The challenge of de‐labeling penicillin allergy

Background Even though 8%‐25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy...

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Published in:	Allergy (Copenhagen) Vol. 75; no. 2; pp. 273 - 288
Main Authors:	Stone, Cosby A., Trubiano, Jason, Coleman, David T., Rukasin, Christine R. F., Phillips, Elizabeth J.
Format:	Journal Article
Language:	English
Published:	Denmark Blackwell Publishing Ltd 01.02.2020
Subjects:	Adult Allergies allergy Anti-Bacterial Agents - adverse effects Anti-Bacterial Agents - chemistry Antibiotic resistance Antibiotics Antimicrobial agents Antimicrobial resistance Antimicrobial Stewardship - methods Cephalosporins - adverse effects Cephalosporins - chemistry Child Child, Preschool Children Cross Reactions Desensitization, Immunologic de‐labeling Drug Hypersensitivity - diagnosis Drug Hypersensitivity - etiology Drug Hypersensitivity - immunology Drug resistance Humans Hypersensitivity (immediate) Intradermal Tests label Labeling Literature reviews Penicillin Penicillins - adverse effects Penicillins - chemistry Population studies Public health Skin tests testing penicillin allergy label de-labeling testing
ISSN:	0105-4538, 1398-9995, 1398-9995
Online Access:	Get full text
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Abstract	Background Even though 8%‐25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de‐labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. Methods We performed an evidence‐based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de‐labeling. Over the period 1928‐2018 in Pubmed and Medline, search terms used included “penicillin allergy” or “penicillin hypersensitivity” alone or in combination with “adverse events,” “testing,” “evaluation,” “effects,” “label,” “de‐labeling,” “prick or epicutaneous,” and “intradermal” skin testing, “oral challenge or provocation,” “cross‐reactivity,” and “antimicrobial stewardship”. Results Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. Conclusions Operationalizing penicillin allergy de‐labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de‐labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.
AbstractList	Even though 8–25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low-risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy, and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de-labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. We performed an evidence-based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels and current approaches and barriers to penicillin allergy de-labeling. Over the period 1928–2018 in Pubmed and Medline, search terms used included “penicillin allergy” or “penicillin hypersensitivity” alone or in combination with “adverse events”, “testing”, “evaluation”, “effects”, “label”, “de-labeling”, “prick or epicutaneous” and “intradermal” skin testing, “oral challenge or provocation” “cross-reactivity” and “antimicrobial stewardship.” BackgroundEven though 8%‐25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de‐labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus.MethodsWe performed an evidence‐based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de‐labeling. Over the period 1928‐2018 in Pubmed and Medline, search terms used included “penicillin allergy” or “penicillin hypersensitivity” alone or in combination with “adverse events,” “testing,” “evaluation,” “effects,” “label,” “de‐labeling,” “prick or epicutaneous,” and “intradermal” skin testing, “oral challenge or provocation,” “cross‐reactivity,” and “antimicrobial stewardship”.ResultsPenicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance.ConclusionsOperationalizing penicillin allergy de‐labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de‐labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs. Even though 8%-25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de-labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. We performed an evidence-based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de-labeling. Over the period 1928-2018 in Pubmed and Medline, search terms used included "penicillin allergy" or "penicillin hypersensitivity" alone or in combination with "adverse events," "testing," "evaluation," "effects," "label," "de-labeling," "prick or epicutaneous," and "intradermal" skin testing, "oral challenge or provocation," "cross-reactivity," and "antimicrobial stewardship". Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. Operationalizing penicillin allergy de-labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de-labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs. Background Even though 8%‐25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de‐labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. Methods We performed an evidence‐based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de‐labeling. Over the period 1928‐2018 in Pubmed and Medline, search terms used included “penicillin allergy” or “penicillin hypersensitivity” alone or in combination with “adverse events,” “testing,” “evaluation,” “effects,” “label,” “de‐labeling,” “prick or epicutaneous,” and “intradermal” skin testing, “oral challenge or provocation,” “cross‐reactivity,” and “antimicrobial stewardship”. Results Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. Conclusions Operationalizing penicillin allergy de‐labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de‐labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs. Even though 8%-25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de-labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus.BACKGROUNDEven though 8%-25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de-labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus.We performed an evidence-based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de-labeling. Over the period 1928-2018 in Pubmed and Medline, search terms used included "penicillin allergy" or "penicillin hypersensitivity" alone or in combination with "adverse events," "testing," "evaluation," "effects," "label," "de-labeling," "prick or epicutaneous," and "intradermal" skin testing, "oral challenge or provocation," "cross-reactivity," and "antimicrobial stewardship".METHODSWe performed an evidence-based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de-labeling. Over the period 1928-2018 in Pubmed and Medline, search terms used included "penicillin allergy" or "penicillin hypersensitivity" alone or in combination with "adverse events," "testing," "evaluation," "effects," "label," "de-labeling," "prick or epicutaneous," and "intradermal" skin testing, "oral challenge or provocation," "cross-reactivity," and "antimicrobial stewardship".Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance.RESULTSPenicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance.Operationalizing penicillin allergy de-labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de-labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.CONCLUSIONSOperationalizing penicillin allergy de-labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de-labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.
