Sorting Through Penicillin Allergies

Special guest Deanna L. McDanel, PharmD, BCPS, BCACP, Clinical Pharmacy Specialist - Ambulatory Care and Clinical Associate Professor at the University of Iowa Healthcare and College of Pharmacy joins us to talk about penicillin allergies.

Listen in as they discuss how to identify the risk of a true penicillin allergy...and when to worry about cross-reactivity.

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Stephen Carek, MD, CAQSM, DipABLM, Clinical Assistant Professor, Family Medicine, Prisma Health/USC-SOMG Family Medicine Residency Program at the USC School of Medicine Greenville
• Anthony A. Donato, Jr., MD, MHPE, Associate Program Director, Internal Medicine from the Reading Health System, and Professor of Medicine at the Sidney Kimmel Medical College at Thomas Jefferson University
• Douglas S. Paauw, MD, MACP, Professor of Medicine at the University of Washington School of Medicine
• Craig D. Williams, PharmD, FNLA, BCPS, Clinical Professor, Department of Pharmacy Practice at the Oregon Health and Science University

None of the speakers have anything to disclose. 

Pharmacist’s Letter offers CE credit for this podcast. Log in to your Pharmacist’s Letter account and look for the title of this podcast in the list of available CE courses.

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Transcript

Narrator 0:05

Welcome to Medication Talk, the official podcast of TRC Healthcare, Homo pharmacist letter, prescriber's letter, RX Advanced, and the most trusted clinical resources. On today's episode, we'll be listening in as our expert panel discusses how to identify the risk of a true penicillin allergy and when to worry about cross-reactivity. Our guest today is Dr. Deanna McDannell from the University of Iowa Healthcare and College of Pharmacy. You'll also hear practical advice from panelists on TRC's editorial advisory board, Dr. Stephen Carrick from the USC School of Medicine Greenville, Dr. Anthony Donato from the Reading Health System, Dr. Douglas Powell from the University of Washington School of Medicine, and Dr. Craig Williams from the Oregon Health and Science University. This podcast is an extract from TRC's Emerging Recommendations panel webinar. Each month, experts and frontline providers discuss current medication therapy topics and practical recommendations to include in TRC's letter articles. The full webinar originally aired on April 18th, 2023.

CE Narrator 1:08

And now, CE information.

Narrator 1:12

Pharmacist Letter offers CE credit for this podcast. Please log into your Pharmacist Letter account and look for the title of this podcast in the list of available CE courses. None of the speakers have anything to disclose. Now, let's join TRC editor, Dr. Lori Dickerson, and start our discussion.

Lori Dickerson 1:31

We're talking about this now because you're in a key spot to identify the risks of a true penicillin penicillin allergy and when to worry about cross-reactivity. And so, Deanna, to get us started, we start our article off with a statistic that about 10% of the population reports a history of reacting to penicillin, but less than 1% of them are truly allergic. Can you comment on this statistic and if these are the percentages that you consider when you're discussing penicillin reactions?

Deanna L. McDanel 1:59

Yeah, this is a you know a well-known statistic and something that we certainly I you know I talk about with almost every single patient that comes into the clinic, and and frankly, they all they all um seem very shocked by this, by this, especially as we know, and we'll talk about a little later, but there is a time decay that we know can happen with penicillin allergies. But yeah, we do know that definitely probably less than 1% of the population have a true allergic reaction to penicillin.

Lori Dickerson 2:26

Okay, good to get that sort of groundwork laid. And stepping to the next question, of course, we know it's important to accurately document penicillin allergies, but let's um just sort of talk through some of the downstream effects of inaccurate documentation of penicillin allergies. What are your thoughts on this point, Deanna?

Deanna L. McDanel 2:46

Yeah, I think you know, ultimately we do see a lot of patients with the label. And when I call it the label, is ultimately is are they truly allergic? And really it does have personal and public health implications. Specifically, as a personal health implication, you know, patients are going to have less or fewer efficacious antibiotic choices, more toxic effects associated with using the broader spectrum antibiotics. And then ultimately, there's been shown to have more postoperative surgical site infections by not using the first-line surgical prophylaxis. For a public health standpoint, you know, ultimately we could lead to using those broader spectrum antibiotics and antibiotic resistance, as well as it's been shown to have higher rates of C. diffacyl by using, again, those broader spectrum or alternate antibiotics and more costly costs to the institution and to the patient, as well as just increased risk of or length of hospital stays. So there's a lot of reasons we absolutely should identify if the label is true.

