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Direct Oral Challenge – Bye-Bye Penicillin Allergy!

December 29, 2023

Written by Ketan Patel

Spoon Feed
While removing low risk amoxicillin allergies in the pediatric ED by direct oral challenge (DOC) may be effective, numerous factors play a role in reliable implementation.

Excuses or lack of feasibility?
This is a cohort study across 3 different teaching PEDs where patients were stratified as a low or high-risk allergy to amoxicillin by survey. Families and physicians were subsequently approached regarding a DOC to remove the allergy in the low-risk group. In those that underwent the DOC, they were effective in removing the label in 98%, safely and effectively.

The intriguing part of this study, however, is how heterogenous the implementation and effectiveness in enrolling subjects were across different sites. Out of 1,189 patients approached, 372 completed a survey to gauge the severity of the allergy. Out of those 372, there was great variability between not only interest in undergoing a DOC by patients/caregivers (87%, 75%, and 58%; P < .02), but in actual willingness by clinicians to perform the DOC (85%, 94%, and 56%; P < .001).

In analyzing reasons for a lack of completion of a DOC in those willing, time seemed to be the biggest factor. Several other important factors, such as physician concern and waning family interest, also seemed to play a role in inability to move on to a DOC.

How will this change my practice?
I am very open to the idea of removing mislabels of allergies, especially antibiotics, for safety of patients and for appropriate antibiotic stewardship. Until we can implement a tool reliably to screen for low-risk patients and pair this with proper education of patients and providers, with DOC in the proper setting, we will only chip away at the problem. It is a worthwhile endeavor, however, as the benefits of such strategies have proven time and again to improve patient outcomes.

Another Spoonful
We’ve explored some tools and strategies on Journal Feed regarding the removal of allergy mislabels in the setting of antibiotics. Studies have shown safety of strategies in the spectrum of both outpatient and ICU settings. We’ve also highlighted tools that are simple to use and effective in identifying patients who could be candidates for allergen removal by DOC. A global push by the entire house of medicine would move the bar exponentially upwards, and it is the goal we should all strive for, despite challenges in implementation.

Multisite Oral Amoxicillin Challenges During Pediatric Emergency Department Visits. JAMA Pediatr. 2023 Oct 2:e233659. doi: 10.1001/jamapediatrics.2023.3659. Online ahead of print.