Disconnects persist between patients, providers after penicillin allergy de-labeling

Almost one-third of patients who had their penicillin allergies de-labeled might decline penicillin prescriptions or remained unsure about their allergy status, according to a study published in Annals of Allergy, Asthma & Immunology.

Incomplete recordkeeping and communication gaps after de-labeling also inhibit appropriate penicillin use, Trisha Pinto, MD, of the department of clinical immunology and allergy, Royal North Shore Hospital Sydney, Australia, and colleagues wrote.

The study design, results

The single-arm interventional study began with 96 inpatients and outpatients who received direct provocation testing (DPT) to a penicillin after specific referral for penicillin allergy de-labeling between Jan. 1, 2017, and Dec. 31, 2019.

The researchers successfully de-labeled 86 of these patients, with eight experiencing gastrointestinal upset and two experiencing a delayed benign rash during the 3-day course of amoxicillin.

After completing this course, 94.12% of the patients whose penicillin allergies were listed in the hospital electronic medical record had their record updated shortly afterward.

A year later, the researchers followed up with 59 patients (average age, 56 years) by telephone and asked them if they would take penicillin if prescribed, with 43 (72.9%) saying they would and eight (13.6%) saying they would not.

Also, five (8.5%) indicated they were not sure because they still did not understand their allergy status, and three (5.1%) said maybe but they would be hesitant to accept a penicillin antibiotic and would prefer an alternative.

The researchers also contacted 27 of the 86 patients’ primary care providers and found that 17 of them (63%) had not received any correspondence about the successful allergy de-labeling and/or had not delisted the allergy in their own EMRs. However, seven (26%) did prescribe penicillin to their patients after they had been de-labeled.

Further, 28 of the contacted patients (47%) had received a penicillin-based antibiotic at some point between the de-labeling and the follow-up, based on provider records and patient interviews.

There were no correlations between penicillin-based use after allergy testing and self-reported penicillin hesitancy or nonacceptance, nor with the accuracy of the PCP’s EMRs.

Additionally, the researchers did not find any significant difference between outpatients or inpatients who had been de-labeled in their long-term acceptance of penicillin antibiotics or between the groups in the accuracy of their EMRs at the community level.

The researchers also found significantly higher odds for receiving penicillin-based antibiotics among the outpatients after de-labeling than among the inpatients (OR = 3.33; P = .04).

Recommendations for improvement

The significant discordances between the new allergy label statuses and the PCPs’ medical records were the main findings of the study, the researchers wrote, adding that Australia’s Medicare system would not limit patients who would want to have their allergies de-labeled.

Instead, the researchers pointed to the lack of compatibility and synchronization in EMRs between hospitals or local health districts and PCPs.

For example, more than 70% of PCPs use an EMR, but they often are specific to those practices and are not integrated with those of local hospitals, according to the researchers.

Improvements could involve telephone follow-up with patients and PCPs alike along with clear and very specific clinical notes about allergy histories and de-labeling outcomes, including patient preference, contraindications and adverse drug reactions, the researchers suggested.

Allied health care providers such as pharmacists could provide interfaces to check penicillin allergy label statuses as well, the researchers continued, and recommend alternative first-line penicillin-based antibiotics for successfully de-labeled patients.

Additional recommendations included the use of uniform eye-catching documents or medical passport smartphone applications to indicate successful penicillin allergy de-labeling as well as contemporaneous updating of hospital EMRs by allergy departments after phone follow-up with patients undergoing de-labeling.

The benefits of these measures could be determined by a prospective, multicenter study of these interventions, the researchers concluded.