Return to sender: the need to re‐address patient antibiotic allergy labels in Australia and New Zealand

Abstract

Background Antibiotic allergies are frequently reported and have significant impacts upon appropriate prescribing and clinical outcomes. We surveyed infectious diseases physicians, allergists, clinical immunologists and hospital pharmacists to evaluate antibiotic allergy knowledge and service delivery in Australia and New Zealand. Methods An online multi-choice questionnaire was developed and endorsed by representatives of the Australasian Society of Clinical Immunology and Allergy (ASCIA), Australasian Society of Infectious Diseases (ASID) and Society of Hospital Pharmacists Australia (SHPA). The 37-item survey was distributed in April 2015 to members of ASCIA, ASID, SHPA and Royal Australasian College of Physicians. Results Of 277 respondents, 94% currently use or would utilise antibiotic allergy testing (AAT) and reported seeing up to 10 patients/week labelled as antibiotic-allergic. Forty-two per cent were not aware of or did not have AAT available. Most felt that AAT would aid antibiotic selection, antibiotic appropriateness and antimicrobial stewardship (79%, 69% and 61%, respectively). Patients with histories of immediate hypersensitivity were more likely to be referred than those with delayed hypersensitivities (76% vs. 41%, p=0.0001). Lack of specialist physicians (20%) and personal experience (17%) were barriers to service delivery. A multidisciplinary approach was the preferred AAT model (53%). Knowledge gaps were identified, with the majority over-estimating rates of penicillin/cephalosporin (78%), penicillin/carbapenem (57%) and penicillin/monobactam (39%) cross-reactivity. Conclusions A high burden of antibiotic allergy labelling and demand for AAT is complicated by a relative lack availability or awareness of AAT services in Australia and New Zealand. Antibiotic allergy education and deployment of AAT, accessible to community and hospital-based clinicians, may improve clinical decisions and reduce antibiotic allergy impacts. A collaborative approach involving ID physicians, pharmacists and allergists/immunologists is required.

The 3 Cs of Antibiotic Allergy—Classification, Cross-Reactivity, and Collaboration

“…Recent work by Romano et al demonstrated patients with cephalosporin allergy commonly tolerated a different cephalosporin of varied R1/R2 side chain. 39 A recent survey of allergists, immunologists, pharmacists and infectious diseases physicians in Australia identified significant knowledge gaps regarding antibiotic cross-reactivity and absence of skin testing diagnostics to confirm, 40 echoed in surveys from the US and UK. 41–43 The older literature also suggests erroneously high rates of cross-reactivity between penicillins and cephalosporins (10–25%).…”

Antibiotic allergy labels-the impact of taking a clinical history

“…So, as well as optimising individual patient outcomes, appropriate allergy labelling and de‐labelling has also become an antimicrobial stewardship issue . Antibiotic allergy testing is very helpful in both de‐labelling penicillin‐allergic patients and identifying real beta‐lactam allergies but is not always readily accessible, especially for hospital inpatients . This study aims to estimate the prevalence of AALs recorded in medical records in an Australian tertiary hospital over an 18‐week period that could be removed immediately (as inappropriate) as well as identifying those in whom it would be relatively safe to perform a direct re‐challenge with a drug provocation test (DPT) based upon clinical grounds.…”

The Safety and Efficacy of an Oral Penicillin Challenge Program in Cancer Patients: A Multicenter Pilot Study

“…In cancer patients, more than 83% of AALs can be removed via formal antibiotic allergy testing, with such “de-labeling” associated with a 10-fold increase in appropriate antibiotic prescribing [ 2 , 3 ]. Unfortunately, despite the value of such programs, more than 50% of clinicians report that formal allergy testing services are either not available to them or not accessible in a timely fashion [ 4 , 5 ]. There has been growing interest in the role of direct oral challenge in patients with low-risk penicillin allergies to help address the obstacles that prevent widespread access to formal skin prick testing programs.…”