Lori Dickerson 3:46

You know, that uh great points there. And specifically, I'm glad that you brought up some of the hospital-specific complications. We do have a hospital-specific version of this letter, and we do um comment on surgical site infections and um C diff, et cetera, and length of hospital stay. We have an audience question coming in, and they're wondering, you know, has that been prospectively studied? Is that more of a link or is there a direct relationship there between uh, you know, uh non-preferred antibiotic due to a penicillin allergy and some of these downstream effects? What are your thoughts on sort of that body of literature, Deanna?

Deanna L. McDanel 4:20

Yeah, I mean, what I've seen is it's been mostly retrospective or causality studies, um, but but certainly has shown to there has been a statistically increased risk of those effects. So, you know, I would say that we uh generally do think of that as a concern when we are you know looking at our inpatients and determining whether or not they should get the penicillin or the beta-lectin.

Lori Dickerson 4:44

Well, great overview there. And um I'm going to uh uh go straight to our next audience question that's coming in, which is uh not currently part of our article, but we are get seeing a lot of chatter about patients not really knowing much about their drug allergies and the documentation of these being pretty poor in the electronic health record. And so, Doug, I'm just wondering from you, what's your experience been with you know seeing allergy documentation either in the record or from the patient and trying to tease that out? Is that a how how challenging is that?

Douglas S. Paauw 5:15

It it is. I mean, the problem is it's uh, you know, we'll say it's an allergy, and there's no description of what it is. And as me as as you allude to, the patients don't often really remember what it is. I you know, I've I've had patients where they say they have penicillin allergy and ask, well, how do you know? Well, my mom told me, well, what did she, you know, well, she just said I should never have penicillin, and then, you know, well, it was either me or my brother, and and and it was she just told us both. And so um, yeah, I think getting an accurate description, and then I think this will be discussed probably, is when people don't have accurate descriptions of a long time ago, that that we really should back away from our the the incredible fear we have of of confronting this.

Craig D. Williams 6:00

The way this works in our EMRs, you can often enter adverse reaction problems as opposed to allergy or hypersensitivity problems, and not all EMRs handle that well, but yeah, documenting what it was, because when we ask the patient sometimes we get answers like it gave me a headache or I got stomach upset or you know, adverse, clearly non-hypersensitivity reactions. If you can clarify that in the EMR, that goes a long way for the next provider. It's not really an allergy, so the patient felt they didn't do well on it for some reason.

Lori Dickerson 6:28

Right. And so definitely when you hear that, it's an opportunity to delabel penicillin allergies. And uh we do want to talk about delabeling and Deanna. This is kind of a new term for probably a lot of folks. Um, and it was new to me when we were picking this piece up. Um, can you comment on this practice and how widespread it is? And of course, uh the push behind that being with respect to antimicrobial stewardship.

Deanna L. McDanel 6:52

Yeah, I mean, our we have definitely gone down the route of a lot of delabeling in our clinic, but it is we are working in a drug allergy practice. So, you know, certainly as we evaluate patients, we feel very confident after the evaluation, whether it be skin testing or by and large, now we're doing most mostly drug challenges, that we feel very confident to delabel allergies. However, I think in most practices, if you get a really good history, frankly, you might be able to delabel patients just simply based on history alone. And unfortunately, as I know was discussed here just moments ago, is most EMRs unfortunately don't sometimes have those adverse reaction buckets. And our health system is a large health system and only still has just the allergy bucket, and it's really frustrating. Um, but we do try to just at least put descriptions into the EMR if we um, you know, again, if I'm working in a non-allergy setting, just making sure they've there's a full description of what their allergy is. So um, and then maybe putting a priority as a lower priority and delabeling to like not high priority or lower priority allergy.

Lori Dickerson 7:57

Well, let's um talk through the specifics of penicillin allergies first next. And we start with gathering details, is uh the first underline in the article, and to document the specific med, the reaction, and how it was managed at home. And so um, can you talk us through, Deanna, how you ask these questions in your clinic?

