Validate an Easy to Administer Algorithm to Define Penicillin (PCN-B-lactam) Allergy Status in Sexually Transmitted Disease (STD) Clinic Outpatients
Phase: PHASE4
Conditions: Penicillin Allergy
Sponsor: Johns Hopkins University

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Validate an Easy to Administer Algorithm to Define Penicillin (B-
lactam) Allergy Status in STD Outpatients
NCT04620746DMID Protocol Number: 18-0023 
Sponsored by: 
National Institute of Allergy and Infectious Diseases (NIAID) 
DMID Funding Mechanism: 
Contract No. HHSN272201300012I 
Principal Investigator: 
Jonathan Zenilman, MD 
DMID Clinical Project Manager: 
Krista Cato MHA, BSN, RN 
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NCT04620746

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STATEMENT OF COMPLIANCE 
The study will be carried out in accordance with Good Clinical Practice (GCP) as required by the 
following: 
• 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 
CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, and 21 CFR Part 312) 
• 
International Conference on Harmonisation (ICH) GCP E6; 62 Federal Register 25691 
(1997); and future revisions 
• 
National Institutes of Health (NIH) Clinical Terms of Award 
All key personnel (all individuals responsible for the design and conduct of this study) have 
completed Human Subjects Protection Training. 

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SIGNATURE PAGE 
The signatures below constitute the approval of this protocol and the attachments and provides 
the necessary assurances that this trial will be conducted according to all stipulations of the 
protocol, including all statements regarding confidentiality, and according to local legal and 
regulatory requirements and applicable US federal regulations and ICH guidelines. 
Site Investigator Signature: 
Signed: 
 
Date: 
 
 
Name, Credentials  
Title 
 
 
 
 
 
 
 
 

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TABLE OF CONTENTS 
STATEMENT OF COMPLIANCE ................................................................................................. i 
SIGNATURE PAGE ..................................................................................................................... i 
LIST OF ABBREVIATIONS ......................................................................................................... v 
PROTOCOL SUMMARY ........................................................................................................... vii 
SCHEMATIC OF STUDY DESIGN ............................................................................................ ix 
SCHEMATIC OF PROVIDER Feasibility Sub STUDY DESIGN .................................................. x 
1 
KEY ROLES ....................................................................................................................... 1 
2 
BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ...................................... 3 
2.1 
Background Information .......................................................................................... 3 
2.2 
Scientific Rationale ................................................................................................. 5 
2.2.1 
Predictive Model Approaches ................................................................................. 5 
2.2.2 
Development of Algorithms to Increase Use of B-lactams ....................................... 6 
2.2.3 
Oral Challenge Approaches .................................................................................... 6 
2.2.4 
Cephalosporin Challenge in Surgical Patients ........................................................ 8 
2.2.5 
Cross Reactivity Between Penicillin and Cephalosporins ........................................ 8 
2.2.6 
Moving Forward: Extending PCN (B-lactam) Allergy Testing and a Path to Improve 
STD Care ................................................................................................................ 8 
2.3 
Potential Risks and Benefits ................................................................................... 9 
2.3.1 
Potential Risks ........................................................................................................ 9 
2.3.2 
Known Potential Benefits ...................................................................................... 10 
3 
OBJECTIVES ................................................................................................................... 11 
3.1 
Study Objectives ................................................................................................... 11 
3.1.1 
Primary Objectives ................................................................................................ 11 
3.1.2 
Secondary Objectives ........................................................................................... 11 
3.2 
Study Outcome Measures .................................................................................... 11 
3.2.1 
Primary Outcome Measures ................................................................................. 11 
3.2.2 
Secondary Outcome Measures ............................................................................. 11 
4 
STUDY DESIGN .............................................................................................................. 13 
4.1 
Assignment to Intervention Group (PST or DOC) .................................................. 13 

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5 
STUDY POPULATION ..................................................................................................... 16 
5.1 
Selection of the Study Population ......................................................................... 16 
5.2 
Inclusion/Exclusion Criteria ................................................................................... 16 
5.2.1 
Subject Inclusion Criteria ...................................................................................... 16 
5.2.2 
Subject Exclusion Criteria ..................................................................................... 16 
5.3 
Pregnant Subjects ................................................................................................ 16 
5.4 
Provider Feasibility Sub Study Population ............................................................. 17 
6 
STUDY PROCEDURES/EVALUATIONS ......................................................................... 18 
6.1 
Study Procedures ................................................................................................. 18 
6.1.1 
Screening ............................................................................................................. 18 
6.1.2 
Enrollment Visit (One Visit, Second Visit if Necessary) ......................................... 19 
6.1.3 
Additional Subject Qualification Criteria to Receive Allergy Testing ...................... 21 
6.2 
PCN Skin Testing ................................................................................................. 22 
6.2.1 
Oral Challenge Following a Negative Skin Test .................................................... 23 
6.3 
Amoxicillin Oral Challenge .................................................................................... 24 
6.3.1 
One-step Oral Challenge (PST Group) ................................................................. 24 
6.3.2 
Two-step Direct Oral Challenge (DOC Group) ...................................................... 25 
6.3.3 
Final Outcomes and Determination of Allergy Status ............................................ 25 
6.3.4 
Managing STD Treatment and Oral Challenge ..................................................... 26 
6.4 
Study Completion and Documentation of Allergy Testing Results ......................... 26 
6.5 
Provider Feasibility Sub study ............................................................................... 26 
6.6 
Data Handling, Data Quality Control and Record Keeping .................................... 27 
6.6.1 
Data Collection ..................................................................................................... 27 
6.6.2 
Data Quality Control.............................................................................................. 28 
6.6.3 
Retention of Data .................................................................................................. 28 
6.6.4 
Protocol Deviations ............................................................................................... 29 
7 
Safety Assessment and Reporting ................................................................................... 30 
7.1 
Safety Assessments ............................................................................................. 30 
7.1.1 
Pre-Skin Testing ................................................................................................... 30 
7.1.2 
Post-Skin Testing .................................................................................................. 31 

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7.1.3 
Oral Challenge ...................................................................................................... 31 
7.2 
Reporting .............................................................................................................. 32 
8 
STATISTICAL CONSIDERATIONS .................................................................................. 33 
8.1 
Study Outcome Measures .................................................................................... 33 
8.1.1 
Primary Outcome Measures ................................................................................. 33 
8.1.2 
Secondary Outcome Measures ............................................................................. 33 
8.2 
Sample Size Considerations ................................................................................. 34 
8.3 
Participant Enrollment and Follow-Up ................................................................... 35 
8.4 
Analysis Plan ........................................................................................................ 35 
8.4.1 
Primary analysis ................................................................................................... 35 
8.4.2 
Analysis of Secondary Endpoints .......................................................................... 36 
9 
SUBJECT CONFIDENTIALITY ........................................................................................ 37 
10 
INFORMED CONSENT PROCESS .................................................................................. 38 
11 
LITERATURE REFERENCES .......................................................................................... 39 
Appendix A: Schedule of EVENTS ............................................................................................ 42 
Appendix B: PCN (B-Lactam) ALLERGY HISTORY SCREENING QUESTIONNAIRE .............. 43 
Appendix c: TOXICITY TABLE .................................................................................................. 49 
Appendix D: PROVIDER FEASIBILITY SURVEY ..................................................................... 51 
Appendix E: ASSESSMENT TOOL FOR OBSERVER .............................................................. 56 
 
 

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LIST OF ABBREVIATIONS 
ADR 
Adverse Drug Reactions  
AE 
Adverse Event 
B-lactam 
Beta-lactam antibiotics 
BP 
Blood pressure 
CDM 
Center for Data Management  
CDMS 
Clinical Data Management System 
CFR 
Code of Federal Regulations 
CRF 
Case Report Form 
DHHS 
Department of Health and Human Services 
DM 
Data Management  
DMID 
Division of Microbiology and Infectious Diseases, NIAID, NIH, 
DHHS 
DOC Group 
Direct Oral Challenge Group 
eCRF 
Electronic Case Report Form 
EMR 
Electronic Medical Record 
FDA 
Food and Drug Administration 
GBS 
Group B streptococcus  
GCP 
Good Clinical Practice 
GI 
Gastrointestinal  
HAART 
Highly Active Antiretroviral Therapy 
HEENT 
Head, ears, eyes, nose, and throat 
HIPAA 
Health Insurance Portability and Accountability Act 
HIV 
Human Immunodeficiency Virus 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IgE 
Immunoglobulin E 
IM 
Intramuscular 
IRB 
Institutional Review Board 
IRT 
Item Response Theory 
mg 
Milligram 
ml 
Milliliter 
N 
Number (typically refers to subjects) 

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NIAID 
National Institute of Allergy and Infectious Diseases, NIH, 
DHHS 
NIH 
National Institutes of Health 
NPV 
Negative Predictive Value 
PCN 
Penicillin  
PD  
Protocol Deviation 
PE 
Physical Exam 
PN 
Participant Number  
PST Group 
Penicillin Skin Test Group 
SAP 
Statistical Analysis Plan 
SI 
Site Investigator 
STD 
Sexually Transmitted Disease 
U/ml 
Units per milliliter 
UK 
United Kingdom 
UPIRISO 
Unanticipated problems involving risks to subjects or others  
US 
United States 
USP 
United States Pharmacopeia 
 
 

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PROTOCOL SUMMARY 
Title: 
Validate an Easy to Administer Algorithm to Define Penicillin 
(B-lactam) Allergy Status in STD Outpatients 
Population: 
Approximately 5000 patients coming for care at Sexually 
Transmitted Disease (STD) clinics, emergency departments or 
ambulatory clinics will be screened to achieve 1000 evaluable 
subjects. 
Number of Sites: 
Four  
Study Duration: 
Approximately 27 months from implementation of field activity 
through closure and analysis. 
Participant Duration: 
One or two-visit study: screening for eligible subjects with 
history of penicillin (PCN) (B-lactam) allergy; enrollment; same 
day administration of PCN (B-lactam) allergy history screening 
questionnaire. 
Each site will perform two allergy validation methods using a 
sequential enrollment design. 
Method 1: skin testing of subjects with low-risk history; one-
step oral challenge of subjects with negative skin tests. 
Method 2: direct two-step oral challenge of subjects with low-
risk history. 
If subject cannot stay to complete all study procedures, skin 
test and/or oral challenge may be completed another day. 
Objectives: 
 
Primary: 
• Validate an algorithm which incorporates a PCN (B-lactam) 
allergy history screening questionnaire followed by an 
allergy validation intervention — 1) skin testing and oral 
challenge or 2) direct two-step oral challenge — to produce 
a short standardized post-study questionnaire (4-6 
questions) for use in ambulatory STD settings. 
• Determine how many subjects who report PCN (B-lactam) 
allergy can be treated with PCN or B-lactam drugs. 
Secondary: 
• Assess subject and provider acceptability of a PCN (B-
lactam) allergy testing algorithm. 

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• Determine the feasibility of implementing PCN skin testing 
followed by oral challenge for those who skin test negative 
or direct two-step oral challenge in an ambulatory STD 
setting. 
Estimated Time to 
Complete Enrollment: 
Approximately 14-16 months for screening and enrollment. 

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SCHEMATIC OF STUDY DESIGN 
Total N: Approximately 5,000 patients screened to achieve 1,000 evaluable subjects. 
 
Prior to 
Enrollment 
(Screening)  
 
Enrollment Visit 
(One day,  
second visit 
if necessary) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study Analysis 
 
 
Assessment of Final Study 
Outcome Measures 
• Determine Negative Predictive Value (NPV) for each question in the PCN (B-
lactam) allergy history screening questionnaire  
• Construct short standardized post-study questionnaire (4-6 questions) 
• Determine NPV for the post-study questionnaire 
Patients coming for care at ambulatory STD clinics self-report a current or past 
allergy to PCN (B-lactam) 
• Obtain written informed consent 
• Evaluate inclusion/exclusion criteria 
• Administer PCN (B-lactam) allergy history screening questionnaire 
• Assign to one of the two allergy validation intervention methods  
METHOD 1: PCN Skin Test (PST) Group 
• Perform skin test for PCN allergy in 
subjects with low-risk history 
• Perform one-step oral challenge in 
subjects with negative PCN skin test 
• Administer subject acceptability survey 
• Provide written documentation of PCN 
allergy testing results 
METHOD 2: Direct Oral Challenge (DOC) 
Group 
• Perform direct two-step oral challenge in 
subjects with low-risk history 
• Administer subject acceptability survey 
• Provide written documentation of PCN 
allergy testing results 

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SCHEMATIC OF PROVIDER FEASIBILITY SUB STUDY DESIGN 
 
Total N: Up to 150 clinicians from the five participating clinics. 
 
