Children with reported penicillin allergy: Public health impact and safety of delabeling

Abstract

Objective: To review the relevant literature related to children with reported penicillin allergy and highlight the different ways in which children could be delabeled and to evaluate the public health impact that a penicillin allergy has for children.

Data sources: Data for this review were obtained via PubMed searches and then retrieval of articles from their respective journals for further review.

Study selections: Studies regarding the safety of different ways to evaluate penicillin allergy in children were identified via PubMed searches. Any study that reported different ways of testing (3-tier, direct oral challenge, 5-day oral challenges) were included. This same format was used when selecting relevant articg:les related to the costs, prescription patterns, and stewardship trends associated with a penicillin allergy label.

Results: This review found that penicillin allergy testing is a safe and effective way to delabel those with reported allergy. In children with low-risk allergy symptoms, a direct oral challenge approach may be optimal. In those children with a history of high-risk allergy symptoms, a 3-tiered approach is ideal. The review also found that there is a significant cost associated with reported penicillin allergy and that there are increased negative health benefits to those children with reported allergy.

Conclusion: Penicillin allergy is overdiagnosed, often incorrectly, and the label is frequently first applied during childhood. Targeting children for the removal of the incorrect penicillin allergy label provides a mechanism to reduce the use of broader-spectrum and less effective antibiotics.

Figure 1:. Antibiotic Pathway in Children with Penicillin Allergy

Pediatric patients commonly present for a range of bacterial illnesses. The most common pediatric illnesses include pneumonia, otitis media and strep pharyngitis. The first-line antibiotic therapy for children with these illnesses are amoxicillin. However, in patients reporting penicillin allergy providers are reluctant to prescribe and often alter their prescribing practices based on the reported allergy. If a Type 1 reaction is suspected, then alternative therapy often includes Azithromycin or Clindamycin both of which are two to five-fold cost increase over Amoxicillin. If the patient is not suspected to have had a Type 1 reaction, then Cefdinir is often the second-line agent which is approximately a five-fold increase over Amoxicillin.

Figure 2:. Risk-Stratified Pathway for Penicillin Allergy Evaluation

Different strategies of evaluation for penicillin allergy are effective in delabeling children. The first step in a penicillin allergy evaluation is to obtain the history of the allergic reaction that includes name of drug, reaction symptoms and timing. Once a comprehensive history is taken there are different pathways that one can progress down. These include a high and low risk pathway along with a pathway in which testing is not recommended. If a patient has low risk symptoms, then a provider based on comfort level could initiate 3-tier skin testing or direct oral challenge studies. Oral challenge options would include a graded, single-dose, or extended day oral challenge. If a patient has high risk symptoms (or was skin tested for low risk symptoms) proceeding on an oral challenge depends upon the result of the skin test and provider comfort. In those with negative skin tests a provider should move forward with a graded oral challenge. If a positive skin test is obtained then it is best to avoid penicillins and all R1 similar cephalosporins and consider further testing for cephalosporins. Testing is not recommended in children who have had skin peeling, mouth/body blisters and severe delayed reactions.