Deanna L. McDanel 8:17

Yeah, so absolutely. Definitely figuring out exactly what medication it was. Um, most commonly you'll have even just something on the list that says penicillins, but you find out it was actually augmentin or moxicillin that the patient took. So it's important to understand exactly what penicillin or cephalosporin they reacted to. The most important for us is how long ago was this? You know, most of our allergies we're finding from patients are many years ago, more than 10 years plus or more. I yes, the other day on Monday, I had um uh more patient with 50 years of history. So I'd been on the chart since childhood. Uh, so just getting the timeline. And then really more importantly is just how long into the course of antibiotics did the reaction happen. So was it immediate within hours, uh, you know, out to six hours or was it days removed? Um, because that will really help you determine if it was likely a delayed reaction or immediate reaction. And then also I don't trust when patients say that they developed hives or even a rash, because ultimately a rash to one patient may actually be hives or hives to a patient may actually be a rash. And so I actually show pictures of what a typical macular, papillar, or morbiliform eruption looks like, or what a hive looks like for patients if they're not certain on what that was. So, and then of course, just determining if there's any other severe symptoms like blistering of skin, skin peeling, um, or signs of anaphylaxis, that's gonna be extremely important. Uh, and then lastly, is just yeah, how did they treat that reaction and and simply have they taken that medication sense? Uh, you believe it or not, we do have a lot of patients where they have a penicillin allergy label, but they've tolerated amoxicillin in the last five years, for example. And and so that alone is an easy delabel. So got it.

Lori Dickerson 10:05

Very good. Okay, Andy, uh, from you next, I wanted to have you walk us through the signs and symptoms that you're looking for when evaluating the patient's penicillin allergy history. I think you've given us some great feedback on that when you reviewed this piece. What are your thoughts on specific things that you're asking about symptom-wise, signs and symptom-wise?

Anthony A. Donato 10:23

Yeah, I think a lot of this has been covered, but um, open-ended questions. Uh, what was the drug and what specifically happened to you? Um, I like to know just how sick they are. Uh, they were. Did you end up in the hospital? Did you end up with an airway problem or all really scary stuff? Um, did you end up in a burn unit? Did you have a horrible rash kind of stuff, or all things that would make me go, yeah, this sounds really, really serious? But I would say for the most part, I think we heard it. It's, I don't know, my mom told me, maybe that was Mickey, maybe that was me. You know, it's it's it's you this the histories are are pretty poor. And remember that uh we're talking about carrying forward uh records. Um my EMR is all of 18 years old, and before that it was paper, and you can't even find stuff. So it's really the memory of the patient or their parents, and it's it can be pretty poor.

Craig D. Williams 11:16

Why you have this paragraph on your screen too is um like Dan alluded to that you know, also ask and look for documentation of other antibiotics is uh because when we can find it in the EMR, especially in our hospitalized patients, they often don't know what they get during the course of the you know one or two week hospitalization. But yeah, we can find those big active times given, that's a huge piece of making us feel comfortable.

Lori Dickerson 11:38

Yeah, the uh our hospital version of this article has a great line that I love that says lean on your EHR if patients aren't sure what they've tolerated in the past. And so, you know, that's a a great, great cue that you guys have brought up. So very good. All right, so Deanna, let's talk about um assessing risk in terms of reaction severity and IgE mediated versus uh not IgE-mediated uh allergic reactions. Can you um explain this for us and let us know if you agree with the wording that we have uh here in our in our article?

Deanna L. McDanel 12:09

Yeah, so IgE mediated we know probably are going to happen likely within the first out first few hours. You know, it's been cited mostly as 30 minutes to two hours. However, the most recent drug allergy practice parameter did did comment on an immediate reaction out to six hours. And and I definitely agree that we have seen some patients with those more delayed, but still can be severe anaphylactic type reactions six hours later. Um, you know, I also don't trust 100% when patients say um it's been within the first day of taking it, especially if it was 20 or 30 years ago, they their recollection of time may be off. Um so you know, I still take a little bit more seriously if it was, if it especially if it sounded like IgE-mediated reaction. But anything beyond that is likely not that. Um, you know, and and probably is more in that we're getting into the point of delayed reactions. And delayed reactions can be typically more than 72 hours after the first dose of the course. Um, and then some of the more severe cutaneous, so scarce, severe cutaneous allergic reactions like Stevens Johnson and whatnot can be out to even weeks. Uh, so it's important to really get those histories on patients and identify the timeline.