Pre-Study 
Implementation 
AND 
End of Study 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinicians who evaluate and treat patients at the participating clinic sites 
•
Obtain electronic informed consent (on-line)  
•
Self-administer the provider feasibility survey as an electronic case report 
form (eCRF)  
•
Assess provider acceptability of a PCN (B-lactam) allergy algorithm 
•
Determine the feasibility of implementing PCN skin testing followed by 
oral challenge for those who skin test negative or direct two-step oral 
challenge in an ambulatory STD setting  
Assessment of Final Study 
Outcome Measures 

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1 
KEY ROLES 
For questions regarding this protocol, contact: Jonathan Zenilman, MD at (410) 550-9080 
Individuals: 
Principal Investigator  
Jonathan Zenilman, MD 
Johns Hopkins University 
 
Site Investigator 
Julie Dombrowski, MD, MPH 
University of Washington  
 
Site Investigator 
Rebecca Lillis, MD 
Louisiana State University 
 
 
 
NIH – Division of 
Microbiology and 
Infectious Diseases 
(DMID) 
DMID/NIAID/NIH 
5601 Fishers Lane 
Bethesda, MD 20892 
Medical Officer 
Lori Newman, MD 
Clinical Project Manager  
Krista Cato MHA, BSN, RN 
 
 
 

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FHI 360 Quantitative 
Sciences 
FHI 360 
359 Blackwell Street, Suite 200  
Durham, NC 27701 
Phone: 919-544-7040 
Statistician 
Pai Lien Chen, PhD 
Data Manager 
Lalitha Venkatasubramanian 
Operations Coordinating 
Center 
FHI 360 
359 Blackwell Street, Suite 200  
Durham, NC 27701 
Phone: 919-544-7040 
Protocol Specialist 
Sandra B Brindis  
Research Assistant 
Carolina Marchena  
 
 

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2 
BACKGROUND INFORMATION AND SCIENTIFIC 
RATIONALE  
2.1 
Background Information  
Penicillin and cephalosporins both belong to the B-lactam class of antibiotics. These antibiotics 
play a critical role in treatment of STDs such as syphilis and gonorrhea. Current first line therapy 
for syphilis is intramuscular benzathine penicillin and for gonorrhea it is the third-generation 
cephalosporin ceftriaxone. Although there is only limited cross reactivity between PCN allergy 
and third generation cephalosporins such as ceftriaxone, many clinical settings will not 
administer this drug to patients reporting PCN (B-lactam) allergy. Second line treatments for 
gonorrhea are not as effective, especially at non-genital sites of exposure. 
There are no first line therapy options for syphilis patients who have B-lactam allergy. These 
patients are usually treated with doxycycline for a prolonged course. Treatment options for 
anorectal and pharyngeal gonorrhea are even more limited. 
Up to 20% of patients seeking medical care report a history of PCN or B-lactam allergy.1,2 
However, when these patients are tested for allergy with formal skin testing, only a small 
minority of them are found to be allergic with immunoglobulin E (IgE) mediated 
hypersensitivity.1,2 The term allergy is often conflated with any type of drug intolerance or 
intolerance history.3 Most providers will not routinely administer B-lactam drugs to patients who 
report PCN allergy.1,2 Over-reported penicillin allergy can adversely impact care in settings 
where STD care is provided.  
It has been nearly three decades since PCN allergy was evaluated in the STD clinic setting by 
Gadde and coauthors4 who studied this issue in Baltimore in the early 1990s. Of the 776 
patients (among 5063 screened) who reported a PCN allergy history, only 55 (7.1%) had skin 
test reactivity, compared to 1.7% of 4287 with no allergy history. Higher skin reactivity rates 
were found in patients who reported anaphylaxis (17%) or urticaria (12%). Atopy rates were 
similar in both skin test positive and negative groups and was not useful as a predictive marker. 
No similar contemporary data are available.   
More recently, the crisis of multiple drug resistant organisms and increased appreciation of PCN 
(B-lactam) allergy overdiagnosis has raised awareness of the issue. Overdiagnosis of PCN (B-
lactam) allergy has been increasingly seen as a critical policy issue5 related to antibiotic 
stewardship and health care costs.6,7 Because patients with PCN (B-lactam) allergy are often 
administered second line drugs that are more broad spectrum and less efficacious, there are 
clear associations between patients with reported PCN (B-lactam) allergy and increased rates of 
Clostridium difficile and methicillin-resistant Staphylococcus aureus,8 surgical site infection for 
elective procedures,9 overall length of stay and overall health care costs in a large Kaiser 
managed care population10 and United Kingdom (UK) teaching hospitals.11  

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Although the impact of PCN (B-lactam) allergy on patient outcomes is substantial, in practice, 
few patients with reported allergy, when evaluated, have confirmed allergy.5,7,10,12,13 
Furthermore, anaphylaxis to penicillin and cephalosporins is rare. Macy13 recently reviewed all 
penicillin and B-lactam use between 2009-2017 in the Kaiser Permanente Southern California 
system. Of 6,144,422 unique health plan members, 2,114,406 members received 4,558,1965 
courses of oral PCNs, and 192,925 persons received 285,984 parenteral PCN courses. Of 
these, there were 32,133 new PCN allergy reports (0.66%) within 30 days. Anaphylaxis 
occurred in only 22 patients (1 in 207,191) with oral B-lactam exposures; there were only 2 
severe cutaneous reactions, both of whom also had had exposure to cotrimoxazole. The clinical 
impression is that anaphylaxis is less common now than in the early B-lactam era, which may 
be due to purer preparations of drug, less parenteral administration and increased use of later 
generation B-lactams.1,2 
The most reliable way to objectively define the presence of PCN allergy is by skin testing. Skin 
testing for PCN allergy can be easily performed as an outpatient with commercially available 
reagents (PRE-PEN® AllerQuest LLC, Plainville CT) and commercially available penicillin G. 
However, allergy referral and testing are typically either not available or difficult to access in 
most busy clinical settings, both inpatient and outpatient. Furthermore, the standard of care for 
STDs requires that patients be treated at the time of diagnosis or as soon as possible after 
exposure, which makes referral for allergy testing impractical. Therefore, patients who are being 
treated for syphilis or gonorrhea or contact exposure and who also report B-lactam allergy, are 
often treated with second line, and potentially less effective, therapy options, even though >90% 
may not have true allergy. 
In clinical practice, because of the increasing demand for PCN (B-lactam) allergy evaluation and 
the lack of available allergist resources, various models to extend PCN skin testing have 
developed in both inpatient and outpatient settings. These models include testing and 
evaluation performed by hospitalists,14 infectious diseases physicians,15 pharmacists16 and as 
part of routine pre-operative evaluations.12  
The currently approved PRE-PEN® kits contain only the PCN major determinant 
(penicilloylpolylysine) and one minor determinant. Since some patients may react only to the 
PCN minor determinants, which may occur in up to a quarter of true allergic cases, the current 
kits are estimated to have a sensitivity of about 75%.17 Skin testing itself is safe, even in 
sensitized subjects. In a large 2018 review, Adkinson17 summarized 54 studies, which included 
19,259 patients, and found a reported adverse event (AE) rate of 0.16%, none of which were 
serious or life threatening. 
Therefore, absent approval of the newer comprehensive kit, there is consensus within the 
allergy community that to define an individual as PCN-allergy negative, skin testing should be 
supplemented by a single dose oral challenge (usually with amoxicillin 250 mg).  
Because of the increased appreciation of the overreporting of PCN allergy, investigators have 
developed PCN allergy evaluation approaches that bypass the skin testing step18 using risk 

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stratification criteria to identify patients with reported allergy who have a high negative 
probability of being truly reactive. Low risk was identified as having GI reaction only (nausea, 
vomiting), having family history without a direct personal history, having had a history of taking a 
B-lactam drug and having an ill-defined allergic reaction in the distant past (>5 years). 
Higher-risk groups were described as having the following symptoms within a year: hives or 
other pruritic rash, blister or bullous skin eruption after B-lactams, or IgE related symptoms 
(swelling/angioedema, syncope, dyspnea/wheezing or hypotension).  
The smaller clinical trials found that if patients had low-risk symptoms only (i.e., no higher-risk 
symptoms), then direct oral challenge was safe. Furthermore, on an institutional basis, these 
protocols are being adopted in practice settings, and have been implemented in a number of 
large health systems such as Kaiser Permanente in California and Partners Health in 
Massachusetts. There have also been smaller reports of similar risk stratification being used to 
optimize pre-operative prophylaxis. 
2.2 
Scientific Rationale  
2.2.1 Predictive Model Approaches 
There has been increased interest in developing predictive models for PCN (B-lactam) allergy. 
Santurino19 employed a retrospective model to assess 466 patients from Salamanca, Spain who 
were evaluated for any adverse drug reaction (ADR) (only 27% were B-lactams). A multivariate 
model was constructed which found that the significant variables were age at time of reaction 
and symptoms suggestive of allergic disease. However, this study is limited because it was a 
relatively small sample, retrospective, assessed older patients with multiple comorbidities and 
medications, and assessed ADRs in general, not specific to B-lactams. It also started from the 
vantage point of individuals who were already diagnosed with an ADR, as opposed to those 
who had histories which are more likely to be remote.  
A more robust approach was undertaken by Chiriac20 who attempted to design a predictive 
model more specifically for B-lactam allergy, using patient populations with high prevalence of 
confirmed B-lactam allergy (26-31%). In the initial phase of the model development, they used 
retrospective patient data (training set) with 1991 patients. Of these, urticarial/angioedema was 
the most common symptom (43.5%). Interestingly, in the multivariate analyses, atopy and 
asthma were not associated. The significant factors for B-lactam allergy were immediate 
reaction, age (younger) at time of reaction, anaphylaxis and multiple episodes. After the model 
was developed, the authors adapted this to a prospective sample of 200 patients (validation 
set). Optimizing the model using different variable weights found that the model with the highest 
sensitivity was 98% in both the training and validation sets, but with an NPV of 77% in the 
retrospective training set and 85% in the prospective sample. Although this study highlights 
present dilemmas in accurate diagnosis of allergy without clinical testing, Blumenthal in, an 

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accompanying editorial,21 points out that 1) this was a population with very high prevalence of 
true allergy; and 2) in typical outpatient clinic populations, the allergy prevalence is much lower 
than Chiriac’s populations. Therefore, we would anticipate that the NPV would be much higher. 
Since our intent in this study is to develop algorithms which have high NPVs, this supports our 
hypothesis. 
2.2.2 Development of Algorithms to Increase Use of B-lactams 
Chiriac22 recently reviewed the standardized drug allergy algorithms that were promulgated 
during the 2018 International Drug Allergy Symposium. These incorporated multiple algorithms, 
including large experiences from the Massachusetts General Hospital/Partners Health, 
Dartmouth, Mayo Clinic, Jacksonville, Rush University, University of Nebraska, University of 
Texas and groups from the UK and other systems. The authors noted that most patients report 
low risk allergy histories and, thus, many B-lactams are likely safe for use. Furthermore, 
standardized allergy algorithms can be used by trained personnel beyond allergy specialists, 
including medical doctors from other specialties, advanced practitioners, and pharmacists. The 
consensus algorithms included a series of elements: 
• 
Definition of high-risk and low-risk phenotypes. 
• 
Clinical practice guidelines for patients who had mild reactions were to use a different 
generation cephalosporin, to perform a test dose procedure or to provide access to skin 
testing. 
• 
Recommendation to go directly to an oral challenge test dose without skin testing for low-
risk patients whose reported “allergy” was more consistent with a non-allergic reaction (e.g., 
mild gastrointestinal (GI) distress). These algorithms are being increasingly adopted. 
2.2.3 Oral Challenge Approaches 
The approaches recommended in the increasingly used algorithms, in many cases, advise 
bypassing skin testing and going directly to an oral challenge in low-risk patients. Two recent 
studies evaluated the impact and safety of this approach. 
Iammatteo23 instituted a direct oral challenge procedure in drug allergy clinics at Montefiore 
Hospital in the Bronx, NY. This study enrolled subjects >7 years old with non-life-threatening 
reported reactions to PCN. The exclusions included bronchospasm, anaphylaxis, non-IgE 
syndromes such as Stevens Johnson, cutaneous and/or mucosal blisters, hypersensitivity 
vasculitis, nephritis, hepatitis or anemia. Of 165 patients screened, 159 were enrolled and 156 
completed a graded challenge without skin testing but which also incorporated a placebo. Of 
those challenged, 19 had reactions of which only 4 were determined to be allergy mediated and 
all were mild. It should be noted that this study skipped skin testing entirely.   

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Macy instituted a large PCN allergy management protocol at Kaiser Permanente San Diego.3 
Between January 2017-December 2018, 806 patients had a direct oral challenge (no skin 
testing). Of these patients, 2 (0.2%) had an acute reaction, 9 (1.1%) had a delayed reaction; all 
were managed on-site with oral antihistamines or IM epinephrine; there were no 
hospitalizations. An additional 23 subjects (2.9%) had subjective reactions, such as mild nausea 
or headache. 
Similarly, Blumenthal24 implemented a risk-based algorithm in a large Boston based health 
system, and in a small study, directly challenged 83 low-risk patients in an outpatient setting. Of 
these patients, 3.6% experienced an immediate reaction (hives and rash), all resolved with 
treatment. In a larger antimicrobial stewardship-oriented intervention25 which was performed in 5 
acute care hospitals in 2016-17, patients with prior B-lactam allergy histories were evaluated 
using an EMR-based decision support tool and allergist consultation. A test dose of the 
prescribed B-lactam was administered in 1,045 instances to 942 patients with allergy histories 
considered low-risk. 96% of these cases did not have skin tests. Forty (3.6%) of patients had 
hypersensitivity reactions, 14 of which occurred within an hour of dosing. All were minor and 
treated successfully. Reactions were most frequent with late generation cephalosporins. 
Mustafa evaluated26 outpatients presenting to a Rochester allergy/immunology center in 2018. 
363 patients reported PCN allergy of which 189 consented to evaluation.159 were randomized 
to either skin test evaluation or direct oral challenge. This study used a shorter observation 
period than previous investigators (30 minutes), and no adverse reactions were encountered. 
Tucker27 evaluated 402 US Marine recruits at a basic training site who reported PCN allergy. In 
the military basic training setting, PCN allergy has substantial impact because of the wide use of 
benzathine penicillin prophylaxis for epidemic Group A streptococcal diseases. By history, most 
of the reported reactions (76%) were cutaneous. 74 were skin tested negative and had 
amoxicillin challenge. The remaining 328 went directly to amoxicillin challenge and only 1.5% 
had cutaneous reactions, no anaphylaxis.   
Over the past 3 years, there has been a marked increase in the number of reports of managing 
PCN allergy by stratifying risk and performing skin testing or direct challenge. When direct 
challenge is performed, the approach has typically involved using amoxicillin. The initial dose is 
25mg of oral amoxicillin as a test dose, and after 30 minutes observation, followed with a 250mg 
dose, followed by 30–60-minute observation.  
In almost all cases, even when adverse events or hypersensitivity reaction occurred, these were 
managed easily with oral antihistamines or IM epinephrine, with rapid resolution. These 
protocols are also increasingly being implemented in ambulatory clinics. Therefore, PCN allergy 
management can be implemented in most ambulatory STD settings. 

