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Empowering Pediatricians With Direct Penicillin Challenges: A Promising Delabeling Strategy
Katherine Park1, David J Schwartz1
1Department of Allergy and Immunology, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.
Insights
Penicillin allergy delabeling is safe and effective in low-risk pediatric patients. A 100% success rate was observed in direct oral penicillin challenges, supporting broader implementation in primary care.
Area of Science:
- Allergy and Immunology
- Clinical Pediatrics
- Pharmacology
Background:
- Penicillin allergy labels are often inaccurate and can lead to unnecessary avoidance of first-line antibiotics.
- A multidisciplinary approach is recommended for penicillin allergy delabeling.
- Direct oral challenges are a key component of delabeling low-risk patients.
Purpose of the Study:
- To evaluate the success rate of penicillin challenges at a military medical center.
- To assess the safety and reaction rate of direct oral penicillin challenges in low-risk pediatric patients.
Main Methods:
- Retrospective review of 74 pediatric penicillin challenges from June 2019 to May 2023.
- Patients were screened for reaction history; low-risk individuals underwent direct graded oral challenges without prior skin testing.
- Higher-risk patients or those with recent reactions/multiple allergies proceeded to skin testing with penicillin agents.
Main Results:
- All 74 pediatric patients successfully passed their penicillin challenges.
- A 100% pass rate was achieved for both direct oral challenges and challenges following skin testing.
Conclusions:
- Direct oral penicillin challenges demonstrate a high success and safety rate in low-risk pediatric populations.
- Expansion of penicillin delabeling strategies into primary care settings should be considered.
- Allergists should lead efforts to educate peers and promote multidisciplinary penicillin allergy delabeling.
Objective:
Current literature supports a multidisciplinary approach to penicillin allergy delabeling. Our study aims to review the success rate of penicillin challenges performed at Walter Reed National Military Medical Center Allergy Clinic and assess the reaction rate associated with a direct oral challenge in low-risk patients.
Materials And Methods:
We conducted a retrospective review of the outcomes of pediatric penicillin challenges at the Walter Reed National Military Medical Center Allergy and Immunology clinic from June 2019 to May 2023. A total of 74 challenges were included in this study. Patients were initially screened to assess the date of reaction, nature of reaction, if the reaction was life-threatening, and if the patient was hospitalized or sought emergency medical care for the reported reaction. After completion of the screening questionnaire, a direct graded challenge was performed (without skin testing) if a patient's history was deemed low risk. Patients with a recent reaction or a history of multiple drug allergies were more likely to be directed to skin prick testing and intra-dermal testing with Pre-pen and Penicillin-G prior to challenge.
Results:
All patients passed all challenges. Thus, there was a 100% pass rate for both direct challenges and skin test with oral challenges.
Conclusion:
Given the low rate of adverse events in this study, expansion of penicillin delabeling in the primary care setting should be considered in patients deemed to be at low risk. It is important for allergists to empower and educate their peers and push forward a movement to create a multidisciplinary approach to penicillin delabeling.
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