A Penicillin Allergy Stewardship Team to Address Unconfirmed Pediatric Penicillin Allergies in Houston, Texas

To increase completed pediatric penicillin (PCN) allergy evaluations from 6 to 24 per month between January 2022 and December 2023.Pediatric patients seen across Texas Children’s Hospital (TCH) Pediatrics (70 primary care clinics) and TCH Urgent Care (13 centers).A team composed of Allergy and Immunology and Infectious Disease (ID) specialists was assembled. ID clinicians underwent 6 months of training to ensure accurate history taking, allergy severity stratification, and parental counseling. PCN allergy evaluations used a telemedicine-first approach followed by in-person evaluation when needed. If indicated, patients underwent oral amoxicillin challenges (OAC), preceded by skin testing (ST). The patient’s historic reaction to PCN determined whether they received ST or proceeded directly with graded OAC. ST was offered if patients developed immediate symptoms (cutaneous or respiratory) within 2 hours of a dose or had urticaria or anaphylaxis features during the antibiotic course. Per 2022 drug allergy guidelines, ST was reserved for the development of urticaria within 2 hours of a dose of amoxicillin, assuming no anaphylaxis or severe features. If ST was negative, patients proceed with a 2-step OAC, with electronic medical record delabeling if passed. If ST was positive or the OAC failed, the allergy alert would remain in the medical record. The primary outcome was average completed evaluations per month. An evaluation was considered complete if a patient completed the in-person allergy testing or if their PCN allergy was resolved. A survey assessed barriers to completion.Of 784 children scheduled for telemedicine visits, 336 (42.9%) completed their full PCN allergy evaluation: 50 via telemedicine alone and 286 after in-person testing. The average monthly evaluations increased from 6 to 19. Additionally, 286 out of 428 (66.8%) completed their in-person evaluations. Most children were delabeled during this visit (212 out of 286, 74.1%), either after having negative PCN ST and passing the graded OAC (n = 150) or by passing the OAC alone (n = 62). Of the 74 out of 286 who remained labeled, 61 had positive PCN ST. Survey results suggested that internal allergist referrals improved completion rates, while the 33% of patients that did not complete the evaluation reported that it was because the PCN allergy was “neutral” to “not important” to them. Among the 211 patients delabeled, 71 (33.6%) were diagnosed with bacterial infections requiring PCN during the study period, most within 90 days of delabeling, and successfully tolerated the antibiotic.Although the goal of 24-monthly completed PCN allergy evaluations was not met, the initiative tripled evaluation rates. Further, many delabeled children went on to require PCN for an infection, highlighting the need for accurate and timely PCN allergy assessment. Future work should explore the expansion of same-day in-person PCN allergy testing in the clinic setting and addressing barriers to these evaluations.Efforts to promote delabeling should be expanded to best serve pediatric patients. Emphasizing the importance of the evaluation to caregivers may improve delabeling rates.