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How is penicillin allergy testing viewed in primary care?

Published online: March 12, 2019

Between 10-15% of patients have a record of penicillin allergy; however, fewer than 10% of these patients are likely to be allergic when formally tested. These patients are usually not prescribed first line treatment, and as a result, are at risk of longer hospital stays, and increased infections with Methicillin-resistant Staphylococcus aureus and Clostridium difficile. Prescription of broad-spectrum antibiotics in these patients contributes to global antibiotic resistance. Penicillin allergy testing can confirm or exclude allergy. General practitioners (GPs) can refer patients for testing; in order to maximize benefit from testing it is important to understand how patients and general practitioners view this service.

In a recent article published in The Journal of Allergy and Clinical Immunology: In Practice, Wanat and colleagues investigated GP and patient views of referring for or attending penicillin allergy testing, and the use of penicillins following negative allergy testing. GPs were recruited from general practices in the north of England with variation in whether they had referred patients for allergy testing previously. Patients with a record of penicillin allergy were recruited from general practices and patients who had undergone penicillin allergy testing were recruited from a hospital allergy clinic. Researchers conducted semi-structured interviews with participants, asking them about their views of penicillin allergy testing and subsequent penicillin use.

Fifty participants completed an interview: 31 patients, 16 of whom had experience of penicillin allergy testing; and 19 GPs. Patients did not see benefits of penicillin allergy testing unless they had previously experienced problems as a result of their penicillin allergy record. Patients who had experienced difficulty in managing infections or who had multiple allergies were more motivated to attend for testing. Patients were concerned with the safety of any test; the perceived probability of a reaction during the test, invasiveness of the test and provision of information were particularly important to them. Patients who had experience of testing reported benefits from having undertaken the allergy assessment; these included viewing the test as providing a definite answer and having access to more antibiotics. However, there were a minority who were still hesitant to take penicillin after a negative allergy test. Clinicians were aware that many penicillin allergy records were likely to be incorrect but felt they could not amend patient records based on their clinical judgment alone. Despite having positive attitudes toward penicillin allergy testing and being willing to prescribe penicillin following a negative test, the majority had limited experience of referring patients and reported wanting more information about testing, especially about the procedures involved, risks and benefits to patients and how to discuss testing with patients. Finally, clinicians differed in their views on who should be responsible for communicating test results to patients, with some taking on this role and some seeing it as the responsibility of an allergy consultant.

The study highlights key barriers and facilitators to using allergy services and subsequent use of penicillin from the perspective of both patients and clinicians. It shows that both patients and clinicians need to be supported to use penicillin allergy testing services. Clinicians and patients would benefit from more information about what the testing involves and harms of a penicillin allergy label; in addition, patients’ concerns about potential benefits and risks of testing need be addressed in order to increase their motivation to attend for testing. There is also need for a clear and consistent approach to de-labelling with support from sub-specialty colleagues.

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