When a patient presents with an infection, antibiotics in the penicillin family are often the best option for clinical efficacy, cost-effectiveness, and safety. An effort currently under way at health care institutions nationwide, including UTMB, is helping ensure more patients can utilize this first-line agent when needed.
Currently, a large number of patients cannot be prescribed penicillin due to a reported allergy on their charts. But for the majority of these patients, this is no longer an active allergy.
“Most people will say, ‘I had a rash as a baby,’ or ‘My mom told me I was allergic,’ but they haven’t had (penicillin) since then,” says UTMB allergist Jennifer McCracken, MD. Patients with this history are the ideal candidates to undergo penicillin allergy evaluation.
In these cases, steps can be taken to de-label the patient so they can receive penicillin in the future. Dr. McCracken says it’s ideal for patients to be de-labeled before they find themselves in need of an antibiotic.
Primary care providers who see a penicillin allergy on their patient’s chart should consider consulting with Allergy and Immunology to ensure de-labeling is a safe option for the patient. If so, and the patient wants to be de-labeled, the provider can send a referral to Allergy and Immunology to begin the process.
Through a visit to the Allergy and Immunology clinic, the allergists can confirm the patient’s history and perform a graded-dose challenge with amoxicillin. Skin testing prior to the oral challenge is not required, but it is available for patients who prefer to take the extra precaution.
If the test is negative, the patient can be successfully de-labeled and have the allergy removed from their chart.
“Most people are pretty motivated to remove this allergy,” says Julia Tripple, MD, interim director of the Division of Allergy and Immunology. “They recognize that they have to take an alternative antibiotic because they have had this penicillin allergy for so long, and they want to be able to take a penicillin if they can.”
Some patients who have had an allergic reaction in the past are hesitant when first presented with the idea. However, they tend to relax when they hear some of the data around allergies.
“I usually share with patients if you haven't had any exposure in 10 years or the greater, there is an 80 percent chance that you have lost that allergy over time and now would be able to tolerate it,” Dr. McCracken says.
David Reynoso, MD, PhD, also champions the effort to de-label penicillin allergies. An Infectious Disease physician, he serves as Director of the Antimicrobial Stewardship Program at UTMB. This initiative aims to improve the quality of antimicrobial use by promoting optimal clinical outcomes through evidence-based antimicrobial management, minimizing antimicrobial toxicities, and reducing antimicrobial resistance.
“The reason stewardship is interested in initiatives like de-labeling and recognizing the problem with reported allergies is that reported allergies keep patients from getting the number-one treatment,” Dr. Reynoso says.
He says pneumonia, urinary infections, skin and soft tissue infections (like abscesses and cellulitis), and sepsis account for about 75 percent of the infections his division sees on a daily basis. The first-line antibiotics for all of those are beta-lactams in the penicillin family.
“When someone has a reported allergy – and beta-lactam allergies are the most commonly reported – it takes them from being able to receive the first-line therapy and bumps them down to getting alternatives that are not effective or not proven to work,” Dr. Reynoso says, adding that studies have shown that patients with reported allergies often have subpar outcomes.
The Antimicrobial Stewardship team has worked alongside the physicians in Allergy and Immunology to advance these efforts for the inpatient service, creating a set of guidelines to help physicians determine which patients may be candidates for penicillin skin testing.
Depending on the infection, some hospitalized patients may be able to undergo skin testing to have the allergy removed from their chart so they can receive a first-line therapy. But as time is of the essence when treating an infection, this is not always the case – making it even more important for patients who can be de-labeled to do so as part of their routine care.
“We want to put this at the forefront for community-based practitioners and ambulatory providers. In that role, it makes sense to de-label folks when they show up for their annual care,” Dr. Reynoso says, “before they actually have a
life-threatening condition for which they can't get a first-line antibiotic.”
 |  |  | Jennifer McCracken, MD, and Julia Tripple, MD, are physicians in the Division of Allergy and Immunology. David Reynoso, MD, PhD, is a physician in the Division of Infectious Diseases and Director of the Antimicrobial Stewardship Program. Learn about Allergy and Immunology services. |