Author	Coleman, David T. Phillips, Elizabeth J. Stone, Cosby A. Trubiano, Jason Rukasin, Christine R. F.
AuthorAffiliation	Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA Department of Pharmacology, Vanderbilt University School of Medicine Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, Western Australia 6150 Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre, Melbourne, VIC AUS Department of Medicine (Austin Health), University of Melbourne, Parkville, VIC, AUS Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center Department of Infectious Diseases, Austin Health, Heidelberg, VIC AUS The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, VIC, AUS
AuthorAffiliation_xml	– name: Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA – name: Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre, Melbourne, VIC AUS – name: Department of Infectious Diseases, Austin Health, Heidelberg, VIC AUS – name: Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center – name: Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, Western Australia 6150 – name: Department of Medicine (Austin Health), University of Melbourne, Parkville, VIC, AUS – name: Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA – name: The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, VIC, AUS – name: Department of Pharmacology, Vanderbilt University School of Medicine
Author_xml	– sequence: 1 givenname: Cosby A. orcidid: 0000-0002-1888-4188 surname: Stone fullname: Stone, Cosby A. organization: Vanderbilt University Medical Center – sequence: 2 givenname: Jason surname: Trubiano fullname: Trubiano, Jason organization: The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre – sequence: 3 givenname: David T. surname: Coleman fullname: Coleman, David T. organization: Vanderbilt University Medical Center – sequence: 4 givenname: Christine R. F. surname: Rukasin fullname: Rukasin, Christine R. F. organization: Vanderbilt University Medical Center – sequence: 5 givenname: Elizabeth J. surname: Phillips fullname: Phillips, Elizabeth J. email: elizabeth.j.phillips@vanderbilt.edu organization: Murdoch University
BackLink	https://www.ncbi.nlm.nih.gov/pubmed/31049971$$D View this record in MEDLINE/PubMed
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Keywords	penicillin allergy label de-labeling testing
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Notes	Funding information Dr. Stone receives funding from 5T32 GM007569‐41 from NIH/NIGMS. Dr. Phillips receives funding related to this project from: National Institutes of Health (1P50GM115305‐01, 1P30AI110527‐01A1, R21AI139021 and R34AI136815), National Health and Medical Research (NHMRC) Foundation of Australia. Dr. Trubiano is supported by an NHMRC Early Career Fellowship and funding from The National Centre for Infections in Cancer and Austin Medical Research Foundation. ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 14 ObjectType-Review-3 content type line 23 CAS, JT, DTC, CRFR, and EJP have all contributed to the manuscript during conceptualization, review of the literature, drafting, editing, and revising the final manuscript. This manuscript has been approved by all the authors. Statement of Author Contributions
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Snippet	Background Even though 8%‐25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in... Even though 8%-25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and... BackgroundEven though 8%‐25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in... Even though 8–25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and...
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SubjectTerms	Adult Allergies allergy Anti-Bacterial Agents - adverse effects Anti-Bacterial Agents - chemistry Antibiotic resistance Antibiotics Antimicrobial agents Antimicrobial resistance Antimicrobial Stewardship - methods Cephalosporins - adverse effects Cephalosporins - chemistry Child Child, Preschool Children Cross Reactions Desensitization, Immunologic de‐labeling Drug Hypersensitivity - diagnosis Drug Hypersensitivity - etiology Drug Hypersensitivity - immunology Drug resistance Humans Hypersensitivity (immediate) Intradermal Tests label Labeling Literature reviews Penicillin Penicillins - adverse effects Penicillins - chemistry Population studies Public health Skin tests testing
Title	The challenge of de‐labeling penicillin allergy
URI	https://onlinelibrary.wiley.com/doi/abs/10.1111%2Fall.13848 https://www.ncbi.nlm.nih.gov/pubmed/31049971 https://www.proquest.com/docview/2355835651 https://www.proquest.com/docview/2229239607 https://pubmed.ncbi.nlm.nih.gov/PMC6824919
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