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Safety, effectiveness, and acceptability of antenatal penicillin allergy evaluation: a systematic review
Lindsay Reddeman1, Justin W J Lim1, Kellie E Murphy2
1Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada.
Insights
Penicillin allergy evaluation in pregnant patients is safe and effective, with over 93% of participants being delabelled. Expanding access can optimize antimicrobial therapy and improve outcomes for mothers and neonates.
Area of Science:
- Obstetrics and Gynecology
- Allergy and Immunology
- Pharmacology
Background:
- Approximately 8-13% of pregnant patients report penicillin allergy, leading to avoidance of crucial beta-lactam antibiotics.
- This avoidance can result in suboptimal treatment, increased antimicrobial resistance, higher healthcare costs, and adverse outcomes for both patients and neonates.
- True penicillin allergy is rare, with up to 95% of unverified allergies being resolved upon evaluation.
Purpose of the Study:
- To systematically review the growing body of evidence on antenatal penicillin allergy evaluation for obstetric providers.
- To summarize the safety, effectiveness, and patient acceptance of penicillin allergy evaluations during pregnancy.
Main Methods:
- A comprehensive systematic search of multiple databases (Medline, Embase, CINAHL, Cochrane, PubMed, clinicaltrials.gov) was performed.
- Included were peer-reviewed studies of pregnant individuals with unverified penicillin allergy undergoing evaluation (≥5 participants).
- Excluded were case reports, non-peer-reviewed sources, and studies on desensitization for verified penicillin allergies.
Main Results:
- Nineteen studies involving 2085 participants were included. Over 93% (1956 participants) were delabelled through various evaluation methods.
- Penicillin skin testing combined with oral or intravenous challenge was a common and effective delabeling strategy.
- Adverse reactions were rare and mild, with no severe events requiring hospital transfer and no recorded adverse antenatal events.
Conclusions:
- Penicillin allergy evaluation during pregnancy is safe, effective, and acceptable to patients.
- There is a strong rationale for increasing access to these evaluations to optimize antimicrobial use.
- Expanding penicillin allergy testing can reduce antibiotic resistance and improve maternal and neonatal health outcomes.
Abstract:
Approximately 8% to 13% of pregnant patients report a penicillin allergy. Penicillins and other beta-lactams are widely used in pregnancy but are often avoided in these patients, resulting in suboptimal therapy, antimicrobial resistance, higher costs, and increased morbidity for patients and neonates. True penicillin allergy is rare, and 95% of unverified penicillin allergies are delabeled upon evaluation. Although penicillin allergy evaluation is safe and recommended for pregnant patients, few patients are assessed. Research concerning antenatal penicillin allergy evaluation is accelerating, and we undertook a systematic review to summarize this growing body of evidence for obstetrical providers. A comprehensive search of Medline, Embase, CINAHL, the Cochrane Central Register of Controlled Trials, PubMed (ahead-of-print and non-Medline records), and ClinicalTrials.gov was conducted in collaboration with a medical information specialist. There were no restrictions on study language, date, or design. All peer-reviewed studies of pregnant people reporting an unverified penicillin allergy and undergoing penicillin allergy evaluation with ≥5 participants were included. Case reports, non-peer-reviewed sources, and studies regarding desensitization of verified penicillin-allergic patients were excluded. Title/abstract review, full-text review, and data extraction were completed independently by 2 authors. Conflicts were resolved by a third author. Studies were evaluated using validated quality assessment tools. Nineteen studies (N=2085) were eligible for inclusion. In total, 1956 (93.81%) participants were delabeled through various approaches: direct oral challenge (18.61%), penicillin skin test and oral challenge (51.12%), penicillin skin test and intravenous challenge (2.97%), penicillin skin test alone (18.00%), history review (1.94%), and unspecified methods (7.41%). Acceptance of penicillin allergy evaluation was 60.88%. Overall, 17 mild and 8 mild delayed allergy-related adverse reactions occurred, requiring minimal intervention. There were 3 severe allergy-related adverse reactions: 2 participants experienced anaphylaxis (managed with intramuscular epinephrine and observation), and 1 patient had mild drug-induced hepatitis (resolved with observation). No hospital transfers were required. No adverse antenatal events were recorded. Penicillin allergy evaluation in pregnancy is safe, effective, and acceptable to patients. The case is strong for expanding access to optimize antimicrobial therapy, reduce antibiotic resistance, and improve outcomes for pregnant people and neonates.
