Evidence tells us patients labeled with a penicillin allergy often experience longer inpatient lengths of stay and higher costs. In addition, they’re often at higher risk for developing serious infections including Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci. We also know that minimizing unnecessary exposure to antimicrobials — particularly those that are penicillin-alternatives — can significantly help reduce these risks.

Through penicillin allergy assessment and skin testing, we’re finding that up to 90 percent of patients labeled with a penicillin allergy actually are not allergic to it. Thus, these assessments should become a central part of antimicrobial stewardship.

Why Is De-labeling So Important?

When patients are de-labeled of a penicillin allergy, it often allows them to receive the antibiotic of choice for a specific disease state rather than inappropriate or inferior antibiotics which are more costly and may cause more adverse side effects. It can also decrease the length of stay on average by one-half day.

At St. Joseph/Candler Health System in Savannah, Ga., for instance, a penicillin allergy skin testing (PAST) program was implemented by the Clinical Pharmacy Specialist, Dr. Bruce Jones, in 2014. Since the program’s rollout, de-labeling patients of a penicillin allergy has saved approximately $300‒$350 per patient during the initial care episode. Over a treatment course, this can lead to thousands of dollars saved since penicillin alternatives can be as much more expensive. Throughout a patient’s lifetime, de-labeling could amount to significant health benefits plus costs savings for both the patient and the healthcare organization. 

Strategies for Overcoming PAST Hurdles

Despite the benefits, PAST poses some practical hurdles for hospitals. Here are a few, along with strategies to overcome them:

• Time – Carving out the time to implement PAST may seem daunting. This is a bit of a misconception, however, because at least 20‒30 percent of patients labeled with a penicillin allergy can be de-labeled through a simple history assessment. For others, a direct challenge or graded challenge may be appropriate. For the rest, PAST typically takes 90‒120 minutes at most if you include the optional oral challenge. That’s a rapid diagnostic test with significant cost savings and improved outcomes that are well worth the time investment.

• Deciding Which Patients to Test – Ideally, if resources allow, anyone who fits criteria for skin testing should be tested. If time or resources are limited, however, priority should be given to patients who might see lower chances of mortality using a penicillin-based drug over an alternative. The next priorities should go to those who might see a decreased length of stay or who might be eligible for discharge sooner. Finally, consider those for whom cost is a factor. Perhaps, for example, PAST results could enable a patient to take a single antibiotic drug instead of three more expensive alternatives. Each facility should work with stakeholders to determine prioritization of skin testing candidates.

• Finding a Champion – A PAST program requires a champion to take charge and see it through, but this person will vary from organization to organization. It could be a number of healthcare providers including a pharmacist, allergist, different physician, nurse, nurse practitioner, or physician’s assistant. It would depend on who’s available and which discipline has the most interest in de-labeling patients of penicillin allergies. According to JAMA, many successful programs have multidisciplinary leadership.

• Awareness – Some providers don’t realize PAST is an option or do not receive accurate information about a patient’s allergy status. Better communication about what an allergic reaction to penicillin looks like and more awareness to how few patients truly have an allergy needs to occur within healthcare organizations.

• Communication – Whether or not a patient has a penicillin allergy — as well as whether or not he or she has been de-labeled — needs to be easy to find in the patient’s electronic health record within a health system. Of course, communicating this allergy status outside of the health system is a little more difficult. Any time a patient is de-labeled, providers such as the patient’s preferred pharmacy, dentist and other clinicians should be updated. For these situations, healthcare organizations might consider giving de-labeled patients a pocket card signed by the appropriate healthcare professional showing that there is no allergy, as well as the date tested.

Penicillin allergy assessment and skin testing are two of the best antimicrobial stewardship initiatives healthcare organizations can adopt. Personally, I cannot think of a better stewardship intervention than clearing patients of a penicillin allergy. Doing so impacts not only one episode of care by reducing costs and improving outcomes, but any subsequent episodes for the rest of their lives. For those interested in further education/training on penicillin allergy assessment and skin testing, there is a recently released certificate program available through the University of South Carolina College of Pharmacy. This program was developed by national experts across the country in penicillin allergy assessment and skin testing.

About the Author:

Christopher M. Bland is a Clinical Associate Professor at the University of Georgia College of Pharmacy. At St. Joseph/ Candler Health System, Dr. Bland’s primary practice areas include Infectious Diseases and Internal Medicine.