Non-allergist inpatient penicillin allergy de-labelling (RIPAL)
Research type
Research Study
Full title
Non-allergist inpatient penicillin allergy de-labelling
IRAS ID
299708
Contact name
Neil Powell
Contact email
Sponsor organisation
Royal Cornwall Hospital NHS Trust
Duration of Study in the UK
0 years, 3 months, 4 days
Research summary
Research Summary:
Penicillin antibiotics are first-line treatment for many common infections. Approximately 15% of inpatients are reported to have a penicillin allergy label precluding the use of penicillin in favour of second line antibiotic agents. This use of non-penicillin antibiotics is associated with exposure to a greater number of antibiotics, increased length of hospital stay, higher hospital readmission rates, increasing the cost of care. In addition, non-penicillin based antibiotics are often more costly, can be less effective in certain clinical circumstances, and are more toxic, and often broader spectrum potentially increasing patient’s risk of future infections with resistant bacteria.
More than ninety per cent of individuals with a penicillin allergy label can tolerate penicillin. Identifying and de-labelling patients who are not allergic to penicillin has the potential to reduce second line antibiotic use in favour of penicillin, thus reducing these associated unintended consequences associated with second line antibiotics.
Historically penicillin allergy testing has been done by allergists using penicillin skin testing prior to the definitive drug provocation test. More recently, drug provocation tests, without preceding skin testing, has been shown to be a safe de-labelling method for inpatients with a low-risk allergy history, and has been done by non-allergists, including pharmacists in several countries but none in UK inpatients.
The requirements of a penicillin allergy de-labelling intervention delivered, by non-allergists have been described by several allergy experts. This study has taken these recommendations and used them to develop an inpatient, non-allergist delivered, penicillin allergy de-labelling intervention that sets out to risk stratify patients and offer those with a low-risk penicillin allergy history, and on second line antibiotics, an amoxicillin test dose to demonstrate penicillin tolerability and to change the patient’s current antibiotic therapy to first line therapy.Lay Summary of Results:
A large number of hospital patients have penicillin allergy records in their medical notes. Most of these patients can take penicillin antibiotics because they are wrongly diagnosed as having a penicillin allergy (PenA) record. The problem with incorrect penicillin allergy diagnoses is they prevent patients from receiving first line care for infections because the penicillin group of antibiotics are the preferred antibiotic for common infections treated in hospitals because they are effective and safe for patients.Pharmacists and junior doctors reviewed hospital patients and found those with penicillin allergy records that were preventing patients from receiving first line antibiotic therapy. We explored with patients what happened when they received a penicillin and if the reaction is identified as a low risk allergy then with the patients permission we either remove the penA label or offered the patient a test dose of penicillin prior to removing the penA label.
We took a penA history from 285 patients and found 45 (15.8%) met low-risk criteria and eligible to have their penicillin allergy record removed without further testing and 73 (25.6%) met criteria eligible for a test dose before removal of their penicillin allergy record. Of 45 low-risk patients eligible for eligible to have their penicillin allergy record removed without further testing, 40 (88.9%) were de-labelled and for 24 (53.3%) of these patients we changed their antibiotic to a penicillin. We were able to test 16 (21.9%) of the 73 eligible patients and changed 9 of these patients inpatients antibiotics to a penicillin.
Two patients experienced antibiotic side effects as a result of the change to penicillin. One patient experienced thrush within 5 days and delayed skin reaction after day 5.
We found that a penicillin allergy de-labelling patient pathway delivered by pharmacists and junior doctors was safe and effective and well accepted by patients and the wider clinical teams.
REC name
Yorkshire & The Humber - Leeds West Research Ethics Committee
REC reference
22/YH/0087
Date of REC Opinion
16 Jun 2022
REC opinion
Further Information Favourable Opinion