Penicillin is a powerful and effective antibiotic that has been used to treat numerous bacterial infections since the 1940s. About 10 percent of Americans believe they’re allergic to penicillin, which results in their frequently being treated with alternative antibiotics that could be less effective. Research has shown, however, that only about 1 out of 10 of those who believe they have a penicillin allergy actually do.
As leaders, medical and financial alike, within the health industry continue to grow in their support for using penicillin skin testing, hospitals and health systems can accurately identify patients with true penicillin allergies, while continuing to use penicillin to treat those who are not allergic—improving care quality while yielding better outcomes and significant cost savings.
Challenges with Penicillin Alternatives
Antibiotic alternatives such as carbapenems, aztreonam, vancomycin, and fluoroquinolones often are prescribed when patients are labeled with a penicillin allergy. Many times, these alternatives are not the treatment of choice because they might not be as effective as a penicillin, might have worse side effects, or cannot be given orally.
These broad-spectrum alternative antibiotics also tend to be more expensive than penicillin. Meanwhile, carrying a penicillin allergy has been observed to result in a half-day increase in length of stay (LOS), on average, for these patients, costing more for the patient and care facility long-term.
Further, unnecessary use of broad-spectrum agents contributes to the rise of multidrug-resistant bacteria. Thus, accurately identifying individuals with a true penicillin allergy is key to both optimizing patient outcomes and reducing unnecessary antibiotic use that leads to bacterial resistance.
Implementing Penicillin Skin Testing
With all the steps that occur before or during inpatient care, the last thing medical practitioners want to do is unnecessarily add another one to the process. However, penicillin skin testing is the most rapid, sensitive, and cost-effective modality for evaluating patients with immediate allergic reactions to penicillin.
National guidelines such as the Center for Disease Control and Prevention’s Be Antibiotics Aware program and the Antibiotic Stewardship Guidelines developed jointly by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America now include penicillin skin testing. It also is endorsed by the American Academy of Allergy, Asthma, & Immunology.
Although the penicillin skin test has been available for more than 40 years, it recently has seen a resurgence in demand as healthcare professionals increasingly have become aware of the option and recognize it as a way to objectively identify a penicillin allergy.
Case Example: St. Joseph’s/Candler Health System
At St. Joseph’s/Candler Health System, Savannah, Ga., only patients who are classified as “unknown”—which accounts for about 50 percent of the system’s patients—or previously have been labeled with a penicillin allergy are tested. Education is key; even many patients who are hesitant about being tested become more comfortable with the idea once it has been explained that they can grow out of allergies or they may have been misdiagnosed in the past, and thus were prescribed alternative therapies.
Candler offers the test Monday through Friday at the hospital during day shift hours and on weekends, if necessary. The test also can be performed on patients at outpatient clinics before they even get to the hospital, which is ideal so the provider and patient know what to expect in advance.
Candler Hospital has tested 207 patients since first implementing penicillin skin testing. Of these, only three tested positive; the other 204 patients were de-labeled. As a result, physicians have been able to change roughly 75 percent of regimens for patients who had previously been labeled with a penicillin allergy, yielding an average drug cost savings of approximately $315 per patient. Given that a test costs the hospital about $140 per patient, the care and cost benefits far outweigh the expense.
More important, penicillins and cephalosporins often are more effective at treating certain serious conditions. When patients are de-labeled of an allergy to penicillin, they often can receive the most effective antibiotic for their condition, which tends to lead to better health outcomes.
For instance, penicillin-based medicines are the backbone of many hospital protocols for treating serious conditions such as sepsis and pneumonia. When alternative antibiotics are used in its place due to an identified “allergy,” they not only cost more, but they also often are associated with worse outcomes, a half-day longer LOS, and higher risk for developing Clostridium difficile infection.
Increased care quality and better outcomes lead to enhanced patient satisfaction, particularly for those who are aware of the test and understand how much more effective a penicillin may be at treating their infection than alternatives. Understandably, these individuals may be eager to confirm or overturn a previously identified or unknown allergy, so just getting tested might help elevate their satisfaction.
In addition and over the long term, patients who are accurately identified and de-labeled of a penicillin allergy may benefit and provide benefits to health systems from cost savings and better outcomes downstream. Although this has not yet been quantified, these savings could be significant for both patients and providers over a patient’s lifetime.
Tips and Strategies for Evaluating Penicillin Allergies
Every hospital and health system should have a process for evaluating penicillin allergies, but the same strategy may not be right for every organization. Penicillin skin testing is an effective option; however, organizations should not overlook the importance of appropriate documentation and interviewing as part of the evaluation.
Hospital leaders, both medical and financial, should consider the following additional tips and strategies when assessing their facilities’ needs and developing a program.
Take advantage of available resources, including the manufacturer, to get started. For hospitals that decide to implement a penicillin allergy skin testing program, there are a number of resources available to help in getting started improving patient care and overall health costs. Hospitals also should take advantage of any hands-on training provided by the manufacturer for useful insight.
Enlist a champion. As with most other programs, it’s important for hospitals to select someone to champion this process and encourage buy-in. A pharmacist would be an ideal champion, if available, but nurses, physicians, residents, and even those in other roles also can be effective champions.
Adopt and tailor best practices to fit with the organization. A hospital that is considering implementing a penicillin skin test program should look to others that have already done so successfully and investigate their best practices from the standpoint of both implementation and costs. The hospital then should look internally to decide what will work best for its particular circumstances, including resources, workflows and budgets.
Hospitals and health systems have an opportunity to reduce the use of broad-spectrum agents and place patients on optimal therapy by providing penicillin skin testing. Research also shows cost savings that justifies the test expense—even for inpatients.
Together, these factors mean that penicillin skin testing can not only help the health system and the patient reduce costs associated with more expensive antibiotic alternatives, but also ensure patients receive the most effective treatment possible for their conditions—ultimately improving care quality and patient outcomes.
Bruce M. Jones, PharmD, BCPS, is an infectious diseases clinical pharmacy specialist at St. Joseph’s/Candler Health System in Savannah, Ga.