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False penicillin allergy status could risk negative consequences
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ATLANTA — Patients who think they are allergic to penicillin — but really aren’t — could be causing potential problems for themselves and the greater population, suggesting a need to find ways to determine who is truly allergic to penicillin.
According to the American Academy of Allergy, Asthma and Immunology, approximately 10% of patients report an allergy to penicillin. However, more than 90% of these patients may not truly be allergic, but have penicillin allergy noted in their medical records.
“Penicillin allergy is associated with a number of negative outcomes such as more use of the problematic antibiotics, more resistance to C. difficle, increased medical costs and increased length hospitalizations,” Roland Solensky, MD, allergy and immunologist, The Corvallis Clinic, Corvallis, Oregon, told said in a plenary session at the annual meeting of the American Academy of Allergy, Asthma and Immunology.
To illustrate his point, Solensky referenced a retrospective study that looked at all patients hospitalized from 2010 to 2012 at Kaiser Foundation hospitals in Southern California. Researchers matched the 11.2% of participants who were labelled as allergic to penicillin by a ratio of 1 to 2 with patients not labelled as penicillin-allergic.
“A novel finding of this study was that the penicillin allergy patients vs. the controls had 30% more [vancomycin-resistant Enterococcus] infections, 23% more C. difficile, and 14% more [methicillin-resistant Staphylococcus aureus]. It was the first time that was shown,” Solensky said. “More than half the patients even had a half day longer hospital stay.”
He referenced another study that looked at the treatment of gram-negative bacilli bloodstream infections in patients with history of penicillin allergy. Primary outcome was clinical failure of those who received beta-lactams vs. those who received nonbeta-lactams. This study showed clinical failure was significantly lower in nonbeta-lactam group.
The CDC has posted information on its website to help medical professionals ascertain if a patient truly allergic It states: “Before prescribing broad-spectrum antibiotics to a patient thought to be penicillin allergic, evaluate the patient for true penicillin allergy (Ig-E mediated) by conducting a history and physical, and when appropriate, a skin test and challenge dose.”
The American Academy of Allergy, Asthma and Immunology advocates for the increased use of penicillin allergy testing “to mitigate the emergence and spread of antibiotic resistance and to ensure the continued availability of effective therapeutics for the treatment of bacterial infections.”
This consequence of false penicillin allergy is compounded by the fact that fewer antibiotics are being approved by the FDA, Solensky said. He noted that since 1987, there have been no new classes of antibiotics discovered.
“The reason this is so important for us is that we don’t have an infinite amount of antibiotics to choose from or treat. We are running out of choices,” Solensky said. “That’s a problem. We have to maintain the ones that we have.”
The previous administration took several steps to bring awareness to the possible shortage of antibiotics.
Then-president Barack Obama issued an Executive Order in 2014 that ordered “significant efforts” to, among other things, "preserve the efficacy of new and existing antibacterial drugs; advance research to develop improved methods for combating antibiotic resistance and conducting antibiotic stewardship; strengthen surveillance efforts in public health and agriculture; develop and promote the use of new, rapid diagnostic technologies; accelerate scientific research and facilitate the development of new antibacterial drugs, vaccines, diagnostics, and other novel therapeutics.”
In a blog post, then-FDA Commissioner Margaret A. Hamburg wrote: “It is a high priority for the FDA to work with our partners to find solutions for this serious public health problem,” adding that each year at least 2 million illnesses and 23,000 deaths in the United States are caused by antibiotic-resistant bacteria.
Still more can still be done, Solensky said. He was among the authors of a letter to the editor that appeared in The Journal of Allergy and Clinical Immunology approximately 18 months ago that discussed the importance of one possible solution: an-FDA approved penicillin skin allergy testing kit.
“[This kit] would be a great advance in the evaluation of penicillin allergy in the United States,” the letter stated in part. “The authors encourage the expedited approval by the FDA of a penicillin skin test that includes benzylppoenicilloyl-polylysine, penicillin G, penicilloate, penilloate, and amoxicillin … without the requirement to perform challenges in skin test positive patients.”
Solensky suggested such a device could have PPL ampule, MDM vials of many of the aforementioned antibiotics, and amoxicillin reagent vial, and saline diluent for amoxicillin and histamine.
“[The kit’s] got everything to make it as user-friendly as it can be. Hopefully that’s something we’ll have in the near future.”
In the meantime, he encouraged attendees to have as many patients as possible get penicillin skin allergy tests so the allergy label can be removed when appropriate, and said asthma and allergy specialists shouldn’t be ashamed to ask for help from other medical professionals to assist in this process.
“There are many patients we can test in an outpatient setting. I believe to do this on a large scale, we will need the involvement of non-allergists,” he said. “If you think about it, what percent of the population has a penicillin allergy label and how many allergists there are? I did the math; every allergist would have to do over 6,000 penicillin skin tests in order to address the problem. Even I’m not going to get to 6,000 — I’m probably only going to get to about 1,500. You need to involve others individuals, such as pharmacists, [infectious disease] physicians, etc.” – by Janel Miller
Disclosure: Healio Family Medicine was unable to confirm Solensky’s disclosures prior to publication.
References:
Solensky, R. Plenary Session 3101. Presented at: American Academy of Allergy, Asthma and Immunology Annual Meeting; March 3-6, 2017; Atlanta
https://www.aaaai.org/conditions-and-treatments/library/allergy-library/penicillin-allergy-faq
https://www.cdc.gov/getsmart/week/downloads/getsmart-penicillin-factsheet.pdf
https://www.aaaai.org/about-aaaai/advocacy/penicillin-allergy-testing