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Penicillin Allergy Assessment in Pregnancy: Safety and Impact on Antibiotic Use
Anna R Wolfson1, Christian M Mancini2, Aleena Banerji1
1Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, Mass.
Insights
Penicillin allergy evaluations in pregnant patients are safe and effective. Allergy testing safely removed penicillin allergy labels in 95% of cases, reducing broad-spectrum antibiotic use and increasing appropriate first-line antibiotic prophylaxis.
Area of Science:
- Obstetrics and Gynecology
- Allergy and Immunology
- Infectious Disease
Background:
- Group B Streptococcus and cesarean section prophylaxis often rely on penicillin and beta-lactam antibiotics.
- Approximately 10% of pregnant individuals report a penicillin allergy, complicating treatment guidelines.
Purpose of the Study:
- To evaluate the safety and impact of penicillin allergy assessment in pregnant patients.
- To determine if allergy evaluations influence antibiotic selection during pregnancy.
Main Methods:
- Retrospective review of obstetrician-ordered Allergy/Immunology (AI) electronic consultations (e-consults).
- Analysis of electronic health records for consultation recommendations, patient histories, and antibiotic utilization.
- Comparison of antibiotic use between patients who received and did not receive in-person AI evaluation.
Main Results:
- 93% of e-consults recommended in-person AI evaluation, with 61% of patients undergoing evaluation.
- Penicillin allergy labels were safely removed in 95% of skin-tested patients.
- In-person AI evaluation was associated with reduced vancomycin, clindamycin, and gentamicin use, and increased penicillin use.
Conclusions:
- Penicillin allergy testing in pregnant patients is safe and effective.
- Allergy evaluations led to increased use of first-line antibiotics for Group B Streptococcus and cesarean section prophylaxis.
- Formal allergy evaluations reduce unnecessary broad-spectrum antibiotic exposure in pregnant populations.
Background:
Penicillin and other beta-lactam antibiotics are recommended for group B Streptococcus and cesarean section prophylaxis, but approximately 10% of pregnant patients report a penicillin allergy.
Objective:
To assess the safety and impact of penicillin allergy evaluation in pregnant patients.
Methods:
In this retrospective study of obstetrician-ordered Allergy/Immunology (AI) electronic consultations (e-consults) from September 20, 2017 through December 31, 2019, we reviewed the electronic health record for e-consult recommendation; patient demographic, obstetric, and allergy histories; and peripartum antibiotic utilization with indication. For patients whose electronic consultation recommended an in-person AI evaluation, testing outcomes were determined, and multivariable logistic regression models were used to compare antibiotic use between patients who did and did not receive an in-person AI evaluation.
Results:
Of 389 obstetrician-ordered e-consults, 363 (93%) recommended an in-person AI evaluation; of these, 222 (61%) patients received an in-person AI evaluation. Of 220 (99%) patients skin tested, 209 (95%) had their penicillin allergy label safely removed. Compared with patients who did not receive an in-person AI evaluation despite it being recommended (n = 141), patients with in-person AI evaluation (n = 222) had reduced peripartum vancomycin (adjusted odds ratio [aOR], 0.07; 95% CI, 0.01-0.33), clindamycin (aOR, 0.17; 95% CI, 0.08-0.34), and gentamicin (aOR, 0.39; 95% CI, 0.19-0.78) use and increased penicillin (aOR, 18.0; 95% CI, 6.30-51.2) use. The fully AI evaluated patients had increased first-line antibiotic prophylaxis for group B Streptococcus (aOR, 26.9; 95% CI, 6.32-114) and cesarean section (aOR, 1.94; 95% CI, 1.06-3.52).
Conclusions:
In a sample of 220 pregnant patients with penicillin allergy histories and in-person AI evaluation, penicillin allergy testing was safe and associated with significantly reduced broad-spectrum antibiotic use and increased first-line beta-lactam antibiotic use.
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