Overdiagnosis of Penicillin Allergy Can Lead To Unintended Side Effects

MedicalResearch.com Interview with:

ESS= Erica S. Shenoy, MD, PhD Harvard Medical School

Dr. Shenoy

ESS= Erica S. Shenoy, MD, PhD
Harvard Medical School
Division of Infectious Diseases, Department of Medicine
Massachusetts General Hospital, Boston

Kimberly G. Blumenthal MD, MSc Division of Rheumatology, Allergy and Immunology Department of Medicine, Massachusetts General Hospital, Boston

Dr. Blumenthal

KGB= Kimberly G. Blumenthal MD, MSc
Division of Rheumatology, Allergy and Immunology
Department of Medicine, Massachusetts General Hospital,Boston

 

EMM= Eric M. Macy MD, MS Department of Allergy Southern California Permanente Medical Group San Diego Medical Center

Dr. Macy

EMM= Eric M. Macy MD, MS
Department of Allergy
Southern California Permanente Medical Group
San Diego Medical Center

TR= Theresa Rowe, DO, MS General Internal Medicine and Geriatrics Feinberg School of Medicine Northwestern University, Chicago, Illinois

Dr. Rowe

TR= Theresa Rowe, DO, MS
General Internal Medicine and Geriatrics
Feinberg School of Medicine
Northwestern University, Chicago, Illinois

MedicalResearch.com: What is the background for this review?

ESS: A key component of reducing antimicrobial resistance is improving how antimicrobials are prescribed—both reducing inappropriate use (i.e., not prescribing when not needed) and favoring the use of narrow-spectrum agents that are less likely to contribute to the development of antimicrobial resistance.

KGB: Because unverified penicillin allergy labels are so prevalent with greater than 32 million Americans affected, and these labels lead to the use of alternative antibiotics that are often more broad-spectrum, we now know that penicillin allergy evaluations are an emerging important component of antibiotic stewardship.  When patients with a reported penicillin allergy are tested, more than 95% of them are not allergic, and thus could (and should) receive penicillins, and often related drugs, when appropriate.

MedicalResearch.com: What are the main findings?

TR: Penicillin or other β-Lactam antibiotics are treatment of choice for several common infections. An incorrectly labeled penicillin allergy often leads to use of alternative antibiotics, which are associated with a variety of negative consequences including treatment failures, adverse reactions, and antimicrobial resistance.

EMM:  Penicillin allergy can be safely evaluated using skin testing first in individuals with higher risk histories and by a direct oral amoxicillin challenge and one hour of observation in individuals with lower risk histories. Testing for penicillin allergy improves patient care and lowers the risk to the patient from future antibiotic use. 

MedicalResearch.com: How can the liability issues surrounding the use of penicillin in a patient with an unreliable history of penicillin allergy be managed?

EMM:  The formal penicillin allergy testing protocols we recommend, with observation of the patient during the oral challenge portion, makes this a very safe procedure. Not testing for penicillin allergy can cause more risk for harm because alternative antibiotics can have higher rates of serious adverse reactions including Clostridioides difficile bowel infections.

MedicalResearch.com: What should readers take away from your report?

 KGB: We want to encourage all providers to think about how penicillin allergies might unnecessarily interfere with their optimal treatment and contribute to antibiotic resistance.  We have accumulating evidence that a penicillin allergy is not benign, and we have methods to safety evaluate penicillin allergies.  Our aim was to inform clinicians about why penicillin allergy evaluations are important and to simplify the approach to penicillin allergy evaluations.

ESS: With over 32 million Americans with a reported penicillin allergy, another takeaway from this paper is that evaluation of penicillin allergy is not just within the purview of specialists such as allergists such as Dr. Blumenthal or Dr. Macy, or infectious diseases physicians such as myself or Dr. Rowe. We want to encourage clinicians of various specialties and role groups to understand how important it is to assess patients. and provide them with the tools to do this safely.

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

 KGB: Future research needs to identify the best methods for implementing penicillin allergy evaluations in different populations, identify which methods are most effective, and which are best received by patients. We also need to identify the best methods to communicate changes in allergy status.  Unfortunately, after disproving penicillin allergy in some patients, the penicillin allergy label sometimes returns.

MedicalResearch.com: Is there anything else you would like to add?

KGB: We want to raise awareness about the harms of a penicillin allergy label that may not be true, and encourage individuals reading this who either have a penicillin allergy on their records or have a family member with one listed to ask their doctor whether or not the allergy should be evaluated further.  As an allergist who specializes in the treatment of patients with drug allergies, I am often asked to evaluate patients for penicillin allergy when they are sick with an infection and need a penicillin or relative immediately.  While these acute evaluations can be done, in my opinion, it is best to evaluate penicillin allergies when patients are well and don’t acutely need an antibiotic.

Any disclosures?

Dr. Blumenthal has a research grant from the AAAAI foundation.  Drs. Blumenthal and Shenoy have a copyright to a clinical decision support tool used internally at Partners Healthcare. Dr Macy has received research grants from ALK Abello, Inc. to study adverse drug reactions and has served on clinical trial safety and monitoring committees for BioMarin, Ultragenyx, and Audentes. Dr Macy reported grants from ALK during the conduct of the study. Dr. Rowe has no disclosures to report.

Citation:

Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019;321(2):188–199. doi:10.1001/jama.2018.19283

Jan 18, 2019 @ 1:54 am

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