Lori Dickerson 13:25

And we have actually next in in the article after this point is the one that we've already talked about that 80% of patients with an IgE reaction won't react after 10 years since IgE antibodies decrease over time. And uh, Deanna, we did talk about there are sort of two sets of statistics that are out there the five-year and the and the 10-year statistics. So, generally speaking, you're these these are the mantras that you would follow.

Deanna L. McDanel 13:46

Absolutely. And and you know, used to be that to be honest, in our practice, we probably were a little more conservative that we wanted to, we would probably skin test patients if it was less than 10 years. But I think now we do know that 50% of people can outgrow within five years, which gives us a little more comfort in even challenging patients directly with the medication. And again, in the clinical setting when we can observe them. Um, but yes, these statistics I probably say at least five to six times a day in my clinic.

Lori Dickerson 14:15

So very good. All right. So now let's um move on to the categories of high versus moderate versus low risk patients. Um and so uh in our risk stratification, again, we've used these terms. And to start, Deanna, what would you consider to be a high risk patient?

Deanna L. McDanel 14:35

Yeah, and you know, this is something that is harder to define uh in the in even in our drugology practice parameter in the drugology world, the the question always is how do you define high versus moderate versus low? Um, generally speaking, this is exactly how I would word it. High risk would be those that definitely had anaphylaxis or anaphylactic shock, or those severe, more delayed cutaneous allergic reactions, so otherwise known as SCAR, and that can be Stevens-Johnson syndrome, um, acute generalized uh erythematis postulosis or AJEP or dress, which is you know drug reaction with eosinophilia and systemic symptoms. So those are going to be more your very high-risk patients or high risk. There's also something in practice that we've started to utilize, and it's from Trubiano and colleagues. Um, it's called the PEN FAST score. Uh, and I don't, I don't think we referred to it necessarily in this article, but it is something that if people want to go out and look for, um, and it's really kind of a quick scoring tool, and essentially it gives you have five-point max, and it's all based on time, um, five less than five years, if they had anaphylaxis or angiodema or the SCAR reaction, and did they require treatment for the reaction? And based on that, the higher the point, so five or more, four or five points would be high risk, and then anything in the one or two points is considered low risk. The other thing, and I know we have this in the article, but low risk, I would agree, are just kind of more just those patients where it was longer ago, it was maybe just related to hives or maybe even a rash, those would be considered on non-severe and non-anaphylactic and low risk allergies.

Lori Dickerson 16:12

And then our moderate risk people are sort of the ones in the middle, right? Non-anaphylic reactions, uh one that's immediate, such as hives, um, uh, but uh of course non-anaphylactic. So, Craig, just to hear from you too, are these sort of the ways that you would bucket your bucket these patients?

Craig D. Williams 16:29

Yeah, no, I think the main that's severe skin reactions and anaphylaxis are the two. And I think um I think one of Deanna's points, that's um, not sure everybody got it, did they see need treatment for the reaction? I think is a great question for us to know from the patient, and kind of goes to the open-ended questions that Andy and Doug were talking about earlier. So if they did not need treatment for whatever they thought they had, whether it was itchiness or what they thought was a rash, um, that's we feel pretty safe compared to, yeah, I had to go to the hospital or I had to see urgent care, and that sets off the alarm bells. And I don't know if I think about moderate. I kind of think there's high risk, and then there's pretty much everyone else. So we can leave moderate in, but I don't know if we're really thinking about like a third category of moderate versus mild, but you know.

Lori Dickerson 17:13

Okay. Okay. And um uh Doug, just to hear from you, uh, is this sort of the approach that you're taking with your patients? And uh who do you typically what are you mostly seeing in your in your clinic? I would guess they're mostly low-risk patients.

