By Nicholas P. Torney, Pharm.D., BCPS, BCIDP, infectious disease clinical pharmacist,
Munson Medical Center, Traverse City
In the United States, roughly 30 million people are estimated to report a penicillin allergy in their medical record.1,2 However, less than 10 percent of those who report a penicillin allergy will have a positive penicillin allergy skin test.3 Despite the accuracy or severity of the recorded penicillin allergy, its presence in the allergy field has been associated with an increased odds for methicillin resistant Staphylococcus aureus (MRSA) and Clostridioides difficile infections4 and an increased odds of surgical site infection.5
These poor outcomes are driven by the receipt of alternative antibiotics such as fluoroquinolones, clindamycin, vancomycin and macrolides. Since “allergy stewardship” and antibiotic stewardship go hand in hand, the concept of de-labeling false penicillin allergies falls in the lap of antimicrobial stewardship programs, of which pharmacists play a key role.
Pharmacists can get involved in multiple ways to improve the outcomes of patients with reported penicillin allergies, some of which include:
1. Developing a standard approach to allergy reconciliation.
2. Providing in-services and education to physicians, advanced practice providers, nurses and pharmacists, regarding appropriate management of patients with penicillin allergies.
3. Implementing a penicillin allergy assessment and skin testing service.
It may appear to the reader that number three above is a large leap from number one and two; however, there are now multiple resources available to help guide pharmacists who are interested in implementing a penicillin allergy assessment and skin testing service in the inpatient or even outpatient setting, with the most robust resource being a complete certification program.
Similar to vaccine administration certification programs, there is now a nationally recognized Penicillin Allergy Assessment and Skin Testing (PAAST) Certificate Program that was developed by experts across the country in collaboration with the University of South Carolina College of Pharmacy. The program provides 15 hours of continuing education (CE) intended for all licensed practitioners (pharmacists, nurses, physicians, advanced practice practitioners), with 11 hours of recorded lectures and a four-hour live session dedicated to demonstrating how to conduct and interpret a penicillin allergy skin test.
To date, there have been eight training sessions conducted across the country. In late September 2019, the Northern Michigan Society of Health-System Pharmacists (NMSHP) supported the first PAAST certificate program in Michigan, hosted in Traverse City. The program was a success with 22 attendees receiving a certificate of completion, which included 11 pharmacists, six pharmacy residents and five student pharmacists.
More information regarding the PAAST certificate program can be found here.
If you would like to set up a live training in your area, send an email to: PAAST@cop.sc.edu and a faculty member of the PAAST certificate program will help you through the process!
What are some other resources available to pharmacists looking to implement a PAAST service?
1. Early in 2019, a “How-to” guide was published in the American Journal of Health-system Pharmacists (AJHP) that describes the process for implementing a penicillin allergy skin testing service at your facility.6 This manuscript walks the reader through the current models for penicillin allergy skin testing, describes how to overcome common barriers, and provides a framework for pharmacists interested in adding this service at their facility. Click here to access the article.
2.Like podcasts? The Society of Infectious Diseases Pharmacists has you covered with a new member-created podcast called Breakpoints. For the first podcast, leaders in the field of ID pharmacy discuss all things penicillin allergy in a three-episode miniseries called The Itch: An SIDP Podcast Miniseries on Penicillin Allergy. No matter where you are at in this process, this podcast will help you get to the next step.
1. Macy E. Penicillin and beta-lactam allergy: epidemiology and diagnosis. Curr Allergy Asthma Rep. 2014; 14:476.
2. Shah NS, Ridgway JP, Pettit N et al. Documenting penicillin allergy: the impact of inconsistency. PloS One. 2016; 11:e0150514
3. Solensky R, Khan DA, Bernstein IL et al. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. 2010; 105:259–73.
4. Blumenthal KG, Lu N, Zhang Y, Li Y, Walensky RP, Choi HK. Risk of methicillin resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy: population based matched cohort study. BMJ. 2018 Jun 27;361.
5. Blumenthal KG, Ryan EE, Li Y, Lee H, Kuhlen JL, Shenoy ES. The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk. Clin Infect Dis. 2018 Jan. 18;66(3):329-336.
6. Bland CM, Bookstaver PB, Griffith NC, Heil EL, Jones BM, Ann Justo J, Staicu ML, Torney NP, Wall GC. A practical guide for pharmacists to successfully implement penicillin allergy skin testing. Am J Health Syst Pharm. 2019 Jan. 25;76(3):136-147.