A Multidisciplinary Quality Improvement Initiative to Facilitate Penicillin Allergy Delabeling Among Hospitalized Pediatric Patients

Abstract

BACKGROUND: Penicillin allergy is reported in up to 10% of the general population; however, .90% of patients reporting an allergy are tolerant. Patients labeled as penicillin allergic have longer hospital stays, increased exposure to suboptimal antibiotics, and an increased risk of methicillin-resistant Staphylococcus aureus and Clostridioides difficile. The primary aim with our quality improvement initiative was to increase penicillin allergy delabeling to at least 10% among all hospitalized pediatric patients reporting a penicillin allergy with efforts directed toward patients determined to be low risk for true allergic reaction.METHODS: Our quality improvement project included several interventions: the development of a multidisciplinary clinical care pathway to identify eligible patients, workflow optimization to support delabeling, an educational intervention, and participation in our institution's quality improvement incentive program. Our interventions were targeted to facilitate appropriate delabeling by the primary hospital medicine team. Statistical process control charts were used to assess the impact of this intervention pre-and postpathway implementation.RESULTS: After implementation of the clinical pathway, the percentage of patients admitted to hospital medicine delabeled of their penicillin allergy by discharge increased to 11.7%. More than one-half of those delabeled (51.2%) received a penicillin-based antimicrobial at time of discharge. There have been no adverse events or allergic reactions requiring emergency medication administration since pathway implementation.CONCLUSIONS: Our quality improvement initiative successfully increased the rate of penicillin allergy delabeling among low-risk hospitalized pediatric patients, allowing for increased use of optimal antibiotics.

New diagnostıc perspectives in the management of pediatrıc beta‐lactam allergy

“…71,73 Furthermore, in contrast to studies in adults, a recent pediatric study classified symptoms of anaphylaxis as a moderate risk but not high risk. 74 The authors also classified immediate symptoms (less than 24 h after the first penicillin dose) as a moderate risk, in agreement with an adult risk stratification study. 14,74 Finally, if a child had low-risk symptoms, a 3-step penicillin testing procedure (SPT, IDT, and DPT) or direct DPTs were suggested, depending on the patient's convenience.…”

“…8 Although an increasing number of adult risk assessment studies have been published in the literature for BL allergy, there are limited data on risk stratification in the pediatric population. 26,[71][72][73][74] In children, mild cutaneous NIR to BLs is generally accepted as a low risk. 2, 35,36,42,49 On the other hand, in a pediatric study by Vyles et al, urticarial reactions, although potentially IgE-mediated, were also classified as low risk.…”

“…72 Besides that, in pediatric studies, itching with rash, isolated vomiting, diarrhea, abdominal pain, headache, cough, runny nose, a family history of penicillin allergy alone, delayed-onset urticaria or maculopapular rash (after first day of therapy or >2 h after last dose), and duration of symptoms >24 h were considered low risk. 26,71,73,74 Pediatric approaches to risk stratification differ from adult data in several respects. First, an unknown clinical history was interpreted as moderate or high risk for BL allergy in children, 71,73,74 whereas this criterion was defined as low risk in adult studies (see Table 1).…”

“…26 However, other clinical algorithms proposed only direct DPT in patients with low-risk BL allergy. 71,73,74 Of note, some characteristics of pediatric patients such as age, atopy, family history of drug allergy, and some specific comorbidities should be considered when determining risk status. Risk stratification tools for the management of pediatric BL allergies are very limited, and largescale validation studies are needed.…”

“…Finally, if a child had low‐risk symptoms, a 3‐step penicillin testing procedure (SPT, IDT, and DPT) or direct DPTs were suggested, depending on the patient's convenience 26 . However, other clinical algorithms proposed only direct DPT in patients with low‐risk BL allergy 71,73,74 . Of note, some characteristics of pediatric patients such as age, atopy, family history of drug allergy, and some specific comorbidities should be considered when determining risk status.…”