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2.2.4 Cephalosporin Challenge in Surgical Patients 
One of the unique aspects about the STD setting is that antibiotic therapy is either single dose 
or very short term. This is especially true with gonorrhea, which is treated with a single dose of 
ceftriaxone. An analogous situation is perioperative antibiotic prophylaxis, in which cefazolin is 
almost universally recommended as first line therapy. Because of data demonstrating that 
surgical site infection is higher in patients treated with non-B-lactam regimens,9 there has been 
interest in this area. Vaisman28 evaluated 485 patients with reported PCN allergy. Using a 
conservative (sensitive) approach to identify allergy by history, he implemented a process to go 
directly to intravenous cefazolin surgical prophylaxis in low-risk patients. This was done in 267 
patients (55%) without adverse reactions. Vorobeichik29 recently performed an extensive review 
of the anesthesia literature. He concluded that overall anaphylaxis rates were extremely low 
(.0004%), and cited studies which found only 3 cases of cephalosporin anaphylaxis in >65,000 
cases where patients had a history of PCN allergy and were administered perioperative 
cephalosporins. These rates were not significantly higher than patients who report no prior 
allergy history. 
2.2.5 Cross Reactivity Between Penicillin and Cephalosporins 
There is an extensive literature on the chemistry of B-lactams and the cross reactivity of 
penicillin and cephalosporin allergy. From a chemical basis, the key issue is the “R” group 
modifying the B-lactam ring. The literature is consistent in concluding that cross reactivity in 
clinical practice is highly overestimated. The most extensive recent review (2018) by Zagursky30 
reviewed cross reactivity in PCN allergy, including an extensive review of the chemical 
structures and a review of studies, which showed that there was limited cross reactivity between 
PCN and cephalosporins, even early generation cephalosporins compared to later generation 
cephalosporins. They concluded that “there is ample evidence to allow the safe use of all but a 
few early generation cephalosporins in patients with penicillin or amoxicillin allergy. Patients with 
a history of penicillin allergy do have a general elevated risk of allergic reaction and may 
develop an allergic response to cephalosporins by coincidence, but the risk is comparable to 
that of receiving a sulfonamide antibiotics”. 
2.2.6 Moving Forward: Extending PCN (B-lactam) Allergy Testing and a 
Path to Improve STD Care 
Increased interest in PCN (B-lactam) allergy testing and defining patient status has been driven 
by parallel trends which have included: 
• 
Recognition that most patients who report PCN (B-lactam) allergy are actually not allergic; 
• 
The public health crisis of antimicrobial resistance and recognition that alternative therapies 
for B-lactam drugs are often more broad-spectrum and may facilitate development of 
resistance; 

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• 
Recognition that overall clinical care costs may be higher in patients who are treated with 
alternative regimens; 
• 
Recognition that alternative regimens are not as effective as B-lactam primary regimens. 
As a result, there has been an explosion of interest in extending PCN (B-lactam) testing outside 
the traditional allergy office. In December 2018 and January 2019 alone, major reviews of this 
topic were published in the Lancet1 and Journal of the American Medical Association,2 both 
publications accompanied by educational materials to facilitate increased diagnostic testing.  
Many experienced clinicians attempt to differentiate hypersensitivity from non-allergic reactions 
(i.e., non-allergic drug toxicity) by taking a careful history of the drug toxicity event(s). However, 
in the STD clinic setting, this may not be practical because of the wide variety of skills sets and 
expertise in these clinics. Because many clinics may not have physicians on staff 100% of the 
time and are ambulatory sites, there is a clear need to develop a path for an easy to administer 
instrument and testing algorithm that can be administered to patients who report a history of 
PCN (B-lactam) allergy. The instrument should have high sensitivity (for discerning which 
patients have true hypersensitivity) and a high NPV in clinic settings (important for clinicians and 
management) to enable B-lactam use to optimize treatment for a meaningful percentage of 
subjects who do not have allergy. 
2.3 
Potential Risks and Benefits 
2.3.1 Potential Risks 
The risks associated with participation in the study are small. PCN skin tests are generally safe 
for adults and children of all ages, including infants. In certain circumstances, though, skin tests 
are not recommended. Skin testing with limited reagents may not be advised if: 
• 
There is a strong history of a severe allergic reaction, e.g., anaphylaxis, within the past 10 
years. 
• 
The subject is taking medication that could interfere with test results. Antihistamines are the 
drugs most commonly associated with suppression of the skin test response. 
• 
The subject has certain skin conditions which interfere with test interpretation, such as 
diffuse eczema or psoriasis. 
The most common side effect of skin testing is slightly swollen, red, itchy bumps (wheals). 
These wheals may be most noticeable during the test. In some people, though, an area of 
swelling, redness and itching may develop a few hours after the test and persist for as long as a 
couple of days. These reactions can be treated with antihistamines, steroids or both. 
Rarely, allergy skin tests can produce a severe, immediate allergic reaction such as swelling of 
the throat, difficulty breathing, a fast heart rate, or low blood pressure. These reactions are 

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largely eliminated by doing a preliminary prick (puncture) skin test which is part of the standard 
of care. Uncommonly, these symptoms can require immediate medical treatment with 
epinephrine.  
Similarly, in people who skin test negative and are given an oral amoxicillin challenge, on rare 
occasions there can be an immediate or rapid development (within 6 hours) of a mild allergic 
reaction. This may include pruritis, rash or hives. In the vast majority of cases, these can be 
effectively treated with antihistamines. 
Rarely, an oral challenge in an individual who skin tests negative can produce IgE-associated 
symptoms which can include rash, urticaria, bronchoconstriction and anaphylaxis requiring 
emergency care. Study staff at each site will be trained in managing these signs and symptoms 
and response kits will be available on site. The risk of this is estimated to be no different than 
that of an individual who does not have an allergy history. 
2.3.2 Known Potential Benefits 
Subjects may benefit from this study by finding out whether they have a true hypersensitivity to 
B-lactam drugs. 
For many illnesses, PCN antibiotics are the best treatment options available. PCN antibiotics 
are often less expensive than other antibiotics. Other kinds of antibiotics may cause side effects. 
Antibiotics without PCN may lead to drug resistance which may make antibiotics less effective in 
the future. 

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3 
OBJECTIVES 
3.1 
Study Objectives 
3.1.1 Primary Objectives 
• 
Validate an algorithm which incorporates a PCN (B-lactam) allergy history screening 
questionnaire followed by an allergy validation intervention — 1) skin testing and oral 
challenge or 2) direct two-step oral challenge — to produce a short standardized post-study 
questionnaire (4-6 questions) for use in ambulatory STD settings.  
• 
Determine how many subjects who report PCN (B-lactam) allergy can be treated with PCN 
or B-lactam drugs. 
3.1.2 Secondary Objectives 
• 
Assess subject and provider acceptability of a PCN (B-lactam) allergy testing algorithm. 
• 
Determine the feasibility of implementing PCN skin testing followed by oral challenge for 
those who skin test negative, or direct two-step oral challenge in an ambulatory STD setting. 
3.2 
Study Outcome Measures 
3.2.1 Primary Outcome Measures 
• 
Algorithm / PCN (B-lactam) allergy history screening questionnaire performance in 
ambulatory STD populations, specifically the NPV of the algorithm on true PCN (B-lactam) 
allergy. 
• 
In ambulatory STD patients who report a history of PCN (B lactam) allergy and who have 
low-risk histories, determine the prevalence of PCN reactivity validated either by skin test or 
by direct oral challenge. 
3.2.2 Secondary Outcome Measures 
• Acceptability 
o Proportion of study subjects who find the testing procedures to be helpful. 
o Reasons why study subjects refuse to participate in the study or find the testing 
procedures to be of no value. 
o Proportion of study subjects who were negative on oral challenge who now feel 
confident in taking PCN or similar antibiotics. 

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o Proportion of study providers who will not offer PCN allergy assessment in the future. 
• 
Feasibility 
o Proportion of study providers who will offer PCN allergy assessment in the future. 
o Reasons why study providers will not offer PCN allergy assessment in the future. 
• 
Both acceptability and feasibility 
o Types and frequencies of elicited reactivity to PCN through skin testing and oral 
challenge among study subjects. 
 

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4 
STUDY DESIGN 
This will be a multicenter study screening approximately 5,000 men and women (to achieve 
1,000 evaluable participants) from different geographic areas of the US over a 14-16-month 
recruitment period (200 participants per site over the recruitment period). We will screen and 
enroll eligible individuals coming for care at ambulatory STD clinics and similar venues who self-
report a history of PCN allergy. 
Two methods of validating PCN allergy will be used: 
• 
Method 1 – PCN Skin Test (PST) Group: skin testing of subjects with low-risk history 
followed by one-step oral challenge of subjects with negative skin tests.  
• 
Method 2 – Direct Oral Challenge (DOC) Group: direct two-step oral challenge of subjects 
with low-risk history. 
Each site will perform both methods, using a sequential enrollment process (See Section 4.1). 
All participants will be administered the same PCN (B-lactam) allergy history screening 
questionnaire. 
4.1 
Assignment to Intervention Group (PST or DOC) 
Each site will perform both allergy validation interventions, Method 1 PST Group and Method 2 
DOC Group. The anticipated enrollment at each site will be 200 subjects overall; 100 in each 
group. Since each intervention has different logistical considerations, sites will enroll subjects in 
sequential block groups of 25. Sites will be assigned the order of block groups randomly. 
For example, sites that are assigned to begin with PST will enroll the first 25 subjects into the 
PST group, then follow with 25 subjects in the DOC group, then PST, etc. until the full 200 are 
enrolled. Similarly, sites assigned to start with the DOC intervention will enroll the first 25 
subjects using the DOC, followed by 25 in PST, then DOC etc., until the full 200 are enrolled. 
Therefore, each site will enroll 8 block groups, 4 in each allergy validation intervention. 
Method 1: Enrollment in the PST Group  
Site staff will review the responses from the allergy history screening questionnaire to identify 
subjects who have low-risk criteria for immediate hypersensitivity (see Sec 6.1.2.1). These 
subjects will receive penicillin skin testing. All subjects who have negative skin tests will be 
offered a one-step oral challenge for final validation.  Subjects who report higher-risk criteria will 
be referred to an allergy provider. 
Method 2: Enrollment in the DOC Group  
Site staff will review the responses provided on the allergy history screening questionnaire to 
identify subjects who have low-risk criteria for immediate hypersensitivity (see Sec 6.1.2.1). 

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These subjects will be offered a two-step direct oral amoxicillin challenge to validate absence of 
allergy. Subjects who report higher-risk criteria will be referred to an allergy provider. 
We anticipate that screening, consenting, enrollment of subjects with a history of PCN (B-
lactam) allergy and all study procedures will take place during one or two clinic visits. Study 
sites can also choose to do oral or electronic consents and complete initial screening 
assessments (including the Allergy History Questionnaire) by telephone. The length of the study 
visit will be about 1-3 hours in addition to the clinical appointment depending into which method 
of PCN allergy validation the participant is enrolled. All participants will be screened for study 
interest and eligibility. Once participants have given their written, oral, or electronic consent and 
been enrolled, study staff will administer the PCN (B-lactam) allergy history screening 
questionnaire. All participants who complete the skin testing and/or oral challenge will be asked 
to complete an acceptability survey on the PCN testing procedures at the end of the study visit. 
See the table below for the anticipated length of time the study visit will take for both the PST 
and the DOC Groups. 
Study Procedures 
Anticipated Length of Time 
PST Group 
 
• 
Screening, informed consent, enrollment 
30 minutes 
• 
Allergy history screening questionnaire* 
30 minutes 
• 
Skin testing (if qualified to receive) 
30-60 minutes  
• 
Oral challenge observation (if qualified to receive) 
60 minutes  
• 
Acceptability survey on the PCN testing procedures 
10 minutes 
TOTAL 
1 to 3¼ hours 
DOC group 
 
• 
Screening, informed consent, enrollment 
30 minutes 
• 
Allergy history screening questionnaire* 
30 minutes 
• 
Oral challenge 1st step observation (if qualified to 
receive) 
30 minutes  
• 
Oral challenge 2nd step observation (if qualified to 
receive) 
30 minutes  
• 
Acceptability survey on the PCN testing procedures 
10 minutes 
TOTAL 
1 – 2¼ hours 
* If subjects have a higher-risk history of allergy based on responses to the questionnaire, their study 
participation will be complete after 1 hour. 
 
If enrolled subjects cannot complete all study procedures for which they are qualified during the 
clinic visit, study staff will give them the option to return at a later date (within six weeks from the 

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screening visit) to complete the skin testing and/or oral challenge and subject acceptability 
survey. 
This study will assess reported PCN (B-lactam) allergy. Although the ultimate goal is to optimize 
therapy for patients with syphilis and gonorrhea who report PCN allergy, for this study patients 
attending the clinic venues for any reason (visit or diagnosis) will be eligible.  
We recognize that clinics have operational and throughput concerns. Since we are assessing 
allergy issues only, the procedures outlined in this protocol can be conducted at any time during 
the clinic visit, including after treatment has been administered. Usual clinical management, 
including treatment and partner services, will not be modified because of the study.   
At some clinic visits, subjects may require treatment for STDs with medications that could 
confound the evaluation of the oral challenge test results. In these cases, the clinicians may opt 
to either delay administration of therapy in the clinic until after the oral challenge is completed or 
provide STD treatment, administer the PCN (B-lactam) allergy history screening questionnaire, 
perform the skin test and then ask the subject to return to the clinic within the next 6 weeks for 
the oral challenge. 
 

