Delabeling for Penicillin Allergy Found Safe in Children

Troy Brown, RN

April 20, 2018

Children with low-risk penicillin allergy symptoms who subsequently tested negative for penicillin allergy and had the allergy labeling removed from their medical records tolerated penicillin without serious adverse or allergic reactions during the following year, a study found.

Still, one fifth of families voiced at least some discomfort with giving their child penicillin, and 84% of primary care providers (PCPs) said parents had not informed them of their child's negative penicillin allergy test result.

David Vyles, DO, MS, from the Section of Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, and colleagues report their findings online April 20 in Pediatrics.

Having a diagnosis of penicillin allergy is associated with negative effects, including higher health risks and prescription costs, the authors write. A previous study "found that patients with a reported penicillin allergy history 'spend significantly more time in the hospital, are exposed to significantly more antibiotics associated with Clostridium difficile and Vancomycin-Resistant Enterococci and are associated with increased hospital use,' " the researchers explain.

In a previous study,  Vyles and colleagues administered a three-step "gold standard" penicillin allergy test to 100 children with low-risk penicillin allergy symptoms, such as skin manifestations (with or without itching), gastrointestinal symptoms (including vomiting or diarrhea), and certain upper respiratory symptoms (including runny nose or cough). Although three children experienced a positive skin prick test result, all 100 successfully completed an oral challenge test, and the penicillin allergy label was removed from their medical records.

In the current follow-up study, Vyles and colleagues called the children's parent or legal guardian approximately 1 year after testing to determine whether the child had received any antibiotics since the testing and, if so, whether they had experienced any antibiotic-related adverse events. The parent completed a short 2-minute telephone survey, which also included questions about whether they had informed the child's PCP about the negative allergy test result and their level of comfort related to giving their child antibiotics.

The researchers also contacted the children's PCPs to ask whether the medical record included a notation that the child was allergic to penicillin, whether an antibiotic had been prescribed for the child since testing, and, if so, whether the child had experienced allergy symptoms. Ninety-eight of the 100 PCPs contacted completed the follow-up questionnaire.

Almost all (90%) of the 81 parents who answered the survey said they were aware of their child's allergy testing results. Although 80% of parents said they had notified their child's PCP of the negative results, 84% of PCPs said they had not been notified by the parents that the child had been tested and received negative results.

Half (52%) of the children's medical records still indicated the child was allergic to penicillin.

About three quarters (73%) of parents responded that they would be "comfortable" or "very comfortable" having their child receive a penicillin antibiotic, whereas 24% said they would be "somewhat comfortable" and 4% said they would be "not comfortable."

Of the 22 parents who said they were "somewhat comfortable" or "not comfortable," 74% said they were afraid their child might experience a repeat allergic reaction to a penicillin antibiotic.

Almost half (n = 36) of patients had filled at least one antibiotic prescription and 10 patients had filled two antibiotic prescriptions, for a total number of 46 prescriptions. The antibiotic most frequently prescribed was amoxicillin and/or penicillin (n = 24; 52%), followed by azithromycin (n = 13; 28%), cefdinir (n = 6; 13%), amoxicillin and clavulanic acid (n = 2; 4%), and cefadroxil (n = 1; 2%).

"In this follow-up project, we found that within 1 year of being tested for allergy, 36 children from our testing population had received 26 penicillin-derivative prescriptions and 1 (4%) child developed a rash ∼24 hours after starting the medication and was relabeled as penicillin allergic. Consistent with our hypothesis, no child suffered a serious allergic reaction after re-exposure to the medication," the researchers explain.

The median (interquartile range) age of children who were given an antibiotic subsequent to allergy testing was 8 (6 - 12) years.

The researchers estimate a total cost savings of $1368.13 and a cost avoidance of $1812. They extrapolated a total potential cost savings generated by the approximately 6700 patients with reported penicillin allergy seen each year in their pediatric emergency department that could result from appropriate penicillin allergy delabeling would be $192,223.

"Delabeling of children changed prescriber behavior in the year after testing, leading to more penicillin prescriptions. This change in prescribing led to actual and potential savings that occurred after delabeling patients as penicillin allergic. Further improvements in the effectiveness of penicillin allergy testing can be realized by ensuring adequate communication of label removal to, importantly, the child's PCP but also the entire health care team," the researchers conclude.

The study was supported by the American Academy of Pediatrics Section on Emergency Medicine Ken Graff Award and a Children’s Hospital of Wisconsin Foundation Vice Innovation award. This publication used research electronic data capture and was supported by a National Institutes of Health Clinical and Translational Science Institute grant. Funding also received from the National Institutes of Health. T he authors have disclosed no relevant financial relationships.

Pediatrics. Published online April 20, 2018. Abstract

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