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What is penicillin?
Penicillins are beta-lactam antibiotics prescribed to destroy susceptible bacteria in the body. They are also ordered as a surgical antimicrobial prophylaxis to prevent postoperative bacterial infections. Penicillins are narrow-spectrum antibiotics that work by interrupting the bacteria cell from building their wall, causing the cell to break down and prevent  division (Karch, 2017, p. 116). As one of the oldest antibiotics developed "penicillins are the most prescribed antibiotics worldwide due to their high effectiveness, low cost and minimal side effects" (Su, Broekhuizen, Verheij, & Rockmann, 2017, p. 1). A common side effect from penicillin is gastrointestinal upset, including nausea, diarrhea, and vomiting. Signs of an IgE-mediated reaction, a severe allergic reaction also known as anaphylaxis, are itching, rash, wheezing, a drop in blood pressure, and cardiovascular collapse. Unfortunately, reported side effects to penicillin are frequently documented into the patient’s chart as an allergy without contest. This inaccurate information becomes part of the patients medical record and follows them throughout their life preventing them from ever getting another beta-lactam antibiotic.

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What is the issue?

Penicillin is the highest reported allergy in the United States, "with a prevalence of 8% to 12% in various studies" (Chen, Tarver, Alvarez, Tran,  & Khan,  2016, p. 686). Current studies show almost 90% of those who report they are allergic to penicillin can actually tolerate taking the antibiotic without having a severe allergic reaction. Many of the reported population have generalized symptoms that may only be uncomfortable side effects, and not a true allergic reaction. There are also some of the population who had been diagnosed with the allergy over ten years prior and have never been retested again. "80% of the population who had an IgE mediated penicillin allergy lose then sensitivity after 10 years" (CDC, 2017).

Who is affected?

The population most affected by this are those who are in need of the narrow-spectrum beta-lactam antibiotics but are denied due to the mislabeling of having a penicillin allergy.

Why is this an issue?

Many of the remaining antibiotics a patient can use are broad-spectrum. These antibiotics alter the normal bacterial flora of the body and allow for growth of drug resistant microorganisms, which are "associated with higher healthcare costs, increased risk for antibiotic resistance, and suboptimal
antibiotic therapy" (CDC, 2017).

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A proactive approach to penicillin allergy testing in hospitalized patients.

In a study done by Chen et al, 252 patients were included in a study that were hospitalized and had a reported penicillin allergy (2016). All applicants provided a detailed history. Five applicants had already received penicillin, so they were removed from the study and the allergy was removed from their chart. The remaining were tested bedside, beginning with a prick puncture test with PRE-PEN. Only four patients had a reaction and were removed from the study. The remaining went on to an oral amoxicillin challenge, which only one failed. At the end of this study 228 patients had their allergy dropped from their chart. Chen et al. (2016) concluded there is a general unawareness a skin test is available. There needs to be increased knowledge about the availability penicillin testing and more training for staff.

The impact of penicillin allergy labels on antibiotic and healthcare use in primary care: a retrospective cohort study

In a retrospective study by Su, Broekhuizen, Verheij, and Rockmann, they discovered that patients who were labeled with having a penicillin allergy were being given broad spectrum antibiotics such as macrolides, quinolones, tetracycline, and vancomycin (2017). These patients were having increased treatment failure rates, adverse reactions, and complications involving clostridium difficile, MRSA, and VRE. Their study also showed that patients who are labeled with a penicillin allergy have a higher readmission rate than those who are not labeled with a penicillin allergy.

Patient and prescriber views of penicillin allergy testing and subsequent antibiotic use: A rapid review

Wanat et al. completed a rapid review of 21 previously written articles regarding penicillin allergies (2018). They found that 7 to 41% of patients still avoid taking penicillin after negative allergy test results. The number one reason was due to fear. Many patients were found to be unaware testing was available, and all were interested in the testing after they were informed. Regarding prescribers, the rapid review found that only 16% referred their patients for allergy testing (Wanat et al., 2018). Also, about 80% have never consulted any allergy service in their career.

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Nurses’ current role
At this time, the role of the clinical nurse in regards to penicillin allergy are to inquire about current medication allergies a patient has, what reaction the medication caused, and to document the noted reaction appropriately in the medical record. Although the above is a crucial component in patient care, it is not always known if there was any further investigating in regards to the allergy. This could be due to time constraints, training, and knowledge. Taking the patients word about their allergy and not completing a comprehensive questionnaire may inevitably lead to a delay and possibly ineffective care down the road.

