Discussion

In Massachusetts LTC facilities, penicillin allergies are prevalent among residents receiving antibiotics. Residents with documented penicillin allergies were 95% less likely to receive beta-lactam antibiotics for any infection. Beta-lactam antibiotics are the preferred treatment for many infectious syndromes, including respiratory tract infections and SSTI. However, their use is notably lower in many LTC patients. The use of alternative antibiotics often leads to suboptimal treatment outcomes, increased antibiotic use, and a higher risk of antimicrobial resistance. ^{Reference Lim, Kong and Stuart2,Reference Krah, Jones, Lake and Hersh3}

The US Centers for Disease Control and Prevention recommends penicillin allergy evaluation as part of hospital antimicrobial stewardship programs to optimize antibiotic use. In addition, the American Academy of Allergy, Asthma, and Immunology’s Drug Allergy Practice Parameter Update of 2022 advocates for proactive penicillin allergy delabeling across all populations. Despite these endorsements, a survey of 121 US hospitals revealed limited access to penicillin allergy assessment in inpatient settings. ^{Reference Mancini, Fu and Zhang7} Our previous study identified significant deficiencies in the documentation of antibiotic allergies in LTC residents. ^{Reference Foong, Fowle and Doron4} Currently, there is no standardized method for implementing penicillin allergy assessment in LTC settings. Barriers such as resource constraints and high staff turnover further complicate the implementation of effective penicillin allergy delabeling strategies in LTC facilities.

Simplified, evidence-based pathways and tools have been developed for use by non-allergists in acute care settings. ^{Reference Shenoy, Macy, Rowe and Blumenthal8,Reference Trubiano, Vogrin and Chua9} These tools consider the initial allergic reaction history and the time elapsed to identify low-risk individuals for delabeling. ^{Reference Shenoy, Macy, Rowe and Blumenthal8,Reference Trubiano, Vogrin and Chua9} Remarkably, about 20% of documented penicillin allergies can be delabeled based solely on allergy history, including cases with a family history of penicillin allergy without a personal history of allergic reactions, and those with intolerance reactions inconsistent with immune-mediated responses. ^{Reference Stone, Trubiano, Coleman, Rukasin and Phillips10} Given their simplicity and low resource requirements, these pathways are particularly viable for implementation in resource-limited settings such as LTC facilities compared to more resource-intensive methods like oral challenges or penicillin skin testing. However, assessment tools designed for penicillin allergy delabeling, such as the PEN-FAST tool, do not adequately account for conditions like dementia or cognitive impairment, complicating the assessment and management of penicillin allergies in LTC populations. ^{Reference Trubiano, Vogrin and Chua9}

This study has several limitations, including its cross-sectional design, which prevents causality inference. The geographical scope, limited to Massachusetts and the inclusion of 20 LTC facilities, restricts the generalizability of the findings. Furthermore, we could not determine the duration of antibiotic use, nor could we use clinical and culture data to assess the appropriateness of antibiotic use. Adjustments for demographic and medical variables may not fully account for all potential confounding factors, such as local antimicrobial resistance patterns and institutional prescribing policies, which can influence antibiotic selection in LTC facilities.

In conclusion, our data demonstrate that LTC residents with documented penicillin allergies are significantly less likely to receive beta-lactams for common infections. This underscores the urgent need to improve penicillin allergy assessments and delabeling strategies in LTC settings.