the acute care setting that utilizes the electronic medical record and partnership with pharmacists.  This framework may be adapted for various healthcare environments and promotes the role of allergy / immunology specialists in antibiotic stewardship.
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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