Survey of Obstetric Providers to Assess the Knowledge and Management of a Reported Penicillin Allergy in Pregnant Women

Abstract

Objective Penicillin allergy is the most commonly reported drug allergy in the United States; however, less than 10% of individuals labeled with a penicillin allergy are truly allergic. A reported penicillin allergy in pregnancy is associated with adverse maternal and perinatal outcomes. Despite recommendations for penicillin allergy testing in pregnancy, limited literature regarding obstetric providers' comfort and knowledge in addressing penicillin allergy and referral patterns exists. The objective of this study is to survey obstetric providers to assess their clinical practice patterns and baseline penicillin allergy knowledge, identify potential knowledge gaps in the management of pregnant patients with reported penicillin allergy, and measure the impact of an educational intervention on provider knowledge and practice patterns.

Study Design An anonymous, electronic 23-question survey administered to all obstetric providers at a single academic medical center assessed obstetric provider characteristics, self-reported antibiotic practice patterns, and antibiotic allergy knowledge before (June 19, 2020) and after (September 16, 2020) a penicillin allergy educational intervention, which consisted of multiple small-group educational sessions and a culminating departmental educational session. Discrete knowledge comparison by provider type and experience level of pre- and postintervention was performed using chi-square tests.

Results Of 277 obstetric providers invited, 124 (45%) responded preintervention and 62 (22%) postintervention. In total, 27% correctly identified the percentage of patients labeled penicillin allergic who would tolerate penicillins, 45% identified cephalosporin cross-reactivity, 59% understood penicillin allergies can wane, and 54% identified penicillin skin testing (PST) as a valid allergy verification tool. Among 48 respondents who attended educational sessions and responded postintervention, their knowledge of penicillin allergy waning (79% preeducation vs. 98% posteducation, p < 0.01) and PST as a valid tool for penicillin allergy verification (50% preeducation vs. 83% posteducation, p < 0.01) improved.

Conclusion Knowledge gaps related to penicillin allergy exist among obstetric providers. Educational initiatives may improve provider knowledge, help in the identification of patients requiring penicillin allergy evaluation, and reduce referral barriers.

Key Points

• Obstetric providers lack adequate knowledge of penicillin allergy.

• Educational interventions can improve discrete knowledge.

• Limited knowledge is a barrier to allergy referral for penicillin allergy delabeling.

Keywords

allergists - allergy referral - penicillin allergy - skin testing - penicillin allergy delabeling

Presentation

This study was presented at the Society for Maternal Fetal Medicines' (SMFM's) 41st Annual Pregnancy Meeting, virtual conference, January 25–31, 2021.