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5 
STUDY POPULATION 
5.1 
Selection of the Study Population 
Approximately 5,000 males and females, 18 years and older, from participating STD clinics, 
emergency departments or ambulatory clinics in different regions of the US will be screened to 
enroll 1,000 evaluable participants who meet all eligibility criteria. The target study population 
will be patients coming for care at the participating clinic sites who self-report a current or past 
allergy to PCN or B-lactams.  
Study staff will inform potential participants of the study, obtain informed consent, and determine 
study eligibility. Individuals who meet all study eligibility criteria and agree to participate will be 
enrolled.   
5.2 
Inclusion/Exclusion Criteria 
5.2.1 Subject Inclusion Criteria 
Subjects must meet all the following inclusion criteria to be eligible to participate in the study: 
• 
18 years of age or older  
• 
Be able to provide informed consent 
• 
Report having a history of allergy to PCN or B-lactam drugs 
5.2.2 Subject Exclusion Criteria 
Subjects meeting any of the following criteria at baseline will be excluded from study 
participation: 
• 
Not able to stay for testing and challenge (1-3 hours) on day of clinic visit (or return within 6 
weeks to complete study procedures) 
• 
Other exclusion criteria, per clinical judgment, which prohibits enrolling in study 
5.3 
Pregnant Subjects 
There is no contraindication to enrolling pregnant subjects and administering the questionnaire 
or performing skin testing. PCN skin testing is safe in this population and is frequently 
performed. Pregnant women will not undergo the direct oral challenge with amoxicillin to verify 
PCN allergy. Pregnant women will be enrolled in the PST Group, complete the questionnaire, 
and have skin testing performed. If necessary, pregnant women may return to the clinic within 6-
weeks to complete the skin testing. Pregnancy will be determined by self-report and/or the 

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standard procedures employed in the participating clinic to diagnose pregnancy when clinically 
indicated. All clinics have access to point-of-care pregnancy tests. 
There is substantial benefit in pregnancy of “delabeling” a PCN (B-lactam) allergy since PCN is 
the only recommended therapy for syphilis in pregnancy, and B-lactam drugs are the preferred 
treatment for bacterial infections, such as amoxicillin for Group B streptococcus (GBS) and 
ceftriaxone for gonorrhea. The ambulatory STD settings in this study service patient populations 
at higher risk of GBS.  
5.4 
Provider Feasibility Sub Study Population 
At each site, we will conduct a short feasibility Sub Study among the clinicians to determine the 
practicality of performing PCN (B-lactam) skin testing and oral challenge in the ambulatory STD 
setting (see secondary objective). Since this is an operational feasibility assessment, the 
sampled population will be clinicians who evaluate and treat patients at the participating clinic 
sites. The surveys will be administered once at the beginning of the study and again at the end. 
We estimate that there will be 15-30 eligible clinicians per site over the course of the study. 
Accounting for personnel turnover, we anticipate that the total sample will be no more than 150 
individual respondents.  

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6 
STUDY PROCEDURES/EVALUATIONS 
6.1 
Study Procedures  
Operational implementation of study screening, enrollment and testing procedures will vary 
across the study sites. For example, depending on the operational considerations of the site, 
individuals may be screened in the waiting area, by the clinician and study staff during the 
actual clinic visit, or by study staff after the clinic visit has been completed. In some clinics it 
may be possible to perform the clinic visit procedures during the 30 to 60-minute ± 10 minutes 
oral amoxicillin challenge observation period.  
Clinical exams will be conducted as appropriate for the visit, but the clinic procedures are not 
included as part of the protocol. Study staff will emphasize to potential subjects that the 
expected time commitment involved in completing the study procedures is in addition to the time 
for the standard of care clinic procedures. A key operational study outcome is discovering if the 
time commitment involved is a barrier for both subjects and/or providers to allergy testing in 
ambulatory STD settings. 
6.1.1 Screening 
Screening will occur through mechanisms allowable at the individual sites including virtual 
screening and/or referral of individuals who have a prior history of reporting PCN allergy. If 
waiting room recruitment is permitted, study staff will approach potential subjects systematically, 
inform them that we are doing a study to optimize antibiotic use in ambulatory STD settings and 
ask if they were ever told they had an allergy to PCN or similar antibiotic. Subjects who report 
an allergy will be asked if they are interested in participating in the study. If the subject 
expresses interest, study staff will review the inclusion/exclusion criteria checklist to ensure the 
subject is eligible for enrollment. We will use standardized and Institutional Review Board (IRB)-
approved screening scripts at all sites. All participants who are eligible for enrollment will be 
assigned a unique 5-digit participant number (PN). The same PN will be used if the participant is 
enrolled. 
In some clinics, direct recruitment in the waiting room is not permitted. In these cases, we will 
post study advertising materials in the clinic waiting area promoting a study for individuals who 
have a history of PCN or B-lactam allergy. The clinic receptionist can also provide information to 
patients at time of registration. The recruitment materials will ask, “Do you have a history of 
penicillin or other antibiotic allergy?” or, “Have you ever been told that you are allergic to 
penicillin or other antibiotics?” Patients will be instructed to contact study staff in the clinic. Clinic 
providers may also refer patients to the study team. 
Some clinics collect drug allergy information in the pre-visit medical history form. In these 
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Authorization to pre-screen potential subjects’ medical records for drug allergy. Interviewers will 
confirm that the drug allergy is to PCN or B-lactam.  
If a potential participant meets all inclusion/exclusion criteria but declines to consent or enroll in 
the study, study staff will record the reason they are not interested in participating in the study 
on a case report form (CRF). No identifying participant information will be collected unless the 
participant consents for enrollment. 
6.1.2 Enrollment Visit (One Visit, Second Visit if Necessary) 
After the participant provides informed consent, study staff will note the date the informed 
consent form (ICF) was signed and appropriate eligibility information on a CRF. Study staff will 
discuss basic demographic information with each participant and record the information on a 
CRF. Study CRFs will be maintained in the participant’s research study record. Study staff will 
then administer the PCN (B-lactam) allergy history screening questionnaire to all participants 
using an iPad. Concomitant medication information will be collected. 
All participants successfully screened, consented, and enrolled in the study will undergo the 
following procedures: 
• 
Written, oral, or electronic informed consent to participate in this study  
• 
Assessment of eligibility 
• 
Enrollment in the study 
• 
Assignment to allergy validation method 
• 
Collection of demographic information (age, gender, race/ethnicity) 
• 
Collection of contact information 
• 
Administration of PCN (B-lactam) allergy history screening questionnaire  
• 
Collection of concomitant medication information 
• 
If antibiotic allergy history shows a low-risk history of PCN (B-lactam) allergy, option to 
receive skin test (if assigned to PST Group) or direct oral challenge (if assigned to DOC 
Group) 
6.1.2.1 
Subject Classification after Administration of PCN (B-lactam) 
Allergy History Screening Questionnaire (Appendix B) 
Subjects will be classified as having a Low-Risk History or a Higher-Risk History for PCN allergy 
based on their responses to the PCN (B-lactam) allergy history screening questionnaire. These 
allergy history categories are defined based on positive responses to the questionnaire 
elements13,18,24,26.  
Low-Risk History 
• 
Isolated GI upset (diarrhea, nausea, vomiting, abdominal pain) 
• 
Chills (rigors)  

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• 
Headache  
• 
Fatigue 
• 
Itching (pruritus), self-limited  
• 
Rash (including maculopapular rash) 
• 
Hives (greater than 5 years ago) 
• 
Flushing / redness 
• 
Family history 
• 
Patient denies allergy history but is in medical record  
 
Higher-Risk History 
• 
Angioedema or swelling of lip, tongue, or around eyes  
• 
Wheezing / chest tightness moderate or severe shortness of breath 
• 
Throat tightness which affected ability to breathe 
• 
Hypotension without rapid recovery 
• 
Arrhythmia / irregular heartbeat or palpitations 
• 
Syncope / pass out / dizzy 
• 
Anaphylaxis or sudden drop in blood pressure  
• 
Hives (5 years or less) 
Late effects (higher-risk events which occurred >24 hours after drug administration) 
• 
Stevens-Johnson syndrome (Loss >10% of skin) 
• 
Organ injury (liver, kidney) 
• 
Low Platelets  
• 
Drug reaction eosinophilia and systemic symptoms (rash with eosinophilia and organ injury) 
• 
Acute generalized exanthem (rash with pustules) 
• 
Dystonia or muscles became very stiff or very weak 
• 
Serum sickness (rash with joint pain, fever, myalgia) 
• 
Anemia 
• 
Documented drug fever 
• 
Erythema multiforme (rash with target lesions) 
• 
Hives (5 years or less) 
6.1.2.2 
Procedures After Defining Risk Category 
Subjects classified with a low-risk history will progress to either skin testing (PST Group) or 
direct oral challenge (DOC Group), depending on which method of validating PCN allergy they 
are assigned. Subjects who meet the higher-risk classification will be advised that further 
elucidation of their allergy status will require a formal allergy evaluation. Referral resources will 
be provided. 

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All participants classified as low-risk and who meet additional qualification criteria to receive 
allergy testing (See Sec 6.1.3) will undergo the following procedures:  
ASSIGNED TO PST GROUP 
• 
Administration of skin test (prick test first and, if indicated, intradermal test) 
• 
If skin test results are negative, option to receive oral challenge of 250 mg of amoxicillin 
• 
Pre-oral challenge brief PE, assessment of vital signs and measurement of peak flow 
• 
Administration of oral challenge 
• 
Post-oral challenge brief PE, vital sign assessment and peak flow measurement 
ASSIGNED TO DOC GROUP 
• 
Pre-oral challenge brief PE, assessment of vital signs and measurement of peak flow 
• 
Administration of oral challenge (first step) of 25 mg of amoxicillin, vital sign assessment 
and, if indicated, administration of oral challenge (second step) of 250 mg of amoxicillin 
• 
Post-oral challenge brief PE, vital sign assessment and peak flow measurement 
All participants will undergo the following procedures after allergy validation methods are offered 
or completed: 
• 
Administration of subject acceptability survey on PCN testing procedures for all subjects 
who were offered skin testing (with or without oral challenge) or direct oral challenge 
• 
Written documentation of PCN allergy testing results for all subjects who received skin 
testing (with or without oral challenge) or direct oral challenge to share with subject’s 
medical care providers 
6.1.3 Additional Subject Qualification Criteria to Receive Allergy Testing 
Subjects classified as low-risk after administration of the PCN (B-lactam) allergy history 
screening questionnaire and who meet any of the following criteria will be ruled out for skin 
testing and/or direct oral challenge: 
• 
Known (per medical record or self-report) Human Immunodeficiency Virus (HIV) which is not 
controlled (defined as any of the following): 
o Not on Highly Active Antiretroviral Therapy (HAART)  
o CD4 <200 in the last 6 months 
• 
 Use of oral antihistamines within 1 week of visit. (Subjects can be advised to stop 
antihistamines and return after 7 days)  
• 
Diffuse eczema, psoriasis, tattoos or other skin condition that would preclude skin testing  
• 
Tachycardia: Pulse >100 
• 
Tachypnea: Respiration rate >16 

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• 
Elevated blood pressure (BP) defined as either systolic >160mm or diastolic >100mm  
• 
Uncontrolled asthma or wheezes present on physical exam (PE) 
• 
Angioedema present on PE 
• 
Stridor of throat, tonsils or uvula, or stridor present on PE 
• 
Maculopapular rash or disseminated pruritis on >2 body areas which developed within 1 
week prior to the visit.*       
Note: This exclusion does not apply to subjects with psoriasis or other chronic skin 
conditions. These subjects qualify if the forearm where the skin testing is performed is 
uninvolved. 
6.2 
PCN Skin Testing 
Depending on the outcome of the PCN (B-lactam) allergy history screening questionnaire, 
participants may qualify to receive the PCN skin test.  
• 
Participants with a higher risk of PCN allergy will not proceed to the PCN skin test or oral 
challenge. Their study participation will be complete. Subjects will be provided with a written 
referral to local allergy providers. 
• 
Participants with a low risk of PCN allergy and assigned to the PST intervention group will 
be offered the PCN skin test. 
Staff will verify that qualified participants do not meet any additional criteria that would preclude 
them from skin testing using the Skin Test Qualification Checklist. Study staff will explain the 
skin testing procedures to participants who may decide to accept or decline skin testing. If they 
decline, they will be asked to complete the subject acceptability survey and their study 
participation will be complete. Staff will note the reason(s) they declined to be skin tested on the 
appropriate CRF. 
Study staff will perform the allergy skin testing for PCN allergy in accordance with standard 
allergy testing procedures and instructions provided in the PRE-PEN® kit package insert.31 
Prick (Puncture) tests will be performed before proceeding to intradermal testing. Prick testing is 
performed at marked sites on the inner volar aspect of the forearm. Testing for controls and 
each reagent is performed singly. 
Reagents and controls for prick and intradermal tests include: 
1. Controls:  
a.) Negative Control: Sodium chloride solution without preservative 
 
 
 e.g., patients presenting with secondary syphilis 

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b.) Positive Control: Histamine: 
i. 
Prick testing: histamine base 1 mg/ml  
ii. 
Intradermal testing: histamine base 0.1 mg/ml 
2. Reagents: 
a.) PRE-PEN® (major determinant) 
b.) Penicillin G 10,000 U/ml (minor determinant)   
Intradermal testing will not be performed if there is a positive or uninterpretable reaction to PRE-
PEN® and/or Penicillin G during the prick test. If the prick skin test results are negative the 
participant is qualified for intradermal testing. Study staff will perform duplicate intradermal skin 
testing of each reagent and single intradermal skin testing of the positive and negative controls 
on the inner volar aspect of the forearm. The same arm will be used for both prick and 
intradermal testing. 
If there is a positive reaction to PRE-PEN® and/or Penicillin G during the prick test or the 
intradermal test, the participant is ruled out of the oral challenge with amoxicillin 250 mg. They 
will be counseled that their PCN allergy history was confirmed. Written documentation will be 
provided to the subject with instructions to share with their medical provider(s).  
If the result of the intradermal test is ambiguous (equivocal), the intradermal test will be 
repeated with both reagents and the negative control in duplicate or, depending on each study 
clinic’s procedures, the subject will be referred to a local allergy consultant or clinic. If the repeat 
intradermal test is positive or ambiguous or the initial reaction was uninterpretable, the 
participant will not proceed to the oral challenge and will be referred to an allergist for further 
evaluation. 
Study staff will photograph the subject’s arm to document the results of the skin test reactions 
using an iPad. No identifiers except a label containing the PN and a measuring guide will be 
included in the photograph. The images will be uploaded to the clinical database. Complete skin 
test responses (both prick and intradermal) will be recorded on the PCN skin test results CRF. 
Occasionally, allergy skin tests can produce a severe, immediate allergic reaction. These are 
largely eliminated by doing the preliminary prick skin test. These can be treated with 
antihistamines, steroids or both. Infrequently, these symptoms this can require immediate 
medical treatment with epinephrine. 
6.2.1 Oral Challenge Following a Negative Skin Test 
In PST group subjects with negative skin test results, the absence of allergy will be confirmed by 
administering a single oral dose of amoxicillin 250 mg followed by one hour of observation to 
ensure that an immediate reaction does not occur.  

