The Burden of Self-Reported Antibiotic Allergies in Health Care and How to Address It: A Systematic Review of the Evidence.

BACKGROUND: Antibiotics are the first-line treatment for bacterial infections; however, overuse and inappropriate prescribing have made antibiotics less effective with increased antimicrobial resistance. Unconfirmed reported antibiotic allergy labels create a significant barrier to optimal antimicrobial stewardship in health care, with clinical and economic implications. OBJECTIVE: A systematic review was conducted to summarize the impact of patient-reported antibiotic allergy on clinical outcomes and various strategies that have been employed to effectively assess and remove these allergy labels, improving patient care. METHODS: The review was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A critical appraisal was conducted on all studies and a narrative synthesis was performed to identify themes. RESULTS: Four themes emerged: the prevalence of antibiotic allergy, impact of antibiotic allergy on antimicrobial prescribing, impact of antibiotic allergy on clinical outcomes, and delabeling strategies to improve clinical outcomes. Of the 32 studies, including 1,089,675 participants, the prevalence of reported antibiotic allergy was between 5% and 35%. Patients with a reported antibiotic allergy had poorer concordance with prescribing guidelines in 30% to 60% of cases, with a higher use of alternatives such as quinolone, tetracycline, macrolide, lincosamide, and carbapenem and lower use of beta-lactam antibiotics. Antibiotic allergy delabeling was identified as an intervention and recommendation to advance the state of the science. CONCLUSIONS: There is substantial evidence within the literature that antibiotic allergy labels significantly impact patient clinical outcomes and a consensus that systematic assessment of reported antibiotic allergies, commonly referred to as delabeling, improves the clinical management of patients.

The role of skin testing and extended antibiotic courses in assessment of children with penicillin allergy: An Australian experience.

AIM: To determine if skin testing (ST) in addition to extended oral provocation challenge (OPC) is necessary for beta-lactam allergy verification in an Australian paediatric population. METHODS: This was a retrospective study (176 children) that undertook assessments for beta-lactam allergy from 2006 to 2015 at a tertiary paediatric hospital. Patients either underwent direct OPC without ST or ST plus challenge if ST was negative. RESULTS: The analysis included children with a history of varying rash types/severity as well as angioedema and reported anaphylaxis. A direct OPC was undertaken in 73 children. Three children reacted with one anaphylaxis. A total of 103 children underwent ST, with 13 children (12.6%) reacting. Of the 90 who subsequently proceeded to OPC, 4 reacted. A total of 132 children were given an extended oral course of the culprit antibiotic, to which 6 children reacted. CONCLUSIONS: A direct OPC with the culprit drug in Australian children can be safely performed, avoiding resource-intensive and painful ST. Our data demonstrate that a prior history of anaphylaxis does not necessarily predict IgE-mediated allergy, as detected by positive immediate ST or reactions to oral challenge. Such history should not detract from efforts to assess these children for antibiotic allergy. We suggest that extended courses of at least 5 days are important in paediatric antibiotic de-labelling as six children (4.5% of those who were prescribed the extended course) reacted in our study and even developed symptoms late in the extended course, from days 2 to 6.

Antibiotic Allergy Labels in Children Are Associated with Adverse Clinical Outcomes.

BACKGROUND: Self-reported antibiotic allergies are common among hospitalized adults and children. However, there is a paucity of studies investigating the impact of an antibiotic allergy label in childhood. OBJECTIVE: To investigate the impact of antibiotic allergy labeling on clinical outcomes in children. METHODS: A retrospective study was conducted in a major pediatric tertiary hospital to capture inpatient admissions (N = 1672) in April 2014 and April 2015. Data, collected by chart review, included documented antibiotic allergy labels, antibiotic prescriptions, admitting specialty, hospital length of stay, and hospital readmissions. RESULTS: Of the 1672 pediatric patients surveyed, 58.1% were male and 44.8% were prescribed antibiotics. Antibiotic allergy labels were recorded in 5.3% of patients; most were ß-lactam allergy labels (85%), mostly to unspecified penicillins. There was an increasing incidence of antibiotic allergy label with age, which was statistically significant (P < .001); no sex effect was seen. Patients with antibiotic allergy labels received more macrolide (P = .045), quinolones (P = .01), lincosamide (P < .001), and metronidazole (P = .009) antibiotics than did patients without an antibiotic allergy label. After adjusting for patient age, sex, principal diagnosis, and admitting specialty, children with any antibiotic or ß-lactam allergy label had longer hospital stays (odds ratio, 1.62; 95% CI, 1.05-2.50; P = .03) with a mean length of hospital stay of 3.8 days for those without a label and 5.2 days for those with a ß-lactam allergy label. CONCLUSIONS: This is the first study demonstrating the negative impact of antibiotic allergy labels on clinical outcomes in children, as evidenced by significant alternate antibiotic use and longer hospital stays.