Quality Improvement to Engage General Pediatrics in Reducing Inaccurate Penicillin Allergy Labels



      To remove inaccurate penicillin allergy labels in the general pediatric clinic setting.


      From October 2017 through December 2021, this collaborative, quality improvement project used education, feedback, electronic health record alerts, and the introduction of oral amoxicillin challenges in a general pediatric clinic setting with the primary aim of decreasing the proportion of penicillin allergy labeled patients. Control charts were used to track the relationship between interventions and improvements in referral rates to allergy clinic, removal of the allergy label at clinic visits and the overall proportion of clinic patients labeled as PCN allergic.


      Referral rates to allergy clinic for penicillin allergy labeled patients increased from a baseline mean of 1.9% to 20.4%. The proportion of PCN allergy labeled patients who had the label removed during a pediatric clinic visit increased from a baseline of 1.1% to 6.6%. The overall proportion of penicillin allergy labeled clinic patients decreased from a baseline of 3.4% to 2.2%.


      With adequate education and collaboration with allergists, general pediatric practitioners can play a significant role in removing inaccurate penicillin allergy labels. Pediatricians can remove some of the burden placed on allergists by evaluating low risk patients in the primary care setting while referring higher risk patients to the specialist.


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        • King LM
        • Bartoces M
        • Fleming-Dutra KE
        • et al.
        Changes in US outpatient antibiotic prescriptions from 2011-2016.
        Clin Infect Dis. 2020; 70: 370-377
        • Castells M
        • Khan DA
        • Phillips EJ.
        Penicillin allergy.
        N Engl J Med. 2019; 381: 2338-2351
        • Staicu ML
        • Vyles D
        • Shenoy ES
        • et al.
        Penicillin allergy delabeling: a multidisciplinary opportunity.
        J Allergy Clin Immunol Pract. 2020; 8 (e2816): 2858-2868
        • Vyles D
        • Chiu A
        • Simpson P
        • et al.
        Parent-reported penicillin allergy symptoms in the pediatric emergency department.
        Acad Pediatr. 2017; 17: 251-255
        • Abrams EM
        • Wakeman A
        • Gerstner TV
        • et al.
        Prevalence of beta-lactam allergy: a retrospective chart review of drug allergy assessment in a predominantly pediatric population.
        Allergy Asthma Clin Immunol. 2016; 12: 59
        • Jeimy S
        • Ben-Shoshan M
        • Abrams EM
        • et al.
        Practical guide for evaluation and management of beta-lactam allergy: position statement from the Canadian Society of Allergy and Clinical Immunology.
        Allergy Asthma Clin Immunol. 2020; 16: 95
        • Stone Jr., CA
        • Trubiano J
        • Coleman DT
        • et al.
        The challenge of de-labeling penicillin allergy.
        Allergy. 2020; 75: 273-288
      1. Penicillin allergy in antibiotic resistance W. penicillin allergy testing should be performed routinely in patients with self-reported penicillin allergy.
        J Allergy Clin Immunol Pract. 2017; 5: 333-334
        • Mirakian R
        • Leech SC
        • Krishna MT
        • et al.
        Management of allergy to penicillins and other beta-lactams.
        Clin Exp Allergy. 2015; 45: 300-327
        • Broyles AD
        • Banerji A
        • Barmettler S
        • et al.
        Practical guidance for the evaluation and management of drug hypersensitivity: specific drugs.
        J Allergy Clin Immunol Pract. 2020; 8: S16-S116
        • Ham Y
        • Sukerman ES
        • Lewis 2nd, JS
        • et al.
        Safety and efficacy of direct two-step penicillin challenges with an inpatient pharmacist-driven allergy evaluation.
        Allergy Asthma Proc. 2021; 42: 153-159
        • Bauer ME
        • MacBrayne C
        • Stein A
        • et al.
        A multidisciplinary quality improvement initiative to facilitate penicillin allergy delabeling among hospitalized pediatric patients.
        Hosp Pediatr. 2021; 11: 427-434
        • Tucker MH
        • Lomas CM
        • Ramchandar N
        • et al.
        Amoxicillin challenge without penicillin skin testing in evaluation of penicillin allergy in a cohort of Marine recruits.
        J Allergy Clin Immunol Pract. 2017; 5: 813-815
        • Vyles D
        • Chiu A
        • Routes J
        • et al.
        Oral amoxicillin challenges in low-risk children during a pediatric emergency department visit.
        J Allergy Clin Immunol Pract. 2020; 8 (e1121): 1126-1128
        • Blumenthal KG
        • Shenoy ES
        • Hurwitz S
        • et al.
        Effect of a drug allergy educational program and antibiotic prescribing guideline on inpatient clinical providers' antibiotic prescribing knowledge.
        J Allergy Clin Immunol Pract. 2014; 2: 407-413
        • Wang H
        • Kozman M
        • Pierce H
        • et al.
        A quality improvement initiative to improve primary care referral rates for penicillin allergy delabeling.
        Ann Allergy Asthma Immunol. 2021;
      2. How to Improve. Boston, Massachusetts: Institute for Healthcare Improvement.
        2022 ((Available on) () Last accessed January 2022)
        • Prieto A
        • Munoz C
        • Bogas G
        • et al.
        Single-dose prolonged drug provocation test, without previous skin testing, is safe for diagnosing children with mild non-immediate reactions to beta-lactams.
        Allergy. 2021; 76: 2544-2554
        • Li J
        • Cvetanovski V
        • Fernando S.
        Single-step direct drug provocation testing is safe for delabelling selected non-low-risk penicillin allergy labels.
        Ann Allergy Asthma Immunol. 2021; 127: 232-235
        • Langley GL MR
        • Nolan KM
        • Nolan TW
        • et al.
        The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.
        2nd Edition. Jossey-Bass, San Francisco, CA2009
        • Berger RE
        • Singh HK
        • Loo AS
        • et al.
        Improving antibiotic stewardship for inpatients with reported beta-lactam allergies and limited access to penicillin skin testing.
        Jt Comm J Qual Patient Saf. 2022; 48: 147-153
        • Exius R
        • Gabrielli S
        • Abrams EM
        • et al.
        Establishing amoxicillin allergy in children through Direct Graded Oral Challenge (GOC): evaluating risk factors for positive challenges, safety, and risk of cross-reactivity to cephalosporines.
        J Allergy Clin Immunol Pract. 2021; 9: 4060-4066
        • Torres MJ
        • Adkinson Jr., NF
        • Caubet JC
        • et al.
        Controversies in drug allergy: beta-lactam hypersensitivity testing.
        J Allergy Clin Immunol Pract. 2019; 7: 40-45
        • Nguyen M
        • Parashar S
        • Lee BR
        • et al.
        Twenty-year comparison of de-labeling penicillin allergic pediatric patients with and without prior skin testing.
        Ann Allergy Asthma Immunol. 2022;
        • Dona I
        • Caubet JC
        • Brockow K
        • et al.
        An EAACI task force report: recognising the potential of the primary care physician in the diagnosis and management of drug hypersensitivity.
        Clin Transl Allergy. 2018; 8: 16
        • Vyles D
        • Mistry RD
        • Heffner V
        • et al.
        Reported knowledge and management of potential penicillin allergy in children.
        Acad Pediatr. 2019; 19: 684-690
        • Wanat M
        • Anthierens S
        • Butler CC
        • et al.
        Management of penicillin allergy in primary care: a qualitative study with patients and primary care physicians.
        BMC Fam Pract. 2021; 22: 112
        • Association AM
        Number of People per Active Physician by Specialty, 2019.
        Association of American Medical Colleges, 2019