Inpatient Penicillin Allergy Delabeling by Nurse-supervised Direct Oral Challenge at a Free-standing Children’s Hospital in Connecticut - Early Experiences
Laura Kvenvold, Caroline Frost, Grace Hong, Ian Michelow, Jennifer GirottoAbstract
Background
About 10% of children report a penicillin allergy. However, when formally tested, only 1% are true allergies and far fewer have anaphylactic reactions. Penicillin allergy labels are not benign and have numerous negative impacts including increased side effects from alternative antibiotics, use of more expensive alternatives, risk for treatment failure, and risk for developing resistant organisms. Updated national practice parameters for antibiotic allergy management published in 2022 emphasized proactive penicillin allergy delabeling and using direct oral drug challenge to delabel low risk patients without the need for skin testing in pediatric patients. We describe our experience from a pilot quality improvement project for penicillin drug allergy delabeling that is supervised by nurses.
Methods
This intervention qualified as a Quality Improvement project. A standardized treatment protocol that aligned with the 2022 practice parameters was created by key stakeholders including the Quality and Safety, Infectious Diseases and Allergy/Immunology Divisions. Clinicians were educated about the penicillin delabeling protocol using an algorithm (Figure 1) to identify patients with penicillin allergy that are low risk for direct oral drug challenge. Stake-holder buy-in was sought to ensure alignment across end-users. An Epic order set and SmartPhrase were created to facilitate implementation of the algorithm and to track data. The pilot protocol went live with the inpatient hospitalist team in October 2024.
Results
To date, 7 patients (3 females, 4 males), aged 3 to 17 years old, have undergone direct oral drug challenge with amoxicillin. Five patients had rash as their documented reaction at presentation and 2 had no clear reaction documented. No adverse events or concerns from nurses or patients’ families have been reported. Feedback from end-users has resulted in adjustments to the formulation and maximum dosing of amoxicillin in the order set.
Conclusion
Our strategy to implement a direct oral drug challenge in hospitalized children with low-risk penicillin allergy is evidence-based, practical, scalable, nurse-driven, and supported by clinicians and patients’ families.