Strategies to identify and prevent penicillin allergy mislabeling and appropriately de-label patients
Taking a good drug allergy history is critical, followed by removing the “penicillin-allergic” label in certain low-risk patients and referring for testing those at high risk.
PRACTICE RECOMMENDATIONS
› Obtain an accurate drug allergy history from all patients who have a listed penicillin allergy. B
› De-label penicillin allergy in patients who report symptoms of an adverse reaction (diarrhea, headache, or nausea) but who (1) do not have other systemic symptoms; (2) do have a family history, but no personal history, of a reaction; or (3) have tolerated the same penicillin derivative since the initial reaction. B
› Refer patients whose reaction history includes hives, shortness of breath, or other allergic-type signs and symptoms for potential skin testing or oral challenge, or both. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Consequences of mislabeling
Clinical consequences. A multitude of clinical consequences result from carrying a “penicillin allergy” label.
Use of broad-spectrum antibiotics leads to increased risk of Clostridium difficile infection and to development of resistant bacteria, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus.2,15
Alternative antibiotics used in the setting of a “penicillin allergy” label might be less efficacious and result in suboptimal outcomes. For example, vancomycin is less effective against methicillin-sensitive S aureus bacteremia than nafcillin or cefazolin.2,21 Beta-lactam antibiotics—in particular, cefazolin—are often first-line for perioperative prophylaxis; patients with reported penicillin allergy often receive a less-optimal alternative, such as clindamycin, vancomycin, or gentamicin.22 These patients are at increased risk of surgical site infection.2,22
In addition, using penicillin alternatives can result in greater risk of drug reactions and adverse effects.2
Increased health care costs. Primarily through observational studies, penicillin allergy has been associated with higher health care costs.23 Patients with reported penicillin allergy had, on average, a longer inpatient stay than patients without penicillin allergy, at a 3-year total estimated additional cost of $64.6 million.24 Inpatients with a listed penicillin allergy had direct drug costs ranging from “no difference” to $609 per patient more than patients without a listed penicillin allergy. Outpatient prescription costs were $14 to $193 higher per patient for patients with a listed penicillin allergy.23
Continue to: Considerations in special populations
