Penicillin Allergy Skin Testing in the Inpatient Setting

Abstract

The consequences of a documented penicillin allergy in the medical record are especially troublesome in acutely ill, hospitalized patients. A penicillin allergy label may lead to alternative or second line therapies resulting in adverse drug events, negative clinical outcomes and increased costs. Reconciling penicillin allergies is a necessity to facilitate early, optimal therapy and is a shared responsibility among the healthcare team. Penicillin skin testing (PST) has been utilized successfully in hospitalized patients to de-label erroneous penicillin allergies and optimize antibiotic therapy. This targeted review aims to discuss the practical development and implementation of PST in the inpatient setting. This includes a needs assessment checklist with common considerations allowing for customization to one's institution based on available personnel, time, and technological resources.

Keywords: allergy; antimicrobial stewardship; beta-lactam; hospitalization; penicillin; skin testing.

Figure 1

Penicillin skin testing procedure including (a) step 1 of the skin prick test and (b) step 2 as the intradermal test with associated interpretation thresholds for each.

Figure 1

Penicillin skin testing procedure including (a) step 1 of the skin prick test and (b) step 2 as the intradermal test with associated interpretation thresholds for each.

Figure 2

Penicillin allergy skin test consult order via computer physician order entry.

Figure 3

Sample portion of penicillin allergy skin test template note.

Figure 4

Process for penicillin allergy de-labeling in the electronic medical record by (a) changing the status of the current penicillin allergy to “resolved”, then (b) entering a placeholder for a tolerated penicillin oral challenge (or for a negative penicillin allergy skin test, as applicable). Panel (c) shows the display of “all” allergies for the patient, both active and inactive (e.g., resolved). The patient’s demographic bar in the electronic medical record is set to display only “active” allergies by default. In the “active” display, the penicillin oral challenge label would remain, but the penicillin allergy label would no longer be seen.

Figure 4

Process for penicillin allergy de-labeling in the electronic medical record by (a) changing the status of the current penicillin allergy to “resolved”, then (b) entering a placeholder for a tolerated penicillin oral challenge (or for a negative penicillin allergy skin test, as applicable). Panel (c) shows the display of “all” allergies for the patient, both active and inactive (e.g., resolved). The patient’s demographic bar in the electronic medical record is set to display only “active” allergies by default. In the “active” display, the penicillin oral challenge label would remain, but the penicillin allergy label would no longer be seen.

Figure 5

Sample patient education card following penicillin allergy skin test.