UH Rainbow Quality Improvement Project Restores Patients’ Access to Penicillin

UH Clinical Update | August 2024

Research shows that while 10% of pediatric patients are labeled as being allergic to penicillin, fewer than half actually are. Some kids, for example, are labeled as suspicious for allergy after receiving amoxicillin for an ear infection and developing a mild rash -- without the follow-up testing to determine whether it’s a true drug allergy.

Ankita Desai, MD

“That's probably the most common thing we see,” says Ankita Desai, MD, Division Chief of Pediatric Infectious Diseases at UH Rainbow Babies & Children’s Hospital and Rainbow Babies & Children's Foundation John Kennell Chair of Excellence in Pediatrics. “It's not a true anaphylactic allergy. A lot of times that penicillin label gets put on the chart, but we don't know if this is a true drug allergy or not. In some cases, it might have been a virus. It may have been a whole host of things that cause rashes in kids.”

Some children, on the other hand, have verified penicillin allergy, but grow out of it over time, she says.

Whatever the cause for the confusion, one thing is clear: It’s crucial to have the most accurate information possible about penicillin allergy status when providing the optimal treatment for kids with infections, Dr. Desai says.

“Penicillins and that family of antibiotics are first-line agents for a whole host of infections in pediatric patients,” she says. “Ear infections, pneumonia, sinusitis -- all of them use amoxicillin- based therapies as first line. When you don't have those in your back pocket, you're forced to use alternative regimens that may not be as easily tolerated, may have more side effects and may not cover the bacteria that we need to target.”

To address this important issue at UH Rainbow, Dr. Desai, Peter Paul Lim, MD -- pediatric infectious diseases fellow at the time -- Kathryn Ruda Wessell, DO, from the Division of Pediatric Allergy/Immunology, and colleagues conducted a quality improvement project aimed at delabeling inaccurate penicillin allergy in hospitalized patients – one of the first published efforts to look at pediatric inpatients. The team developed a penicillin allergy screening questionnaire and divided 40 patients into three risk categories based on the results. Patients deemed to have no risk were automatically delabeled for penicillin allergy, while low-risk patients underwent an oral amoxicillin challenge during their hospital stay, and high-risk patients were referred to an allergist.

Of the 12 patients who underwent the oral amoxicillin challenge, 11 were successfully delabeled from being allergic to penicillin. Overall, the project resulted in 16 of the 40 patients screened being successfully delabeled.

“I was not surprised by the findings because we expected that many people really didn't have a true allergy,” Dr. Desai says. “I think this gave parents the confidence to know that their kid didn't have a reaction when they tried it, and that they could feel more comfortable in the future accepting penicillin in the outpatient setting if they needed it again. It gave the provider and the parent that level of confidence that they would be fine.”

Dr. Desai says she and her team are currently using this process for patients who need penicillin-based therapy and are labeled as allergic. But she says she hopes to implement the process more broadly in the future.

 “But big picture, we would love to have clinical decision support for providers incorporated into the EMR to help evaluate antibiotic allergies and guide optimal prescribing,” she says.