Ingrid Hein

November 16, 2016

SAN FRANSISCO — Providers of inpatient care who have prescribing authority have a poor understanding of when to consult an allergist about penicillin allergies, according to results from a new survey.

Despite acknowledging the need for allergy consultation in clinical scenarios, only 20% of respondents were able to judge when a patient would need a consultation with an allergist, and 42% did not know that penicillin allergy can resolve over time.

"You can't know what you aren't taught," said lead investigator Allison Ramsey, MD, from the University of Rochester School of Medicine and Dentistry in New York.

"I don't think this is emphasized in training; a teaching gap has led to a knowledge gap," she told Medscape Medical News.

One of the problems is that there are not enough allergists to promote testing, she pointed out.

Research shows that although 10% of inpatients claim to have a penicillin allergy, only about 10% of those show an intolerance on testing, and even fewer are actually allergic, as reported by Medscape Medical News. Without testing, patients are unnecessarily given broad-spectrum second-line antibiotics.

A better understanding of penicillin-allergic patients would help improve antibiotic stewardship in hospitals, said Dr Ramsey.

"You want to save your powerful antibiotics for when they're really needed," she explained. "From a specialty perspective, this is an area where we as allergists can seize this opportunity and become an important resource."

Results from a survey of prescribers at Rochester Regional Health were presented here at the American College of Allergy, Asthma & Immunology 2016 Annual Scientific Meeting.

From February to April of this year, 276 respondents from various levels of training and specialties answered 15 questions about the penicillin-allergic patient.

The majority of respondents were advanced practice providers (45%) or attending physicians (46%). Of the other 9% who were residents, 43% specialized in internal medicine, 20% in an internal medicine subspecialty, 12% in pharmacy, 7% in ob/gyn, and 18% in surgery.

All respondents showed an overall lack of knowledge, the investigators report.

When asked what percentage of patients with a reported penicillin allergy will tolerate penicillin, only 30% of respondents knew the correct answer, which is 90%.

"If a drug is on the allergy list, most providers are just going to avoid it," Dr Ramsey said. "But we know that only about 10% actually have an allergy. They should consult us for testing to make sure. That's not happening right now."

When asked about consulting an allergist or immunologist, 80% of attending providers and advanced practitioners reported that they never do, or do so only once a year, even though, when provided two hypothetical clinical scenarios, they reported that they would.

In addition, 93.1% of subspecialty practitioners reported never or rarely consulting an allergist or immunologist, as did 88.5% of practitioners outside of internal medicine.

Of all the respondents, 42% said they believe penicillin allergy does not resolve with time, and only 20% identified appropriate patients for penicillin skin testing in clinical vignettes.

"Confirm it or Remove it"

Several studies have shown that patients with a penicillin allergy documented on their electronic health record have longer hospital stays and less success with antibiotics, which puts them at risk for adverse effects.

"More effective drugs would decrease hospital stays," Dr Ramsey said. Testing and ensuring that results on patient records are accurate would dramatically decrease the use of second-line antibiotics "because, in many cases, they are unnecessary," she added.

It is a significant health risk to carry an unconfirmed penicillin allergy.

"It is a significant health risk to carry an unconfirmed penicillin allergy," said Eric Macy, MD, from the Department of Allergy at the San Diego Medical Center and the Southern California Permanente Medical Group.

"We need to get doctors and immunologists to address this issue," he said, because "they're not reacting. They're going to do what has always been done: when someone has an allergy to something, avoid it."

More and more hospitals are implementing an antibiotic stewardship program, as recommended by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (Clin Infect Dis. 2016;62:e51-e77), he reported.

Confirming or removing a penicillin allergy not only affects the patient's health, it also saves the healthcare system money, explained Dr Macy.

He cited a study in which he and his colleague matched 51,582 hospitalized patients with a documented penicillin allergy with a control group (J Allergy Clin Immunol. 2014;133:790-796). Over 3 years, patients with a penicillin allergy on their record spent 10% more time in the hospital.

"If you give patients suboptimal antibiotics, you're going to get more infections," he explained. The researchers calculated that testing patients to ensure more targeted medication would have saved the hospital more than $1 million in hospital time, even when the cost of testing was included.

"If you have individuals who carry a history of penicillin allergy, confirm it or remove it," Dr Macy said. "If it's negative, get it off the chart."

American College of Allergy, Asthma & Immunology (ACAAI) 2016 Annual Scientific Meeting: Abstract O054. November 14, 2016.


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