For children with a history of penicillin allergy, new evidence suggests a vast majority of kids could be “de-labeled” after undergoing a risk assessment and oral challenge in the pediatric emergency room. George Hoganson, MD, a Washington University emergency medicine fellow at St. Louis Children’s Hospital, is collaborating on a two-year, multi-center study to test children described as penicillin allergic, but who very likely do not have a true penicillin allergy in the St. Louis Children's Hospital Emergency Department.
Dr. Hoganson joins the show to discuss the study, which involves a penicillin oral challenge with observation in the Children’s emergency room.
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New Study Aims to Evaluate Penicillin Allergies in Kids
Featured Speaker:
George Hoganson, MD
George Hoganson, MD is a Washington University pediatric emergency medicine fellow at St. Louis Children's Hospital. Transcription:
New Study Aims to Evaluate Penicillin Allergies in Kids
Melanie Cole (Host): For children with a history of penicillin allergy, new evidence suggests a vast majority of kids could be de-labeled after undergoing a risk assessment and oral challenge in the pediatric emergency room. My guest today is Dr. George Hoganson. He’s a Washington University Pediatric Emergency Medicine Fellow at St. Louis Children’s Hospital. Dr. Hoganson, it’s a pleasure to have you with us today. Tell us a little bit about the current state of penicillin use in the pediatric population.
George Hoganson, MD (Guest): So, penicillin-based antibiotics are some of our most effective drugs to treat common pediatric conditions. They are the drug of choice for everything from strep throat, ear infections, to community acquired pneumonia. They are also cheap and widely available. So, they are an excellent choice for a lot of the reasons parents bring their children into the pediatrician.
Host: Well then describe for us how a child is diagnosed as penicillin allergic and tell us a little bit about the criteria associated with a soft history. What point do you actually determine that a child is genuinely allergic?
Dr. Hoganson: Most often, patients are diagnosed with a penicillin allergy when new symptoms develop after the patient has started the antibiotic. Now oftentimes, the course – the standard course of an antibiotic treatment with a penicillin is anywhere from seven to ten days and the symptoms that are often reported rash, vomiting, as well as a variety of other symptoms are often not due to the antibiotic itself but the condition for which we have prescribed the antibiotic for.
But because some of the symptoms can be mistaken for a true drug allergy; most providers will stop the antibiotic and then transition to another drug. What often happens in the situation though is the patient is labeled as penicillin allergic at that point. But what we know, is that about 90% of the patients that we are diagnosing with a penicillin allergy don’t have a true allergy. The allergic reactions we get concerned about are called IGE mediated or type one hypersensitivity reactions and these are the reactions that when we think of an allergic response are potentially life threatening.
Now what’s interesting, is despite about five to ten percent of children being diagnosed with a penicillin allergy; a true allergic or anaphylactic reaction is actually only occurring in about one in every 2500 to every one in 5000 children. So, this issue of whose labelled appropriately has consequences for that patient both in the short run as well as longer term and on a population wide level.
Host: Well then talk about those consequences or implications. Why is it necessary to weed out those soft histories?
Dr. Hoganson: First, it’s important to give patients the best available treatment to treat their condition. As mentioned, very often, penicillin based antibiotics are our agent of choice. In addition, these antibiotics are relatively inexpensive and widely available to patients. So, increased cost and easy access to treatment are an issue that I think the healthcare system overall but especially with children we have to address. And then there’s also the population health perspective that not using the correct antibiotic leads to ineffective treatment, increased cost, and antibiotic resistance which is a growing public health problem.
Host: So, describe the multicenter study for us and how oral challenges are administered and monitored.
Dr. Hoganson: This is a study that’s being done in collaboration with Medical College of Wisconsin as well as Cincinnati Children’s Hospital and it’s being conducted in the emergency room at these three centers. We are recruiting patients between two and 16 years of age. And the way the process works is that patients that show up to the emergency room that are there to seek treatment for some other reason, on their chart and on intake, they often self-identify as being penicillin allergic. Now oftentimes, these are the parents. Occasionally it’s something that’s already documented in the medical history and so we have a team of research assistants and coordinators that basically comb through that initial data and find patients again, in that age range.