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6.3 
Amoxicillin Oral Challenge 
Study staff will explain the oral challenge testing procedures to all qualified participants in both 
allergy validation intervention groups who may decide to accept or decline the oral challenge. If 
they decline, they will be asked to complete the subject acceptability survey and their study 
participation will be complete. Staff will note the reason(s) a subject declined to take the oral 
challenge on the appropriate CRF.  
For those who consent to oral challenge, study team will perform a focused PE and record vital 
signs (including peak flow) on the oral challenge testing results CRF before the oral challenge is 
performed. The focused PE will include: 
• Eyes: 
Documentation of no angioedema 
• Pharynx: 
Documentation of no stridor 
• Lungs: 
Documentation of no wheezing or uncontrolled asthma 
• Skin: 
Documentation of no maculopapular rash, disseminated pruritis or urticaria 
Staff will verify that qualified participants do not meet any additional criteria that would preclude 
them from oral challenge using the Oral Challenge Qualification Checklist. At baseline, if 
subjects have pulse >100, respiration rate >16, or elevated BP (defined as systolic >160mm or 
diastolic >100mm), the oral challenge will not be performed. Additional reasons assessed during 
the focused PE for not receiving the oral challenge are listed in Section 6.1.3 and summarized 
in the listing above. 
6.3.1 One-step Oral Challenge (PST Group) 
After confirming the participant is qualified, amoxicillin 250 mg will be administered, and time of 
administration will be recorded. The subjects will be observed for 60 minutes± 10 minutes, after 
which vital signs, the PE and peak flow will be repeated. Note that each observation time point 
has a time window of +/- 10 minutes. 
If subjects report the presence of difficulty breathing, swelling in lip/mouth/tongue/throat, eye 
itchiness/tearing, skin hives/itchiness or abdominal pain/nausea/vomiting while they are waiting 
for final evaluation, study staff will include the reactions with the post-oral challenge vital signs 
and the focused PE assessment performed after the 60-minute observation period ± 10 
minutes. Standard treatment will be provided, including antihistamines, steroids and/or 
epinephrine, if indicated and dependent on the specific medical condition that arises.  
If vital signs (including peak flow) and focused PE are within reasonable limits after the 60-
minute ± 10 minutes waiting period, the subject will be counseled that they do not have an 
allergy to PCN (B-lactams). They will be provided with written documentation that they will be 
encouraged to share with their medical providers, including the STD clinic and their primary care 
physician (if they have one). 

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6.3.2 Two-step Direct Oral Challenge (DOC Group) 
Preliminary Dose 
After confirming the participant is qualified, amoxicillin 25 mg will be administered, and time of 
administration will be recorded. The subjects will be observed for 30 minutes  10 minutes, after 
which vital signs including peak flow will be repeated. 
Administration of Full Challenge Dose 
If vital signs are within reasonable limits after the 30-minute ± 10 minutes waiting period, the 
subject will be given the full challenge dose of 250 mg amoxicillin. The subject will be observed 
for an additional 30 minutes  10 minutes , after which vital signs, the PE and peak flow will be 
repeated. 
If subjects report the presence of difficulty breathing, swelling in lip/mouth/tongue/throat, eye 
itchiness/tearing, skin hives/itchiness or abdominal pain/nausea/vomiting while they are waiting 
for final evaluation, study staff will include the reactions with the post-oral challenge vital signs 
and the focused PE assessment performed after 30-minute  10 minutes observation period. 
Standard treatment will be provided, including antihistamines, steroids and/or epinephrine, if 
indicated and dependent on the specific medical condition that arises. 
6.3.3 Final Outcomes and Determination of Allergy Status 
If vital signs (including peak flow) and focused PE are within reasonable limits after the 
applicable observation periods, subjects will be counseled that they do not have an allergy to 
PCN (B-lactams). They will be provided with written documentation that they will be encouraged 
to share with their medical providers, including the STD clinic and their primary care physician (if 
they have one). 
Final outcomes of the oral challenge will be recorded on a CRF as no reaction (negative), 
reaction (positive) or unevaluable (if the participant leaves the clinic before the applicable 
observation period is completed). If there is a reaction, after providing standard treatment, study 
staff will record the type of reaction, severity and how long after the amoxicillin was 
administered it occurred on the oral challenge testing results CRF. 
If reactions to the amoxicillin oral challenge occur, they will be graded and documented using 
the Toxicity Table (Appendix C). 
Rarely, an oral challenge in an individual who skin tests negative can produce an acute reaction 
(e.g., anaphylaxis) requiring emergency care. Unexpected reactions that place a subject at 
increased risk will be treated as necessary and reported to the IRB and DMID as required. 

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6.3.4 Managing STD Treatment and Oral Challenge 
In some cases, subjects will require treatment for STDs at the visit with medications which may 
have side effects. This could confound the results from the oral challenge. If there are concerns, 
the clinicians may opt to delay administration of therapy until after the oral challenge is 
completed in the clinic or provide STD treatment, administer the PCN (B-lactam) allergy history 
screening questionnaire, perform the skin test and have the subject return to clinic for the oral 
challenge within 6 weeks of the clinic visit. 
6.4 
Study Completion and Documentation of Allergy Testing Results   
After the skin testing and/or oral challenge is completed, the participants will be asked to 
complete the subject acceptability survey to get their opinion of the PCN testing procedures 
conducted during the study, their results, and the subject’s confidence that they will be able to 
take PCN (B-lactam) drugs in the future.  
The subjects will be provided written documentation of the PCN (B-lactam) allergy testing 
procedures performed including a description of the skin testing and oral challenge, and 
verification of their PCN allergy test results (negative, positive or referral to allergist for further 
testing), which they will be encouraged to share with their medical providers.  
In addition, we will provide the local STD clinic with the results, and these can be inserted into 
the medical record, as appropriate. 
Subjects who have higher-risk histories which preclude skin testing and direct oral challenge or 
have ambiguous or uninterpretable results will be provided with a referral to local allergy 
providers. Each research site will maintain a list of local allergy providers for referral. 
There are no follow up visits required. Subjects will be given instructions to contact study staff in 
the unlikely event of complications.  
Incentives for a participant’s time, transportation, and other expenses will be provided according 
to local IRB approval. Study staff will provide incentives depending on what procedures from the 
study visit the participant completed. 
6.5 
Provider Feasibility Sub study 
A key operational question is provider acceptability and feasibility of PCN allergy evaluation 
including the allergy history screening questionnaire, skin testing and oral challenge in busy 
ambulatory STD settings. We will administer a brief electronic survey to providers at each of the 
clinics before implementation of the study and again at study conclusion. Since these are short 
surveys, and focus exclusively on clinical practice characteristics, consent will be obtained using 
either on-line consent or through an oral consent process.  

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All clinic providers who complete the provider feasibility survey will undergo the following 
procedures: 
• 
Electronic informed consent (on-line or oral) to participate in the sub study 
• 
Self-administration of the provider feasibility survey as an eCRF both pre-study 
implementation and at the end of the study 
Although pre/post evaluation data will be available in aggregate, all clinic-based providers will 
be assigned a 5-digit Provider ID number which will be used to compare responses for 
individual providers at the beginning and end of the study. We anticipate that among the 5 
participating clinics, we should be able to generate 50-100 surveys from staff who were present 
at the beginning and at the end of study. We anticipate that the total number of respondents will 
be no more than 150. 
6.6 
Data Handling, Data Quality Control and Record Keeping 
For this study the FHI 360 Center for Data Management (CDM) will be responsible for all issues 
relating to data collection (forms, tools, and systems), quality control, and management. FHI 360 
Biostatistics will provide statistical support for this study. 
A detailed data management (DM) plan will be written prior to study initiation. The following is a 
summary of the plan.  
6.6.1 Data Collection 
Data will be collected using CRFs that are specifically designed for this study. The data 
collected on the CRFs will be captured in a clinical data management system (CDMS), that 
meets the technical requirements described in 21CFR Part 11, GCP and HIPAA. The CDMS will 
be validated to ensure that it meets the scientific, regulatory, and logistical requirements of the 
study before it is used to capture data. Before using the CDMS, all study personnel will receive 
training on the system along with study specific training. After they are trained, users will be 
provided with individual system access rights. 
Data will be collected at the study site by appropriately designated and trained personnel. All 
screened participants who meet eligibility requirements will be assigned a PN. CRFs must be 
completed for each eligible participant. For eligible participants who decide not to enroll, data for 
the reason they declined enrollment will be collected on a refuser survey CRF. No identifying 
information will be collected on participants who do not consent for enrollment. Most of the data 
will be collected using paper CRFs. However, the PCN (B-lactam) allergy history screening 
questionnaire for participants and the provider feasibility survey for clinicians will be eCRFs. 
Data for the eCRFs will be collected using iPads. 
No names or personal identifying information will be collected on the CRFs. Data will be verified 
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manual review. Each site investigator (SI) or designee is responsible for the accuracy of data 
entered on the CRFs and will sign a statement on the final form for each participant 
acknowledging the review of all CRFs for that participant and certifying that all information on 
them is complete and accurate. 
The completed CRFs will be scanned and emailed to CDM. 
Digital images of the skin testing results will be collected and stored in the CDMS. 
6.6.2 Data Quality Control 
CDM is responsible for the accuracy, quality, completeness and internal consistency of the data 
from this study. Data handling, including data quality control, will comply with international 
regulatory guidelines, including ICH GCP guidelines. Data management and control processes 
specific to this study, along with all steps and actions taken regarding data management and 
data quality control, will be described in the DM plan. 
Paper CRFs received at FHI 360 will be processed and entered, then queried for completeness, 
consistency and the presence of mandatory values. Logical checks will be implemented to 
ensure data quality and accuracy. Any necessary data changes will be made in the clinical 
database, and data review and validation procedures will be repeated as needed. Discrepancies 
found will be queried. 
Data corrections will be made through the CDMS. The system audit trail captures the reason for 
each change, the previous and new data values, date and time and the username of the staff 
person making the change. 
The statistician will request data freezes for all interim and final reports. Thorough cleaning and 
closure of participant data will be performed at study close-out according to the DM plan. Prior 
to closure, all participant data will be complete or accounted for. 
At the conclusion of the study, the CDMS and all other study data will be locked to prevent 
further changes. Locking the study data represents the acknowledgement that all data have 
been captured and confirmed as accurate. 
6.6.3 Retention of Data 
At study close-out, the CDM will archive all the final datasets, CRFs, design documentation, 
protocol and all other documents in a study data repository. Records may not be destroyed 
without written permission from NIAID/DMID. 
Study sites will maintain study records and reports, including, but not limited to, CRFs, source 
documents, ICFs, test results, and medication inventory records for 3 years after study 
completion. The investigators may transfer custody of the records to another person who will 
accept responsibility for them. Notice of transfer must be given to the sponsor preferably before, 
but no more than ten days after, the transfer. 

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No records will be destroyed without the written consent of the sponsor. It is the responsibility of 
the sponsor to inform the investigators and FHI 360 CDM when these documents no longer 
need to be retained. 
6.6.4 Protocol Deviations 
A protocol deviation (PD) is any noncompliance with the study protocol, GCP or protocol-
specific Manual of Procedures requirements. The noncompliance may be either on the part of 
the participant, the SI, or other study personnel. As a result of deviations, corrective actions will 
be developed though a plan agreed upon by the site, the study Principal Investigator and DMID 
and then implemented promptly.  
It is the responsibility of the SI and other study personnel to use continuous vigilance to identify 
and report deviations within five working days of identification of the PD, or within five working 
days of the scheduled protocol-required activity. All deviations must be promptly reported to 
DMID using the approved DMID PD form and reporting methods. 
All deviations from the protocol must be addressed in study participant source documents. A 
completed copy of the DMID PD form must be maintained in the Regulatory File. PDs must be 
sent to the local IRB/Independent Ethics Committee per their guidelines. The SIs and other 
study personnel are responsible for knowing and adhering to their IRB requirements. 

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7 
SAFETY ASSESSMENT AND REPORTING 
This clinical study poses only minimal risk to study subjects. Minimal risk is defined by 45 US 
CFR 46.102 (j) as follows: 
“Minimal risk means that the probability and magnitude of harm or discomfort anticipated in the 
research are not greater in and of themselves than those ordinarily encountered in daily life or 
during the performance of routine physical or psychological examinations or tests.” 
Our experience indicates there will be infrequent problems with AEs. The PRE-PEN® 
(benzylpenicilloyl polylysine injection USP) kit was FDA approved in 2009 for the assessment of 
sensitization to PCN (benzylpenicillin or penicillin G) in those patients suspected of having a 
clinical hypersensitivity to PCN. Rarely, a systemic allergic reaction including anaphylaxis may 
follow a skin test with PRE-PEN®. To decrease the risk of a systemic allergic reaction, we will 
perform prick (puncture) skin testing first. Intradermal skin testing will be performed only if the 
prick test is entirely negative. Occasionally, patients may develop an intense local inflammatory 
response at the skin test site. Rarely, patients will develop a systemic allergic reaction, 
manifested by generalized erythema, pruritus, angioedema, urticaria, dyspnea, hypotension, or 
anaphylaxis. We will use standard of care treatment for any reactions. Study staff will be trained 
and anaphylaxis kits will be available at all sites. If necessary, subjects will be referred to local 
urgent care or emergency department facilities. 
7.1 
Safety Assessments 
For the purposes of safety assessment and reporting, there are three potential safety 
checkpoints in this clinical trial: 
1) Pre-skin testing 
2) Post-skin testing 
3) Oral challenge 
These checkpoints are applicable to all subjects consented and enrolled after the initial 
screening questions. 
7.1.1 Pre-Skin Testing 
Prior to skin testing, study staff will verify that subjects: 
• 
Have not responded ‘yes’ to any of the high-risk PCN allergy history questions on the PCN 
(B-lactam) Allergy History Screening Questionnaire  
• 
Have not used oral antihistamines within the past week 
• 
Do not have severe eczema, psoriasis, or other major skin conditions in the areas where 
testing will be done (usually the arms) 

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• 
Do not have large tattoos on their arms 
• 
If HIV positive, are on HAART 
• 
If HIV positive, CD4 not <200 in the past 6 months 
7.1.2 Post-Skin Testing 
• 
Subjects will be observed for 30 + 5 minutes and 60 + 5 minutes after skin testing. 
Assessment of elicited reactivity to PCN will include local skin reactions including erythema, 
induration and itching which will be evaluated both by self-report and physical exam. 
Systemic reactions are extremely rare. 
• 
Subjects with positive skin tests will not progress to oral challenge step. 
An impending generalized reaction to immediate hypersensitivity skin testing is unusual. If any 
acute reactions occur, they will be treated as necessary and reported to the IRB and DMID as 
required. 
7.1.3 Oral Challenge 
Pregnancy status will be verified. Pregnant women will not be enrolled in the DOC group. 
Prior to the oral challenge, vital signs will be recorded (heart rate, respiratory rate, blood 
pressure and peak flow). A focused PE will be performed (eyes, pharynx, lungs and skin). 
Subjects will be observed for 60 minutes ± 10 minutes after the amoxicillin is administered. Vital 
signs, peak flow measurement and focused PE will be repeated after the 60-minute observation 
period ± 10 minutes.  
After oral challenge, subjects will be assessed for the most common elicited reactions 
associated with amoxicillin which will be graded and documented using the Toxicity Table 
(Appendix C):  
• 
Cardiovascular: lightheadedness, loss of consciousness 
• 
Skin: urticaria, flushing, rash, angioedema 
• 
HEENT: conjunctivitis, rhinitis, congestion 
• 
Respiratory: shortness of breath, wheezing 
• 
GI: nausea, vomiting, diarrhea 
Data will be collected on reactions to amoxicillin as a diagnostic tool for defining an allergic 
reaction that was not identified by the skin testing. Unanticipated reactions that place the subject 
at increased risk will be recorded on the AE CRF and reported to the IRB and DMID according 
to their reporting guidelines. 
Subjects will be provided with contact information for study staff to report the development of 
additional symptoms.  

