The podcast explores the surprising reality of penicillin allergies, highlighting that many reported cases may not be clinically significant. It reveals that 90-95% of patients could safely tolerate penicillin after proper evaluation. The Penicillin Allergy Decision Rule (PEN-FAST) is introduced as a useful tool for clinicians, helping them assess allergy risk based on specific criteria. A low score on this tool suggests that patients can receive the most effective antibiotics for their infections without fear of allergies.
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Misconceptions About Penicillin Allergies
Many patients labeled as penicillin allergic don't truly have a penicillin allergy.
Childhood rashes from infections are often mistaken for true allergies.
volunteer_activism ADVICE
Use PEN-FAST to Assess Allergy Risk
Use the PEN-FAST tool on MD Calc to assess penicillin allergy risk.
If the patient's answers to all three key questions are 'no,' allergy risk is less than 1%.
volunteer_activism ADVICE
Manage Low-Risk Penicillin Allergy Patients
For patients with a low PEN-FAST score (around 5% risk), discuss risk-benefit of cephalosporin use.
In urgent cases like sepsis, proceeding with ceftriaxone or cefepime is usually appropriate.
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Penicillin allergies are relatively uncommon despite their frequent reports
10% of the population reports a penicillin allergy but only 5% of these cases are clinically significant
90-95% of patients may tolerate a rechallenge after appropriate allergy evaluation
Penicillin Allergy Decision Rule (PEN-FAST) on MD Calc
Useful tool to assess patients for penicillin allergies
Five years or less since reaction = 2 points (even if unknown)
Anaphylaxis or angioedema OR Severe cutaneous reaction = 2 points
Treatment required for reaction (e.g. epinephrine) = 1 point (even if unknown)
A score of 0 on PEN-FAST indicates a less than 1% risk of a positive penicillin allergy test
A score of 1 or 2 indicates a 5% risk of a positive penicillin allergy test
A low score on PEN-FAST should prompt clinicians to proceed with the best empiric antibiotic for the patient’s infection
References
Broyles AD, Banerji A, Barmettler S, et al. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs [published correction appears in J Allergy Clin Immunol Pract. 2021 Jan;9(1):603. doi: 10.1016/j.jaip.2020.10.025.] [published correction appears in J Allergy Clin Immunol Pract. 2021 Jan;9(1):605. doi: 10.1016/j.jaip.2020.11.036.]. J Allergy Clin Immunol Pract. 2020;8(9S):S16-S116. doi:10.1016/j.jaip.2020.08.006
Piotin A, Godet J, Trubiano JA, et al. Predictive factors of amoxicillin immediate hypersensitivity and validation of PEN-FAST clinical decision rule [published correction appears in Ann Allergy Asthma Immunol. 2022 Jun;128(6):740. doi: 10.1016/j.anai.2022.04.005.]. Ann Allergy Asthma Immunol. 2022;128(1):27-32. doi:10.1016/j.anai.2021.07.005
Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019;321(2):188-199. doi:10.1001/jama.2018.19283
Trubiano JA, Vogrin S, Chua KYL, et al. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med. 2020;180(5):745-752. doi:10.1001/jamainternmed.2020.0403
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