Publication History

Received: 05 November 2021

Accepted: 03 June 2022

Accepted Manuscript online:
16 June 2022

Article published online:
12 September 2022

• References

• 1 Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and management of penicillin allergy: a review. JAMA 2019; 321 (02) 188-199
• 2 Sacco KA, Bates A, Brigham TJ, Imam JS, Burton MC. Clinical outcomes following inpatient penicillin allergy testing: a systematic review and meta-analysis. Allergy 2017; 72 (09) 1288-1296
• 3 Jeffres MN, Narayanan PP, Shuster JE, Schramm GE. Consequences of avoiding β-lactams in patients with β-lactam allergies. J Allergy Clin Immunol 2016; 137 (04) 1148-1153
• 4 Hopkins MK, Dotters-Katz S, Boggess K, Heine RP, Smid M. Perioperative antibiotic choice in labored versus unlabored cesareans and risk of postcesarean infectious morbidity. Am J Perinatol 2018; 35 (02) 127-133
• 5 MacFadden DR, LaDelfa A, Leen J. et al. Impact of reported beta-lactam allergy on inpatient outcomes: a multicenter prospective cohort study. Clin Infect Dis 2016; 63 (07) 904-910
• 6 Sade K, Holtzer I, Levo Y, Kivity S. The economic burden of antibiotic treatment of penicillin-allergic patients in internal medicine wards of a general tertiary care hospital. Clin Exp Allergy 2003; 33 (04) 501-506
• 7 Li M, Krishna MT, Razaq S, Pillay D. A real-time prospective evaluation of clinical pharmaco-economic impact of diagnostic label of 'penicillin allergy' in a UK teaching hospital. J Clin Pathol 2014; 67 (12) 1088-1092
• 8 Mensah KB, Opoku-Agyeman K, Ansah C. Antibiotic use during pregnancy: a retrospective study of prescription patterns and birth outcomes at an antenatal clinic in rural Ghana. J Pharm Policy Pract 2017; 10: 24
• 9 Regan JA, Klebanoff MA, Nugent RP. Vaginal Infections and Prematurity Study Group. The epidemiology of group B streptococcal colonization in pregnancy. Obstet Gynecol 1991; 77 (04) 604-610
• 10 Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: final data for 2019. Natl Vital Stat Rep 2021; 70 (02) 1-51
• 11 Desai SH, Kaplan MS, Chen Q, Macy EM. Morbidity in pregnant women associated with unverified penicillin allergies, antibiotic use, and group B streptococcus infections. Perm J 2017; 21: 16-080
• 12 Nanduri SA, Petit S, Smelser C. et al. Epidemiology of Invasive early-onset and late-onset group B streptococcal disease in the United States, 2006 to 2015: multistate laboratory and population-based surveillance. JAMA Pediatr 2019; 173 (03) 224-233
• 13 Macy E. Penicillin skin testing in pregnant women with a history of penicillin allergy and group B streptococcus colonization. Ann Allergy Asthma Immunol 2006; 97 (02) 164-168
• 14 Desravines N, Waldron J, Venkatesh KK, Kwan M, Boggess KA. Outpatient penicillin allergy testing in pregnant women who report an allergy. Obstet Gynecol 2021; 137 (01) 56-61
• 15 Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin no. 199: use of prophylactic antibiotics in labor and delivery. Obstet Gynecol 2018; 132 (03) e103-e119
• 16 Trubiano JA, Beekmann SE, Worth LJ. et al. Improving antimicrobial stewardship by antibiotic allergy delabeling: evaluation of knowledge, attitude, and practices throughout the emerging infections network. Open Forum Infect Dis 2016; 3 (03) ofw153
• 17 Blumenthal KG, Shenoy ES, Hurwitz S, Varughese CA, Hooper DC, Banerji A. Effect of a drug allergy educational program and antibiotic prescribing guideline on inpatient clinical providers' antibiotic prescribing knowledge. J Allergy Clin Immunol Pract 2014; 2 (04) 407-413
• 18 Edwards RK, Tang Y, Raglan GB, Szychowski JM, Schulkin J, Schrag SJ. Survey of American obstetricians regarding group B streptococcus: opinions and practice patterns. Am J Obstet Gynecol 2015; 213 (02) 229.e1-229.e7
• 19 Cook E, Ramirez M, Turrentine M. Time has come for routine penicillin allergy testing in obstetrics. AJP Rep 2020; 10 (01) e15-e19
• 20 Kuder MM, Lennox MG, Li M, Lang DM, Pien L. Skin testing and oral amoxicillin challenge in the outpatient allergy and clinical immunology clinic in pregnant women with penicillin allergy. Ann Allergy Asthma Immunol 2020; 125 (06) 646-651
• 21 Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Antibiotic allergy. Lancet 2019; 393 (10167): 183-198
• 22 Prevention of Group B Streptococcal Early-Onset Disease in Newborns. Prevention of group B streptococcal early-onset disease in newborns: ACOG committee opinion, number 797. Obstet Gynecol 2020; 135 (02) e51-e72
• 23 Wolfson AR, Mancini CM, Banerji A. et al. Penicillin allergy assessment in pregnancy: safety and impact on antibiotic use. J Allergy Clin Immunol Pract 2021; 9 (03) 1338-1346
• 24 Garcia JFB, Aun MV, Motta AA, Castells M, Kalil J, Giavina-Bianchi P. Algorithm to guide re-exposure to penicillin in allergic pregnant women with syphilis: efficacy and safety. World Allergy Organ J 2021; 14 (06) 100549
• 25 Blumenthal KG, Shenoy ES. Penicillin allergy in pregnancy. JAMA 2020; 323 (12) 1216