The Journal of Allergy and Clinical Immunology: In Practice
Original ArticlePenicillin Allergy Assessment in Pregnancy: Safety and Impact on Antibiotic Use
Introduction
Although 32 million Americans report penicillin allergy, less than 0.1% of these patients see an allergist for penicillin allergy evaluation.1,2 Penicillin allergy evaluation, which includes history-appropriate penicillin skin testing and/or oral amoxicillin challenge, is safe in the general population; removal of the penicillin allergy label (“delabeling”) is possible in up to 95% of patients with unconfirmed penicillin allergy histories and is associated with shifts in antibiotic use toward penicillins and other beta-lactam antibiotics.3,4 Previously, concerns about the safety of penicillin skin testing,5 anaphylaxis,6 and epinephrine use7 in pregnancy precluded allergy testing in pregnant women. However, severe allergic reactions, such as anaphylaxis, are rare,8 and initial studies demonstrated tolerance of penicillin skin testing and subsequent penicillin use in pregnant women.9,10 However, the safety of penicillin skin testing followed by oral challenge in pregnant patients has only been evaluated in small cohorts to date.
A history of penicillin allergy in pregnant patients is associated with increased exposure to broad-spectrum antibiotics, increased cost of care, and higher rates of adverse outcomes, such as new adverse drug reactions and longer hospitalizations.11 Beta-lactam antibiotics are first-line agents for antibiotic prophylaxis and treatment during the peripartum period. Group B Streptococcus (GBS) is the leading cause of infection in newborns12; the primary risk factor for GBS infection is colonization of the genitourinary tract of the mother, which occurs in 10% to 30% of women.13,14 Since guidelines were introduced to use penicillin antibiotics to treat GBS in the mother, neonatal infection rates declined by 80%.12 Similarly, in 2018, approximately one-third of deliveries in the United States were by cesarean section (C-section),15 for which cefazolin is recommended to prevent surgical-site infections because of its safety16,17 and effectiveness.18,19 Because the use of penicillin and other beta-lactams is important for pregnant patients,20, 21, 22 the American College of Obstetricians and Gynecologists encourages penicillin allergy testing in pregnant patients with a reported penicillin allergy.23
The Massachusetts General Hospital (MGH) Department of Obstetrics and Gynecology delivers more than 3500 babies per year, and 12.8% of patients in our hospital system have a reported penicillin allergy.24 As such, we designed a feasible program to routinely and proactively evaluate obstetric patients with a reported penicillin allergy. In this study, we present our electronic consultation (e-consult) program design and assess the safety and effectiveness of in-person Allergy/Immunology (AI) evaluation on peripartum antibiotic utilization.
Section snippets
MGH AI program for penicillin allergy assessment in obstetrics
E-consults are asynchronous, clinician-to-clinician exchanges that rely exclusively on information in the patient's electronic health record (EHR); they are designed to provide focused, patient-specific clinical guidance for nonurgent questions. The referring provider enters an order in the EHR, which is transmitted directly to the “In basket” of the specialist. The specialist reviews the clinical question in the order as well as relevant information in the patient's EHR and provides
Allergy evaluation and outcomes
Of 389 obstetric patients with a history of penicillin allergy, 363 (93%) were recommended for an in-person AI evaluation and 222 (61%) patients received in-person AI evaluation (Figure 1). There were 141 patients who were evaluated only with an e-consult although an in-person evaluation was recommended. The reasons in-person evaluation was not completed were largely unknown (52%), although 24 (17%) patients delivered before their scheduled appointment and 21 (15%) canceled their AI
Discussion
We used e-consults to identify and triage 389 obstetric patients with reported penicillin allergy in a large northeastern academic medical center; we evaluated 222 pregnant patients in-person in the third trimester, with resultant delabeling of 95% of them without any severe reactions or discernable impact related to timing or mode of delivery. To our knowledge, this study is at least twice as large as any penicillin-allergic pregnant cohort that has undergone penicillin allergy evaluation in
Acknowledgments
Sincerest thanks to Benjamin Slawski, NP, for performing many of the clinic visits for our patients as well as Susan A. Goldstein, MSIE, and Jason H. Wasfy, MD, MPhil, for their ongoing support for the e-consult system.
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This work was supported by National Institutes of Health (grant no. K01AI125631), the American Academy of Allergy Asthma and Immunology Foundation (AAAAI), and the Massachusetts General Hospital Claflin Distinguished Scholars Award. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the AAAAI Foundation, or the Massachusetts General Hospital.
Conflicts of interest: N. A. Phadke reports spousal employment by Chiesi Farmaceutici. K. G. Blumenthal and E. S. Shenoy report a licensed clinical decision support tool for inpatient beta-lactam allergy evaluation. The rest of the authors declare that they have no relevant conflicts of interest.