Douglas S. Paauw 17:26

Yeah, well, I mean, with with these vague past histories, and I you know, I have a very low threshold of of of if I think the antibiotics are the appropriate antibiotic challenging them with these histories of you know, more than 10 years ago, 20, 30 years ago, and and then, you know, and I know this might be discussed, but I'll you know I'll sometimes have patients take a dose just for their own comfort level and stick around a little bit. Uh, because most of these are, you know, uh my experience, I really haven't had anything bad happen with these vague type of histories.

Lori Dickerson 17:59

Okay. All right, well, then let's um get into sort of evaluating our options. And one thing I want to uh reiterate there have been some questions coming up to this article, it is really focusing on patients with a history of penicillin allergy and not folks with a history of acephalosporin allergy, which is uh a different a different uh scenario. And we um, you know, have that covered in our clinical resource chart, but in in the discussion today, we're going to be focusing on penicillin allergies. And so, Deanna, to get us kicked off with evaluating our options, we say for high-risk patients with severe delayed reactions, avoid all beta-lactams and prescribe an alternative antibiotic class. And uh, what are your thoughts on this statement?

Deanna L. McDanel 18:44

Yeah, I think with uh delayed reactions, we we, you know, we're really thinking about those high-risk. So Stevens-Johnson, and I, you know, if we've ever seen that in practice, it's hopefully it's not something you see very often. It might be one in a career. Um, and I I definitely have had just a couple of patients in my history of doing this for 20 years that we've questioned if it was Stevens-Johnson in the outpatient world, um, not seeing them on the inpatient side. But you know, in those aspects, we not we're not certain if it's drug-specific or class. And and the data is still questionable on that, but to be honest, it's probably safest to just avoid all beta lacteums or especially all penicillins in that case, if it's a penicillin that caused it, because you never want to induce a severe delayed reaction again in a patient. And so often we'll just recommend alternates at that point.

Lori Dickerson 19:36

And um, a question coming in with this definition of high-risk patients with delayed reactions. Um, with the high-risk patients here are not, we're not including folks who've had anaphylaxis. That's a different bucket of folks, right? Correct, correct.

Deanna L. McDanel 19:49

So I would not include the anaphylactic immediate reactions, it's more these what we consider scar or the severe cutaneous allergic reactions. So we've got a jet for us and Stevens-Johnson.

Lori Dickerson 20:00

Might be clearer to just sort of say for those with severe delayed reactions and get the high risk out, because I think some people do uh uh equate high risk with anaphylaxis, so that's something. I agree.

Deanna L. McDanel 20:11

Yeah, that's yeah, that's a good clarifying point.

Lori Dickerson 20:14

Okay, so um we then of course um make our next point, which would be to assess cross-reactivity. And uh, only about 2% of patients with a true penicillin allergy cross-react to cephalosporins. And that's something that you know we've all learned in pharmacy school and and medical school and it's et cetera. And so um, I guess to talk a little bit more about this, Deanna, and um, you know, the cross-reactivity and and um what options can be used in in these patients uh who do have a penicillin allergy. Can you comment on that?

Deanna L. McDanel 20:49

Yeah, so this is really a game changer, and really the paradigm has been shifting over the last maybe decade or so of practice. I know we um my my drugology clinic started just due to patients being referred to if whether they could get cephalin, for example, if that with a penicillin allergy. And now we know that that myth has been bunked, or you're debunked myths, I guess. And and absolutely, and even the practice parameter now fully supports that um is gives cephasolin regardless of their history, even if it's anaphylaxis. Uh, so that's because ultimately what it gets down to is the sharing of an R1 side chain. Uh so though I know there there was discussion about putting in and maybe in the supplementary as a table of what those R1 side chains are. And I think um it's good to always look at that. And I think that might be coming up here. Um it's just really the R1 sidechain is the primary target now, or what we know is the the antigenic responses are to that versus the core beta lactam structure. So that 2% or less is is well known. It's probably even frankly less than that. Um, and so it, but you know, ultimately if they do share an R1 sidechain that. That risk is higher that they could have a cross-reactive reaction. Um, but the yeah, the parameter really, the drug allergy parameter is very good and goes through kind of the recommendations. But you know, some game changers now is uh if you're a non-anaphylactic history and you have a penicillin non-anaphylactic history, you just give the cephalosforin. Um so that has been really a big, um, big change. Um now, if it is an anaphylactic history, you would probably want to recommend um you know doing penicillin guided skin testing or challenges, depending on the risk and how long ago the anaphylaxis happened before you would prescribe that cephalus worm with the same R1 side chain. Again, if it's a dissimilar side chain, though, just give it. And that is a practice change. So I think that's something that we're um probably in our practices gonna still feel a little uncomfortable with, but um certainly should feel with the guidance of the you know of the of the experts and the parameter to kind of back you up that that's okay to do it if it's like a structurally dissimilar um cephalosporm, just give it.