They also look at a number of inclusion and exclusion criteria to determine if the patient is eligible. If the patient is eligible, they will be approached by one of our research staff members and asked to be consented for a questionnaire. Now the questionnaire that we are using has been validated across a number of other projects, across the country that have looked at this issue. And we feel confident in it’s ability to identify patients that are at high risk of having a true allergy to penicillin versus low risk.
Now a vast majority of patients that will be screened are low risk, but it does do a good job of eliminating those high risk participants or potential participants I should say. After they have consented to the questionnaire, and if they are low risk, they are then consented again to ask if they are willing to receive the oral penicillin challenge which consists of 500 milligrams of amoxicillin. At which point, the patient will receive the study medication and then be observed in the Emergency Room for about 60 minutes. It should be noted that this is the gold standard way that we test for penicillin allergies is to – it’s basically the oral challenge is the thing that really oftentimes determines if the patient is truly penicillin allergic or not.
So, we are kind of taking something that’s often done in an allergist’s office after a number of steps and we are kind of consolidating that with a questionnaire in a medically controlled environment like the Emergency Room. Obviously, if a patient were to have a reaction; we have the staff on hand, but I can tell you that from the experience both at the other centers and then projects that have replicated this; those events have been exceptionally low.
Host: Well I find it reassuring that you are doing this challenge in the Emergency Room as you said, where there’s staff right there on hand. Do you find that it’s difficult to convince parents whose children have soft histories to begin using penicillin again? How can pediatricians help to educate parents on this because I would think that parents would be nervous about even trying this challenge.
Dr. Hoganson: Yeah 100%. We completely agree with that. I think the way I personally as well as our staff approach all patient encounters is that oftentimes the parents, they are almost always the patient’s best advocate and establishing good bidirectional communication, encouraging questions and getting buy in and helping them understand some of the data that led to this project and how we are doing this in a controlled manner can go a long way. Because I think parents again, a vast majority wants what is best for their children and when you explain things, I think the buy in kind of comes naturally from that.
Host: So, what else would a pediatrician or provider need to know about this study and the impact of it’s potential findings? How do you see this applied to their clinical practices?
Dr. Hoganson: Pediatricians are at the front line of child and parent education when it comes to the health of children. And the penicillin allergy issue is an important topic that as mentioned can affect up to five to ten percent of their patients. And again, being aware that roughly 90% of these patients are misdiagnosed as having a penicillin allergy when they are truly not allergic is really important. And as we talked about it, has short term implications about their ability to receive the standard of care for common pediatric conditions as well as public health consequences. So, I mean the power is really in their hands to shape this discussion with families and if nothing else, I mean studies like this and those that are being replicated across the country are hopefully getting word out that this is an issue that’s going to need to be addressed both with projects like this and then other creative solutions in the community.
Host: Dr. Hoganson, before we wrap up, how can a pediatrician or provider learn more about this study and what would you like the take home message to be for other providers about this really important study and challenge and risk assessment that you are doing which really as you said, impacts so many prescriptions from everything from strep throat to bronchitis, anything children have that you might prescribe amoxicillin, penicillin for.
Dr. Hoganson: Pediatricians, nurse practitioners, their staff are free to contact me or our team at St. Louis Children’s Hospital to discuss the project and we welcome these conversations. And again, I think this is all in an effort to allow children to receive the very best in treatment and potentially address a public health issue and pediatricians are really at the frontline of dealing again with children’s health and public health and so, I see this project as kind of a natural extension of their work. Again, if there are any questions or concerns or they’d like to learn more about the project, myself and our team are always open to have those discussions.
