Penicillin allergies are fake news. More than 95 percent of people with penicillin allergies are not allergic. A recent article highlighted the opportunity anethesiologists have in helping evaluate beta-lactam allergies, in particular to cephalosporins. The author was correct, these allergies are common and usually not real. Unfortunately, premedication with antihistamines as suggested may mask allergic reactions and not clear the allergy, though the idea to think about retesting in a controlled OR setting is fantastic. Still, responsibility lands squarely on the shoulders of allergists to make a dent in this problem.
Why should we care? There are proven costs with being labeled as penicillin or amoxicillin allergic: greater risk of C. difficile infections, longer hospitalizations, more expensive antibiotics. Much has been published about efforts to clear penicillin allergies, but the scale of the problem is daunting. There are 30 million people in the U.S. who have a penicillin allergy. This is understandably hard to conceptualize, so let me break it down at the local level.
Within my hospital system of around 2 million patients, there are 40,000 children with penicillin and amoxicillin allergies. I have a medication allergy clinic where I can see at most 3 or 4 patients in an afternoon. At this rate, I will be clearing penicillin allergies for the next 300 years!
The AAAAI has a position statement recommending routine evaluation of beta-lactam allergies because of recognition of mislabeled allergies as a public health issue, and JAMA published a review and toolkit in January to assist with this. Even the Today Show highlighted the issue in recent weeks. Though the publicity undoubtedly will help, very few patients perceive their amoxicillin allergy as an issue. Why not just choose a different antibiotic? As we know, these are usually less effective, more expensive, and have more side effects.
To tackle the problem of mislabeled beta-lactam allergies, we need help making clean-up of these allergies more efficient, and to prevent their labeling in the first place.
Some things can be done quickly to help. Clear documentation of reactions by all health care providers in the EMR is vital. Including the exact date of the reaction, when it started in relation to when the medication started, if there is a rash how long it lasted, its features (more than writing hives, saying whether the rash is raised or flat, and fixed or mobile), and uploading pictures to the EMR will all assist the evaluation. I have had parents who can’t recall which of their children has the amoxicillin allergy; we end up testing all of them because somehow it was listed in all of their charts.
We can let families know that rashes may not be due to amoxicillin and that they should have allergy evaluation as soon as possible. Prepping for when they visit the allergist, and letting the families know what to expect, may help overcome initial hesitation to visit another doctor. The child (or adult) may not need skin testing (in the past this was always done with painful intradermal injections – essentially multiple PPDs). Our guidelines around who needs skin testing are in flux, and more physicians are skipping this and going directly to oral challenges.
We can start to change our societal narrative around drug allergies. Counseling the family that drug allergies are not “inherited” will go a long way. Grandma’s drug allergy should not affect a toddler’s prescription for amoxicillin.
Allergists will continue to clear the allergies and keep studying this problem so that we can safely give our tiny patients access to a lifetime of narrow-spectrum but extremely effective antibiotics. One day we may be able to have better diagnostic tools to confirm that the rash is just due to a virus. And that will be not fake news, but news we can all look forward to.
Cathleen Collins is a pediatric allergist.
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