Penicillin allergy testing enables operational readiness in forward deployments

SAN ANTONIO — A proof-of-concept study showed that de-labeling sailors with reported penicillin allergies can improve operational readiness, according to data presented at the American Academy of Allergy, Asthma & Immunology Annual Meeting.

“Direct oral challenge for penicillin allergy has increasingly become a safe, cost-effective option, especially in health care systems with limited access to allergy specialists,” W. Grant Day, LT, MC, USN, department of medicine, Naval Medical Center, said during his presentation.

The military health care system has a paucity of allergists, Day continued. Also, carriers and amphibious assault ships principally carry penicillin antibiotics, including amoxicillin, he said.

“Sailors with penicillin allergy are historically treated with often substandard antimicrobial therapy in the forward deployed setting,” Day said. “They’re even medically evacuated due to this while they’re deployed, which can lead to costly and potentially dangerous patient transfers.”

Direct oral challenges for patients at low risk for penicillin allergies have been shown to be safe in primary care settings, Day said, prompting the researchers to investigate whether this testing can be safe and effective among forward deployed sailors.

To assess risks for penicillin allergy, the researchers used the Banks score, which includes six questions:

• Did your reaction occur within the last year?
• Did your reaction involve any systemic symptoms other than rash or skin symptoms?
• Was your reaction life-threatening?
• Did your reaction involve blistering, ulceration, sloughing of your skin or lining of your mouth or genitals, or were you diagnosed with Stevens-Johnson syndrome or toxic epidermal necrolysis?
• Did your reaction involve any organ dysfunction or failure, or were you diagnosed with serum sickness, drug reaction with eosinophilia or acute interstitial nephritis?
• Have you taken and tolerated a penicillin or penicillin derivative since your reaction?

Each “yes” response was worth one point. Patients with a score of 1 or more were referred to an allergy/immunology specialist for further evaluation. Twelve sailors had Banks scores of 0, qualifying them for direct oral challenges.

Primary care physicians performed the direct oral challenges for these sailors, who were on board a landing helicopter dock or landing ship dock amphibious ship that were part of an amphibious ready group set to deploy.

“Our hope is to try to optimize their force medical readiness prior to deployment,” Day said.

The direct oral challenges consisted of a 250 mg dose of amoxicillin, followed by 60 minutes of observation. None of the 12 sailors had any adverse reactions, Day said, and they were successfully liberated of their penicillin allergy.

“The benefits of these operational penicillin allergy tests really can be divided into three spheres,” Day said, “one being access, two, quality, and three being cost.”

First, access means reduced time away from duty, de-labeling in medically austere environments and leveraged amphibious ready group/carrier strike group-wide marketing.

“A lot of these active-duty sailors cannot be taken away from work, especially if their operational tempo is very increased,” Day said.

Next, quality means reduced risk for adverse reactions, access to antibiotics and operational antibiotic stewardship. Finally, cost benefits include $2,000 saved each year per sailor whose penicillin allergy was de-labeled, reduced medevac and mission costs and, again, reduced time away from duty.

“This is really vital, especially in a military setting where cost for the taxpayer is definitely something to be considered,” Day said.

The researchers concluded that penicillin allergy testing and clearance can be safe and effective in forward deployed medical settings, although they said future expansion is needed to confirm these findings.

Also, the researchers said that eliminating penicillin allergies in an amphibious ready group is a first step in implementing testing across battalions, fleets and flights with sweeping impacts on service members’ operational readiness.

“The potential reduction in adverse events, and antibiotic stewardship, can keep warfighters on the frontline and mission capable,” Day said.