Issue 13 / 11 April 2016

EXPERTS are calling for the reassessment of antibiotic allergy labels (AAL) to help reduce the widespread use of broad spectrum antibiotics.

Associate professor of medicine at the Australian National University and infectious diseases physician, Sanjaya Senanayake, told MJA InSight that “as doctors, whenever we see ‘allergy hyphen penicillin’ written on a patient’s notes, this needs to be investigated further”.

He said that making the distinction between a true allergy and an adverse drug side effect, like nausea or a rash, was essential in addressing the growing problem of antibiotic resistance.

“If we find it was a symptom of benign origin, we have the opportunity to give plain old penicillin as opposed to broad-based antibiotics, and we should take it.”

Professor Senanayake was commenting on research published today in the MJA which found the prevalence of antibiotic allergy labels was 24% among general medicine inpatients.

The study included 453 people with a median age of 82 years who were admitted to the general medicine units of Austin Health and Alfred Health over a 3-week period in 2015.

A questionnaire was administered to clarify any AAL history, which was followed by a correlation of responses with electronic and admissions record descriptions. A hypothetical oral-rechallenge in a supervised setting was offered to patients with low-risk allergy phenotypes.

The authors found that 107 patients had an AAL. Most of these patients were women, and more presented with concurrent immunosuppression than those without AAL.

A total of 54% of patients with AALs were willing to undergo an oral rechallenge, of whom 48% had a low-risk allergy phenotype.

The authors wrote that AALs were associated with increased prescribing of ceftriaxone and fluoroquinolone, antibiotics commonly restricted by antimicrobial stewardship programs.

“These findings inform a mandate to assess AALs in the interests of appropriate antibiotic use and drug safety.”

Lead author of the study and infectious diseases registrar at Austin Health, Dr Jason Trubiano, said in an MJA podcast  that it was frustrating “when our well-laid antibiotic plans are undone by an allergy label”.

However, these allergy labels were also of detriment to the patient, as an antibiotic like penicillin was far superior in treating community-acquired pneumonia, blood infections, and urinary tract infections compared to the broad spectrum alternatives.

“We have to try and find out how big the burden is, and what we can do to correct that in the future through dedicated antibiotic allergy services, oral challenges, or just rubbing them off the drug chart,” Dr Trubiano said.

Peter Collignon, professor of microbiology at the Australian National University, told MJA InSight that the high rate of AAL prevalence revealed by the research was significant, particularly among an elderly group of patients.

“It is likely that a lot of these allergies categorised as low risk were not in fact allergies, but adverse reactions.”

Professor Collignon said it was essential for GPs to determine how long ago the patient had their reported antibiotic reaction.

“Many years ago, antibiotics like penicillin could end up with impurities in them, so it could have been the impurities that the patient was reacting to and not the antibiotic itself.”

He said that if a patient reported symptoms that were indicative of an adverse drug side effect, like a rash or nausea, it was feasible for the GP to perform an oral challenge in a safe environment.

Professor Senanayake agreed, adding that “some GPs might feel more confident if this was done in a hospital where there is 24-hour care, but they should remember that they can always call for advice from a specialist, or a hospital, whenever they need it”.

Dr Trubiano said the next step now was to determine what existing services were available for GPs to manage the documentation of these allergies, and how new services could be implemented.

“We’ve created two dedicated antibiotic allergy clinics here at Austin Health and the Peter MacCallum Centre,” he said.

“Effectively, they’re de-labelling clinics where they want to get people in, test them, and remove the allergy label.”

He said the work these clinics were doing was highly effective, with previous research suggesting that it is possible to remove around 90% of people’s allergy labels.

However, it is essential to also develop simpler and cost-effective measures that GPs could roll out themselves.

“GPs are at the forefront and hopefully [this AAL burden] could be stopped in the GP clinic,” Dr Trubiano said.


Poll

Are antibiotic allergies worth rechallenging?
  • Yes, it would widen prescribing choice (75%, 81 Votes)
  • Maybe, under the right supervision (24%, 26 Votes)
  • No, it's quicker to prescribe something else (1%, 1 Votes)

Total Voters: 108

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7 thoughts on “Rechallenging antibiotic allergies

  1. Neville Ludbey says:

    Agree

  2. Richard Middleton says:

    This issue has been the bane of my professional life for longer than I care to remember.  As an anaesthetist it is one of the more significant irritating matters that we have to deal with and for what it is worth, here are my thoughts.

