Program teaches pediatric residents about penicillin allergy de-labeling
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Key takeaways:
- Nine out of 10 patients who report a penicillin allergy can tolerate penicillin and are not allergic.
- Formal curricula in de-labeling penicillin allergies are lacking in residency training.
SAN ANTONIO — A formal curriculum was used to train pediatric residents in de-labeling penicillin allergies in a primary care setting, according to data presented at the American Academy of Allergy, Asthma & Immunology Annual Meeting.
“Ten percent of the general population reports an allergy to penicillin. However, nine out of 10 of these patients will tolerate penicillin and are not allergic,” Sabine Eid, MD, a first-year allergy and immunology fellow at Children’s Hospital Colorado, said during her presentation.
Even though awareness and recognition of the importance of de-labeling erroneous penicillin allergies have increased, Eid continued, the residency program at Nationwide Children’s Hospital did not have any formal training.
“Our goal was to develop a formal curriculum to improve education of pediatric trainees to better assess and ideally de-label penicillin allergy in the primary care setting,” Eid said.
The de-labeling protocol
After discussions with a multi-disciplinary team of trainees, primary care providers and allergists/immunologists, the researchers developed a standardized protocol for identifying and de-labeling penicillin allergy in the primary care setting.
“The protocol prompts the medical providers how to proceed with evaluation and testing,” Eid said.
According to the protocol, penicillin allergy evaluations begin with a patient or family interview or chart review of previous symptoms. If the answers to any of these questions are “yes” or “not sure,” the patient should be referred to an allergy clinic and the label should remain.
Patients with “no” responses to all the questions would be eligible for an oral dose challenge in the clinic. The challenge begins by determining if the allergy is low risk and obtaining consent. The patient then receives a single weight-based dose of amoxicillin and is observed for 60 minutes.
If there is no reaction, the successful challenge is noted under the allergies tab in the electronic health record, and the label is removed. Any reactions that do occur should be managed with appropriate therapies.
Resident training
The researchers aimed to increase the number of pediatric residents who completed educational training in penicillin allergy de-labeling from a baseline of zero to four residents per month by June 2021 and sustain that total for 1 year.
“Our global goal was to increase pediatrician comfort with evaluation and management of low-risk amoxicillin allergy in the primary care setting,” Eid said.
Key drivers in reaching these goals, Eid continued, were pediatric resident education, comfort in and practice with graded dose challenges to amoxicillin in the office, and community access to guidelines and the clinical decision tool. Interventions included:
- Creating a learning module, “Approach to low-risk penicillin allergy,” through the facility’s Learning Center.
- Making learning modules easier to find by including them in regularly accessed residency forums such as a shared drive.
- Working with pediatric chief residents to attend noon reports, primary care retreats or other resident conferences to notify them about the module.
- Having rotating residents participate in graded dose challenges in the National Children’s Hospital Allergy Clinic.
- Developing guidelines for performing challenges to amoxicillin in the primary care office.
- Including a PDF at the end of the learning module as well as hard copies for those who request them.
- Encouraging residents to discuss amoxicillin challenges with primary care attendings and National Children’s Hospital Continuity and Pediatric Education in Community Sites clinics.
The researchers also measured residents’ levels of comfort with amoxicillin challenges on a scale of 1 to 5, with higher scores indicating greater comfort.
Prior to the module, four residents reported a level of 1, five residents reported a level of 2, four residents reported a level of 3, three residents reported a level of 4, and only one resident reported a level of 5.
“Afterwards, all participants selected 3 to 5 for comfort level with amoxicillin challenge,” Eid said, with three residents reporting a level of 3, six residents reporting a level of 4 and three residents reporting a level of 5.
The researchers launched training in January 2021. Within 8 months, they achieved their goal of four residents completing training per month.
“We included access to the module in the residents’ weekly email from the program in February,” Eid said. “We made the module a component of the primary care block in April and started sending bimonthly reminder emails in June.”
Multiple plan-do-study-act cycles between January and May of 2021 helped the researchers achieve their goal, Eid continued, with continued participation attributed to bimonthly email reminders sent to residents during their primary care rotation.
However, Eid said, the program did not sustain its success.
“Some limitations include resident and primary care physician awareness of the module,” Eid said, adding that there were space and time limitations as well.
