Survey reveals PCPs’ gaps in knowledge surrounding penicillin allergy

Most primary care providers understood that many patients with penicillin allergy labels are not truly allergic, and they recognized when an immediate reaction to penicillin should preclude its further use, according to survey results.

However, these results, published as a letter to the editor in Pediatric Allergy and Immunology, also showed that many PCPs and pediatricians did not recognize severe delayed cutaneous reactions such as Stevens-Johnson syndrome as a precluding factor for penicillin treatment.

“Our findings highlight the importance of providing better medical education or better tools that will help [PCPs] to make the right clinical decision regarding the natural history of penicillin allergy, appropriate management of delayed drug reactions, and proper documentation of true allergic reactions to avoid unnecessary labeling of penicillin allergy,” Yoram Faitelson, MD, MSc, senior physician at The Barbara and David Kipper Institute of Allergy and Immunology of Schneider Children’s Medical Center of Israel in Tel Aviv, and Avraham Beigelman, MD, associate professor of pediatrics in the division of allergy, immunology, and pulmonary medicine and clinical director of the Food Allergy Program at Washington University school of Medicine in St. Louis, wrote in the letter.

Because PCPs are the main medical providers for many patients with allergies, Faitelson and Beigelman conducted a cross-sectional study between January and March 2021 using an electronic questionnaire of 22 items related to the management of penicillin allergic reactions to better understand this group’s knowledge base. Of the 303 respondents, 169 (55%; women, 62%) were pediatricians and 134 (45%; women, 68%) were family physicians. Mean time since medical school graduation was 23 years among pediatricians and 24.4 years among family physicians, with a majority of both groups serving at community clinics (78% and 89%).

Pediatricians and family physicians reported that a comparable proportion of their patient populations had a penicillin allergy label (7.8% and 9.5%), but pediatricians estimated that fewer of these were true allergies than family physicians (1.9% vs. 3.6%; P = .001).

A significantly greater proportion of family physicians incorrectly agreed with the statement that a penicillin allergy label should be for life (80% vs. 59%; P = .001), and fewer were likely to refer patients to an allergist for an evaluation (62% vs. 80%; P = .001).

About one-third of both groups (pediatricians, 32%; family physicians, 27%) incorrectly agreed that oral amoxicillin commonly causes anaphylactic reactions or death, suggesting they overestimated the severity of allergic reactions, according to the researchers.

When asking the providers about various medical scenarios, 11% of pediatricians and 10% of family physicians said they would prescribe penicillin for a patient with streptococcal tonsillitis despite a history of an immediate allergic reaction of anaphylaxis. Also, many pediatricians and family providers were incorrectly willing to prescribe penicillin following a severe cutaneous reaction, or Stevens-Johnson syndrome (68% vs. 52%) or drug-induced hypersensitivity syndrome (62% vs. 48%; P = .01 for both).

However, many were correct in saying they would prescribe penicillin following a history of a nonallergic reaction, diarrhea (pediatricians, 82%; family physicians, 72%; P = .027).

Overall, these results suggest that de-labeling children with a presumed penicillin allergy should be done as soon as possible, because the family physicians surveyed here seemed less likely to refer patients to allergists.