Studies of proactive penicillin skin testing in hospitalized patients

Study	Patients enrolled/tested	Penicillin skin testing (PST) results	Use of beta-lactam antibiotics as a result of PST	Study details/comments
Arroliga (2003)^[1]	100/96	1 positive 10 nondiagnostic 85 negative	38 patients received antibiotics 31 of 38 received beta-lactams	Intensive care unit patients.
Wall (2004)^[2]	26/23	1 indeterminate 22 negative	26 of 26 received a beta-lactam antibiotic	PST performed by allergist-trained pharmacist. Almost all patients (n = 22) were referred for evaluation by infectious diseases consultation.
Park (2011)^[3]	503/71	4 positive 67 negative	29 of 71 received a beta-lactam Patients enrolled but not evaluated 54 (26%) received a beta-lactam	Pharmacist screened all patients and recommended allergy consultation for PST in select patients.
Rimawi (2013)^[4]	482/146	1 positive 145 negative	145 received beta-lactam antibiotics	Most inclusive study with about one-third of inpatients with penicillin allergy included in study. Beta-lactam antibiotics used were predominantly broad-spectrum, including piperacillin-tazobactam (n = 42), ceftriaxone (n = 27), and cefepime (n = 23). In this study, 217 patients were excluded because of uncertain allergy history, but were PST-eligible.
King (2016)^[5]	NA/50	50 negative	37 of 50 were changed to beta-lactam antibiotic	Patients were highly selected, including screened for skin test eligibility and already prescribed a broad-spectrum antibiotic.
Heil (2016)^[6]	90/76	64 negative 9 nondiagnostic 3 positive	54 of 64 had changed to antibiotic therapy (34 of 54 more narrow spectrum, 43 of 54 more effective therapy, 33 of 54 less costly therapy)	Skin testing service run by infectious diseases fellows and patients were highly selected through antibiotic stewardship team referral, infectious diseases consultation service, or the direct request of hospital team.
Chen (2016)^[7]	252/228 PST was completed in 19% of penicillin-allergic inpatients	223 negative 5 positive (5 negative history only)	49 patients were on a penicillin or cephalosporin before PST versus 77 after Active orders for broad-spectrum antibiotics decreased (vancomycin decreased 33%, clindamycin decreased 61%, quinolones decreased 36%, carbapenems decreased 50%, and aztreonam decreased 68%)	Electronic health record screened 1203 patients with penicillin allergy. Pharmacist prioritized based on patient length of stay, antibiotic therapy, and comorbidities.
Blumenthal (2017)^[8]	278/42 Included all internal medicine patients at a tertiary care academic medical center with penicillin allergy being treated for an infection	43 negative	For all enrolled patients: Odds of receiving a penicillin or cephalosporin as an inpatient were not increased as a result of this policy (adjusted odds ratio [OR] 1.3 [0.8, 2.0]) In the subgroup of patients who were skin tested (43): Odds of receiving a penicillin or cephalosporin as an inpatient (adjusted OR 5.6 [2.5, 12.4]) and on discharge (adjusted OR 2.5 [1.04, 6.2]) were both increased	Only study that provides insight into policy impact of proactive PST with adjusted analyses.

PST: penicillin skin testing; NA: not available.

References:

Arroliga ME, Radojicic C, Gordon SM, et al. A prospective observational study of the effect of penicillin skin testing on antibiotic use in the intensive care unit. Infect Control Hosp Epidemiol 2003; 24:347.
Wall GC, Peters L, Leaders CB, Wille JA. Pharmacist-managed service providing penicillin allergy skin tests. Am J Health Syst Pharm 2004; 61:1271.
Park MA, McClimon BJ, Ferguson B, et al. Collaboration between allergists and pharmacists increases beta-lactam antibiotic prescriptions in patients with a history of penicillin allergy. Int Arch Allergy Immunol 2011; 154:57.
Rimawi RH, Cook PP, Gooch M, et al. The impact of penicillin skin testing on clinical practice and antimicrobial stewardship. J Hosp Med 2013; 8:341.
King EA, Challa S, Curtin P, Bielory L. Penicillin skin testing in hospitalized patients with beta-lactam allergies: Effect on antibiotic selection and cost. Ann Allergy Asthma Immunol 2016; 117:67.
Heil EL, Bork JT, Schmaizie SA, et al. Implementation of an infectious disease fellow managed penicillin allergy skin testing service. Open Forum Infect Dis 2016; 3:ofw155. eCollection 2016.
Chen JR, Tarver SA, Alvarez KS, et al. A proactive approach to penicillin allergy testing in hospitalized patients. J Allergy Clin Immunol Pract 2016.
Blumenthal KG, Wickner PG, Hurwitz S, et al. Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship. J Allergy Clin Immunol 2017.

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Studies of proactive penicillin skin testing in hospitalized patients