The Operating Theatre Journal February 2022

Are you sure you are allergic to penicillin? Professionals
and patients are urged to double-check
Published on 20 January 2022doi: 10.3310/alert_48839
Millions of people in the UK have penicillin allergy recorded in their
medical notes. Many of them are not truly allergic. New research
highlights the importance of both doctors and patients discussing
recorded penicillin allergies.
Penicillins are first-line treatment for many infections. People with a
penicillin allergy listed in their medical records will not receive them.
This keeps people with a true allergy safe. However, it means that
people who are not allergic will receive second choice antibiotics if
their notes are incorrect. This can mean longer hospital stays and more
risk of antibiotic-resistant bacteria.
This research explored patients’ and physicians’ views on penicillin
allergy. It found that both groups were often unsure if the allergy was
true. There was also confusion over the difference between a side
effect and an allergy. Patients tended not to question the allergy once
it was in their notes. Similarly, doctors were often reluctant to override
the allergy record in case of an allergic reaction.
Having penicillin allergy wrongly included in medical notes has negative
consequences. The study is part of a larger project designed to see if
testing for penicillin allergy and removing incorrect records improves
patient health outcomes and antibiotic use.
Currently, few GPs have access to testing for penicillin allergy or know
how to refer people. These results show the need for more widespread
communication about testing. More testing would mean that many
people could safely have penicillin allergy removed from their records.
Further information on penicillin allergy is available on the NHS website.
What’s the issue?
Antibiotics, particularly penicillins, are used to treat bacterial
infections. Around 1 in 15 people have an allergy to antibiotics listed
in their medical records. Three million people in the UK are unable to
access highly effective penicillins.
Most reported reactions to penicillins are mild. However, true allergic
reactions can be severe, and include breathing difficulties and loss of
consciousness.
Previous research has suggested that as few as 1 in 10 people with
a penicillin allergy listed in their medical records are truly allergic.
Occasionally, symptoms of the infection being treated (such as a rash)
can be confused with an allergic reaction. Or side effects might be
thought to be an allergy. The most common side effects of antibiotics
affect the digestive system (vomiting, nausea, diarrhoea). They are
usually mild and stop when treatment finishes. Symptoms or side effects
can lead to an allergy being incorrectly listed in medical records.
Penicillin is an effective first-choice antibiotic. People with penicillin
allergy listed in their records are given the next best medication.
Allergies are included in medical records to safeguard people against
having a reaction. However, having a penicillin allergy listed in medical
records is linked with negative outcomes. They include longer hospital
stays, more antibiotic prescriptions, an increased risk both of surgicalsite
infection and infection with antibiotic-resistant superbugs, and
death. It is therefore important to ensure the information is accurate.
The National Institute for Health and Clinical Excellence (NICE) asks
clinicians to ‘double check’ patients with a penicillin allergy recorded.
This is because another antibiotic might not be as effective for their
illness. In addition, many alternatives to penicillin (broad-spectrum
antibiotics) act against a wider range of bacteria. They are more likely
to promote antibiotic resistance. Progress towards new antibiotics has
been slow.
This study explored clinicians’ and patients’ views of penicillin allergy,
and of testing for it.
What’s new?
Researchers interviewed 31 patients with documented penicillin
allergy in the North of England. They also interviewed 19 primary care
physicians both with and without experience of dealing with penicillin
allergy.
Five main themes emerged from the interviews.
1. Patients’ understanding of allergy
Many people were diagnosed with allergy a long time ago. They were
more convinced of their allergy if symptoms occurred immediately
after taking penicillin, or were very severe. Some questioned if allergy
was hereditary. Many were unclear about the difference between side
effects and allergies.
2. Impact of allergy on patients
People who believed themselves to have a true allergy typically
reminded healthcare professionals of their allergy and checked
medicines for penicillin. People who were at risk of recurrent infections
worried more about running out of antibiotic options than those who
rarely took antibiotics.
3. Doctor-patient interaction
Most patients accepted the diagnosis of allergy without question and
did not discuss it with their physician. Some would take advice from
their physician about whether allergy testing would be beneficial.
4. Doctors’ uncertainties about diagnoses
Doctors said they routinely checked medical records for allergies, and
valued reminders on the electronic system. Some also checked with
the patient. Others noted that the on-screen system did not distinguish
between side effects and allergies. This made several doctors doubt
allergy status. Physicians also queried how the diagnosis was originally
made and whether it was based on family history.
Most doctors were aware of the over-diagnosis of penicillin allergy. A
severe reaction (anaphylaxis) was clear-cut but some symptoms (such
as rash) made allergy difficult to diagnose.
5. Prescribing decisions
Doctors did not find it difficult to source alternative antibiotics when
there was only one allergy. Even when they doubted the recorded
allergy, they often avoided prescribing penicillin. Some doctors
challenged the recorded allergy, for instance where penicillin was the
best choice. They discussed it with the patient and came to a decision
together after reviewing the medical history.
Some doctors had referred patients for allergy tests, though most were
uncertain about the criteria needed and what testing involved. Doctors
rarely initiated discussions about the negative consequences of having a
penicillin allergy recorded in medical notes. They said this was because
it would not affect the patients’ day-to-day lives.
The research team concluded that both doctors and patients should be
more aware of the negative consequences of having penicillin allergy
incorrectly included in medical notes.
Why is this important?
Diagnosing penicillin allergy is clinically difficult and medical records
are often incomplete. Doctors tend not to prescribe penicillin if an
allergy is noted, even when they doubt it is a true allergy.
The interviews identified gaps in patients’ understanding of penicillin
allergy and how it differs from side effects. More discussions between
doctors and patients would be helpful. (Continues on page 25)
24 THE OPERATING THEATRE JOURNAL www.otjonline.com