Program streamlines penicillin allergy testing referrals for pregnant women
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LOUISVILLE, Ky. — A direct referral pathway streamlined the de-labeling of penicillin allergies among pregnant patients, according to a poster presented at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.
“In pregnant women, the most common drug allergy reported is penicillin allergy,” Malina Patel, MD, a third-year resident in the division of internal medicine at Rush Medical College, told Healio.
This becomes very important during the third trimester, when these women are tested for group B streptococcus (GBS), Patel said, adding that penicillin is the preferred antibiotic when these tests come back positive.
“A lot of times if patients have this allergy listed, physicians will avoid any penicillin, and with that come complications like C section infections, higher rates of postpartum endometriosis, and then maybe the newborn having to stay in the NICU,” Patel said.
Considering these complications, Rush University Medical Center developed a referral system where any time that patients with a penicillin allergy listed on their chart has a prenatal visit with the OB/GYN department, they automatically get a referral to see the division of allergy and immunology.
So far, the allergy clinic has seen 41 pregnant women and tested 24 of them for penicillin allergy. Two of these women had positive skin tests. Three had positive amoxicillin oral challenges, including one with delayed rash, one with burning in the throat and one with numbness in the throat and tongue. The other 19 (76%) were de-labeled.
Among the 17 who have not been tested yet, four refrained from testing because of provider preference or because they had experienced an IgE reaction within the previous 5 years.
“So, we wouldn’t want to test them at that time,” Patel said.
Also, three declined a test due to their own preference, and the other 10 still need to return to the clinic for testing.
To date, 14 of these patients have delivered their babies, including eight who were de-labeled. Three of those who were de-labeled also had tested positive for GBS and were then able to receive prophylaxis with a penicillin antibiotic.
Patel noted the program’s success in successfully de-labeling most of its patients, although she added that further data are needed to assess safety outcomes, the use of alternative antibiotics, complications and the need for IV antibiotics in the newborn, in addition to other information.
“Overall, we’re still collecting a lot of data,” Patel said.
Patel also would like to examine when patients were tested in terms of trimester, as well as how many referrals were made compared with how many patients visited the allergy clinic.
“If a hundred were referred, did only 50 come to the clinic?” she asked, adding that she would like to work with her colleagues in OB/GYN to get these patients into the allergy clinic sooner for testing.
Already, Patel said, American College of Obstetricians and Gynecologists guidelines say that penicillin allergy testing is safe for pregnant women in any trimester.
“It is very important for OB/GYN physicians to know that if they see a penicillin allergy, the sooner they get them into our clinic, the faster we could maybe de-label them,” Patel said.
“A lot of times, they would wait until the third trimester to send a referral. By then, by the time they get an appointment and get tested, it could even be beyond the pregnancy. So sooner is better,” she continued.
OB/GYN physicians may even be able to de-label some very low-risk patients themselves, Patel said, beginning with questions such as, first, asking what their initial reaction was.
“From there, questionnaires can help them determine if these patients are at a low risk vs. a high risk. If they’re a high risk, then definitely they should be coming to our clinic,” Patel said.
“Sometimes, there are patients who say, ‘Oh, actually I had amoxicillin last year for a UTI.’ Well, you’re de-labeled. You de-labeled yourself,” Patel said.
Other low-risk patients include those who had previously tolerated penicillin although it was many years before and those who may have a family history of penicillin allergy but who never experienced any reaction themselves.
“The label was put on because they say that their mom had it,” Patel said. “And I then tell them that that’s not how it works.”
OB/GYNs could conduct oral challenges for low-risk patients themselves, Patel said, but many of them do not because it is easier to refer these patients to the allergy clinic.
In the meanwhile, Patel encourages other practices to establish similar referral programs.
“Right now, it’s just an abstract. But it would be great to look into formally making a questionnaire that they could implement in their practice to determine low risk vs. high risk with a few quick questions that patients could complete on the clipboard as they’re signing in,” Patel said. “And that could help make this faster.”
Meanwhile, the Rush program will continue to refer patients from OB/GYN to the allergy clinic.
“Implementing this referral pathway has just made it a lot easier, especially when the OB/GYN attendings are aware that they should be sending us these patients,” Patel said.
Much of the success of the program comes from the collaboration and good relationship between the departments, according to Patel.
“In the year since we’ve started this study, we’ve been seeing a lot more pregnant patients in our clinic than ever before,” Patel continued. “But it’s been great. It’s been a very fulfilling study so far.”
For more information:
Malina Patel, MD, can be reached at malinapatel@yahoo.com.