From the Journals

Skin testing and decision support can clarify penicillin allergy



Penicillin allergy skin testing or a computerized guideline app with decision support can increase the use of penicillin or cephalosporin among inpatients reporting penicillin allergy.

“Despite a reported penicillin allergy, more than 95% of patients evaluated for such allergy are found penicillin and cephalosporin tolerant,” wrote Kimberly G. Blumenthal, MD, of Massachusetts General Hospital, Boston, and her coauthors.

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While guidelines support active attention to clarifying penicillin allergies, the researchers noted a lack of evidence on the optimal approach to evaluating and managing inpatient penicillin allergy (J Allergy Clin Immunol. 2017 Feb 27. doi: 10.1016/j.jaci.2017.02.005).

In this study, they recruited 625 patients reporting penicillin allergy and explored three approaches over three periods of time. These were standard of care, in which penicillin skin testing and test dose challenge is performed only after allergy/immunology consultation; penicillin skin testing performed in all patients not otherwise ineligible for skin testing; and a computerized guideline available on any computer or mobile device within the hospital.

Researchers saw a significant 80% increase in the odds of penicillin or cephalosporin use overall during the period in which the computerized guidelines were available (P = .02).

“The guideline empowered inpatient providers to group allergic reactions into hypersensitivity type, then recommended if and how specific beta-lactam antibiotics [should] be used (i.e. very low risk: full doses; low risk: test doses; medium to high risk: Allergy/Immunology consultation; serious type II-IV hypersensitivity reactions: avoidance),” the authors wrote.

While patients during the skin testing period did not have a significantly increased odds of receiving the antibiotics overall, the adjusted per-protocol analysis showed a nearly sixfold higher odds of receiving penicillin or cephalosporin (odds ratio, 5.7; P less than .001).

Among the 278 patients present during the skin-testing period, 179 (64%) were eligible for skin testing, in that they did not have penicillin intolerances such as gastrointestinal upset, were not taking medications that interfered with skin testing, didn’t have multiple beta-lactam allergies, had not experienced penicillin anaphylaxis in the last 5 years, or had a type II-IV hypersensitivity reaction to penicillin. Of these, 43 (24%) were tested, none of whom were allergic.

The per-protocol analysis of skin testing also showed a 2.5-fold increase in the odds of discharge use of penicillin or cephalosporin (P = .04).

“Since the impact of overreporting penicillin allergy is felt beyond antibiotic utilization to resultant readmissions, treatment failures, and adverse events, safely increasing the use of penicillin and cephalosporin antibiotics in this patient population is a crucial first step towards improved quality of care and reduced cost,” the authors wrote.

The study was supported by the Brigham Care Redesign Incubator and Start-Up Program. No conflicts of interest were declared.

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