In late September, Jason Knudson, M.D., FAAFP, Spearfish Clinic, North 10th Street, completed the first successful outpatient oral amoxicillin challenge with his patient, James Walton, a Paramedic at Sanford Underground Research Facility in Lead.
The challenge, which is performed frequently in the inpatient setting, is now available at four of our clinics — Spearfish Clinic, North 10th Street, Custer Clinic, Sturgis Clinic and Rapid City Clinic, Flormann Street — can be used in patients identified to be at low risk of penicillin allergy to rule out immediate allergic reactions to penicillin antibiotics.
The success was an encouraging development for Marilee Obritsch, Antimicrobial Stewardship Program Clinical Pharmacist and the Antibiotic Awareness team: David Delahoyde,
Pharmacy Resident, Ryan Flynn, ASP Clinical Pharmacist, and for all of the Monument Health organization.
Frequently, a patient’s chart will indicate a penicillin allergy because the patient had a past reaction such as a rash that occurred while they were taking antibiotics as a child. However, the reaction may actually have been a symptom of a viral illness. Patients can also be listed as having a penicillin allergy when a close family member has an allergy. This often occurs without actual verification of the allergy in the patient.
“We’re losing some of our antibiotics because bugs are becoming resistant to them,” says Dr. Knudson. “Penicillin is a great antibiotic. And so to take a big tool out of our arsenal to treat infections really ties a hand behind our back sometimes. That being said, you want to use it when it’s right, and you don’t want to overuse it.”
James, for example, always assumed that he was allergic to penicillins simply because that’s what he was told and because the allergy is common in his family. As an adult, though, he started to believe that it was worth confirming, especially because during his previous career as a flight paramedic, he had some worrisome experiences while on broad spectrum antibiotics.
“I’ve taken ciprofloxacin (cipro) for other things in the past and ended up rupturing both of my Achilles tendons,” he says. Tendon weakness is suspected as a side effect of fluoroquinolone antibiotics, though thus far the relationship is inconclusive.
There are some further compelling reasons to undergo the challenge. For one, many common illnesses persist when a penicillin-based antibiotic would be an ideal treatment. Amoxicillin/penicillin are also some of the cheaper antibiotics and have less side effects than other broad spectrum antibiotics. Finally, the challenge is common while patients are already hospitalized, which can be frightening and stressful for them, or, they may not be able to receive certain kinds of antibiotics before, during or after surgeries due to the uncertainty of their allergy. It makes sense for those who are unsure to undergo the challenge in the clinic setting, when the stakes are far lower.
The challenge itself is fairly simple: once the patient has been made aware of all the facts and risks and has passed a preliminary screening, which consists of four questions, they are administered a dose of amoxicillin in the clinic. They then remain under the supervision of a health care provider for thirty minutes. Afterwards, the patient can choose to remain in the exam room or waiting room for an additional thirty minutes for monitoring. The patients are instructed to come back or reach out in the rare case that allergic reaction symptoms are delayed. If no allergic reactions occur, the patient is then considered safe to take penicillins, and the allergy is removed from the patient chart.
“I just think this is a tremendous opportunity for our clinics to be able to have this potential visit type right now,” says Marilee. “Without these visits in Spearfish, Custer or Sturgis, patients have to go to Rapid City to get this testing done, and they have a very long wait. As long as you pick your patient using the tool appropriately, you’ll have good outcomes.”
The screening tool, called PENFAST, is available within EPIC to all providers in the clinic setting.
Story and photo by Kory Lanphear