Antibiotic Allergy De-Labeling: A Pathway against Antibiotic Resistance

Abstract

Antibiotics are one of the most frequently prescribed drugs. Unfortunately, they also are the most common cause for self-reported drug allergy, limiting the use of effective therapies. However, evidence shows that more than 90% of patients labeled as allergic to antibiotics are not allergic. Importantly, the label of antibiotic allergy, whether real or not, constitutes a major public health problem as it directly impacts antimicrobial stewardship: it has been associated with broad-spectrum antibiotic use, often resulting in the emergence of bacterial resistance. Therefore, an accurate diagnosis is crucial for de-labeling patients who claim to be allergic but are not really allergic. This review presents allergy methods for achieving successful antibiotic allergy de-labeling. Patient clinical history is often inaccurately reported, thus not being able to de-label most patients. In vitro testing offers a complementary approach but it shows limitations. Immunoassay for quantifying specific IgE is the most used one, although it gives low sensitivity and is limited to few betalactams. Basophil activation test is not validated and not available in all centers. Therefore, true de-labeling still relies on in vivo tests including drug provocation and/or skin tests, which are not risk-exempt and require specialized healthcare professionals for results interpretation and patient management. Moreover, differences on the pattern of antibiotic consumption cause differences in the diagnostic approach among different countries. A multidisciplinary approach is recommended to reduce the risks associated with the reported penicillin allergy label.

Direct oral challenge for immediate and non‐immediate beta‐lactam allergy in children: A real‐world multicenter study

“…[7][8][9][10][11][12][13] From a community point of view, the use of second-line antibiotics may facilitate the emergence of bacterial resistance and increase healthcare costs. 14 Many adults with a penicillin allergy label acquired it in childhood, so its pernicious effects are prolonged throughout life. 15 Most reactions associated with the use of BLA appear during the course of treatment of an infectious disease, and they are usually mild and limited to the skin, in the form of a maculopapular rash or urticaria.…”

“…Children labeled as allergic to BLA are at risk of receiving less appropriate antibiotics and as a result, suffering side effects and having longer hospital stays 7–13 . From a community point of view, the use of second‐line antibiotics may facilitate the emergence of bacterial resistance and increase healthcare costs 14 . Many adults with a penicillin allergy label acquired it in childhood, so its pernicious effects are prolonged throughout life 15 .…”

Performance characteristics of basophil activations tests for diagnosing penicillin allergy: a meta-analysis

“…Juhlin et al in 1978 first suggested that basophil degranulation could be used in clinical allergy diagnoses (26). The use of basophil activation testing (BAT) in penicillin allergy diagnosis has not yet become common practice (27). The latest EAACI position paper on improving diagnosis of beta-lactam hypersensitivity from 2020 (16) recommends in vitro testing such as BAT or sIgE, prior toin vivo testing in high risk patients, or instead of ST when the latter is contra indicated or not possible.…”

Standardizing In Vitro β-Lactam Antibiotic Allergy Testing with Synthetic IgE

“…This mislabeling triggers socioeconomic and health problems, such as antibiotic resistance, necessitating delabeling initiatives in antibiotic stewardship programs. 2,3 Delabeling initiatives encompass both in vivo and in vitro testing approaches. However, the routine clinical application of these methods is constrained by the time-consuming and risky nature of in vivo tests and the low sensitivity (approximately 81% false negatives) exhibited by current in vitro techniques.…”

“…However, accurate clinical and analytical assessment reveals a significant misclassification of individuals as allergic, leading to unnecessary prescription of alternative antibiotics. This mislabeling triggers socioeconomic and health problems, such as antibiotic resistance, necessitating delabeling initiatives in antibiotic stewardship programs. , …”