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- Page navigation anchor for RE: PCN delabelling in primary clinicRE: PCN delabelling in primary clinic
Wittmer et al showed that low risk penicillin de-labelling is safe and effective in a primary care clinic and should be encouraged across the country especially in places with poor access to allergists. Timely penicillin de-labelling is important for patients and reduces risk of adverse effects from less effective alternatives.
The manuscript did not mention the rationale of using 1000mg of amoxicillin as an oral challenge dose. As a practicing allergist, a total dose of 250mg or 500mg as an oral amoxicillin challenge dose is generally used as it demonstrates drug tolerance and is considered therapeutic dosing. This dosing is similar to what is suggested by Shenoy et al[1]. Higher doses of amoxicillin are associated with an increase in GI side effects.
Furthermore, direct oral challenge to penicillin without skin testing has been a standard of care in most allergy practices especially in pediatric populations. If future primary care practices were to follow suit with low-risk de-labelling, utilizing established Canadian guidelines for penicillin allergy can be helpful in creating a screening tool for low-risk patients that can be applied to both adults and children [2].
Competing Interests: None declared.References
- Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019 Jan 15;321(2):188–99.
- 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 Dec 1;16(1):1–10.
- Page navigation anchor for RE: Penicillin delabelling of patients at risk of STIRE: Penicillin delabelling of patients at risk of STI
The Practice article by Wittmer R et al highlights the growing concerns of misleading allergy information that has been made worse during the SARS-CoV-2 pandemic with patients having little or no access to drug testing or challenge clinics at this time.
Whilst several different information gathering questionnaires are available to safely 'de-label' patients, none of these are actually used outside of studies in secondary care or made available to patients during routine pre-assessment clinics by Anaesthetists who are uniquely positioned to address a significant proportion of patients. All Anaesthetists are trained in managing allergic reactions and anaphylaxis. The single dose oral amoxicillin in low-risk patients is a safe strategy even for children [1], so not using this 'routinely' in most (primary and secondary care) settings remains a disservice to our patients (for example, low uptake of such de-labeling by infectious disease specialists when patients return to out-patient follow-up having recovered and haemodynamically stable).
Community pharmacists or advanced care practitioners are equally in a good position to engineer such changes that would greatly benefit patients, but need support from primary care physicians and training in secondary care to recognize gaps in allergy history taking and clinical evaluation [2].
In conclusion, penicillin de-labeling can be done by many medical (and surgical) specialties and we are wast...
Show MoreCompeting Interests: None declared.References
- 1. Searns JB, Stein A, MacBrayne C et al. 1332. Single Dose Oral Amoxicillin Challenge is a Safe and Effective Strategy to Delabel Penicillin Allergies among Low Risk Hospitalized Children.Open Forum Infect Dis. 2020 Dec 31;7(Suppl 1):S677–8.
- 2. Devchand M, Kirkpatrick CMJ, Stevenson W et al. Evaluation of a pharmacist-led penicillin allergy de-labelling ward round: a novel antimicrobial stewardship intervention. J Antimicrob Chemother. 2019 Jun 1;74(6):1725-1730.
- 3. Staicu ML, Vyles D, Shenoy ES et al. Penicillin Allergy Delabeling: A Multidisciplinary Opportunity. J Allergy Clin Immunol Pract. 2020 Oct;8(9):2858-2868.e16.