    1) It is often, but not always, a nurse who has told the patient that they are ‘llergic’ to something or other. This of course is NOT restricted to an IV push but also to oral ‘biotics’ that have cause a stomach upset or even ‘thrush’ Also and just as problematically, opioids that have cause nausea and vomiting or even constipation, but that is another sorry chapter. This indicates a clear and woeful lack of training, education or intelligence on teh part of the person fixing the label in the mind of the patient.  

    Hospital protocols  do not help the situation when it engenders a situation of institutional fear such that even the most trivial of events or utterly irrelevant (to the prevailing matter) reaction is labeled with a red band. When a patient with diarrhea from grapes is labeled the same as the person next door who needs ICU if they inhale a molecule of penicillin, it completely undermines the very real benefit of red wrist bands.  I suppose the answer is to have an entire range of wrist bands of different colours for different risks??    

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  3. Richard Middleton says:

    2) An amazing number of patients, particularly women, are firmly wedded to the idea of ‘being llergic’ to something or other. Presumably it validates them in some bizarre fashion and makes them medically more unique. This is the likely reason why …

    3) it is so very very hard at a preoperative discussion to explain to some such people the difference between an allergy and a side effect and why their nausea and vomiting with opioids can be overcome with the correct dose of an antiemetic. 

    On that topic, all too often, homeopathic doses of metoclopramide are still being given by attending health care staff who still do not know the correct dose/kg and appear to be unwilling to learn.

    4) Most people are grateful for the information and resulting reassurance. It is very common to be told “Nobody has told me that before doctor” and I wonder at the professional engagement of previous medical attendants. However, the shattering of world views and personally unique status that can result for some from these careful explanations can cause hostility, both overt and covert and on a couple of occasions, complaints have been made that “the doctor upset me”.  

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  4. Richard Middleton says:

    5) Such a complaint can provide welcome material for any administrator, medical or non medical, who seeks to exert their influence over the uppity professionals who work in ‘their’ hospital.

    The answer? All involved have to lift their game, from the GP to the admitting nurse and attending medical staff. This will  require a little more education for some, guidelines for others and an intellect adjustment for a minority. It is unacceptable for anybody to say “Not my area of expertise” or “Too busy”.

    As for testing with oral challenge, would it not be simpler and safer to perform an intradermal challenge, as we sometimes do in the peri-operative period?   

  5. Douglas Gow says:

    Here’s another (retired) anaesthetist who shares Richard’s views.

    As an aside, during the Falklands war every single casualty that came aboard the hospital ship was given 2x ten million units of penicillin as they crossed the gangway.  I think it was then 30% of the Brit population who claimed they were “allergic to penicillin”, but there wasn’t a single reaction of any note.

    And don’t get me started on “allergic to narcotics”!

  6. Adrian Clifford says:

    As a retired anaesthetist, I thought I’d add my 2 bobs worth to this discussion.

    Before ignoring the patient’s response as to whether they are allergic to a medication paticularly penicillin, I suggest you assess the intelligence of the patient and act accordingly.

    As to giving penicillin injections to all and sundry, (reference the Falklands war) that is tantamount to malpractise if there is a reaction. Many years ago as a junior resident, I saw a patient die from anaphylaxis at the end of a penicillln injection.

  7. Sue Ieraci says:

    Despite not being an anaesthetist and not being retired, I concur with the previous commentators that common side-effects (like vomiting from morphine) are frequently listed as “allergies”. The problem is not just over-reporting by staff, though. The national drug chart for hospitals has re-defned drug allergy reporting to “adverse drug reactions”, which now – necessarily – includes a longer list, and therefore a longer time to question and document each “reaction”. The chart can be seen here: http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/NIMC-acute

    This is just one more example where a process designed to improve safety (reduce dangerous drug reactions) can cause a side-stream hazards in another area. Combine this with our current culture, where every “error” leads to a systemic response, and it is easy to see why clinicians will enter whatever the patient tells them, and may have neither the time nor the motivation to elicit precise details. Our risk-averse culture also means that relatively junior staff find it easier to prescribe a more broad-spectrum antibiotic than not try a “challenge” – again for fear of being blamed if the patient were to have a reaction.

    In general, our clinical governance systems avoid taking risk, even for the overall benefit of the patient. This rule could be added to the Choosing Wisely campaign: do not prescribe an alternative antibiotic for an alleged antibiotic “allergy” without first confirming the details of the reaction.

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