Penicillin allergy delabeling: Opportunities for implementation and dissemination

Abstract

Although existing as a safety measure to prevent iatrogenic harm, unconfirmed penicillin allergy labels have a negative impact on personal and public health. One downstream effect of unconfirmed penicillin allergy is the continued emergence and transmission of resistant bacteria and their associated health care costs. Recognizing the consequences of inaccurate penicillin allergy labels, professional and public health organizations have started promoting the adoption of proactive penicillin allergy evaluations, with the ultimate goal of removing the penicillin allergy label when the allergy is disproved, also known as penicillin allergy "delabeling." A penicillin allergy evaluation includes a comprehensive allergy history often followed by drug challenge, sometimes with preceding skin testing. Currently, penicillin allergy delabeling is largely carried out by allergy specialists in outpatient settings. Penicillin allergy delabeling is performed on inpatients, albeit rarely, often at the time of need, as a point-of-care procedure. Access to penicillin allergy evaluation services is limited. Recent studies demonstrate the feasibility of expanding penicillin allergy evaluations and delabeling to internists, pediatricians, emergency medicine physicians, infectious diseases specialists, and clinical pharmacists. However, reducing the impact of mislabeled penicillin allergy will require comprehensive efforts and new investments. In this review, we summarize the current practices of penicillin allergy delabeling and discuss expansion opportunities for penicillin allergy delabeling as quality improvement.

Figure 1.

Acquisition of a penicillin allergy label, consequences of a label, and delabeling. # reaction could be drug allergy but could also be from the underlying infection or a drug-infection interaction. * penicillin allergy label may also be kept for patients who have a confirmed penicillin intolerance or adverse effect.

Figure 2.

Resources required to perform penicillin allergy evaluation and delabeling. EHR, electronic health record.

Figure 3.

Penicillin allergy delabeling across the care continuum. Colors indicate the frequency with which penicillin allergy delabeling as quality improvement is implemented in these settings in the United States. Settings in dark blue represent opportunities for the expansion of delabeling as quality improvement.

Figure 4.

Considerations for expansion of penicillin allergy delabeling into routine care in a radial cluster diagram. CPs, clinical pharmacists; EHR, electronic health record; LPNs, licensed practical nurses; MAs, medical assistants; NPs, nurse practitioners; PAs, physician assistants.