Lori Dickerson 23:10

Okay, so lots of great information there, some MedChem for everybody that can can uh get everybody uh uh flashbacks to to being in the classroom. Um and so we did not include the R group side chains in the article that you see in front of you. It is included in our in our hospital, our uh hospital pharmacist letter, and it's also in our clinical resource. And so uh more specifics about the um R chains are there. But for a patient with a history of anaphylaxis, we say advise using a cephalosborne with a lower cross-reactivity risk, such as cephiroxime. And we chose cephuroxime here as an example of uh, you know, one that um did not that was dissimilar and would be a go-to. And so just wanted to confirm with you, Deanna, that that would be a go-to that you would consider.

Deanna L. McDanel 23:57

Yeah, absolutely. Yeah, that would be a reasonable one because it does not generally share the same R1 side chain to um most to penicillin.

Lori Dickerson 24:05

So and then um we also have a table with you know selected meds with dissimilar R1 side chains to amoxicillin. And so just to ask you here, Deanna, if there are others that you know you would want to comment on that would be appropriate for use too, or is this a list that you uh would would would recommend?

Deanna L. McDanel 24:24

Yeah, so looking at this list that looks, yeah, that would all be medications again, and and the cephazolin, again, as I highlight, is one that you should use regardless, just because it does not have um its structure is so unique, it does not actually have an R1 site gene. So just use it. But yes, this is like a good list for you to kind of back up back to if you um have an allergy to moxicillin, again, an anaphylactic allergy to moxicillin or concern about prescribing acephalosporin.

Lori Dickerson 24:53

And then for our uh hospital pharmacist letter, we would say if someone has a history of anaphylaxis to a penicillin, you'd use a cephalosporin uh with a dissimilar um chain, right? To similar our chain. Similar stuff. Dissimilar. Yes. Yes, very good. Okay. Um I'm gonna come back to you, Craig. Uh, lots of stuff we've talked about here. I know this is something that you've been involved with at your institution too. Is this consistent with your approach also?

Craig D. Williams 25:19

It is, yeah. It's uh, I mean, I have some sympathy and empathy for my colleagues on the outpatient side, everything gets tougher, you know, being on the hospital side, it's a bit easier for us to uh give the greater challenges and uh knowing we have the backup if we need it. For those with an anaphylacticology, you occasionally transfer them to the ICU and go ahead and do the greater challenge, it's obviously not an option outside the hospital, but but just in general, being able to do this at the hospital gives us a comfort level. Um the only point I might uh local education is that while these kind of anaphylactic or acute reactions can occur up to six hours out, the so many of them are I don't know what percent occur beyond even an hour, but it's very small. So our greatest challenge is you give a dose, wait 15 minutes, give a higher dose, wait another 15 minutes, and then you're on to full dosing. So generally pretty rapid progression.

Lori Dickerson 26:09

Um got it.

Craig D. Williams 26:10

But yeah, it's it's uh privilege to be able to do this on the inpatient side versus the outpatient side.

Deanna L. McDanel 26:16

Yeah, and Craig, I might just touch on that real quick too. And in the outpatient world, in a drug allergy clinic, again, or even um in providers' offices, if you're comfortable doing this, you know, our our rule of thumb is give give the dose again if it's in that lower risk or moderate risk group. Um, even anaphylaxis, if it's more than you know, five or ten years ago, you could really do this, but um, is just give give the dose, give a full dose, as we don't even do graded challenges very much in our practice. We'll just give the full dose. And we often use amoxicillin just because that clears them not only from a penicillin allergy, but an amino penicillin allergy. Um, and then we'll watch them an hour. Now, the the parameter says 30 minutes or longer, and I think it's just comfort. Um, but yeah, like you said, it most of those reactions are going to happen pretty quick. So usually an hour is sufficient time to feel comfortable delabeling the allergy if they tolerate.

