Direct oral penicillin challenge in secondary care with low-risk patients: the SPACE mixed-methods study with cost-effectiveness analysis
Krishna, Mamidipudi Thirumala Jani, Yogini H Williams, Iestyn Mujica-Mota, Ruben Bestwick, Rebecca Siciliano, Michele West, Robert Michael Bhogal, Rashmeet Ng, Bee Yean Kildonaviciute, Kornelija
Krishna, Mamidipudi Thirumala
Jani, Yogini H
Williams, Iestyn
Mujica-Mota, Ruben
Bestwick, Rebecca
Siciliano, Michele
West, Robert Michael
Bhogal, Rashmeet
Ng, Bee Yean
Kildonaviciute, Kornelija
Affiliation
University of Birmingham; University Hospitals Birmingham NHS Foundation Trust; University College London Hospitals NHS Foundation Trust; UCL School of Pharmacy; University of Leeds; Oxford University Hospitals NHS Foundation Trust; Royal Cornwall Hospitals NHS Trust; Leeds Teaching Hospitals NHS Trust; Allergy UK; The UK Sepsis Trust
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Publication date
2025-04
Subject
Collections
Research Projects
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Abstract
Background: One in five inpatients carries a penicillin allergy label. However, 90-95% of labels are incorrect. Penicillin allergy labels lead to increased risk for serious hospital infections and longer hospital stay and are associated with higher estimated healthcare costs. Penicillin allergy testing is onerous and requires a specialist. Routine inpatient testing is not available. Recent evidence suggests that a direct oral penicillin challenge delivered by non-allergy specialists is safe in 'low risk' patients, who are highly unlikely to be allergic based on history.
Aims: To explore behaviour, attitudes and acceptability of patients, healthcare professionals and managers regarding a direct oral penicillin challenge in 'low risk' patients. To inform development of an implementation framework and determine potential cost-effectiveness.
Methods: This study (1 May 2021-30 April 2023) involved delivery of direct oral penicillin challenge by non-allergy specialists across three clinical settings (medical/infectious diseases wards, presurgical and haematology-oncology units) at three hospitals. The study had three workstreams: Workstream 1: Screening for potential suitability. Patients were stratified into 'low risk' and 'high risk'. 'Low-risk' patients underwent direct oral penicillin challenge. Workstream 2: One-to-one semistructured interviews with patients (N = 43) and focus group (N = 28) discussions with stakeholders. Workstream 3: Care pathway mapping, decision-analytic modelling and value of information analysis were carried out to determine potential cost-effectiveness of direct oral penicillin challenge.
Results: One thousand and fifty-four of 2257 screened patients were eligible, 270 of 643 approached patients consented (42%). Two hundred and fifty-nine patients were risk-stratified (155 'low risk'; 104 'high risk'). Of the 155 'low risk' patients, 126 underwent direct oral penicillin challenge, 122 (97%) were de-labelled with no serious allergic reactions and 43 patients were interviewed. Low-risk patients accepted their allergy labels, had limited knowledge of the adverse impact and most were keen to have their labels reviewed. Healthcare professionals demonstrated a risk-averse approach, although would engage in the intervention with training, resource availability and a governance framework in place. The total costs of the direct oral penicillin challenge pathway were higher than the costs of direct oral penicillin challenge alone (£940 vs. £98-288 per patient). There were minimal expected savings in antibiotic and hospital costs in the short term and potentially large healthcare cost savings over 5 years.
Limitations: Relatively small sample size for direct oral penicillin challenge, poor conversion rate, particularly in acute settings, patients with limited English language proficiency could not be included and the study was not sufficiently powered and controlled to conduct a cost-effectiveness evaluation.
Conclusions: This first multicentre United Kingdom study showed that non-allergy specialist-led direct oral penicillin challenge is feasible in secondary care. A high proportion of direct oral penicillin challenges were successful, with positive feedback from patients. Majority of screened patients did not progress through the study pathway. Going forward, a multipronged approach is needed to enhance equitability of direct oral penicillin challenge in routine practice. Follow-up mechanisms to consider the intervention during a clinically stable state and a governance framework for those lacking capacity to consent are needed. The cost of delivering a direct oral penicillin challenge pathway in its entirety is significantly higher than the costs of performing direct oral penicillin challenge per se.
Future work: A randomised controlled trial with long-term follow-up is needed to determine the cost-effectiveness of direct oral penicillin challenge.
Plain language summary
Many patients who experience minor side effects when taking penicillin are wrongly labelled as ‘allergic’, leading to huge numbers of people with incorrect penicillin allergy labels in hospitals. Patients with an allergy label receive different antibiotics which might be toxic and less effective. Allergy tests are not routinely available due to very few specialists in the National Health Service. We developed a simple way to remove incorrect labels in patients at low risk of genuine allergy. This involves taking a careful history from the patient to decide if they are at low risk of having a genuine allergy to penicillin. Then, if suitable, they are offered a test dose or a challenge test (penicillin capsule to be swallowed without doing other allergy tests) in a hospital after taking prior informed consent. In this study, the test was performed by trained healthcare professionals with no specialist background in allergy. We included patients admitted in hospital wards and outpatients from surgery and cancer units in three hospitals. We did 126 challenge tests and showed that almost all (97%) did not have an allergy. One patient developed stomach upset and three had mild rash. Very few patients in the wards were eligible to participate for medical reasons, and a greater percentage of outpatients were suitable. We spoke to patients and healthcare professionals about this pathway. Professionals understood its importance but thought appropriate training, safety and resources were required. Patients were keen to find out if they were really allergic and felt safe undergoing the challenge test in hospital. The main reasons for not taking part were personal circumstances. We showed that the penicillin challenge test can be delivered by non-allergy healthcare professionals, but a smaller percentage of patients were eligible to undergo this test than that shown in previous studies. We developed recommendations for wider roll-out of this pathway and gained good understanding of how it would work in the ‘real world’. The cost saving appears small in the short term and more research is needed to understand the long-term benefits.
Citation
Krishna MT, Jani YH, Williams I, Mujica-Mota R, Bestwick R, Siciliano M, West RM, Bhogal R, Ng BY, Kildonaviciute K, Pollard R, Jones N, Dunsmure L, McErlean M, Powell N, Hullur CC, Balaji A, Sandoe J, Warner A, Daniels R, Thomas C, Misbah SA, Savic L. Direct oral penicillin challenge in secondary care with low-risk patients: the SPACE mixed-methods study with cost-effectiveness analysis. Health Soc Care Deliv Res. 2025 Apr;13(9):1-96. doi: 10.3310/MTYW6557.
Type
Article