Written by Jason Lesnick
Spoon Feed
This international study found the vast majority of patients with a penicillin allergy who were eligible for a direct oral challenge (DOC) were able to have this allergy removed without adverse events.
I challenge your PCN allergy!
This prospective, multicenter, 8-country, effectiveness-implementation study asked whether patients with a low-risk penicillin allergy could undergo a digital penicillin allergy toolkit screening (the National Antibiotic Allergy Network App), then undergo DOC and remove the listed allergy.
This data was then used to do a target trial emulation looking at secondary effectiveness outcomes. The authors analyzed 5121 patients; 1573 (30.7%) underwent DOC, and 1502 (95.5%) had PCN removed as an allergy. 6 (0.4%) of the 71 (4.5%) of participants who had a positive DOC had a serious adverse event, but none experienced anaphylaxis, mortality, or ICU admission.
The target trial emulation identified participants with a PEN-FAST <3, or ‘green’ on the antibiotic allergy assessment tool. 892 of these underwent penicillin DOC within 7 days of their allergy assessment (intervention), while 960 were left with a listed penicillin allergy (controls).
In their weighted, low-risk sample, penicillin DOC was associated with a higher rate of penicillin prescribing (RR 13.25, 95%CI 7.82–22.46; P <0.001) and oral penicillin prescribing (RR 14.62, 95%CI 7.65–27.91; P <0.001) within 90 days. Those who underwent DOC had lower rates of prescribing of restricted antibiotics (RR 0.78, 95%CI 0.63–0.96; P = 0.018) and WHO “Watch” or “Reserve” antibiotics (RR 0.73, 95%CI 0.60–0.89; P = 0.002) at 90 days. Inpatient DOC was associated with a lower rate of acquisition of multidrug-resistant gram-negative bacteria within 90 days (RR 0.57, 95%CI 0.33–0.99; P = 0.046).
How will this change my practice?
54% of the penicillin allergy assessments were performed by pharmacists. This collaborative intervention lends itself to a multidisciplinary project to improve antibiotic stewardship. I know our antibiotic stewardship committee was looking for a QI project, so I shared this with them.
Source
Direct Oral Challenge for Penicillin Allergy: The International Network of Antibiotic Allergy Nations (iNAAN) Study. Clin Infect Dis. 2026 Jul 8;82(6):e1148-e1162. doi: 10.1093/cid/ciag082. PMID: 41921035; PMCID: PMC13341246.