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7.2 
Reporting 
Federal regulations require that institutions engaging in human subjects’ research have written 
procedures to ensure investigators properly report certain events to the IRB. Events must be 
reported promptly after the event is discovered or within 10 working days after discovery of the 
event. 
All potential unanticipated problems involving risks to subjects or others (UPIRSO) must be 
reported. An event is considered an UPIRSO when it meets all of the following criteria: 
1. It is unexpected (in terms of nature, severity, or frequency) given (a) the research 
procedures that are described in the IRB-approved research protocol and informed 
consent document; and (b) the characteristics of the population being studied; 
2. It is related or possibly related to participation in the research (i.e. there is a reasonable 
possibility that the incident, experience, or outcome may have been caused by the 
procedures involved in the research); 
and 
3. It places subjects or others [e.g., study staff or relatives of a subject] at a greater risk of 
harm (including physical, psychological, economic, or social harm) than was previously 
known or recognized. 
Other events that require prompt reporting include potential breaches of confidentiality and 
unresolved participant complaints.  
 

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8 
STATISTICAL CONSIDERATIONS 
8.1 
Study Outcome Measures 
8.1.1 Primary Outcome Measures 
The following primary outcome measures will be used to address the primary study objectives: 
• 
Algorithm / PCN (B-lactam) allergy history screening questionnaire performance in 
ambulatory STD populations, specifically the NPV of the algorithm on true PCN (B-lactam) 
allergy. 
• 
In ambulatory STD patients who report a history of PCN (B lactam) allergy and who have 
low-risk histories, determine the prevalence of PCN reactivity validated either by skin test or 
by direct oral challenge. 
8.1.2 Secondary Outcome Measures 
The following secondary outcome measures will be used to address the secondary study 
objectives: 
• 
Acceptability 
o Proportion of study subjects who find the testing procedures to be helpful. 
o Reasons why study subjects refuse to participate in the study or find the testing 
procedures to be of no value. 
o Proportion of study subjects who were negative on oral challenge who now feel confident 
in taking PCN or similar antibiotics. 
o Proportion of study providers who will not offer PCN allergy assessment in the future. 
• 
Feasibility  
o Proportion of study providers who will offer PCN allergy assessment in the future. 
o Reasons why study providers will not offer PCN allergy assessment in the future. 
• 
Both acceptability and feasibility 
o Types and frequencies of elicited reactivity to PCN through skin testing and oral 
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8.2 
Sample Size Considerations 
The sample size for this study was selected to have adequate study power to conclude a high 
NPV of the PCN (B-lactam) allergy history screening questionnaire in ruling out the presence of 
true PCN (B-lactam) allergy. To address the objective properly, we applied Steinberg’s et al.32 
approach to obtain the minimal sample size needed to achieve a lower 95% confidence bound 
for NPV that exceeds the NPV with a useless test at a fixed level of significance with a given 
study power. Based on this approach, the sample size calculation depends on the prevalence of 
PCN allergy in the population and among observed study participants and the sensitivity and 
specificity of the PCN allergy diagnostic kit (PRE-PEN®). To target at least 85% power at 5% of 
significant level, the listed sample sizes (see table) provide lower 95% confidence bounds for 
NPV under the following various assumptions: 
• 
The true population prevalence with PCN allergy: 1%, 3%, 5%    
• 
The observed % of PCN allergy in this study: 1%, 3%, 5%   
• 
The PCN allergy diagnostic kit with sensitivity at least 85% and specificity 95% 
• 
5% of participants who report a PCN allergy history will have a high-risk allergy history 
and therefore will not proceed to skin testing.  
Population 
prevalence 
of PCN 
allergy 
Observed 
% of PCN 
allergy in 
study 
Estimated 
NPV 
The lower 95% confidence bound for NPV 
99.0% 
98.4% 
97.9% 
97.5% 
97.3% 
97.0% 
95.0% 
1% 
1% 
99.84% 
1259 
796 
635 
556 
526 
488 
351 
3% 
99.51% 
420 
265 
212 
185 
175 
163 
117 
5% 
99.18% 
252 
159 
127 
111 
105 
98 
70 
3% 
1% 
99.84% 
8119 
2964 
1958 
1559 
1421 
1259 
759 
3% 
99.51% 
2707 
988 
653 
520 
474 
420 
253 
5% 
99.18% 
1624 
593 
392 
312 
284 
252 
152 
5% 
1% 
99.84% 
113000 
9519 
4770 
3378 
2950 
2483 
1259 
3% 
99.51% 
37547 
3174 
1590 
1126 
984 
828 
420 

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5% 
99.18% 
22533 
1905 
954 
676 
590 
497 
252 
 
For example, with 3% PCN allergy prevalence in population and among observed study 
participants, the NPV for a useless test is 97%. A useful PCN (B-lactam) allergy history 
screening questionnaire should have the lower 95% confidence bound for NPV greater than 
97%. Based on the list a minimum sample size of 988 subjects who reported to have PCN 
allergy history would provide an estimated NPV = 99.51% with 85% power to conclude that the 
NPV of the study allergy history screening questionnaire is least 98.4% at 5% significant level. 
8.3 
Participant Enrollment and Follow-Up 
The final statistical report will include an accounting of all subjects screened, including the 
number enrolled, the number excluded, the number with high-risk history of PCN allergy, the 
number who refused to participate in skin testing, the number who received skin testing, the 
number excluded from oral challenge, the number who refused oral challenge, the number who 
received oral challenge and other key study status indicators. The reason for excluding any 
study subject during the study process will be documented. The study population flow chart will 
be provided. 
8.4 
Analysis Plan 
A detailed statistical analysis plan (SAP) will be developed prior to performing any analyses. 
The following is a summary of the planned analyses. Any changes made to this summary plan 
will be documented in the detailed SAP. 
8.4.1 Primary analysis 
The primary analysis will estimate with corresponding exact 95% confidence intervals: 
• 
The prevalence of PCN reactivity validated either by skin test or by direct oral challenge 
among those participants who report a history of PCN (B lactam) allergy and who have low-
risk histories. 
• 
The NPV on true PCN (B-lactam) allergy of the algorithm / PCN (B-lactam) allergy history 
screening questionnaire performance in the study population.  
The NPV for each question will be estimated and its performance will be assessed.  
To construct a short standardized post-study questionnaire (4-6 questions) from the PCN (B-
lactam) allergy history screening questionnaire, we will use Item Response Theory (IRT) to 
evaluate each question item’s discrimination ability of true PCN (B-lactam) allergy and use 
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predicting the true PCN (B-lactam) allergy. Based on the results of IRT and variable importance 
analyses, we will then apply machine learning approaches (e.g., random forest approach via R 
packages of caret)33 to select a short post-study questionnaire that has the highest NPV among 
those possible short questionnaires with 4-6 selected questions.    
8.4.2 Analysis of Secondary Endpoints 
The frequency and the percentage of participants 1) who experienced elicited reactivity to PCN 
allergy skin testing in the PST Group and oral challenge in both groups; 2) who refused to 
participate the study; 3) who found the testing procedures of no value will be tabulated by study 
site. The proportions of participants 1) experiencing elicited reactivity to penicillin allergy testing; 
2) reporting reasons for refusing to participate in the study or finding the testing procedures to 
be of no value; 3) describing confidence in taking PCN or similar antibiotics among those who 
were negative on oral challenge will be calculated with corresponding exact 95% confidence 
intervals. 
The same approach will also be used to evaluate the feasibility of providers who will offer the 
PCN allergy assessment in the future and the reasons among those providers who will not offer 
the PCN allergy assessment in the future.  The evaluation of the secondary endpoints will be 
conducted by intervention group and overall  
 

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9 
SUBJECT CONFIDENTIALITY 
The participating investigators, their staff, and the sponsor(s) and their agents hold participant 
confidentiality strictly in trust. This confidentiality includes clinical information relating to enrolled 
participants. All clinical information will be maintained at the sites. 
The study protocol, documentation, data, and all other information generated during 
participation in the study will be held in strict confidence. No information concerning the study, 
or the data generated from the study, will be released to any unauthorized third party without 
prior written approval of the sponsor. Subject confidentiality will be maintained when study 
results are published or discussed at conferences. Authorized representatives of the sponsor or 
governmental regulatory agencies may inspect all documents and records required to be 
maintained by the investigator. The clinical study site will permit access to such records. 
All records will be kept locked, and all computer entry and networking programs will be carried 
out with coded numbers only and with password protected systems. All evaluation forms, 
reports, and other records that leave the site will be identified only by a coded number. 
This research is covered by a Certificate of Confidentiality from the NIH. The researchers with 
this Certificate may not disclose or use information, documents, or biospecimens that may 
identify a subject in any federal, state, or local civil, criminal, administrative, legislative, or other 
action, suit, or proceeding, or be used as evidence, for example, if there is a court subpoena, 
unless a subject has consented for this use. Information, documents, or biospecimens protected 
by this Certificate cannot be disclosed to anyone else who is not connected with the research 
except, if there is a federal, state, or local law that requires disclosure (such as to report child 
abuse or communicable diseases but not for federal, state, or local civil, criminal, administrative, 
legislative, or other proceedings); if a subject has consented to the disclosure, including for their 
medical treatment; or if it is used for other scientific research, as allowed by federal regulations 
protecting research subjects. 

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10 
INFORMED CONSENT PROCESS 
Federal regulations specify the elements of informed consent that must be conveyed to 
research participants through the informed consent process (see 21 CFR 50.20). It is the 
responsibility of the SI and his/her assigned staff to ensure that all required information has 
been provided to potential research participants. The consent forms for this study will be IRB 
approved. 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in 
the study and continuing throughout the individual’s study participation. Participants may 
withdraw consent at any time during the trial. Study staff will provide the potential participant 
consent forms (as approved by the IRB) which describe the study procedures and risks in detail. 
Documentation of obtaining informed consent will be noted. Staff will ask the potential 
participant to read and review the document, or have it read to them, and will also be available 
to answer any questions the participant may have. Those who administer consent will provide 
extensive discussion of risks and possible benefits to the potential participants. Informed 
consent can be obtained orally, written and electronically using procedures approved by the 
IRB. The potential participant will provide consent before any procedures are performed 
specifically for the study. The potential participants will have the opportunity to discuss the study 
prior to agreeing to participate. A copy (or electronically) of the applicable consent form will be 
provided to the participant. The consent will state that the administration and quality of their 
medical care will not be adversely affected if they decline to participate in this study. 
The study staff’s approach to study subjects will be compliant with HIPAA regulations. 
 

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11 
LITERATURE REFERENCES 
1. 
Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Antibiotic allergy. Lancet. Jan 12, 
2019;393(10167):183-198. 
2. 
Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin 
Allergy: A Review. JAMA. Jan 15, 2019;321(2):188-199. 
3. 
Vyles D, Macy E. Self-reported beta-lactam intolerance: not a class effect, dangerous to 
patients, and rarely allergy. Expert Rev Anti Infect Ther. Jun 2019;17(6):429-435. 
4. 
Gadde J, Spence M, Wheeler B, Adkinson NF, Jr. Clinical experience with penicillin skin 
testing in a large inner-city STD clinic. JAMA. Nov 24, 1993;270(20):2456-2463. 
5. 
Rubin R. Overdiagnosis of Penicillin Allergy Leads to Costly, Inappropriate Treatment. 
JAMA. Nov 13, 2018;320(18):1846-1848. 
6. 
Blumenthal KG, Wickner PG, Hurwitz S, et al. Tackling inpatient penicillin allergies: 
Assessing tools for antimicrobial stewardship. J Allergy Clin Immunol. Jul 
2017;140(1):154-161 e156. 
7. 
Macy E. Penicillin allergy: optimizing diagnostic protocols, public health implications, and 
future research needs. Curr Opin Allergy Clin Immunol. Aug 2015;15(4):308-313. 
8. 
Blumenthal KG, Lu N, Zhang Y, Li Y, Walensky RP, Choi HK. Risk of meticillin resistant 
Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin 
allergy: population based matched cohort study. BMJ. Jun 27, 2018;361:k2400. 
9. 
Blumenthal KG, Ryan EE, Li Y, Lee H, Kuhlen JL, Shenoy ES. The Impact of a Reported 
Penicillin Allergy on Surgical Site Infection Risk. Clin Infect Dis. Jan 18, 2018;66(3):329-
336. 
10. 
Macy E, Contreras R. Health care use and serious infection prevalence associated with 
penicillin "allergy" in hospitalized patients: A cohort study. J Allergy Clin Immunol. Mar 
2014;133(3):790-796. 
11. 
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. Dec 2014;67(12):1088-1092. 
12. 
McDanel DL, Azar AE, Dowden AM, et al. Screening for Beta-Lactam Allergy in Joint 
Arthroplasty Patients to Improve Surgical Prophylaxis Practice. J Arthroplasty. Sep 
2017;32(9S):S101-S108. 
13. 
Macy E, Vyles D. Who needs penicillin allergy testing? Ann Allergy Asthma Immunol. 
Nov 2018;121(5):523-529. 

