A multicentre observational study to investigate feasibility of a direct oral penicillin challenge in de-labelling ‘low risk’ patients with penicillin allergy by non-allergy healthcare professionals (SPACE study): Implications for healthcare systems

• Published in: The Journal of infection Vol. 88; no. 3; pp. 106116 - None
• Main Authors: Krishna, Mamidipudi Thirumala, Bhogal, Rashmeet, Ng, Bee Yean, Kildonaviciute, Kornelija, Jani, Yogini H., Williams, Iestyn, Sandoe, Jonathan A.T., Pollard, Rachel, Jones, Nicola, Dunsmure, Louise, Powell, Neil, Hullur, Chidanand, Balaji, Ariyur, Moriarty, Catherine, Jackson, Beverley, Warner, Amena, Daniels, Ron, West, Robert, Thomas, Caroline, Misbah, Siraj A., Savic, Louise
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.03.2024; W.B. Saunders
• Subjects: Anti-Bacterial Agents - adverse effects; Antimicrobial resistance; Delivery of Health Care; Direct oral penicillin challenge; Drug Hypersensitivity - diagnosis; Feasibility Studies; High risk; Humans; Hypersensitivity; Low risk; Penicillin allergy; Penicillins - adverse effects; Risk stratification; Skin Tests; High risk; Direct oral penicillin challenge; Antimicrobial resistance; Low risk; Penicillin allergy; Risk stratification
• ISSN: 0163-4453; 1532-2742; 1532-2742
• DOI: 10.1016/j.jinf.2024.01.015

The huge burden of inaccurate penicillin allergy labels (PALs) is an important driver of antimicrobial resistance. This is magnified by insufficient allergy specialists and lack of ‘point-of-care’ tests. We investigated the feasibility of non-allergy healthcare professionals (HCPs) delivering direct oral penicillin challenges (DPCs) for penicillin allergy de-labelling. This prospective observational study was conducted in three hospitals in England across three settings (acute medical, pre-surgical and haematology-oncology). Patients with a PAL were screened and stratified as low risk/high risk. Low risk patients (non-immune mediated symptoms, benign rash, tolerated amoxicillin since and family history) underwent a DPC. N = 2257 PALs were screened, 1054 were eligible; 643 were approached, 373 declined, 270 consented and 259 risk stratified (low risk = 155; high risk = 104). One hundred and twenty-six low risk patients underwent DPC, 122 (96.8%) were de-labelled with no serious allergic reactions. Conversion rate from screening-to-consent was 12% [3.3% and 17.9% in acute and elective settings respectively; odds ratios for consent were 3.42 (p < 0.001) and 5.53 (p < 0.001) in haematology-oncology and pre-surgical setting respectively. Common reasons for failure to progress in the study included difficulty in reaching patients, clinical instability/medical reasons, lacking capacity to consent and psychological factors. DPCs can be delivered by non-allergy HCPs. A high proportion of patients with PALs did not progress in the study pathway. Strategies to deliver DPC at optimal points of the care pathway are needed to enhance uptake. Elective settings offer greater opportunities than acute settings for DPC. The safety and simplicity of DPCs lends itself to adoption by healthcare systems beyond the UK, including in resource-limited settings. [Display omitted] Non-allergy healthcare professionals can safely perform direct oral penicillin challenges.A high proportion of patients did not progress in the study pathway.Outpatient settings offer greater opportunities for penicillin allergy de-labelling.Multi-pronged strategies are needed in the patient pathway to enhance uptake.