Program de-labels penicillin allergies among patients with hematologic malignancies
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Key takeaways:
- 74% of patients had their penicillin allergy label removed.
- 82% of those who had their labels removed later received and tolerated beta-lactam antibiotics.
- 94% of providers said the program was very valuable.
Patients with hematologic malignancies and penicillin or amoxicillin allergies passed challenges to these labels and received beta-lactam antibiotics, according to a study published in Antimicrobial Stewardship & Healthcare Epidemiology.
Providers said that these challenges were valuable as well, Vima M. Patel, MD, allergist and immunologist, section of allergy and immunology, division of pulmonary allergy and critical care, University of Pennsylvania Perelman School of Medicine, and colleagues wrote.
The penicillin allergy testing service (PATS) comprised an allergist and a nurse practitioner who screened hospitalized patients with hematologic malignancies for penicillin or amoxicillin allergy labels via the electronic health record.
After identifying patients who were eligible for testing, the PATS consulted with their primary hospital teams to obtain permission to proceed and then surveyed these patients to characterize their allergy history.
An allergist performed standardized penicillin skin testing (PST) for patients with IgE-mediated or unknown reactions as soon as testing could be coordinated. Patients with negative PST results then had incremental aminopenicillin challenges.
When skin tests were negative and patients tolerated the challenge, the researchers documented the results and removed the allergy label from the EHR after discussion with the care team and the patient.
Between November 2020 and April 2021, 23 patients (median age, 61; 52.2% male; 73.9% white) participated in the program. Twenty (87%) of these patients were actively receiving chemotherapy for hematologic malignancies.
Specifically, 11 (48%) of these patients reported a penicillin allergy, and three (13%) reported an amoxicillin allergy. Nine (39%) patients were not certain about the specific class of penicillin they were allergic to.
Patient descriptions of allergic reactions included rash (n = 13), hives (n = 7), facial swelling (n = 1), shortness of breath (n = 1), anaphylaxis (n = 1), chest pain (n = 1), fatigue (n = 1) and unknown (n = 2).
Once the PATS obtained relevant patient histories, 17 (74%) were eligible for PST. Five of the remaining patients did not meet the criteria for testing, and the allergy label was removed for one patient based on clinical history alone.
All 17 patients who were tested had negative PST, and 16 of them had and passed an incremental aminopenicillin oral challenge. The remaining patient declined the challenge despite the negative PST. All 16 patients who passed the incremental challenge agreed to have their penicillin allergies de-labeled.
During the next 3 months, 14 of the 17 tested and de-labeled patients received beta-lactam antibiotics, including penicillins for three patients and cephalosporins for 11 patients.
Indications included neutropenic fever, sepsis, cellulitis, joint infection, dental prophylaxis, urinary tract infection and pneumonia, with these medications considered first-line choices in all cases.
The patient with the negative PST who declined the challenge used cefepime later. None of the patients who used beta-lactam antibiotics had any allergic reactions.
When hematology-oncology physicians, advanced practice providers, nurses and pharmacists were surveyed, 12 of 17 (71%) said they had a “very good” understanding of the purpose of the study. Also, they rated communication between the PATS and the clinical team as “very clear” (10 of 17; 59%) or “moderately clear” (7 of 17, 41%).
Providers additionally said the clinical team was “completely” (10 of 17; 59%) or “moderately” (7 of 17; 41%) receptive to penicillin testing for patients and “completely” (15 of 17; 88%) or “moderately” (two of 17; 12%) receptive to removing labels based on negative testing.
However, nine of 22 providers (41%) said participation in testing would interfere with their patient’s wellness, with two (9%) saying their patient was too sick for testing and seven (32%) concerned that testing might conflict with other treatments.
Three of 13 providers (23%) said some patients initially were reluctant to remove allergy labeling because they feared they may still be allergic despite the negative tests.
One patient (8%) did not trust the de-labeling process, and another patient (8%) waited to decide about de-labeling until after talking with their primary physician or oncologist.
Finally, 17 of 18 providers (94%) said PATS was very valuable for patients, and 15 (83%) said a dedicated team routinely performing penicillin allergy evaluations among hospitalized patients would be very valuable.
Noting that penicillin allergies have been associated with poorer outcomes among patients with hematologic malignancies, the researchers said these patients are particularly likely to benefit from routine verification and de-labeling of penicillin allergies as appropriate.
Also, they continued, the high rates of beta-lactam use among these patients after their de-labeling demonstrates how often these patients may need antibiotic care.
Still, the researchers said, the reluctance among some patients and providers to participate in de-labeling even after negative testing indicates opportunities for further study to better understand barriers and facilitators in allergy de-labeling.
Perspective
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The most surprising thing about these findings is how few patients were actually able to participate compared with the patients approached. This speaks to the complicated physical and emotional toll of cancer diagnoses and treatment. The penicillin allergy evaluations must seem like “one more thing” to overwhelmed and often quite ill patients.
These results also are in line with a previous study of patients with malignancies, where the ratio of patients approached vs. those who consent to evaluation was high.
De-labeling programs absolutely would benefit patients with hematologic malignancies because these patients are at high risk for severe infections and at high risk for death from infections. This is an area where penicillin allergy evaluations should become more accepted.
For allergy/immunology physicians, this is an important group to target. For hematology/oncology physicians, normalizing penicillin allergy evaluations as part of standard cancer therapy should be the goal. The two specialties have an excellent opportunity to work together to improve patient care. There are great examples of this already for reactions to chemotherapy.
Larger studies in hematology/oncology patients, and also larger studies looking at direct challenges in hematology/oncology patients, would be very helpful.
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