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Q&A: Implementing pharmacist-administered penicillin allergy skin testing
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Last year, experts suggested in an article published in Clinical Infectious Diseases that pharmacists should have a bigger role in penicillin allergy skin testing. The authors said it would expand access to the service and be good for antimicrobial stewardship efforts.
In a new paper, Christopher M. Bland, PharmD, FCCP, FIDSA, BCPS, clinical associate professor at the University of Georgia College of Pharmacy and clinical pharmacy specialist in the St. Joseph’s/Candler Health System, and colleagues outlined how institutions can implement penicillin allergy skin testing.
Bland and colleagues noted that less than 10% of patients labeled to have a penicillin allergy are confirmed to have the allergy upon skin testing.
“This labeling results in use of alternative antibiotics and thus unwanted adverse consequences including potentiated antimicrobial resistance, increased costs, and worse
clinical outcomes,” they wrote in the American Journal of Health-System Pharmacy.
Infectious Disease News spoke with Bland about the guide and the pharmacist’s role in penicillin allergy skin testing. – by Marley Ghizzone
Why should pharmacists have a role in penicillin allergy skin testing?
There are a number of reasons why pharmacists should play a vital role in penicillin allergy skin testing. Pharmacists are well trained in the area of drug allergy management, including penicillin allergies. Pharmacists at the point of medication order entry or verification can perform allergy or medication histories to determine if the specific patient is a good candidate for skin testing. Pharmacists also are leaders in antimicrobial stewardship and have a significant interest in getting the best antimicrobial agent for each patient’s infectious disease. Therefore, the process of delabeling penicillin allergies through either clarification with medication/allergy history or performing skin testing allows for long-term benefit for that patient. As our paper discusses, there are a number of successful models published in the literature using pharmacists alone or in conjunction with other members of the health care team including allergists, when available.
What does the guide cover?
This guide was written in response to the vast number of inquiries a number of our co-authors have received regarding penicillin skin testing. In Savannah, Georgia, alone, we have had more than 50 inquiries regarding logistics of penicillin skin testing since our initial publication in February 2017. Many hospitals and health systems are convinced of the value and want to perform penicillin allergy assessment and skin testing but were really unsure where to start. Therefore, I recruited the penicillin allergy pharmacist experts nationally to write a “How To” paper to help institutions with penicillin allergy assessment and skin testing no matter where they are in the process.
Who can and cannot be tested?
It is important to stress that a number of patients’ self-reported penicillin allergy can be evaluated and reconciled, even if skin testing procedures are not available. A number of these allergies are found to be false with good medication and allergy history questioning, and these patients can safely be given a penicillin and do not require skin testing. If a patient is deemed low-risk with a history that is unlikely to be IgE mediated, an oral amoxicillin challenge would be appropriate and again skin testing would not be required. Penicillin allergy skin testing is indicated for patients with what is deemed an IgE-mediated reaction, such as urticaria or anaphylaxis. Depending on the setting (inpatient or outpatient), care should be taken to ensure medications are available in case of a positive reaction to a skin test (very rare).
What training is required for pharmacists?
The company who manufacturers the commercial product (PRE-PEN; ALK Abelló) provides onsite training for those pharmacists (or other health care providers) wishing to perform skin testing. There are also examples of allergists training pharmacists in penicillin skin testing to expand this service. Additionally, in January 2019, a comprehensive penicillin allergy assessment and skin testing (PAAST) certificate was launched by the University of South Carolina. This is an accredited 15-hour continuing education program that combines interactive and in-depth home study with live programming offered at host sites nationally to train patients in PAAST.
What barriers or challenges stand in the way of penicillin allergy skin testing?
The primary barriers are similar to that of many other initiatives — time and resources. Most pharmacists are interested in allergy assessment and skin testing and also have a number of other stewardship activities “competing” for their time. Additionally, if there are no residents, fellows or allergists on site, this may limit implementation. However, our paper details a number of successful models with limited resources. An additional challenge is in relationship to pharmacy state boards and whether pharmacists within an individual state are allowed to perform skin testing within their scope of practice. Our senior author, Geoffrey C. Wall, PharmD, FCCP, BCPS, from Drake University, contacted all 50 state boards of pharmacy, and those results are contained within the manuscript. Although cost may be perceived as an obstacle, there are a number of recent abstracts and papers documenting the cost-effectiveness of penicillin skin testing.
Reference:
Bland CM, et al. Am J Health Syst Pharm. 2019;doi:10.1093/ajhp/zxy043.
Disclosures: Bland reports receiving grant funding from ALK Abelló. Please see the article for all other authors’ relevant financial disclosures.