Importance of nurse involvement
The person who patients believe to be the most trustworthy in the hospital is the nurse.  The nurse is the person who spends the most time at bedside, and will be entrusted with detailed personal information. It is the nurse’s duty to be aware of the potential sub optimal care a patient could receive by being mislabeled with a penicillin allergy. This can be done by getting a thorough drug reaction history to identify true penicillin allergy. Although nurses may not be able to always resolve the issue on their own, they can advocate for patients who would be good candidates and ultimately benefit from penicillin allergy testing.

Why is participation limited
The first method of challenging a penicillin allergy once a patient has been labeled with the allergy is a skin test. This is a simple procedure that a nurse can be taught and shown how to interpret, but finding time for training can be difficult. The PRE-PEN company has three components to teaching, first online lessons, followed by a 90-minute in-service while practicing on others in the class, followed by testing on three patients within eight weeks of the training (PRE-PEN, 2017). However, in order for nurses to be trained to do skin testing, administration and physicians needs to be aware of the importance of the training and financial implications of not having patients tested.

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1) Education for nurses and patients

It is important to educate nurses what side effects can happen when a person takes penicillin. It is also important to teach the nurse what a true allergic reaction to penicillin looks like. Once the nurse is aware of the different signs and symptoms, they can then educate the patient. The nurse can also educate the patient on the importance of skin testing to either confirm or rule out true penicillin allergy. A patient may not be able to have testing while in the hospital but can ask for a referral to see an allergy specialist after discharge. The skin test is usually covered by insurance. Once a patient has a negative skin test, the allergy can safely be removed from their medical and pharmacy records.

2) Penicillin hard stop questionnaire

A hard stop questionnaire would force the nurse to ask a series of questions regarding any reported penicillin allergy. The questions would be yes or no answered with responses scored. A higher score would indicate a likely allergy and the label could be added to the chart. Moderate would need interventions before labeling such as a skin test. A low score would not allow the allergy to be added to the chart. This could be because the patient did not have a severe allergic reaction, only generalized side effects, or have had a penicillin or beta-lactam before without a reaction. Although this may take more time during the nurse's admission assessment, creating a hard stop questionnaire before adding a penicillin allergy to a patient’s chart will provide thorough documentation and also prevent mislabeling.

3) Teach nurses how to perform and interpret a skin test

The company who makes the penicillin allergy skin test has an education plan set up for any healthcare member who has the qualifications and skills to perform the procedure. Nurses have learned critical thinking and psychomotor skills to administer medications and asses for adverse reactions. Teaching nurses to perform a skin test should be a task within their scope of practice to accomplish and interpret.

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1) Focused assessment

A focused assessment is “performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected” (Treas & Wilkinson, 2014, p. 42). This information is gathered and added to a comprehensive assessment. When a patient has a reported penicillin allergy, it is important for the nurse to complete a focused assessment and add it to the patient’s chart noting the signs and symptoms they experienced. Completion of this assessment puts the nurse into a leadership role by advocating for the patient for further testing to rule out a possible mislabeled penicillin allergy. The leadership the nurse takes will improve patient outcomes, lower costs, and prevent longer hospital stays if alternative antibiotics need to be used.

2) Ethics in Nursing

Ethics of care “directs attention to the specific situations of individual patients, viewed within their own life narrative” (Treas & Wilkinson, 2014, p. 1533). Ethics guide the care nurses provide to their patients. One of the moral concepts that nurses follow when making ethical decisions is nonmaleficence, which means to do not harm and prevent harm. Risk of harm is not always clear, so the nurse must use critical thinking and leadership to make sure that the treatment plan does not cause more harm than good. If the nurse recognizes the patient would benefit from a beta-lactam antibiotic and they have a documented allergy due to a side effect, the nurse should advocate for the patient, encouraging the provider to order allergy testing before immediately going to a broad-spectrum antibiotic.

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Mislabeling patients with a penicillin allergy is a growing problem in the United States and worldwide. Alternative antibiotics to penicillin or beta-lactams are broad spectrum, causing a rise in healthcare costs, higher rates of patients developing drug resistant bacterial infections, and patients experiencing longer hospital stays. It is up to us as Registered Nurses to ask comprehensive questions regarding a penicillin allergy, educating our patients on the difference between common side effects and a severe allergic reaction, and advocating for our patients to have current penicillin allergy testing if they have potentially been mislabeled and are in need of the antibiotic.

If you have any questions please reach out to me and I will get back to you promptly. Thank you for taking the time to view my padlet presentation about the dangers of mislabeling a patient with a penicillin allergy and the important role the nurse has in improving patient outcomes. I hope this has transformed the way you view penicillin allergies and taught you some ways to help patients, family members, or friends from being mislabeled. Thank you.