Host: Thank you so much Dr. Hoganson for joining us. What a great topic. Such an interesting study that you are conducting. That wraps up this episode of Radio Rounds with St. Louis Children’s Hospital. To consult with a specialist or learn more about services and resources available at St. Louis Children’s Hospital, please call the Children’s Direct Physician Access Line at 1-800-678-HELP. You can also head on over to our website at www.stlouischildrens.org for more information and to get connected with one of our providers. If you as a provider found this podcast as informative as I did, please share. Share with other pediatricians. Share on your social media and with other providers and parents and be sure not to miss all the other interesting podcasts in our library. Until next time, I’m Melanie Cole.
New Study Aims to Evaluate Penicillin Allergies in Kids
Melanie Cole (Host): For children with a history of penicillin allergy, new evidence suggests a vast majority of kids could be de-labeled after undergoing a risk assessment and oral challenge in the pediatric emergency room. My guest today is Dr. George Hoganson. He’s a Washington University Pediatric Emergency Medicine Fellow at St. Louis Children’s Hospital. Dr. Hoganson, it’s a pleasure to have you with us today. Tell us a little bit about the current state of penicillin use in the pediatric population.
George Hoganson, MD (Guest): So, penicillin-based antibiotics are some of our most effective drugs to treat common pediatric conditions. They are the drug of choice for everything from strep throat, ear infections, to community acquired pneumonia. They are also cheap and widely available. So, they are an excellent choice for a lot of the reasons parents bring their children into the pediatrician.
Host: Well then describe for us how a child is diagnosed as penicillin allergic and tell us a little bit about the criteria associated with a soft history. What point do you actually determine that a child is genuinely allergic?
Dr. Hoganson: Most often, patients are diagnosed with a penicillin allergy when new symptoms develop after the patient has started the antibiotic. Now oftentimes, the course – the standard course of an antibiotic treatment with a penicillin is anywhere from seven to ten days and the symptoms that are often reported rash, vomiting, as well as a variety of other symptoms are often not due to the antibiotic itself but the condition for which we have prescribed the antibiotic for.
But because some of the symptoms can be mistaken for a true drug allergy; most providers will stop the antibiotic and then transition to another drug. What often happens in the situation though is the patient is labeled as penicillin allergic at that point. But what we know, is that about 90% of the patients that we are diagnosing with a penicillin allergy don’t have a true allergy. The allergic reactions we get concerned about are called IGE mediated or type one hypersensitivity reactions and these are the reactions that when we think of an allergic response are potentially life threatening.
Now what’s interesting, is despite about five to ten percent of children being diagnosed with a penicillin allergy; a true allergic or anaphylactic reaction is actually only occurring in about one in every 2500 to every one in 5000 children. So, this issue of whose labelled appropriately has consequences for that patient both in the short run as well as longer term and on a population wide level.
Host: Well then talk about those consequences or implications. Why is it necessary to weed out those soft histories?
Dr. Hoganson: First, it’s important to give patients the best available treatment to treat their condition. As mentioned, very often, penicillin based antibiotics are our agent of choice. In addition, these antibiotics are relatively inexpensive and widely available to patients. So, increased cost and easy access to treatment are an issue that I think the healthcare system overall but especially with children we have to address. And then there’s also the population health perspective that not using the correct antibiotic leads to ineffective treatment, increased cost, and antibiotic resistance which is a growing public health problem.
Host: So, describe the multicenter study for us and how oral challenges are administered and monitored.
Dr. Hoganson: This is a study that’s being done in collaboration with Medical College of Wisconsin as well as Cincinnati Children’s Hospital and it’s being conducted in the emergency room at these three centers. We are recruiting patients between two and 16 years of age. And the way the process works is that patients that show up to the emergency room that are there to seek treatment for some other reason, on their chart and on intake, they often self-identify as being penicillin allergic. Now oftentimes, these are the parents. Occasionally it’s something that’s already documented in the medical history and so we have a team of research assistants and coordinators that basically comb through that initial data and find patients again, in that age range.
They also look at a number of inclusion and exclusion criteria to determine if the patient is eligible. If the patient is eligible, they will be approached by one of our research staff members and asked to be consented for a questionnaire. Now the questionnaire that we are using has been validated across a number of other projects, across the country that have looked at this issue. And we feel confident in it’s ability to identify patients that are at high risk of having a true allergy to penicillin versus low risk.