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14. 
Leis JA, Palmay L, Ho G, et al. Point-of-Care beta-Lactam Allergy Skin Testing by 
Antimicrobial Stewardship Programs: A Pragmatic Multicenter Prospective Evaluation. 
Clin Infect Dis. Oct 1, 2017;65(7):1059-1065. 
15. 
Heil EL, Bork JT, Schmalzle SA, et al. Implementation of an Infectious Disease Fellow-
Managed Penicillin Allergy Skin Testing Service. Open Forum Infect Dis. Sep 
2016;3(3):ofw155. 
16. 
Cheon E, Horowitz HW. New Avenues for Antimicrobial Stewardship: The Case for 
Penicillin Skin Testing by Pharmacists. Clin Infect Dis. Jun 15, 2019;68(12):2123-2124. 
17. 
Adkinson NF, Jr., Mendelson LM, Ressler C, Keogh JC. Penicillin minor determinants: 
History and relevance for current diagnosis. Ann Allergy Asthma Immunol. Nov 
2018;121(5):537-544. 
18. 
Banks TA, Tucker M, Macy E. Evaluating Penicillin Allergies Without Skin Testing. Curr 
Allergy Asthma Rep. Mar 22, 2019;19(5):27. 
19. 
Hierro Santurino B, Mateos Conde J, Cabero Morán MT, Mirón Canelo JA, Armentia 
Medina A. A Predictive Model for the Diagnosis of Allergic Drug Reactions According to 
the Medical History. J Allergy Clin Immunol Pract. Mar - Apr 2016;4(2):292-300.e293. 
20. 
Chiriac AM, Wang Y, Schrijvers R, et al. Designing Predictive Models for Beta-Lactam 
Allergy Using the Drug Allergy and Hypersensitivity Database. J Allergy Clin Immunol 
Pract. Jan - Feb 2018;6(1):139-148 e132. 
21. 
Blumenthal KG. The Role of the Clinical History in Drug Allergy Prediction. J Allergy Clin 
Immunol Pract. Jan - Feb 2018;6(1):149-150. 
22. 
Chiriac AM, Banerji A, Gruchalla RS, et al. Controversies in Drug Allergy: Drug Allergy 
Pathways. J Allergy Clin Immunol Pract. Jan 2019;7(1):46-60 e44. 
23. 
Iammatteo M, Alvarez Arango S, Ferastraoaru D, et al. Safety and Outcomes of Oral 
Graded Challenges to Amoxicillin without Prior Skin Testing. J Allergy Clin Immunol 
Pract. May 23 2018. Jan 2019;7(1):236-243. 
24. 
Blumenthal KG, Huebner EM, Fu X, et al. Risk-based pathway for outpatient penicillin 
allergy evaluations. J Allergy Clin Immunol Pract. Sep - Oct 2019;7(7):2411-2414 e2411. 
25. 
Blumenthal KG, Li Y, Hsu JT, et al. Outcomes from an inpatient beta-lactam allergy 
guideline across a large US health system. Infect Control Hosp Epidemiol. May 
2019;40(5):528-535. 
26. 
Mustafa SS, Conn K, Ramsey A. Comparing Direct Challenge to Penicillin Skin Testing 
for the Outpatient Evaluation of Penicillin Allergy: A Randomized Controlled Trial. J 
Allergy Clin Immunol Pract. Sep - Oct 2019;7(7):2163-2170. 

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27. 
Tucker MH, Lomas CM, Ramchandar N, Waldram JD. Amoxicillin challenge without 
penicillin skin testing in evaluation of penicillin allergy in a cohort of Marine recruits. J 
Allergy Clin Immunol Pract. May - Jun 2017;5(3):813-815. 
28. 
Vaisman A, McCready J, Hicks S, Powis J. Optimizing preoperative prophylaxis in 
patients with reported beta-lactam allergy: a novel extension of antimicrobial 
stewardship. J Antimicrob Chemother. Sep 1, 2017;72(9):2657-2660. 
29. 
Vorobeichik L, Weber EA, Tarshis J. Misconceptions Surrounding Penicillin Allergy: 
Implications for Anesthesiologists. Anesth Analg. Sep 2018;127(3):642-649. 
30. 
Zagursky RJ, Pichichero ME. Cross-reactivity in beta-Lactam Allergy. J Allergy Clin 
Immunol Pract. Jan - Feb 2018;6(1):72-81 e71. 
31. 
PRE-PEN® (benzylpenicilloyl polylysine injection USP) Skin Test Antigen [package 
insert]. Plainville, CT: AllerQuest, LLC; 2013. 
32. 
Steinberg DM, Fine J, Chappell R. Sample size for positive and negative predictive value 
in diagnostic research using case-control designs. Biostatistics. Jan 2009;10(1):94-105. 
33. 
Kuhn M. Contributions from Jed Wing, Steve Weston, Andre Williams, Chris Keefer, 
Allan Engelhardt, Tony Cooper, Zachary Mayer, Brenton Kenkel, the R Core Team, 
Michael Benesty, Reynald Lescarbeau, Andrew Ziem, Luca Scrucca, Yuan Tang and 
Can Candan. Caret: Classification and Regression Training. R package version. 
(2016)6.0-74. https://CRAN.R-project.org/package=caret. 
 
 

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APPENDIX A: SCHEDULE OF EVENTS 
Procedures 
Enrollment 
Visit  
Additional 
Visit  
(within 6 
weeks as 
necessary to 
complete 
study 
procedures) 
Written, oral, or electronic informed consent  
X 
 
Assessment of eligibility criteria 
X 
 
Review demographic information 
X 
 
Administration of PCN (B-lactam) Allergy History Screening 
Questionnaire 
X 
 
Review of concomitant medications  
X 
(X) 
 
Allergy Validation Method 1: PST Group 
Assessment of PCN Skin Test qualification criteria 
X 
(X) 
If additional criteria met, PCN Skin Test (prick and/or 
intradermal) 
X 
(X) 
Photo documentation of skin testing (iPad) 
X 
(X) 
Assessment of Oral Challenge qualification criteria 
X 
(X) 
Assessment of vital signs (plus peak flow) and focused PE 
before and after Oral Challenge 
X 
(X) 
If additional criteria met, Oral Challenge of 250 mg amoxicillin 
X 
(X) 
 
Allergy Validation Method 2: DOC Group 
Assessment of Oral Challenge qualification criteria 
X 
(X) 
Assessment of vital signs (plus peak flow) and focused PE 
before and after Oral Challenge 
X 
(X) 
If additional criteria met, two-step Oral Challenge – initial dose 
of 25 mg amoxicillin followed by full dose of 250 mg 
X 
(X) 
 
Completion of CRFs 
X 
(X) 
Assessment of Adverse Events 
X 
(X) 
Administration of subject acceptability survey 
X 
(X) 
Provide written documentation of PCN allergy testing results 
or referral to allergist 
X 
(X) 
 
At enrollment, all procedures will be completed unless participant cannot stay for skin testing and/or oral challenge. 
(X) indicates procedures that may not have been completed during Enrollment Visit because of time constraints 

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APPENDIX B: PCN (B-LACTAM) ALLERGY HISTORY SCREENING 
QUESTIONNAIRE 
Section 1: Allergy History 
1) 
How long ago was the reaction to the antibiotic? 
a. 
< 6 months 
b. 
6 months-1 year  
c. 
2-5 years  
d. 
6-10 years  
e. 
> 10 years 
f. 
Don’t remember / Unknown 
2) 
What was the name of the drug you reacted to?  
a. 
(Please list) _________________________________________________ 
b. 
Don’t remember / Unknown 
3) 
How was the antibiotic administered? 
a. 
Pill or Liquid by mouth 
b. 
Injection (a shot) into a muscle or through a vein 
c. 
Don’t remember / Unknown 
4)        When did your allergic reaction to the antibiotic start? 
a. 
Less than 1 hour after the first dose 
b. 
Between 1 and 6 hours after the first dose 
c. 
More than 6 hours, but less than 24 hours after the first dose 
d. 
24 hours or more after the first dose 
e. 
Unknown 
5) 
How many days did you receive your antibiotic treatment? 
a. 
One day only 
b. 
About ______ days of treatment 
c. 
Don’t remember / Unknown  
6)        People experience many different kinds of symptoms during an allergic reaction to an 
antibiotic. What were the symptoms of your allergic reaction? (OK to select more than 
one)  
a. 
Can’t remember (check only after reading entire list) 

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b. 
Non-specific symptom(s) (e.g., “sick” “thought I was a goner” “high as a kite” “like 
I had the flu” 
Responses to the symptoms listed below should be graded on a 5-point scale: 
 Don’t Recall /None / Mild / Moderate / Severe 
Low-Risk Allergy History 
a. 
Isolated GI upset (diarrhea, nausea, vomiting, abdominal pain) 
b. 
Chills (rigors)  
c. 
Headache  
d. 
Fatigue 
e. 
Itching (pruritus), self-limited, 
f. 
Rash (including maculopapular rash)  
g. 
Hives (greater than 5 years ago) 
h. 
Flushing / redness 
i. 
Family history 
j. 
Patient denies allergy history but is in medical record  
Higher-Risk Allergy History: Skin Testing and Oral Challenge Contraindicated 
a. 
Angioedema or swelling of lip, tongue, or around eyes 
b. 
Wheezing / chest tightness moderate or severe shortness of breath 
c. 
Throat tightness which affected ability to breathe 
d. 
Hypotension without rapid recovery 
e. 
Arrhythmia / irregular heartbeat or palpitations 
f. 
Syncope / pass out / dizzy 
g. 
Anaphylaxis or sudden drop in blood pressure 
h. 
Hives (5 years or less) 
Late Effect Symptoms (higher-risk events occurred >24 hours after drug administration)   
a. 
Stevens-Johnson syndrome (Loss >10% of skin) 
b. 
Organ injury (liver, kidney) 
c. 
Low Platelets  
d. 
Drug reaction eosinophilia and systemic symptoms (rash with eosinophilia and 
organ injury) 
e. 
Acute generalized exanthem (rash with pustules) 
f. 
Dystonia or muscles became very stiff or very weak 
g. 
Serum sickness (rash with joint pain, fever, myalgia) 
h. 
Anemia 

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i. 
Documented drug fever 
j. 
Erythema multiforme (rash with target lesions) 
k. 
Hives (5 years or less) 
7) 
What treatment did you receive for the allergic reaction on the day it started? (OK to 
select more than one) 
a. 
No treatment  
b. 
Went to the hospital emergency room or urgent care center 
c. 
Was admitted to the hospital 
d. 
Given epinephrine / adrenaline 
e. 
Given steroid pills or injections 
f. 
Given a steroid cream 
g. 
Given an antihistamine (anti-itch pill) 
h. 
Antibiotic discontinued 
i. 
Fluids through a vein 
j. 
Other (please list) ____________________________________________ 
k. 
Unknown 
8) 
Did you stop taking the antibiotic or did you finish the course? 
a. 
Stopped after the reaction started 
b. 
Continued to take the antibiotic after the reaction  
c. 
Don’t remember 
9) 
Since you had the antibiotic reaction, have you ever taken any of the following 
antibiotics? 
a. 
Amoxicillin/Clavulanate (Augmentin) 
b. 
Cephalexin (Keflex) 
c. 
Ceftriaxone (Rocephin)  
d. 
Benzathine Penicillin (Bicillin) (injections) 
e. 
Cefuroxime (Ceftin) 
f. 
Cefadroxil (Duricef) 
g. 
Ampicillin 
h. 
Amoxicillin  
i. 
Cefaclor (Ceclor) 
j. 
Cefixime (Suprax) 
k. 
Any other drug whose name ended with “cillin” 
l. 
Any other drug whose name started with “cef”  
m. 
Other (Please list) ___________________________________________ 
n. 
Don’t know or remember 
10) 
Since you had the antibiotic reaction, have you ever been treated for gonorrhea, syphilis 
or strep throat? 

