What is the importance of antibiotic allergy delabeling in patients with reported antibiotic allergies?

From the Guidelines

Antibiotic allergy delabeling is a crucial step in clinical practice that should be prioritized to improve patient outcomes, reduce antimicrobial resistance, and decrease healthcare costs. When considering the importance of antibiotic allergy delabeling, it is essential to understand the burden of a penicillin allergy label, as approximately 10% of patients report a history of reacting to a penicillin class antibiotic, but 90% of these individuals tolerate penicillins and are labeled allergic unnecessarily 1. The process of delabeling involves a systematic approach to verify if a patient truly has an allergy, typically beginning with a detailed clinical history to assess the nature and timing of the previous reaction, followed by skin testing when appropriate, and in some cases, direct oral challenges under medical supervision. For penicillin allergies specifically, skin testing with Pre-Pen (benzylpenicilloyl polylysine) and penicillin G can effectively rule out IgE-mediated reactions, and if skin tests are negative, an oral challenge with amoxicillin (typically 250-500 mg) can confirm tolerance 1. Successful delabeling allows patients to access first-line antibiotics, reducing antimicrobial resistance, decreasing healthcare costs, and improving clinical outcomes, with the risk of recurrent allergic reactions in appropriately delabeled patients being extremely low, generally less than 2% 1. Key benefits of delabeling include:

• Reduced use of broad-spectrum antibiotics
• Decreased risk of developing vancomycin-resistant Enterococcus, Clostridium difficile, or methicillin-resistant Staphylococcus aureus
• Lower medical costs and shorter hospital stays
• Improved antibiotic selection and reduced risk of surgical site infections
• Potential cost savings through reduced healthcare utilization 1. Implementing a formal antibiotic allergy assessment program with clear protocols for testing and documentation is essential for healthcare facilities to maximize the benefits of delabeling. Healthcare providers should prioritize antibiotic allergy delabeling as a routine practice to improve patient care and outcomes.

From the Research

Importance of Antibiotic Allergy Delabeling

• Antibiotic allergy delabeling is crucial for reducing the risks associated with reported penicillin allergy labels, as more than 90% of patients labeled as allergic to antibiotics are not allergic 2, 3.
• The label of antibiotic allergy, whether real or not, constitutes a major public health problem as it directly impacts antimicrobial stewardship, leading to broad-spectrum antibiotic use and the emergence of bacterial resistance 2.
• Accurate diagnosis is essential for de-labeling patients who claim to be allergic but are not really allergic, and a multidisciplinary approach is recommended to reduce the risks associated with the reported penicillin allergy label 2, 4.

Strategies for Antibiotic Allergy Delabeling

• Various delabeling strategies can be used, including direct penicillin challenge, penicillin skin testing, and amoxicillin challenge, depending on the patient's risk history 5, 6.
• Patients with low-risk allergy histories can undergo direct amoxicillin challenge, while moderate-risk patients can be evaluated with penicillin skin testing 6.
• Drug challenge is the preferred method for evaluation of fluoroquinolone and macrolide allergy 5.

Benefits of Antibiotic Allergy Delabeling

• Antibiotic allergy delabeling can decrease antibiotic resistance, reduce costs, and optimize patient outcomes 3.
• Delabeling patients in a proactive manner can reduce patient morbidity and improve readiness with optimal antibiotic options 5, 3.
• Evaluation and clearance of penicillin allergies can improve clinical outcomes, decrease adverse effects from higher risk alternative broad-spectrum antibiotics, and prevent the spread of antibiotic resistance 3.

Target Populations for Antibiotic Allergy Delabeling

• Recent programs have targeted patients thought to be most likely to benefit from removal of inaccurate antibiotic allergy labels, including those with β-lactam antibiotic allergies and high-risk populations likely to need β-lactam antibiotics as first-line treatment 4.
• High-risk populations likely to benefit from first-line β-lactam antibiotics include perioperative, prenatal, and immunocompromised patients 4.
• Delabeling programs have been successful in the inpatient and outpatient settings at enabling appropriate antibiotic use, and have been implemented with good outcomes in pediatric patients and programs utilizing telehealth 4.