Anthony A. Donato 27:10

Um, Dr. Badano, this is Andy Donato. Um, uh, what would you want those outpatient doctors to have on site in case there's a reaction? Do you recommend Yeah, that's a great point.

Deanna L. McDanel 27:18

Yes, absolutely. You should still have full full precautions on hand. You know, luckily in our practice, we've had very few patients that in the thousands we've done this and that have had anaphylaxis, but probably it's good to have a full anaphylaxis kit in the event that you do have one, you know, have that happen to you.

Lori Dickerson 27:36

Okay. Very good. Great discussion. And I guess to tie it, we have a lot of audience questions coming in that are hospital-specific. I want to get to, but to close out the article, uh, we do make the recommendation to refer high-risk patients or anyone hesitant to take a beta-lactam after a prior reaction to allergy for evaluation. And so um, Stephen and Doug, I wanted to hear from you about uh you know the practicality of these referrals in your practices is something that you're you're doing at this point, Stephen.

Stephen Carek 28:07

Yeah, try to do as much as we can, especially for patients that we think it's gonna be a really benefit for them, like patients who are trying to treat for syphilis or have had um maybe they've had recurring UTIs or something, they're getting antibiotics that maybe you know uh have more adverse side effect profiles like chloroquinolones for the and trying to get immunologists is mostly pretty quick. Um, I'd say you know, most communities have more primary doctors than they do allergists, and probably a ton of patients have this sort of mislabeling of uh penicillin uh allergy on their charts, and just trying to negotiate with them saying this is something that'd be important, could be benefit for you, um trying to introduce some of the public health ramifications of it as well. And this is something that we just are trying to change the sort of current paradigm, um, can help sort of convince the patient that this may be something good for them.

Lori Dickerson 28:58

Very good. And and uh Doug, what has your experience been?

Douglas S. Paauw 29:01

Yeah, the two groups I do are the the highest high risk of patients with you know anaphylaxis that that I really I really and I think you teed it up at the beginning, some of the risks of choosing other antibiotics that are higher risk in reality to the patient than and then exposing them to a penicillin. And certainly cephal sporins are okay and people, but the the group is the person who has had really, really high, high risk, or the person that I have tried to convince them and and you know I've wanted to re-challenge them, and they just say no, absolutely not, then I will offer them. Do you want to see a specialist who can test you and work with you? And and some of them will accept that. But some of my patients just absolutely this has been drilled into them, they refuse to take a penicillin.

Deanna L. McDanel 29:47

Right, yeah, right. We see that as well in practice, yeah.

Craig D. Williams 29:50

I'm sure to learn we have some listeners who say, I definitely have an earth to get my patient allergies the next six months. Um, there's places where that's uh just not a reality. So I think you give them some great points for people to feel like they can, you know, take some of this on themselves.

Lori Dickerson 30:04

A couple of rapid fire questions for you, Deanna. We for a hospital version. Uh, one that has come in is can patients with a history of anaphlaxis to a penicillin get a carbapenum if broad and broader antibiotic coverage is needed? What are your thoughts on that point?

Deanna L. McDanel 30:17

Absolutely. Regardless of their reaction to penicillin, similar to cephalin, just give the carbapenum. Um, same thing with astrianam. I think the only the only caveat to that, not a penicillin allergy to astrianam, but if you have a ceptazidine allergy, they do um estrionam and and ceptazidine do share a similar R1 side chain. So again, it gets at that higher risk of cross-reactivity with those patients specifically. But otherwise, just the guidance is just give it.

Lori Dickerson 30:45

Very good. Well, this has been a really great discussion. Uh, panelists, thank you guys so much for all of your feedback and practical tips. Please do check out our new clinical resource, Managing Betalactam allergies, for detailed answers to many questions, including types of hypersensitive area reactions, the role of skin testing, desensitization, and drug challenges, and so much more.

Narrator 31:07

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