Nonspecialist health care professionals able to remove incorrect penicillin allergy labels

Cosby A. Stone Jr., MD, MPH

Basically, the authors found that it was possible to make a big impact on penicillin allergy labels in multiple settings when nonallergy health care providers were trained to evaluate them using a standardized protocol. A penicillin allergy label is basically a patient’s report of a possible penicillin allergy that has never been tested or evaluated. We have previously assumed for decades that a patient’s report of a possible penicillin allergy was automatically true, but in reality, less than 5% of them actually were true allergies. They either weren’t allergies to begin with, or people grew out of the reactions over time. The authors were also able to do these evaluations led by nonallergists in both elective and acute care settings. While that might be potentially surprising to folks who aren’t currently familiar with our hard-won ability to identify low-risk penicillin allergies by history alone, it is not surprising to those of us who are doing similar work. This is great stuff!

The more you train and educate clinicians on how to identify low-risk penicillin allergies within their clinical sphere, the more they will begin to notice how those untested allergies are interfering with optimal care when we need to use antibiotics. An untested allergy frequently keeps us from giving the right drug at the right time.

Once you are aware that testing most penicillin allergies is fairly simple and safe, it creates a pressure to intervene, and from there, starting to test and disprove low-risk penicillin allergies with a direct challenge isn't a big step. Such testing and delabeling then leads to patients being more likely to get the antibiotics that they need, when they need them. The main issue at that point is carving out the necessary space, time and ability to do the evaluations and testing.

The only thing that we have learned recently from our own efforts is that every health care system probably needs to have dedicated champions who take on the delabeling of unnecessary low-risk penicillin allergies as a priority for their institution. Given the millions of people who report untested penicillin allergies, it probably needs to be a full-time job, supported by their institution. The champion could be a pharmacist, nurse practitioner, nonallergy physician or allergist. I think anyone with enough clinical background and the right attitude can do this valuable work.

Beyond that, the advantage that these authors have is that they have set delabeling as a national priority! How wonderful. In the United States, I personally think that clarifying and appropriately managing our patients’ reports of penicillin allergy should become a key quality metric for our antibiotic stewardship efforts. If it did, I bet we would start to see rapid improvements in our antibiotic stewardship and treatment outcomes. Some institutions in the United States are currently doing this penicillin allergy testing work because it is becoming rapidly apparent that it is the right thing to do.

However, incentivizing it in some coherent national way would be more likely to accelerate us all in the right direction.

Really, the barrier to entry when testing low-risk penicillin allergies continues to get lower. There are validated instruments to identify low-risk penicillin allergies when you are talking to the patient. There are many published experiences from around the world showing that testing and delabeling low-risk penicillin allergies is safe and beneficial in almost any population you can think of, including critically ill folks. This means that there are increasing numbers of experts to learn from and safe protocols to follow. In the outpatient setting, this is a reimbursable procedure, which means your institution will be compensated for your work if you test a penicillin allergy.

In that context, testing a patient’s penicillin allergy clearly provides durable, long-lasting benefit for the patient, their treating physicians, their hospitals, the health care system, insurance companies and public health. You don’t find many opportunities in which the incentives line up that way for everyone involved to do something for a patient’s health. That’s why I love this work. All signs point toward “Go!”