Clinical approach to penicillin-allergic patients: A survey

Background: Approximately 10% of individuals report a history of penicillin allergy. Objective: We chose to survey various physician groups to determine how they would manage penicillin-allergic patients who present with an infectious process for which penicillin is the drug of choice. Methods: In situations where penicillin was the drug of choice, physicians were asked to choose the type of antibiotic treatment for patients who presented with diseases of varying severity and who had either vague or convincing penicillin-allergic histories. Results: A total of 601 surveys were mailed and 93 (16%) were returned. For those patients who present with a vague history of penicillin allergy, 58% and 59% of the physicians surveyed stated that they would choose cephalosporins for individuals with mild and moderate diseases, respectively. In contrast, in the vague penicillin history/severe disease scenario, physicians were split between choosing cephalosporins (42% of responders) and vancomycin (40% of responders). For those patients who present with a convincing history of penicillin allergy, 55% of the physicians chose erythromycin for individuals with mild disease; 44% chose quinolones for individuals with moderate disease, and 63% chose vancomycin for individuals with severe disease. In each of the three disease severities, physicians were significantly more likely to choose cephalosporins for patients with a vague history of penicillin allergy than for patients with a convincing history (each P<10^-5). Conclusion: The choice of antibiotics is influenced both by the type of penicillin allergic history and by the severity of the disease process to be treated. To decrease the use of broad- spectrum antibiotics in patients labeled 'penicillin-allergic', an effort should be made to identify, by skin testing, those patients who lack penicillin-specific IgE antibodies.