Penicillin de-labelling project improves accuracy of antibiotic allergy diagnoses

“Are you allergic to any antibiotics?” Most patients will have been asked this at one point or another whether at the hospital, by their family physician, or at the pharmacy. But while many may genuinely have an intolerance to penicillin, Dr Tiffany Wong and Dr Rochelle Stimpson report that the diagnosis is inaccurate for over 90% of patients. 

Interest has grown about the penicillin allergy de-labeling project, among multidisciplinary teams across BC since an update in 2020. The project focuses on removing inaccurate penicillin allergy labels, with the goals of increasing health care options and lowering costs associated with prolonged treatments and suboptimal patient outcomes. Over the past three years, Dr Wong, an allergist at BC Children's Hospital, and Dr Stimpson, a family doctor at BC Centre for Disease Control, have been actively supporting the participation of new sites and encouraging more care providers throughout the province to join the initiative.

Beta-lactam antibiotics, the class of antibiotic to which penicillin and amoxicillin belong, are the first-line choice for a wide-range of uses, including treating common bacterial infections to providing preventative care for surgical and dental procedures. Due to the widespread use and effectiveness of antibiotics, incorrectly labeling penicillin allergies can have a profound impact on patients and the health care system as a whole. “The mislabeling of penicillin allergies is a significant public health issue,” says Dr Wong, with 8% to 25% of patients worldwide being mistakenly identified as allergic, even though up to 98% of them are tolerant. The high rate of incorrect penicillin allergy labels carries serious public health implications, leading to concerns such as:

• Increased risk of adverse events
• Unnecessary use of alternative antibiotics
• Longer treatment courses
• Poorer patient outcomes
• Increased costs to the health care system

Over the past four years, the project has made significant strides by developing The Penicillin Allergy Electronic Assessment Tool, hosted by FirstLine. This tool was a collaborative effort, developed by a diverse team of allergists, pediatricians, pharmacists, obstetricians, and family physicians from BC. The electronic version, adapted from a proven risk assessment algorithm, serves as an easily accessible tool for health care providers. After extensive testing against the gold standard for allergy diagnosis, the finalized algorithm offers the most precise approach for assessing patient risk, while maintaining a low rate of false negatives. The electronic algorithm offers significant benefits, including reducing the likelihood of human error and identifying a greater proportion of low-risk penicillin allergy patients than its paper counterpart.

The high prevalence of penicillin allergy labels among the population, combined with the enthusiasm for the new assessment tool and the active participation of Drs Wong and Stimpson, has generated considerable interest in adopting and implementing this initiative in BC. Prior to the Spreading Quality Improvement (SQI) initiative’s launch, the project had naturally migrated to community clinics in Vancouver, the Downtown Eastside, and UHNBC in Prince George. The Penicillin Allergy De-labeling project stood out as one of the successful Quality Improvement (QI) initiatives chosen through the Specialist Services Committee’s (SSC) SQI program when it launched in 2021. By the end of 2022, the project had engaged 11 sites.

The Institute for Healthcare Improvement’s Sprint framework, which was adopted as a structure to initiate the project, aimed to encourage rapid adoption, foster efficient collaboration with participating sites, facilitate peer networking, and pilot an innovative approach to advancing QI initiatives. These efforts were supported by a collaborative team consisting of Dr Wong, Dr Stimpson, Bethina Abrahams (Director of Medical Staff Development Initiatives, PHSA) and Haneen Albayati (SQI Quality Lead, PHSA).

The final learning session of the Sprint is scheduled for October 2024. This session will focus on a detailed review of the project's implementation journey and highlight the key insights gained from using this innovative approach to spread quality improvement initiatives. This session will also celebrate the province-wide engagement and the progress made throughout the Sprint.

With growing interest from new sites to adopt the penicillin de-labeling project, the PHSA SQI team continues to develop plans to extend support to these sites and explore future opportunities to continue expanding this initiative.

For questions about the penicillin de-labeling project or other SQI initiatives, please contact the PHSA SQI team at SQI@phsa.ca

This project is funded in part by the Spreading Quality Improvement (SQI) initiative, which is part of the Specialist Services Committee, a joint collaborative committee representing a partnership between Doctors of BC and the Government of BC.