True Rate of Allergy among Pediatric Inpatients with Penicillin Allergy Labels (TRIAL).

Background: Penicillin allergy is a common drug allergy diagnosis in pediatric patients; however, upon appropriate allergy testing, many of these patients are found not to have a true allergy. For patients with a reported allergy, alternative antibiotics are prescribed, which are less effective, more toxic, or more expensive. There is a lack of data evaluating allergies in hospitalized children and comparing allergy assessments conducted by pediatric allergists and pharmacists. Objective: To estimate the percentage of pediatric patients admitted with reported penicillin allergy who did not have a true penicillin allergy. Methods: This single-centre prospective cohort study included inpatients between 6 months and 17 years of age, with a documented penicillin allergy, who were admitted to the general pediatric and oncology units of a tertiary care children's hospital between November 2019 and March 2023. The allergy history, evaluation, and risk categorization were performed by pharmacists. The history was reviewed with the allergist, and the patient was then referred, underwent skin testing, or received oral amoxicillin challenge with monitoring for 1 hour. Results: Thirty patients were included, of whom 29 (97%) had delabelling of their penicillin allergy. Four patients (13%) had delabelling on the basis of history alone, without risk assessment. Twenty-five (83%) of the patients were assessed as having low risk; 24 of these had delabelling following oral challenge, and 1 did not complete the oral challenge because of transfer to another hospital. One patient (3%) was assessed as having moderate risk, with delabelling on the basis of results of skin testing and oral challenge. The pharmacist's and allergist's risk assessments were in agreement in 29 (97%) of the 30 cases. Conclusions: Pediatric patients, including those with oncologic malignancies, are often mislabelled as having a penicillin allergy. Pharmacists are able to accurately determine true allergy risk and delabel penicillin allergies for pediatric patients in the hospital setting.

Contexte: L'allergie à la pénicilline est un diagnostic d'allergie médicamenteuse courant chez les patients pédiatriques; cependant, après des tests d'allergie appropriés, bon nombre de ces patients ne présentent pas de véritable allergie. Pour ceux présentant une allergie signalée, des antibiotiques alternatifs sont prescrits, moins efficaces, plus toxiques ou plus coûteux. Peu de données permettent d'évaluer les allergies chez les enfants hospitalisés et de comparer les évaluations des allergies réalisées par les allergologues pédiatriques et les pharmaciens. Objectif: Estimer le pourcentage de patients pédiatriques admis avec une allergie à la pénicilline signalée, mais qui n'avaient pas de véritable allergie à la pénicilline. Méthodologie: Cette étude de cohorte prospective monocentrique comprenait des patients hospitalisés âgés de 6 mois à 17 ans, présentant une allergie documentée à la pénicilline, qui ont été admis dans les unités de pédiatrie générale et d'oncologie d'un hôpital pour enfants de soins tertiaires entre novembre 2019 et mars 2023. Les antécédents, l'évaluation et la catégorisation des risques de l'allergie ont été renseignés par les pharmaciens. L'anamnèse a été revue avec l'allergologue, et le patient a ensuite été référé, a subi un test cutané ou a reçu une provocation orale à l'amoxicilline avec surveillance pendant 1 heure. Résultats: Sur 30 patients inclus, 29 (97 %) ont vu un désétiquetage de leur allergie à la pénicilline. Quatre patients (13 %) ont bénéficié d'un désétiquetage sur la seule base de leurs antécédents, sans évaluation des risques. Vingt-cinq (83 %) patients ont été évalués comme présentant un faible risque; 24 d'entre eux ont bénéficié d'un désétiquetage à la suite d'une provocation orale, et 1 n'a pas terminé la provocation orale en raison d'un transfert vers un autre hôpital. Un patient (3 %) a été évalué comme présentant un risque modéré, avec un désétiquetage basé sur les résultats des tests cutanés et de la provocation orale. Les évaluations des risques par le pharmacien et l'allergologue concordaient dans 29 (97 %) des 30 cas. Conclusions: Les patients pédiatriques, y compris ceux atteints de cancers malins, sont souvent étiquetés à tort comme ayant une allergie à la pénicilline. Les pharmaciens sont en mesure de déterminer avec précision le risque réel d'allergie et de désétiqueter les allergies à la pénicilline chez les patients pédiatriques en milieu hospitalier.

Penicillin de-labelling in vancouver, British Columbia, Canada: comparison of approaches, outcomes and future directions.

BACKGROUND: Inaccurate penicillin allergy labels lead to inappropriate antibiotic prescriptions and harmful patient consequences. System-wide efforts are needed to remove incorrect penicillin allergy labels, but more health services research is required on how to best deliver these services. METHODS: Data was extracted from five hospitals in Vancouver, British Columbia, Canada from October 2018-May 2022. The primary outcomes of this study were to outline de-labelling protocol designs, identify the roles of various healthcare professionals in de-labelling protocols and identify rates of de-labelling penicillin allergies and associated adverse events at various institutions. Our secondary outcome was to describe de-labelling rates for special populations, including pediatric, obstetric and immunocompromised subpopulations. To achieve these outcomes, participating institutions provided their de-labelling protocol designs and data on program participants. Protocols were then compared to find common themes and differences. Furthermore, adverse events were reviewed and percentages of patients de-labelled at each institution and in total were calculated. RESULTS: Protocols demonstrated a high level of variability, including different methods of participant identification, risk-stratification and roles of providers. All protocols used oral and direct oral challenges, heavily involved pharmacists and had physician oversight. Despite the differences, of the 711 patients enrolled in all programs, 697 (98.0%) were de-labelled. There were 9 adverse events (1.3%) with oral challenges with mainly minor symptoms. CONCLUSIONS: Our data demonstrates that de-labelling programs effectively and safely remove penicillin allergy labels, including pediatric, obstetric and immunocompromised patients. Consistent with current literature, most patients with a penicillin allergy label are not allergic. De-labelling programs could benefit from increasing clinician engagement by increasing accessibility of resources to providers, including guidance for de-labelling of special populations.