Risk of meticillin resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy: population based matched cohort studyBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2400 (Published 27 June 2018) Cite this as: BMJ 2018;361:k2400
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The problem extends beyond MRSA and Clostridium difficile , and stewardship should still be followed in the presence or absence of penicillin allergy.
We commend the research study of Blumenthal et al. Any scientific evidence that identifies risk factors for the emergence of alert organisms will assist in optimizing use of antimicrobials and enhance antimicrobial stewardship.
We also wish to make a number of observations:
It is imperative that the nature of the allergy is elucidated and that it is confirmed whether it is genuine or not. As by doing so this would reduce the number of patients who are deprived from this effective and relatively safe group of antimicrobials as a result of false documentation of penicillin allergy (1,2).
Another equally important clinical governance matter is that once the documented allergy to penicillin is confirmed to be unfounded then the records should be corrected accordingly otherwise the patient will continue to be considered as Penicillin allergic whenever he/she seek healthcare intervention in future.
The problem of allergy to penicillin and hence the inevitable use of antimicrobials that are more likely to lead to the emergence of MRSA and Clostridium difficile particularly Cephalosporins and Clindamycin means that there is also the risk of emergence of other multi-drug resistant organisms such as Extended-Spectrum Beta-lactamase (ESBL) Producing organisms, Carbapenemase-Producing Enterobacteriacea (CPE) and Glycopeptide-Resistant Enterococci (GRE) (3,4,5).
The study eloquently has shown that as a result of penicillin allergy alternative antimicrobials which were more likely to induce collateral damage have led to a higher rate of emergence of MRSA and Clostridium dificile. But then even when alternative antimicrobials have to be used with genuine penicillin allergy the principle of antimicrobial stewardship still has to be followed.
It would therefore be helpful to conduct a further study to establish whether there was a difference in the emergence of alert organisms between General Practices that have adhered to antimicrobial stewardship and those that haven’t when treating patients who were labelled as allergic to penicillin.
Competing interests: No competing interests
I read with interest the article by Blumenthal et al. and agree that penicillin allergy needs to be systematically addressed. However, I am worried it would be impractical for physicians to perform comprehensive allergy assessments in addition to their usual duties. For instance, 87% of British general practice trainee agree that the 10-minute consultation time is insufficient. One general practitioner even faced disciplinary hearings for extending some of his appointment slots to 20 minutes. Similarly, there are often rota gaps in the NHS hospitals that require physicians to perform more than their usual duties. Some established allergy assessment methods, such as Naranjo algorithm, are time-consuming that would add extra workload to physicians.
If a patient's main reason for visit is not penicillin allergy reaction, an allergy assessment may end up in the bottom of physicians' priority lists. A study showed that about 36% of patients' adverse drug reactions were inadequately documented during hospital admission. When work is busy, the word "prioritise" could be used as a trump card to not perform a less needed task. For instance, I cannot imagine a surgeon being very happy if trainees spend most of the time assessing patients' allergies rather than discussing the surgical issues. Their best time-saving solution may be simply prescribing an alternative antibiotic.
A better solution is to delegate the duty of allergy assessment to clinical pharmacists. Being an ex-pharmacist myself, I know plenty of pharmacists who would love to be more involved in patients' therapeutic management. Pharmacist involvement has been shown to improve allergy documentation. Many NHS primary care services are now providing pharmacist support for physicians and patients. I would like to suggest physicians to make good use of pharmacists to perform allergy assessments, which are important for patient safety.
 Blumenthal, K.G.; Lu, N.; Zhang, Y.; Li, Y.; Walensky, R.P.; Choi, H.K. Risk of meticillin resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy: population based matched cohort study. BMJ 2018, 361, k2400, 10.1136/bmj.k2400.
 Irving, G.; Holden, J. Calling time on the 10-minute consultation. Br. J. Gen. Pract. 2012, 62, 238-239, 10.3399/bjgp12X641375.
 Dyer, C. GP who deleted appointment slots to ease workload pressure is spared punishment. BMJ 2017, 358, j4141, 10.1136/bmj.j4141.
 Oliver, D. David Oliver: “Ghost wards” and rota gaps show the need for official safe staffing levels. BMJ 2018, 361, k2322, 10.1136/bmj.k2322.
 Naranjo, C.A.; Busto, U.; Sellers, E.M.; Sandor, P.; Ruiz, I.; Roberts, E.A.; Janecek, E.; Domecq, C.; Greenblatt, D.J. A method for estimating the probability of adverse drug reactions. Clinical Pharmacology & Therapeutics 1981, 30, 239-245, 10.1038/clpt.1981.154.
 Yeung, E.Y.H. Adverse drug reactions: a potential role for pharmacists. Br. J. Gen. Pract. 2015, 65, 511, 10.3399/bjgp15X686821.
 Yeung, E.Y. When the words 'handover' and 'prioritise' are overused. Br. J. Gen. Pract. 2017, 67, 300, 10.3399/bjgp17X691649.
 Goh, S. Communicating effectively by lamenting the issues correctly. https://www.bmj.com/content/361/bmj.k1704/rr-3 (accessed Jul 3, 2018).
 Yeung, E.Y.H. Explaining the role of pharmacists in multidisciplinary care. Br. J. Gen. Pract. 2017, 67, 447-448, 10.3399/bjgp17X692753.
 Deeks, L.S.; Naunton, M.; Kosari, S. Pharmacists’ perceptions of their emerging general practice roles in UK primary care: a qualitative interview study. Br. J. Gen. Pract. 2017, 67, 396-396, 10.3399/bjgp17X692237.
Competing interests: I have been paid for working as a physician and pharmacist, but not for writing this letter.