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
De-labeling requires a systems approach. Given the mismatch between the large number of patients labeled “penicillin allergic” and the few allergy specialists, referral alone is not enough to solve the problem of mislabeling. Targeting specific populations for testing, such as patients presenting to an inner-city sexually transmitted infection clinic19 or preoperative patients, as is done at the Mayo Clinic,9 has been successful. Skin testing in an inpatient setting has also been shown to be safe and effective,13 allowing for protocol-driven testing under the supervision of trained pharmacists (and others), to relieve the burden on allergy specialists.9
CORRESPONDENCE
Andrew Lutzkanin, MD, 500 University Drive, PO Box 850, Hershey, PA 17033; alutzkanin@pennstatehealth.psu.edu
