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Allergic to Penicillin: Allergists answer Can this label be REMOVED without testing?

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DEEP DIVE: We find the pearls

I’m dr tiffany wong i’m a pediatric allergist at the bc children’s hospital today we are talking about penicillin allergy de-labeling how many people have told you they’re allergic to penicillin chances are you have heard this multiple times studies indicate that 10 of the population reports an allergy to penicillin in reality upon proper assessment 90 of these

Patients are not truly allergic erroneous penicillin allergy labels have negative public health implications we will be reviewing the nature of penicillin allergy the reasons for discrepancy between reported and true rates of penicillin allergy and how we can tackle this problem together so what is a penicillin allergy true allergic reactions to penicillin fall into

One of two categories immediate reactions and delayed reactions the pathogenesis natural history and management of these two types of allergic reactions is different immediate allergic reactions to penicillin are characterized by the presence of some signs and symptoms of anaphylaxis these are mediated by pre-formed ige antibodies this requires prior exposure to

An antibiotic or a member of the same class of antibiotics for a minimum of 10 days it’s extremely rare for a patient to have an immediate allergic reaction to an antibiotic on their first ever course of the medication symptoms of an immediate allergic reaction can include hives angioedema rhinitis conjunctivitis difficulty swallowing voice changes throat clearing

Coughing wheezing shortness of breath increased worker breathing vomiting diarrhea lethargy hypotension loss of consciousness and a sense of sudden impending doom when two or more of these symptoms are present this is diagnostic of anaphylaxis delayed reactions to penicillin typically occur at least six hours after taking the medication these reactions typically

Require prior exposure to the medication they almost never occur in the first 10 days of the first course of the medication most delayed reactions are benign and they consist of an itchy macular popular rash which lasts for a few days to a few weeks without other symptoms in rare situations severe symptoms can occur with a delayed allergic reaction to penicillin

Severe symptoms can include systemic fever arthritis organ involvement vasculitis purpura target lesions or eosinophilia these can be seen in various rare forms of delayed drug reactions including serum sickness drug reaction with eosinophilia and systemic symptoms erythema multiforme stephen johnson syndrome and toxic epidermal necrolysis patients with these

Symptoms should be evaluated by an allergist prior to a drug challenge why are patients accidentally labeled with an antibiotic allergy when they don’t really have one there are three main reasons most commonly the patient was administered an antibiotic for symptoms such as pharyngitis myalgia cough rhinitis fever headache or otitis media these symptoms are

Most commonly caused by a viral infection viral and bacterial infections often cause a rash especially in children and an antibiotic is mistakenly blamed as the cause of the rash the second reason patients can be incorrectly labeled with an antibiotic allergy is when the patient mistakenly assumes that they are allergic to it simply because they didn’t tolerate

It well they may have experienced common known side effects including dizziness nausea diarrhea or yeast infection and mistakenly drawn the conclusion that they must be allergic finally sometimes patients assume they are allergic to an antibiotic because there is a family history it’s important to note antibiotic allergies don’t run in families and there’s no

Reason to avoid an antibiotic based on family history we know that erroneous penicillin allergies are incredibly common and one of the important things is to identify the issues that those cause and there are lots of implications for rhony spencer analogy that are important in particular there has been direct evidence that having a penicillin allergy labeled as

Allergic but not actually having a true allergy does increase the use of alternative antibiotic therapy and specifically second and third line agents that we know are not as effective for treatment of infection or prevention of infection a good example of this is in surgery an alternative antibiotic is given for surgical site prophylaxis does directly result in a

Four to six fold increased chance of surgical site infection and so it’s important to to de-label or to remove those erroneous penicillin allergies for those exact reasons in addition to that uh direct use of alternative antibiotic therapy we also show that there is a increase in length in the hospital stay as well as those alternative antibiotics are often more

Expensive and so that does create an increased cost to the system and finally one of the big things that we’re talking about right now is increase antimicrobial resistance and by choosing a second or third line agent you might actually be increasing the rates of antimicrobial resistance and thus later on in life both reducing the options for antibiotic therapy

For that patient specifically as well as the population as a whole as an obstetrician gynecologist i work with a special population of women who are pregnant and one of the big questions that we got is whether we could offer penicillin allergy testing or de-labeling services to women who had a robust medicinal allergy in pregnancy and there were some specific

Reasons that we offered this and we did an analysis of our patient population and show that more than 50 percent of women who labor and deliver will actually receive an antibiotic during their stay whether that is for groupie strep prophylaxis for surgical site infection prophylaxis and cesarean suction or the development of fever and labor so we have actually

Proven that offering the same to labeling services that non-pregnant adults have is both safe for pregnant women and we do this at in a specialized clinic but it can be done in any multi-disciplinary type clinic or any really any clinic about testing penicillin allergies and that it actually directly impacts prescribing during labor and delivery so not only are you

Getting the benefit of the labeling services as well as allergy testing in this pregnancy but you’re getting them long term and specifically we’ve shown that those patients who are tested and their allergy status is clarified and they are deemed non-allergic to penicillin that they actually have changes in prescribing during their labor and delivery resulting

In increased use of first-line medications during their hospital stay at our sexually transmitted infection clinic we see patients longitudinally for hiv pre-exposure prophylaxis and episodically for sti management we know that our patients are at elevated risk for acquiring other stis which are often treated with penicillins or cephalosporins ideally we can

De-label our patients before they require treatment and the ability to do the de-labeling in our clinic settings simplifies the process as weightless to see allergies tend to be quite long and patients already comfortable in our setting our hiv prep patients see us every three months as long as they’re in prep and have an established rapport with the providers

As a community pediatrician i’m often confronted by patients who disclose that they have a penicillin or penicillin derivative allergy on routine history taking or admission to hospital when they’re unwell it’s a common dilemma that will often force us to utilize second line antibiotics that are more expensive knowing fully well that the history of a true allergy

Is unconvincing over the last year i’ve worked with dr wong on a community labeling initiative to help identify these patients and provide oral challenges with single doses of amoxicillin in my community clinic i gained confidence in doing so by applying the recommendations from the cps practice point beta lifetime allergy in the pediatric population and getting

First-hand experience i have found that the process is not only safe and effective in identifying these patients but it’s truly gratifying to see the relief that patients and their parents experience when they are finally freed of that label so what can you do to help you label penicillin allergies in your patients the first step is to stop and take a history

Describing the timing and characterizing the symptoms suspected of adverse reaction are key to determining whether a penicillin allergy exists or not decision support tools are available through canadian resources such as the canadian pediatric society canadian society for allergy and clinical immunology and in this we’ve taken decision support tools one step

Further and are excited to share that we have partnered with spectrum to create a mobile assessment tool it will take you in real time through a penicillin allergy history and provide recommendations based on the answers provided it can be accessed by anyone through either weblink or the spectrum app on any mobile device finally if you’re unsure send a referral

To an allergist for drug allergy assessment let’s all work together to create better antibiotic choices for all of our patients you

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Allergic to Penicillin: Allergists answer "Can this label be REMOVED without testing?" By The Review Course in Family Medicine