Betalactam hypersensitivity: The importance of delabelling in primary care

Abstract

An allergy work-up was performed on adult patients with a history of a penicillin allergy seen by primary medical care in Monastir (Tunisia) between July 2016 and February 2018. Patients with negative skin tests were challenged with amoxicillin. Patients who were delabelled were contacted by phone after 6 months to determine outcomes after any therapeutic penicillin-class antibiotic intake.Results: A total of 39 patients were evaluated and 33 (84.6%) were delabelled. Five patients were penicillin skin-test positive and one was oral challenge positive. We succeeded in contacting 33 delabelled patients at 6 months. Twenty-two patients tolerated a subsequent therapeutic course of amoxicillin, eight patients did not retake penicillin due to a lack of therapeutic indication, and three patients refused an indicated penicillin use fearful of another reaction. Conclusion: This study highlights the importance of allergy work-up in the diagnosis of beta-lactam hypersensitivity. Most patients were excessively labelled as betalactam allergic and this mislabelling could increase healthcare costs and lead to the development of drug resistance by the use of wide-spectrum antibiotics K E Y W O R D S betalactams hypersensitivity, challenge test, drug delabling, drug hypersensitivity, skin tests 1 | INTRODUCTION Beta-lactam (BL) antibiotics are widely prescribed in the general population, particularly in outpatients, because of their effectiveness against many gram-positive, gram-negative and anaerobic infections, and their low cost.However, the prescription of these drugs is limited by the occurrence of BL immunologic hypersensitivity side effects. Indeed, previous publications have reported that 10-20% of patients in clinical practice are BL allegy label since the diagnosis of drug hypersensitivity is not confirmed by an appropriate allergy work-up in these studies. 1,2 Recent publications have demonstrated that, after a complete investigation, based on skin testing and eventually oral challenge tests, more than 90% of individuals with a history of penicillin allergy are able to tolerate penicillins. 3,4 Thus, the unnecessary avoidance of BL in patients could increase healthcare costs due to the use of more expensive and/or less effective alternative antibiotics. A recent meta-analysis demonstrated that an "antimicrobial allergy label" was associated with significant reductions in antibiotic guideline appropriateness and a worsening of hospital outcomes, ie, an increase in patient readmissions, length of stay and antibiotic costs. 5 On the other hand, BL mislabelling could lead to the development of drug resistance by the use of wide-spectrum antibiotics. In this respect, it has been demonstrated in a large Caucasian Research data are not shared The aim of the present study was to assess the outcomes of an allergy work-up of patients with a penicillin allergy label by primary care.

Beta-lactam allergy in patients: an antibiotic stewardship challenge

“…Antimicrobials are responsible for the most commonly reported drug allergies, especially BL antibiotics 1 2. In this study a quality indicator to detect incorrect BL allergy labels in hospitalised patients was implemented.…”

“…Performing a drug challenge under medical supervision with or without prior skin testing is a good way to delabel patients with an antibiotic allergy 2. The intervention of the Allergy and Pharmacy Services in identifying and challenging ‘BL-allergic’ patients is effective in terms of the number of patients they delabel.…”

“…In any case, the labelling of patients as allergic to BL is magnified, as this study and many other studies have shown. This could be associated with confusion by physicians regarding drug side effects when an allergic reaction occurs and the absence of an objective allergy assessment of the suspected hypersensitivity reaction 2…”

“…Beta-lactam (BL) antibiotics are the most widely used antimicrobials in the general population due to their effectiveness and low cost 1. However, penicillins and cephalosporins account for almost 50% of antimicrobial drug allergies 1 2. Recent publications have shown that more than 90% of these patients are able to tolerate BL antibiotics because they do not have true allergies.…”

Diseño, obtención y caracterización de proteínas recombinantes a partir de determinantes antigénicos asociadas a reacciones alérgicas a ß-lactámicos.

“…En este contexto, una de las principales claves es el método de diagnóstico elegido 45 , lo que pone de manifiesto la importancia de desarrollar nuevas pruebas que permitan una clasificación de pacientes más selectiva y fiable. 46…”