One Allergy, Two Paths: Navigating Penicillin Allergy Evaluation in Pregnant Patients, Direct Challenges Versus...

Area of Science:

• Obstetrics and Gynecology
• Clinical Pharmacology
• Allergy and Immunology

Background:

• Unverified penicillin allergy labels are prevalent, leading to adverse maternal and neonatal outcomes.
• Penicillin allergy evaluation in pregnancy is recommended to prevent neonatal Group B streptococcal disease complications.
• Traditional penicillin skin testing (PST) followed by challenge is standard, but direct oral challenge (DOC) is emerging.

Purpose of the Study:

• To present a pro-con discussion on the use of direct oral challenges (DOCs) for penicillin allergy evaluation during pregnancy.
• To review evidence supporting both PST and DOCs in pregnant populations.
• To explore how DOCs can address disparities in penicillin allergy delabeling.

Main Methods:

• Narrative review of existing literature on penicillin allergy testing in pregnancy.
• Analysis of data supporting penicillin skin testing (PST) followed by penicillin challenge.
• Examination of evidence for direct oral challenges (DOCs) from observational studies, RCTs, and meta-analyses.

Main Results:

• Penicillin skin testing (PST) followed by challenge has a strong evidence base for identifying penicillin sensitization.
• Direct oral challenge (DOC) is supported by robust evidence, particularly for low-risk patients and in pregnant populations.
• DOCs show promise in improving penicillin allergy delabeling rates and addressing health disparities.

Conclusions:

• Both PST and DOCs are valuable tools for penicillin allergy evaluation in pregnancy.
• Direct oral challenge (DOC) is an increasingly accepted standard of care for appropriately risk-stratified pregnant patients.
• Shared decision-making and evidence-based strategies are crucial for optimizing antibiotic use in pregnancy.