1332. Single Dose Oral Amoxicillin Challenge is a Safe and Effective Strategy to Delabel Penicillin Allergies among Low Risk Hospitalized Children

Abstract

Background Over 90% of children with reported penicillin allergy can tolerate penicillin without incident. Developing effective and safe strategies to remove inappropriate penicillin allergies has the potential to improve care; however, guidance on how to identify, test, and delabel patients is limited. Methods In April 2019, Children’s Hospital Colorado (CHCO) implemented a penicillin allergy clinical pathway (CP) alongside a risk assessment tool to stratify patients based on allergic history (Figure 1). Patients at “no increased risk” were educated and delabeled without testing. Low risk patients were offered an oral amoxicillin drug challenge with close observation. A single, non-graded, treatment dose of amoxicillin (45 mg/kg, max dose 1000mg) was used for low risk patients, and no preceding allergic skin testing was performed. Patients with no signs or symptoms of allergic response 60 minutes after amoxicillin administration were delabeled. Children delabeled of penicillin allergies on the CHCO hospital medicine service were compared between the pre-CP (1/1/17-3/31/19) and post-CP (4/1/19-3/31/20) cohorts. Figure 1. Penicillin Allergy Risk Assessment Results Pre-CP, 683/10624 (6.4%) patients reported a penicillin allergy and 18/683 (2.6%) were delabeled by discharge. Post-CP, 345/6559 (5.3%) patients reported a penicillin allergy and 47/345 (13.6%) were delabeled by discharge (P-value < 0.0001, Figure 2). Among the 47 post-CP patients, 11 were delabeled by history alone, 19 underwent oral amoxicillin drug challenge per CP, and 17 received a different treatment dose penicillin per treatment team. Only one penicillin-exposed patients had a reaction. This patient developed a delayed, non-progressive rash and had penicillin allergy restored to their chart. No patient required emergency medical intervention, and none were “relabeled” penicillin allergic in the 6 months following discharge. Figure 2. Monthly Rate of Penicillin Allergic Patients Delabeled by Discharge Conclusion A drug challenge using a single non-graded dose of oral amoxicillin is a safe and effective strategy to delabel low risk children of inappropriate penicillin allergies when implemented alongside a risk assessment tool. Further studies are needed to evaluate the long-term benefits of delabeling inappropriate penicillin allergies and to continue monitoring for adverse events. Disclosures All Authors: No reported disclosures

Health outcomes of penicillin allergy testing in children: a systematic review

“…There were 25 full manuscripts and 12 conference abstracts. Of these, there was one randomized controlled feasibility trial (82 participants), 13 one pre–post study with no control group (1028 participants), 14 34 observational studies (7287 participants) 2 , 15–46 and one qualitative study (14 participants). 47 In the observational studies, there was a median of 111 participants (range 8–1914).…”

“…The uncontrolled, pre–post study found a difference in the rate of delabelling between pre- and post-implementation of a clinical pathway (2.6% versus 13.6%, P < 0.0001). 14 Three studies reported the use of letters to communicate the results of negative PAT. 18 , 23 , 46 One study asked primary care providers whether parents had informed them of negative PAT.…”

“…The rate of relabelling ranged from 0% to 3.3%. Two children 32 were relabelled after reporting a reaction followed by positive repeat PAT, three 14 , 23 , 44 reported reactions but were not re-evaluated, and one 16 had no documented reason for relabelling. The follow-up period for this outcome varied between studies; the shortest was at the point of discharge from hospital, 16 and the longest was 112 months after negative PAT.…”

Ambulatory cephalosporin prescribing practices at a freestanding children’s hospital network

“…Rash without other anaphylaxis criteria may be amenable to rechallenge and prevent unnecessary broad-spectrum cephalosporin prescriptions. 9 Limitations inherent to retrospective studies include incomplete data that may skew frequencies (eg, missed encounters from verbal orders, allergies removed after encounters or not documented); however, our method of chart review minimizes incomplete information. Other factors difficult to infer from chart review, such as provider preference, pharmacy availability, and insurance coverage, could have contributed to prescription choice.…”