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a. 
Yes (please list medication) ___________________________________ 
b. 
No 
 
 

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Section 2: Skin Testing History 
Questions to ask before skin testing is performed 
11) 
Have you ever been skin tested for allergy to penicillin? 
a. 
Yes (if Yes, go to Q12; otherwise skip to Q13) 
b. 
No 
c. 
Unknown 
12) 
What were the results of the skin test? 
a. 
Positive 
b. 
Negative 
c. 
Unknown 
13) 
In the past week have you taken any of the following medications, including over the 
counter (OTC)?  (Include only medications that you have taken orally, no skin or 
eye medications) 
a. 
OTC cough and cold remedies containing antihistamines 
b. 
Benadryl 
c. 
Non-sedating antihistamines (Zyrtec, Allegra, Claritin, Xyzal) 
d. 
Antivert / meclizine, Dramamine and Phenergan 
e. 
Hydroxyzine (Atarax/Vistaril) 
f. 
Other (please list) _________________________________________________ 
g. 
None – I have not taken any of these medications 
(If Yes to a, b, c, d or e, exclude from skin test)) 
 
 

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Section 3: Subject Acceptability Survey 
Questions to ask after skin testing and oral challenge procedures are completed  
FOR ALL SUBJECTS 
14) 
Did you find the penicillin testing procedures to be helpful? 
(Scale of 1-5, where 1 is extremely helpful, 5 is not helpful at all) 
(if 4 or 5, go to Q15; otherwise skip to Q16) 
15) 
Why were the penicillin testing procedures not helpful? 
a. 
Took too long 
b. 
Testing was uncomfortable 
c. 
Other (Please list) ____________________________________________ 
16) 
Were you comfortable with allergy testing conducted in settings where STD services are 
provided rather than by an allergist? 
(Scale of 1-5, where 1 is extremely comfortable, 5 is not comfortable at all) 
17) 
If a friend or family member had a history of penicillin allergy, would you refer them for 
testing?  
(Scale of 1-5 where 1 is definitely yes, 5 is definitely no) 
FOR SUBJECTS WHO HAVE BEEN SKIN TESTED AND ARE NEGATIVE FOR PCN 
ALLERGY  
18) 
How confident are you that you can now take penicillin or similar antibiotics? 
(Scale of 1-5 where 1 is very confident and 5 is not confident at all)  
 
 

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APPENDIX C: TOXICITY TABLE 
Clinical Adverse Events 
NEUROLOGICAL/ 
CARDIOVASCULAR 
Mild 
(Grade 1) 
Moderate 
(Grade 2) 
Severe 
(Grade 3) 
Pre-syncope/Syncope 
Lightheadedness  
Dizziness (pre-
syncope), diaphoresis 
and sense of 
impending doom 
Confusion, collapse, 
loss of consciousness 
Hypotension  
 
 
Decrease in systolic 
blood pressure 
greater than 30% 
from baseline 
Pulse 
 
Increase or decrease 
of 20bpm from 
baseline 
Increase or decrease 
of 30bpm from 
baseline 
CUTANEOUS 
Mild 
(Grade 1) 
Moderate 
(Grade 2) 
Severe 
(Grade 3) 
Urticaria and angioedema   
Flushing or sensation 
of heat or warmth  
Generalized urticaria 
and/or periorbital 
edema or 
angioedema (not 
laryngeal, tongue or 
uvular) 
Generalized urticaria 
and laryngeal, tongue 
or uvula swelling with 
or without stridor    
HEENT  
Mild 
(Grade 1) 
Moderate 
(Grade 2) 
Severe 
(Grade 3) 
Eyes, face and periorbital area  Conjunctival 
erythema, pruritus or 
tearing  
Conjunctivitis plus 
rhinitis (e.g., 
sneezing, rhinorrhea, 
nasal pruritus and/or 
nasal congestion),  
Upper respiratory 
 
Cough perceived to 
come from the upper 
airway (not the lungs, 
larynx, or trachea) 
without stridor 
Upper respiratory 
symptoms and cough 
perceived to come 
from the lungs, larynx, 
or trachea with stridor 
RESPIRATORY 
Mild 
(Grade 1) 
Moderate 
(Grade 2) 
Severe 
(Grade 3) 

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Shortness of breath 
(bronchospasm)   
Transient; no 
treatment; 71% - 80% 
of baseline peak flow 
Bronchospasm 
(dyspnea, 
hoarseness, wheeze) 
that requires medical 
intervention; 
normalizes with 
bronchodilator; 60% - 
70% (of baseline 
peak flow) 
<60% of baseline 
peak flow 
 
Bronchospasm that 
does not resolve or 
progresses to 
respiratory failure 
GASTROINTESTINAL   
Mild 
(Grade 1) 
Moderate 
(Grade 2) 
Severe 
(Grade 3) 
Abdominal cramps, vomiting 
or diarrhea 
Transient abdominal 
cramps 
Abdominal cramps, 
nausea, vomiting or 
diarrhea 
Abdominal cramps, 
nausea, vomiting or 
diarrhea with 
signs/symptoms of 
dehydration that 
requires medical 
intervention 
 
 
 
 
 

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APPENDIX D: PROVIDER FEASIBILITY SURVEY 
SECTION 1: PRE-TRIAL SURVEY 
 
1. What is your practice setting? Check (X) only one 
a. Public health clinic ..................................................................................................... |___| 
b. Outpatient primary care clinic ......................  ............................................................. |___| 
c. Outpatient specialty clinic ►Specify_______________________ ............................ |___| 
d. Other clinic setting► Specify:  ___________________________ ............................ |___| 
 
2. What type of provider are you? Check (X) only one 
a. Physician (MD/DO) ......................................  ............................................................. |___| 
b. Nurse practitioner ........................................  ............................................................. |___| 
c. Physician assistant .................................................................................................... |___| 
d. RN ............................................................................................................................. |___| 
e. Other ► Specify:  ___________________________________ ............................... |___| 
 
3. What is your specialty or defined area of practice? Check (X) all that apply 
a. Adult medicine .............................................  ............................................................. |___| 
b. Family medicine ..........................................  ............................................................. |___| 
c. Infectious disease only .............................................................................................. |___| 
d. Pediatric/Adolescent medicine ................................................................................... |___| 
e. OB-GYN .................................................................................................................... |___| 
f. Preventive medicine ....................................  ............................................................. |___| 
g. Other ► Specify:  ___________________________________ ............................... |___| 
 
4. What is your current approach to penicillin (PCN) allergic patients? Check (X) all that apply 
a. Use alternative antibiotic ............................  ............................................................. |___| 
b. Penicillin skin testing ..................................  ............................................................. |___| 
c. Oral challenge .......................................................................................................... |___| 
d. Referral to allergist ................................................................................................... |___| 
e. Other ► Specify:  ___________________________________ .............................. |___| 
 
5. Do you have access to PCN skin testing? .. |___| 
0=No (Skip to Q8) 

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1=Yes (Continue to Q6) 
 
6. Do you offer/perform PCN skin testing on site?|___| 
0=No  
1=Yes  
 
7.  What are the barriers to offering / performing PCN skin test to your allergic patients?  
Check (X) all that apply  
a. Lack of training ............................................  ............................................................. |___| 
b. Cost of testing .............................................  ............................................................. |___| 
c. Length of time to perform test .................................................................................... |___| 
d. Fear of precipitating a severe allergic reaction in a patient ........................................ |___| 
e. I don’t think PCN skin testing is necessary ................................................................ |___| 
f. Not interested in offering / performing skin testing ..................................................... |___| 
g. Other ► Specify: ________________________________________ ...................... |___| 
 
8. Do you have offer / perform oral challenge for your PCN allergic patients? ..................... |___| 
0=No (Skip to Q10) 
1=Yes (Continue to Q9) 
 
9. Who do you test? Check (X) all that apply  
a. Patients with low risk history and skip skin testing ..................................................... |___| 
b. Patients who are negative on skin test.........  ............................................................. |___| 
c. Other criteria used ► Specify: _________________________________ ................ |___| 
 
10. What are the barriers to offering / performing oral challenge to your PCN allergic patients? 
Check (X) all that apply  
a. Lack of training ............................................  ............................................................. |___| 
b. Cost of testing .............................................  ............................................................. |___| 
c. Length of time to perform test .................................................................................... |___| 
d. Fear of precipitating a severe allergic reaction in a patient ........................................ |___| 
e. I don’t think oral challenge is necessary .................................................................... |___| 
f. Not interested in offering / performing an oral challenge ............................................ |___| 
g. Other ► Specify:  __________________________________________ .................. |___| 
 
 
 

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SECTION 2: POST-TRIAL SURVEY 
 
1. What is your practice setting? Check (X) only one 
a. Public health clinic ..................................................................................................... |___| 
b. Outpatient primary care clinic ......................  ............................................................. |___| 
c. Outpatient specialty clinic ►Specify_______________________ ............................ |___| 
d. Other clinic setting► Specify:  ___________________________ ............................ |___| 
 
2. What type of provider are you? Check (X) only one 
a. Physician (MD/DO) ......................................  ............................................................. |___| 
b. Nurse practitioner ........................................  ............................................................. |___| 
c. Physician assistant .................................................................................................... |___| 
d. RN ............................................................................................................................. |___| 
e. Other ► Specify:  ___________________________________ ............................... |___| 
 
3. What is your specialty or defined area of practice? Check (X) all that apply 
a. Adult medicine .............................................  ............................................................. |___| 
b. Family medicine ..........................................  ............................................................. |___| 
c. Infectious disease only .............................................................................................. |___| 
d. Pediatric/Adolescent medicine ................................................................................... |___| 
e. OB-GYN .................................................................................................................... |___| 
f. Preventive medicine ....................................  ............................................................. |___| 
g. Other ► Specify:  ___________________________________ ............................... |___| 
 
4. What is your current approach to penicillin (PCN) allergic patients? Check (X) all that apply 
a. Use alternative antibiotic .............................  ............................................................. |___| 
b. Penicillin skin testing ...................................  ............................................................. |___| 
c. Oral challenge ........................................................................................................... |___| 
d. Referral to allergist .................................................................................................... |___| 
e. Other ► Specify:  ___________________________________ 
                           |___| 
 
5. Prior to the trial, did you offer/perform PCN skin testing on site?  
 
 
   |___| 
0=No  
1=Yes  
 

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6. Prior to the trial, did you offer/perform oral challenge for your PCN allergic patients?  |___| 
0=No 
1=Yes 
 
7. Which PCN allergy intervention did you perform? 
 
 
 
 
|___| 
0=PCN Skin Testing 
1=Direct Oral Challenge 
2=Both 
 
8. Which method did you prefer?  
 
 
 
 
 
 
 
|___| 
0=PCN Skin Testing 
1=Direct Oral Challenge 
2=No preference 
 
9. Please explain why you preferred the allergy intervention method you chose in Q8. 
Describe:   _______________________________________________________________ 
_________________________________________________________________________ 
 
10. After participating in the trial, do you feel PCN allergy assessment can be performed safely 
and effectively in a setting which treats patients with STIs? Check (X) only one 
a. Strongly agree ........................................................................................................... |___| 
b. Somewhat agree ....................................................................................................... |___| 
c. Neither agree not disagree ........................................................................................ |___| 
d. Somewhat disagree ................................................................................................... |___| 
e. Strongly disagree ...................................................................................................... |___| 
 
11. Do you think your clinic will offer this service in the future?  ............................................ |___| 
0=No   ►Continue to Q7 
1=Yes   ►End of survey. Skip to initials 
 
12. Please indicate the reasons you will not offer PCN allergy assessment in the future. Check 
(X) all that apply 
a. Lack of organizational support .....................  ............................................................. |___| 
b. Reimbursement ...........................................  ............................................................. |___| 
c. Local site training ...................................................................................................... |___| 

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d. Don’t believe that the results will be useful ................................................................ |___| 
e. Risk of adverse reaction ............................................................................................ |___| 
f. Lack of time for providers to do the testing  .  ............................................................. |___| 
g. Lack of access to reagents  .........................  ............................................................. |___| 
h. Other barriers to offering / performing this service ► Describe:   _______________ 
_____________________________________________ .......................................... |___| 
 

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APPENDIX E: ASSESSMENT TOOL FOR OBSERVER 
Validate an Easy to Administer Algorithm to Define Penicillin (B-lactam) Allergy Status in STD 
Outpatients 
DMID Protocol Number (#18-0023) 
PARTICIPANT I.D. ___________________________________ 
Assessment Tool for Observer 
1. Screening Procedure (Check all that apply) 
 
 
Staff approach subjects in waiting area  
____ 
 
 
Flyers posted in waiting area 
 
 
____ 
 
 
Recruitment materials provided at reception 
____ 
 
 
Referral from Clinicians  
 
 
____ 
 
 
Allergy identified in Medical Record 
 
____ 
 
 
Other _______________ 
 
 
____ 
 
2. Informed Consent Obtained (ICF)  
 
 
_____ 
3. Copy of ICF provided to participant 
 
 
 
_____ 
4. Questionnaire Administered 
 
 
 
_____ 
5. Defined as Low-Risk or High-Risk Group  
 
_____ 
a. If High-Risk Defined STOP 
b. If Low-Risk Continue 
6. Exclusion Criteria Assessed 
 
 
 
 
_____  
 
 
 
a. If Excluded STOP 
 
7. SKIN TESTING GROUP 
a. Verify skin test reagents correctly labeled  
 
_____  
 
b. Skin Prick Targets Marked appropriately  
 
_____ 
c. Skin Pricks administered in the correctly 
 labeled area 
 
 
 
 
 
_____ 
d. Positive and Negative Controls Correct  
 
_____ 
e. Intradermal Targets Mapped and Marked 
 
_____ 
f. 
Intradermal Tests administered  
 
 
_____ 
g. Waiting Time Appropriate 
 
 
 
_____ 
h. Positive and Negative Controls Correct  
 
_____ 
i. 
If positive, photograph and document 
 
 
_____ 
 
8. Oral Challenge (After Skin Testing) 
a. Physical assessment and Vital Signs time =0 
(Peak Flow: Use highest value of 3 successive readings) 
_____ 
b. Oral Challenge administered 
 
 
 
_____ 
c. Physical assessment and Vital Signs time =60 min. 
_____ 
d. Results Explained to Subject 
 
 
 
_____  
 
 
 
30-June-2021 
 
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Version 4.0 
 
 
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Validate an Easy to Administer Algorithm to Define Penicillin (B-lactam) Allergy Status in STD 
Outpatients 
DMID Protocol Number (#18-0023) 
PARTICIPANT I.D. ___________________________________ 
9. Direct Oral Challenge 
Low Dose (25 mg) 
a. Physical assessment and Vital Signs time =0 
 
_____ 
b. Oral Challenge administered 
 
 
 
_____ 
c. Physical assessment and Vital Signs time =30 min. 
_____ 
d. Results Explained to Subject 
 
 
Full Dose (250 mg) 
a. Physical assessment and Vital Signs time =0 
 
_____ 
b. Oral Challenge administered 
 
 
 
_____ 
c. Physical assessment and Vital Signs time =30 min. 
_____  
 
d. Results Explained to Subject 
 
 
 
_____ 
 
10. Participant Accessibility Survey  
 
 
 
_____ 
 
 
 
 
 
 
 
 
 
11. Notification Letter Provided 
 
 
 
 
_____ 
 
12. Is Action Plan Required?  
 
 
 
☐ Yes  
☐ No  
 
 
 
Comments: ______________________________________________________________ 
________________________________________________________________________ 
________________________________________________________________________ 
________________________________________________________________________ 
 
Completed By: _______________________________________________ Date:  _______________ 
 
 
 
 (Name, Observer Signature) 
 
Reviewed By:  _______________________________________________    Date: _______________ 
                                             (Name, Site Investigator Signature) 
 
 
30-June-2021 
 
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