Penicillin allergy label burden persists despite negative testing

Published Online: July 2, 2015

Over eight percent of the patients engaged with medical care carry a penicillin allergy label, although less than one percent of patients are truly allergic. Recent studies suggest that a label of penicillin allergy carries the risk of increased hospitalization, antibiotic resistant infections, and increased medical care costs. Penicillin skin testing and oral challenge are safe and efficacious ways to remove the label of penicillin allergy, however, it is unknown how effectively this occurs in real clinical practice.

A study led by Dr. Kali Svarczkopf Gerace and Dr. Elizabeth Phillips was recently published in The Journal of Allergy and Clinical Immunology: In Practice that examined the effectiveness of negative penicillin allergy testing in removing penicillin allergy labels at their institution. A chart review was performed to determine the rates of allergy label removal from the electronic health record for adult patients who had negative penicillin skin testing from January 2010 to May of 2014. Attempts were also made to contact all of the patients included in the study to complete a survey regarding their awareness and interpretation of their testing results.

Of the 69/100 patients who had negative skin testing, the penicillin allergy label remained active in the electronic medical record for 26 (37.6%) patients. Twenty-four of those patients had documented oral tolerance in their chart based on either oral challenge in clinic or completion of a course of antibiotics. Of the patients who had a negative observed oral challenge with penicillin, the penicillin allergy label remained 28% of the time. For those patients who had documented tolerance based on completion of a course of penicillin family antibiotic, the allergy label remained 17.6% of the time. Despite the incomplete effectiveness of penicillin allergy label removal, all of the 42 patients who completed a follow-up survey correctly identified the results of their penicillin allergy testing. Twelve out of twenty-nine (41%) of the patients with negative skin testing reported that they continue to avoid all penicillins, either due to personal (42%) or primary care physician’s (58%) concerns. Nearly half of the patients who reported continued avoidance said that they would even tell a new provider that they were allergic to penicillin.

This study indicates a gap between the efficacy of penicillin allergy testing and the effectiveness of allergy label removal when testing is negative, which will negatively impact the potential public health benefit of penicillin allergy testing. This gap is related to both the lack of removal of the penicillin allergy label following negative testing and the lack of patient and primary care provider confidence in results. Efforts should be focused on using oral challenges at the time of testing to demonstrate clear tolerance of penicillins to patients, diligent allergy label removal by the allergist from the electronic medical record, and dissemination of supporting documentation to the patient and the entire healthcare team. Additional focus should include improved education and communication with patients, other medical care providers, pharmacists and the community at large regarding the clinical meaning of negative penicillin allergy testing.

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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