Antibiotic Prescribing Practices Differ between Patients with Penicillin Intolerance and Penicillin Allergy Labels

Abstract

<b><i>Introduction:</i></b> Penicillin allergy labels are common. However, many penicillin allergy labels have been applied incorrectly and in fact represent penicillin intolerance. Patients with penicillin intolerance can receive penicillin antibiotics. The effect of penicillin intolerance labels on prescribing practices is uncertain. <b><i>Methods:</i></b> This multicenter retrospective cohort study included consecutive general medicine patients admitted to two tertiary hospitals over a 12-month period. Electronic medical records were reviewed for allergy and prescribing practices. Instances of penicillin prescription to patients with previously labeled penicillin allergies underwent case note review. <b><i>Results:</i></b> There were 12,134 individual hospital admissions included in the study. The number of admissions with a previous penicillin allergy label was 1,312 (10.8%) and with a penicillin intolerance label was 60 (0.5%). Penicillin allergy labels were associated with increased likelihood of being prescribed vancomycin (odds ratio 1.42, 95% confidence interval 1.16–1.75, <i>p</i> = 0.001) and moxifloxacin (odds ratio 20.0, 95% confidence interval 13.4–29.9, <i>p</i> < 0.001). Penicillin intolerance was not associated with increased likelihood of receiving these antibiotics. There were 75 admissions during which an individual with a penicillin allergy label was prescribed one of the specified penicillins and only one adverse reaction in this group. These cases included eight deliberate challenges and 15 cases in which allergy history clarification was sufficient to delabel the allergy. <b><i>Conclusions:</i></b> This study supports that prescribing practices differ between patients with penicillin allergy labels and intolerance labels. Penicillin challenges may be undertaken safely in the inpatient setting. Further studies are required to investigate how best to interrogate penicillin allergy labels in this cohort.

Artificial intelligence–enabled penicillin allergy delabelling: an implementation study

“…Many penicillin allergy labels in electronic medical records (EMRs) are not consistent with allergy 1 . This inaccuracy is significant, as EMR penicillin allergy and intolerance labels have been shown to be associated with different antibiotic prescribing practices 2 . Furthermore, penicillin allergy labels are associated with worse outcomes, including increased hospital readmissions and delayed antibiotic administration in the setting of sepsis 3,4 .…”

Prevalence of Trimethoprim-Sulfamethoxazole Adverse Reaction Mislabelling in Australia

“…Reaction descriptions (free text or pick-list) were categorized as allergy or intolerance with gold-standard classification using the expert criteria from previous studies [7] and were developed originally with a penicillin classification tool [8] (see online suppl. Tables 1, 2).…”

“…Patients did not undergo formal immunological evaluation. Risk stratification using criteria of reaction severity [7] was also applied.…”

Inaccurate penicillin allergy labels: Consequences, solutions, and opportunities for rhinologists

“…Additionally, even if a person previously experienced an IgE‐mediated reaction, such as anaphylaxis, about 80% of these patients become tolerant after a decade 8 . Thus, without careful scrutiny of a patient's history or evidence of objective allergy testing, patients mislabeled with a penicillin allergy are often inappropriately given β‐lactam alternatives, such as clindamycin or fluoroquinolones, both of which are associated with greater adverse events and subsequent unintended consequences compared with β‐lactams 6,9 …”

“…8 Thus, without careful scrutiny of a patient's history or evidence of objective allergy testing, patients mislabeled with a penicillin allergy are often inappropriately given β-lactam alternatives, such as clindamycin or fluoroquinolones, both of which are associated with greater adverse events and subsequent unintended consequences compared with β-lactams. 6,9 As physicians who diagnose, treat, and manage common sinonasal pathology for patients of all ages in the clinic and operating room, rhinologists are well-positioned to aid in delabeling patients that hold an incorrect current allergy to penicillin. Many rhinologists already provide testing and management for allergic diseases as part of their practice.…”