Now a vast majority of patients that will be screened are low risk, but it does do a good job of eliminating those high risk participants or potential participants I should say. After they have consented to the questionnaire, and if they are low risk, they are then consented again to ask if they are willing to receive the oral penicillin challenge which consists of 500 milligrams of amoxicillin. At which point, the patient will receive the study medication and then be observed in the Emergency Room for about 60 minutes. It should be noted that this is the gold standard way that we test for penicillin allergies is to – it’s basically the oral challenge is the thing that really oftentimes determines if the patient is truly penicillin allergic or not.
So, we are kind of taking something that’s often done in an allergist’s office after a number of steps and we are kind of consolidating that with a questionnaire in a medically controlled environment like the Emergency Room. Obviously, if a patient were to have a reaction; we have the staff on hand, but I can tell you that from the experience both at the other centers and then projects that have replicated this; those events have been exceptionally low.
Host: Well I find it reassuring that you are doing this challenge in the Emergency Room as you said, where there’s staff right there on hand. Do you find that it’s difficult to convince parents whose children have soft histories to begin using penicillin again? How can pediatricians help to educate parents on this because I would think that parents would be nervous about even trying this challenge.
Dr. Hoganson: Yeah 100%. We completely agree with that. I think the way I personally as well as our staff approach all patient encounters is that oftentimes the parents, they are almost always the patient’s best advocate and establishing good bidirectional communication, encouraging questions and getting buy in and helping them understand some of the data that led to this project and how we are doing this in a controlled manner can go a long way. Because I think parents again, a vast majority wants what is best for their children and when you explain things, I think the buy in kind of comes naturally from that.
Host: So, what else would a pediatrician or provider need to know about this study and the impact of it’s potential findings? How do you see this applied to their clinical practices?
Dr. Hoganson: Pediatricians are at the front line of child and parent education when it comes to the health of children. And the penicillin allergy issue is an important topic that as mentioned can affect up to five to ten percent of their patients. And again, being aware that roughly 90% of these patients are misdiagnosed as having a penicillin allergy when they are truly not allergic is really important. And as we talked about it, has short term implications about their ability to receive the standard of care for common pediatric conditions as well as public health consequences. So, I mean the power is really in their hands to shape this discussion with families and if nothing else, I mean studies like this and those that are being replicated across the country are hopefully getting word out that this is an issue that’s going to need to be addressed both with projects like this and then other creative solutions in the community.
Host: Dr. Hoganson, before we wrap up, how can a pediatrician or provider learn more about this study and what would you like the take home message to be for other providers about this really important study and challenge and risk assessment that you are doing which really as you said, impacts so many prescriptions from everything from strep throat to bronchitis, anything children have that you might prescribe amoxicillin, penicillin for.
Dr. Hoganson: Pediatricians, nurse practitioners, their staff are free to contact me or our team at St. Louis Children’s Hospital to discuss the project and we welcome these conversations. And again, I think this is all in an effort to allow children to receive the very best in treatment and potentially address a public health issue and pediatricians are really at the frontline of dealing again with children’s health and public health and so, I see this project as kind of a natural extension of their work. Again, if there are any questions or concerns or they’d like to learn more about the project, myself and our team are always open to have those discussions.
Host: Thank you so much Dr. Hoganson for joining us. What a great topic. Such an interesting study that you are conducting. That wraps up this episode of Radio Rounds with St. Louis Children’s Hospital. To consult with a specialist or learn more about services and resources available at St. Louis Children’s Hospital, please call the Children’s Direct Physician Access Line at 1-800-678-HELP. You can also head on over to our website at www.stlouischildrens.org for more information and to get connected with one of our providers. If you as a provider found this podcast as informative as I did, please share. Share with other pediatricians. Share on your social media and with other providers and parents and be sure not to miss all the other interesting podcasts in our library. Until next time, I’m Melanie Cole.