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Towards Better Antibiotic Stewardship: Safely Delabeling Penicillin Allergies

The assertion of penicillin allergy among patients is a global challenge capable of resulting in detrimental health consequences and significant mortalities. Particularly, patients who avoid penicillin due to self-reported allergic reactions raise substantial concerns, as these individuals are more susceptible to negative outcomes, escalated medical costs, increased toxicity, higher propensity to multidrug-resistant infections, and Clostridioides difficile infection.

In 2016, the Infectious Diseases Society of America (IDSA) and the American Academy of Allergy, Asthma, and Immunology recommended that patients purportedly allergic to β-lactams, particularly penicillin, should undertake allergy assessments and skin testing when appropriate. They, however, acknowledged that their recommendation was not strongly fortified by high-quality evidence, since most existing publications had not demonstrated any substantial alterations as part of comprehensive antimicrobial stewardship.

Fast forward to today’s reality, considerable strides have been made in showing the value of extensive penicillin allergy assessment and skin testing. Back in 2014, our facility introduced penicillin skin testing (PST) in our broader antimicrobial stewardship framework. This approach led to a decline in the use of broad-spectrum antimicrobials, especially carbapenems, and fostered a direct antimicrobial cost saving of between $314 and $353 per patient.

In a bid to determine candidate patients for PST, a comprehensive evaluation is conducted during detailed patient interviews. The patients are then stratified into low, medium, or high-risk categories, which in turn informs the appropriate intervention, be it rechallenge, graded challenge, PST, or desensitization.

As PST can be quite time-consuming, we recommend an approach that ensures maximum returns by identifying the best candidates for testing. In our experience, approximately 70% of skin-tested patients have immediate changes to their antimicrobial regimen, with most of them starting β-lactam.

As far as implementing PST is concerned, there are barriers such as determining the right model for an individual institution and having a guiding individual or team to oversee the implementation. Training personnel is another hurdle towards PST implementation. To overcome such challenges, institutions may consider leveraging the services of PST program implementation specialists or rely on free online resources offering evidence-based strategies for delabeling penicillin allergies.

Ultimately, the delabeling of patients identified as having a false penicillin allergy is not only essential for immediate therapy changes but also for prevention of future erroneous labels. The crux of this process is to ensure that the penicillin allergy records of such individuals are duly updated to encourage long-term β-lactam prescribing when readmissions occur, which calls for robust patient education and record-keeping.

In conclusion, based on the available resources, we can safely postulate that PST can be adopted as a key antimicrobial stewardship initiative across hospitals and health facilities. This is especially useful for safe administration of β-lactams as first-line medication for patients with moderate to severe penicillin allergies.


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