TESTING AND DOCUMENTATION OF PENICILLIN ALLERGY AS A COMPONENT OF ANTIMICROBIAL STEWARDSHIP

To advocate that state board of pharmacy regulations include penicillin allergy skin testing under pharmacists’ scope of practice; further,

To advocate involvement of pharmacists in the clarification and assessment of penicillin allergy, intolerance, and adverse drug events; further,

To advocate for documentation and de-labeling of penicillin allergies, intolerances, reactions, and severities in the medical record when appropriate to facilitate optimal antimicrobial selection; further,

To recommend the use of penicillin skin testing, graded antibiotic challenges, and oral direct challenges in appropriate candidates when clinically indicated to optimize antimicrobial selection; further,

To support the education and training of pharmacists in the assessment, management, and documentation of penicillin allergies, intolerances, and adverse events; further,

To advocate for reimbursement for pharmacists’ patient care services involved in penicillin allergy skin testing; further,

To educate patients, healthcare providers, and the public about the risks of inaccurate penicillin allergy labeling and the role of pharmacists in health-record reconciliation and the value of pharmacist-driven health-record reconciliation, including penicillin skin testing.

Rationale

Approximately 10% of all patients in the United States report having a penicillin allergy; however, only 1 in 10 patients with a labeled penicillin allergy are truly allergic. Furthermore, approximately 80% of patients with an IgE-mediated penicillin allergy lose their sensitivity after 10 years. Specific rates of cross-reactivity between penicillins and cephalosporins vary depending on specific resources, although the likelihood of cross-reactivity is lower than previously described. Historically, it has been estimated that 10% of patients with a true penicillin allergy will experience an allergic reaction if administered a cephalosporin, but this data is from early cross-reactivity studies with potential contamination of early cephalosporin products with penicillin G. More recent data suggest cross-reactivity rates of less than 1%. Cross-reactivity is more closely associated with structurally similar R-1 side chains than with the beta-lactam ring itself.

Penicillin allergies have led to considerable public health risks and unintended consequences, including receipt of more broad-spectrum antibiotics, suboptimal therapy for infectious disease management, more antibiotic-related costs, increased risk of adverse effects, and increased risk of methicillin-resistant Staphylococcus aureus and Clostridioides difficile. As such, structured and thorough interview assessments with appropriate documentation and de-labeling of penicillin allergies are necessary to combat these potential negative consequences of labeled penicillin allergies. Penicillin skin testing and graded or oral challenges are excellent opportunities to assist in the assessment and de-labeling of penicillin allergies. Although pharmacists are well positioned to be involved in these processes, state boards of pharmacy have different regulations regarding whether penicillin skin testing is within pharmacists’ scope of practice. Penicillin allergy assessment, management, and documentation are excellent opportunities to improve pharmacist involvement in patient care and to improve antimicrobial stewardship initiatives for health systems, and offer a potential opportunity for pharmacists to bill for their services.

The American Academy of Allergy, Asthma, and Immunology, as part of the Choosing Wisely campaign, recommends against the overuse of non-beta-lactam antibiotics in patients with a history of penicillin allergy, without appropriate evaluation. In a research abstract from the Canadian Society of Allergy and Clinical Immunology meeting in 2014, researchers found that only 15% of hospital-discharged patients notified a family physician of a negative penicillin allergy evaluation; at the same time, 30% were still listed as penicillin allergic upon readmission to the hospital. Additionally, the existence of a pharmacist‐provided allergy skin test has proven to positively impact patient care by optimizing antibiotic regimens and accelerate discharges for patients while reducing healthcare costs.