Connect
MJA
MJA

How antibiotic allergy labels may be harming our most vulnerable patients

Jason A Trubiano, M Lindsay Grayson, Karin A Thursky, Elizabeth J Phillips and Monica A Slavin
Med J Aust 2018; 208 (11): . || doi: 10.5694/mja17.00487
Published online: 18 June 2018

Antibiotic allergy testing programs will ensure that vulnerable patients receive appropriate antibiotic therapy

Antibiotic allergy labels are accumulated by various mechanisms and are often incorrectly self-reported or recorded. Incorrect antibiotic allergy labels frequently persist in community and hospital medical records throughout patients’ health care journeys, either with the phenotype unverified by clinicians or recorded as unknown.1,2 Among a cohort of older Australian general medical inpatients, we identified that 25% had a mismatch between their reported and recorded antibiotic allergy.3 Further, as an additional source of incorrect antibiotic allergy labels, patients with a true immunological basis for antibiotic allergy, such as immediate (IgE-mediated) reactions, may lose reactivity over time.4 Incorrect antibiotic allergy labels often prevent the use of appropriate narrow spectrum penicillin and targeted antibiotic therapies in both community and hospital practice, frequently among the patients most in need.4,5


  • 1 Austin Health, Melbourne, VIC
  • 2 Peter MacCallum Cancer Centre and National Centre for Infections in Cancer, Melbourne, VIC
  • 3 University of Melbourne, Melbourne, VIC
  • 4 Royal Melbourne Hospital, Melbourne, VIC
  • 5 Institute for Immunology and Infectious Diseases, Murdoch University, Perth, WA



Acknowledgements: 

We thank Megan Crane for her significant contribution to the manuscript preparation and Michael Sutherland for establishing the Austin Health multidisciplinary antibiotic allergy testing service.

Competing interests:

No relevant disclosures.

  • 1. Trubiano JA, Chen C, Cheng AC, et al. Antimicrobial allergy ‘labels’ drive inappropriate antimicrobial prescribing: lessons for stewardship. J Antimicrob Chemother 2016; 71: 1715-1722.
  • 2. Knezevic B, Sprigg D, Seet J, et al. The revolving door: antibiotic allergy labelling in a tertiary care centre. Intern Med J 2016; 46: 1276-1283.
  • 3. Zhou L, Dhopeshwarkar N, Blumenthal KG, et al. Drug allergies documented in electronic health records of a large healthcare system. Allergy 2016; 71: 1305-1313.
  • 4. Trubiano JA, Leung VK, Chu MY, et al. The impact of antimicrobial allergy labels on antimicrobial usage in cancer patients. Antimicrob Resist Infect Control 2015; 4: 23.
  • 5. MacFadden DR, LaDelfa A, Leen J, et al. Impact of reported beta-lactam allergy on inpatient outcomes: a multicenter prospective cohort study. Clin Infect Dis 2016; 63: 904-910.
  • 6. Trubiano JA, Pai Mangalore R, Baey YW, et al. Old but not forgotten: Antibiotic allergies in General Medicine (the AGM Study). Med J Aust 2016; 204: 273. <MJA full text>
  • 7. Caubet JC, Frossard C, Fellay B, Eigenmann PA. Skin tests and in vitro allergy tests have a poor diagnostic value for benign skin rashes due to beta-lactams in children. Pediatr Allergy Immunol 2015; 26: 80-82.
  • 8. Vezir E, Dibek Misirlioglu E, Civelek E, et al. Direct oral provocation tests in non-immediate mild cutaneous reactions related to beta-lactam antibiotics. Pediatr Allergy Immunol 2016; 27: 50-54.
  • 9. Bourke J, Pavlos R, James I, Phillips E. Improving the effectiveness of penicillin allergy de-labeling. J Allergy Clin Immunol Pract 2015; 3: 365-334 e361.
  • 10. Trubiano JA, Worth LJ, Urbancic K, et al. Return to sender: the need to re-address patient antibiotic allergy labels in Australia and New Zealand. Intern Med J 2016; 46: 1311-1317.
  • 11. Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin “allergy” in hospitalized patients: a cohort study. J Allergy Clin Immunol 2014; 133: 790-796.
  • 12. Campagna JD, Bond MC, Schabelman E, Hayes BD. The use of cephalosporins in penicillin-allergic patients: a literature review. J Emerg Med 2012; 42: 612-620.
  • 13. Romano A, Gaeta F, Arribas Poves MF, Valluzzi RL. Cross-reactivity among beta-lactams. Curr Allergy Asthma Rep 2016; 16: 24.
  • 14. Kula B, Djordjevic G, Robinson JL. A systematic review: can one prescribe carbapenems to patients with IgE-mediated allergy to penicillins or cephalosporins? Clin Infect Dis 2014; 59: 1113-1122.
  • 15. Patriarca G, Schiavino D, Lombardo C, et al. Tolerability of aztreonam in patients with IgE-mediated hypersensitivity to beta-lactams. Int J Immunopathol Pharmacol 2008; 21: 375-379.
  • 16. Ressner RA, Gada SM, Banks TA. Antimicrobial stewardship and the allergist: reclaiming our antibiotic armamentarium. Clin Infect Dis 2016; 62: 400-401.
  • 17. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: 159-177.
  • 18. Schuts EC, Hulscher M, Mouton JW, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis 2016; 16: 847-856.
  • 19. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62: e51-77.
  • 20. King EA, Challa S, Curtin P, Bielory L. Penicillin skin testing in hospitalized patients with beta-lactam allergies: effect on antibiotic selection and cost. Ann Allergy Asthma Immunol 2016; 117: 67-71.
  • 21. Trubiano JA, Thursky KA, Stewardson AJ, et al. Impact of an integrated antibiotic allergy testing program on antimicrobial stewardship: a multicenter evaluation. Clin Infect Dis 2017; 65: 166-174.
  • 22. Marwood J, Aguirrebarrena G, Kerr S, et al. De-labelling self-reported penicillin allergy within the emergency department through the use of skin tests and oral drug provocation testing. Emerg Med Australas 2017; 29: 509-515.
  • 23. Confino-Cohen R, Rosman Y, Meir-Shafrir K, et al. Oral challenge without skin testing safely excludes clinically significant delayed-onset penicillin hypersensitivity. J Allergy Clin Immunol Pract 2017; 5: 669-675.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.