A Multifaceted Approach to Self-Reported Antimicrobial Allergy Delabeling Is Possible With a Multidisciplinary Team Initiative

We read with interest the article from Shannon and Krop 1 on the use of an allergy assessment tool in an antimicrobial stewardship (AS) initiative. In our tertiary level hospital, the AS team in collaboration with the immunology department undertook a hospital-wide point prevalence survey of selfreported antimicrobial allergy (AA) status to assess the prevalence of AA and the nature of reported allergy and, if possible, use this information to enable the AS team to overcome inappropriate AA labels. To our knowledge, this is the first hospital-wide survey of its kind in Ireland. Of the 725 inpatients on the day of the survey, 582 patients were available and able to participate. We found that 73 patients (12.5%) self-reported AA. The most common allergy was to penicillins (78.1%), and 26% of those reporting allergies implicated more than 1 antimicrobial class (Table 1). Patients attending the national stem cell transplant service within our hospital had a higher prevalence of self-reported AA (31.6%). Our point prevalence survey was informative in severalways. The prevalence of self-reported AA is in line with the international literature. Patients under the care of the stem cell transplant service have higher rates of self-reported AA, reflecting what was previously reported by Trubiano et al. Many reported AA(s) in our study could be considered an antimicrobial intolerance or recognized adverse effect without being IgE mediated, as seen elsewhere. The AS team in our hospital is multidisciplinary, composed of clinical microbiology and infectious disease physicians and pharmacists. Because it has become increasingly apparent from the literature that AS programs should tackle inappropriate AA reporting, a point reinforced by the recent Infectious Disease Society of America/Society of Healthcare Epidemiology of America guidelines for the implementation of an AS program, we collaborated with the clinical immunologist to address this issue. Often, only a small proportion (approximately 1%) of those reporting an AA is confirmed as true allergy. The use of skin testing to investigate AA requires significant resources by clinicians specialized in allergy. Allergology is not a recognized specialty in Ireland. Most hospitals, including larger teaching hospitals, have no clinical immunology or allergology services. The number of trained allergologists/ immunologists per head of population is 1 per 113,000 in Australia, where Trubiano and Phillips are proposing that allergy clinics become a component of AS programs. In Ireland, however, the ratio is 1 per 606,000. Our hospital has access to clinical immunology services but is underresourced to investigate each self-reported AA. Incorrect AA often remains unrefuted. To this end, the immunology department and the AS team have developed an innovative multipronged approach to delabel patients' self-reported AAwhere appropriate. The first part of this program is structured training of health care professionals, and the second is implementation of a protocol for investigating AA. To educate health care professionals, an e-learning module has been developed on AA by our immunology department, the first in Ireland. As our data highlighted the need for a better understanding of allergy among prescribers, we were targeting predominantly clinicians. However, as articles from Shannon and Krop and Estep et al show the importance of educating and empowering pharmacists, as well as clinicians, to challenge inaccurate AA, this program will be extended to pharmacists going forward. The second step is the development of protocol-driven assessment of low-risk drug allergy. We are developing a clear management algorithm for the investigation of those with AA; this will stratify those