Rising to the Challenge: An ID Provider-Led Initiative to Address Penicillin Allergy Labels at a Large Veterans Affairs Medical Center

Reuben J Arasaratnam; Jessica M Guastadisegni; Marcus A Kouma; Daniel Maxwell; Linda Yang; Donald F Storey

doi:10.1093/ofid/ofae396

Rising to the Challenge: An ID Provider-Led Initiative to Address Penicillin Allergy Labels at a Large Veterans Affairs Medical Center

Open Forum Infect Dis. 2024 Jul 11;11(8):ofae396. doi: 10.1093/ofid/ofae396. eCollection 2024 Aug.

Authors

Reuben J Arasaratnam¹, Jessica M Guastadisegni², Marcus A Kouma², Daniel Maxwell¹, Linda Yang², Donald F Storey¹

Affiliations

¹ Veterans Affairs North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
² Pharmacy Department, Veterans Affairs North Texas Health Care System, Dallas, Texas, USA.

Abstract

Background: Given the negative consequences associated with a penicillin allergy label, broader penicillin allergy delabeling initiatives are highly desirable but hindered by the shortage of allergists in the United States. To address this problem at our facility, the infectious diseases section introduced a quality improvement initiative to evaluate and remove allergy labels among inpatient veterans.

Methods: Between 15 November 2022 and 15 December 2023, we identified inpatients with a penicillin allergy label. We subsequently interviewed eligible candidates to stratify penicillin allergy risk and attempt to remove the allergy label directly via chart review, following inpatient oral amoxicillin challenge or outpatient community care allergy referral. Delabeling outcomes, subsequent penicillin-class prescriptions, and relabeling were tracked after successful allergy label removal.

Results: We screened 272 veterans, of whom 154 were interviewed for this intervention. A total of 53 patients were delabeled: 26 directly, 23 following oral amoxicillin challenge, and 4 following outpatient allergy referrals. Of the patients who were delabeled, 25 received subsequent penicillin-class prescriptions. No adverse reactions occurred following inpatient oral amoxicillin challenges. Patients with a low-risk penicillin allergy history were more likely to undergo a challenge if admitted with an infectious diseases-related condition. Only 1 inappropriate relabeling event occurred during the study period, which was subsequently corrected.

Conclusions: An infectious diseases provider-led initiative resulted in penicillin allergy label removal in more than one third of inpatients evaluated using direct removal or oral amoxicillin challenge. Efforts focused on patients who had been admitted for infections were particularly successful.

Keywords: amoxicillin challenge; beta-lactam; delabeling; penicillin allergy; veterans affairs.