Ahead, the researchers said they will work to maintain their goal of four residents per month, continue bimonthly emails to residents in the primary care block, encourage resident leadership in each clinic and expand the project to pediatric colleagues in private practice.
“We are really excited about this project,” Eid said. “I’m interested to see how it develops over the next coming years.”
Perspective
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Our awareness of the adverse effects of unnecessary penicillin allergies continues to grow, along with our ability to identify patients who are exceedingly likely to have either grown out of an allergy or never had one to begin with.
Because of all the negative ways that penicillin allergies impact a patient’s optimal care, de-labeling programs are going to be a crucial part of improving the quality of the care we deliver and of antimicrobial stewardship.
I do think this program has potential to work, and now that we have gotten better at the “why” and the “who” of de-labeling, the biggest question remains the “how.” We implemented a program like this with our pharmacy colleagues, and it has led to more than 500 penicillin allergies being removed at the point of care in our inpatient settings since then. One key that I think is important to programs like this is that the biggest successes seem to be when individuals take ownership of the issue and become champions for de-labeling.
The key features for low-risk de-labeling are to be able to teach someone how to identify a low-risk penicillin allergy, to be able to comfortably talk to a patient who has one, and to do so in a way that builds rapport and the patient’s comfort that you are giving them high-quality information and are trustworthy, prior to offering them a challenge.
I think that there are lots of folks who can potentially do this very well, including physicians, pharmacists and nurses. The program being described here focuses on pediatricians, and I think that is excellent. The earlier we intervene in unnecessary penicillin allergies, the higher the return on the investment. Patients get more years of their life with better antibiotics available.
I think teaching everyone about penicillin allergy evaluation and de-labeling increases acceptance when the subject is brought up, and it teaches learners how to contextualize what is actually risky in terms of giving a future dose.
The only suggestion that I might make for our field right now is that when the rubber hits the road and you are trying to get rid of as many unnecessary penicillin allergies as possible, it seems like most institutions will probably need trustworthy champions who own de-labeling as a key part of their job description and who are willing to be the one who hunts them down on a daily basis, even when everyone else is too busy. I have to say that it is a very satisfying job. People tend to love it when you help their patient escape from being painted into a corner of suboptimal treatment.
Perspective
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In this study, Eid and colleagues designed and implemented an online education module on penicillin allergy for pediatric residents. Pediatric residents were alerted to the availability of the penicillin allergy education module by announcements at conferences and bimonthly e-mail reminders during a primary care rotation.
Following participation in the module, researchers found that pediatric residents had an increased level of comfort with amoxicillin challenge. By 8 months after implementation of the penicillin allergy education module, the program reached the goal of participation of four residents per month. However, this level of participation was not sustained.
Penicillin allergy label is associated with increased risk of infection with drug-resistant organisms, increased risk of worse clinical outcomes during infections and increased risk of adverse drug reactions during infections. However, most patients with penicillin allergy are not truly penicillin allergic on further evaluation. Prior studies have shown that health care providers, including in primary care, have a lack of knowledge about harms associated with penicillin allergy label, the low rate of true penicillin allergy in patients with penicillin allergy label, how to evaluate penicillin allergy label and indications for referral to an allergist.
Often, training programs lack formal education on drug allergy evaluation, including for penicillin allergy. The implementation of penicillin allergy education programs, including through antibiotic stewardship programs and by algorithms for the non-allergist to evaluate penicillin allergy and guide antibiotic choices, have previously been shown to be successful in removing penicillin allergy label for patients, reducing the use of alternative and broad-spectrum antibiotics, increasing the use of penicillins and cephalosporins and reducing health care costs and utilization.
Many training programs do not have formal penicillin allergy education. In this penicillin allergy education program, researchers have designed and implemented an online module training program on penicillin allergy for pediatric residents. The creation of an online module allows for easy and convenient access with the ability to complete the module at any point in time.
Following completion of the module, Eid and colleagues found that participants were more comfortable with amoxicillin challenge.
The future steps for this program include investigation on how the sustainability of participation can be improved to establish a long-term education program. Researchers can also investigate the impact of the education program on the number of amoxicillin challenges performed in primary care and the number of patients with listed penicillin allergy who were de-labeled as a result of this program to evaluate the ultimate impact of this education program on patient care.
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Eid S, et al. Abstract 125. Presented at: AAAAI Annual Meeting; Feb. 24-27, 2023; San Antonio.
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