E-consults could make penicillin allergy delabeling more accessible for pregnant patients

Key takeaways:

• Five patients were delabeled through electronic consult history alone.
• All patients who were GBS positive and had been delabeled were able to receive penicillin during delivery.

Electronic consults with allergists helped pregnant women with reported penicillin allergy be evaluated and delabeled before delivery, according to a poster presented at the American Academy of Allergy, Asthma & Immunology Annual Meeting.

Nonie Arora, MD, MBA, an allergy/immunology fellow at University of North Carolina, said the study was a follow-up to a previous study conducted by her colleague and mentor, Mildred Kwan, MD, PhD, FAAAAI, associate professor of medicine in the division of rheumatology, allergy and immunology at University of North Carolina.

“Dr. Kwan’s previous work demonstrated that our clinic was successfully able to remove inaccurate penicillin allergy labels in pregnant women,” Arora told Healio. “She wanted to expedite these evaluations [through e-consults] and partner with the obstetrics department to try to delabel women well before delivery.”

Arora said she joined Kwan’s study due to her interest in drug allergy and women’s health, a topic she learned about during her internal medicine residency at University of Michigan. Arora was surprised to learn that fewer than 10% of people labeled with penicillin allergies are truly allergic.

“I am particularly interested in delabeling penicillin allergies during pregnancy because many women need antibiotics at the time of labor due to colonization with group B streptococcus (GBS) bacteria,” Arora said. “Penicillin is the best treatment for this, so it is a great time to delabel patients.”

As Healio previously reported, infants born to women with penicillin allergies and GBS had a higher risk for extended hospital stay and readmission within a week of birth.

E-consults for allergy delabeling

Arora and her colleagues evaluated the efficacy of using e-consults to assess penicillin allergy among pregnant patients.

Midwives and obstetricians requested e-consults for their pregnant patients who reported a penicillin allergy, and an allergist would review the patient’s history and identify their allergy risk. Those considered at risk for a true penicillin allergy were referred to an in-person visit at the allergy clinic, whereas those deemed nonallergic or intolerant would be delabeled based on chart review alone, and those deemed severe risk would have their label maintained.

Out of 59 patients who were evaluated for reported penicillin allergy, 38 (64%) were delabeled. Five were delabeled during the e-consult based on their history, two patients were delabeled in clinic based on their history, 20 via direct oral challenge and 11 via skin test and oral challenge.

Out of 45 patients who attended a clinic visit if necessary, 38 (84%) were delabeled.

“Only one patient in our study who underwent an oral challenge to penicillin was labeled as allergic,” Arora said.

Fourteen patients (22%) did not attend a clinic visit, a problem Arora and her colleagues are trying to solve next.

“The most challenging piece, which we are working on, is figuring out how to reduce the barriers to access care for the women who were referred to see us but not able to visit the clinic,” Arora said.

At the time the poster was presented, 39 patients had delivered. Fourteen (36%) were GBS positive at delivery, and 10 had been delabeled and were able to receive penicillin during delivery.

Next steps

Arora is hoping this research will make penicillin delabeling more accessible for pregnant women before delivery so they can receive appropriate antibiotics if needed.

“Allergists should strongly consider whether they can incorporate delabeling pregnant women into their practice,” Arora said. “In particular, finding ways to connect with local obstetrics practices can help pregnant patients find an allergist in time to be delabeled before delivery. Allergists should also consider partnering with primary care and other specialties for which beta-lactam antibiotic use is important, such as infectious disease and oncology.”

For more information:

Nonie Arora, MD, MBA, can be reached at nonie.arora@unc.edu.