PC2180: Outpatient General Pediatric Penicillin Delabeling of Low Risk Patients

Purpose/Objectives: Twenty percent of patients report a penicillin allergy. These patients often receive broader antibiotics with greater side effects. This leads to poor patient outcomes, emergence of bacterial resistance, and increase health care expenditures. However, a reported penicillin allergy is disproven in 95% of labeled patients. From August 2016 to August 2020 at Langley Air Force Base, 40% of all pediatric patients with reported penicillin allergy did not have proper allergy labeling in their EMR. Out of those patients, 89% were never referred to an allergist to confirm or investigate their newly diagnosed penicillin allergy further.
The purpose of this quality improvement project is to: create a standardized process to recognize and manage penicillin allergies, promptly identify low-risk delabeling patients, and establish an integrated general pediatrician ran penicillin delabeling clinic in the military health system.

Design/Methods: Sixty-eight patients, ages 6 months to 17 years old, presented to Langley pediatric clinic from January 2021 to March 2022. A penicillin pathway driven by medical technicians was created. Once a technician discovered a reported penicillin allergy of a presenting patient or parent of a patient reported a penicillin allergy, then a screening questionnaire was given. These results were then given to the pediatric provider who then confirmed the questionnaire, verified and/or corrected allergy documentation in the EMR, and a referral was placed to the integrated general pediatrician ran delabeling clinic. On a once monthly basis, low-risk patients went to the delabeling clinic and received direct Amoxicillin oral challenge. The delabeling clinic was run by a general pediatrician, and an allergy-immunologist was available for any questions during clinic days. This challenge involved giving 45 mg/kg (250 mg max) one-time Amoxicillin dose followed by 1 hour observation. Written consent was obtained prior to oral challenge, and vitals (including: heart rate, respiratory rate, blood pressure, and SpO2 percentage) with physical exam was obtain before and after oral challenge.

Results: In just over 1 year, 21% of patients were discovered to have patient reported penicillin allergy with no allergy present in EMR. Two of those patients received Amoxicillin, but no adverse outcome was seen. All 68 patients were referred to the low-risk delabeling clinic. In 3 months, 19 out of 19 patients were delabeled without any adverse outcomes. Saving the military $52,174 in projected cost.

Conclusion/Discussion: Penicillin allergies are commonly misdiagnosed and the management after reported penicillin allergy is unclear. This has led to patient safety events and significant increase in projected cost to our healthcare system. However, via this streamline process, patients can be identified and safely managed and delabeled by a general pediatrician in the military health system.