Penicillin Allergy
Loren Bonner
How feasible is it to have a full-time pharmacist run an outpatient penicillin allergy testing clinic? Brevard County, FL researchers think it’s possible: A first-of-its kind pharmacist-led revenue generating clinic successfully delabeled 96% of patients from their penicillin allergy. All delabeled patients received appropriate antibiotics following testing.
With physician shortages, specifically allergy physician shortages, and concerns for antimicrobial resistance, lead author Eric Linn, PharmD, said having a pharmacist-led clinic working with multiple provider disciplines can fill an unmet need in the community to delabel or clarify penicillin allergies for patients.
Approximately 10% of hospitalized patients have a penicillin allergy listed in their EHR. That label alone can lead to increased health care costs, treatment failures, and multidrug resistant organisms. Several physician groups recommend penicillin allergy testing to facilitate optimal antibiotic use.
“All our results were similar to previous research in terms of positive or true penicillin allergies, which builds on the safety and reliability of the three-part process to safely delabel penicillin allergies,” Linn said.
He said that as far as they could tell, the clinic was the first of its kind to showcase a pharmacist-led revenue generating clinic for penicillin allergies as well.
“We initially had varying results in our reimbursement process, so we worked closely with our medical coders and received feedback from patients’ insurances on coverage,” said Linn, who is with Health First Holmes Regional Medical Center in Melbourne, FL. “With some trial and error, we were able to find the correct ICD-10 and CPT codes required for a consistent reimbursement stream across multiple insurance providers and with minimal friction for the patient.”
The average revenue reimbursement was $423 per patient, and the average time for a pharmacist to complete an appointment was 96 minutes, according to the findings.
The results of the study, published in the May–June 2025 issue of JAPhA, can provide a framework for other health systems or clinics interested in putting into place a similar program of their own.
Details
The site for the institutional review board-exempt, retrospective cohort study was an outpatient clinic within a nonacademic community hospital in Florida. A total of 457 outpatients received penicillin allergy testing during the study period, which lasted from July 2022 through December 2023. A variety of physician specialties referred patients to the clinic for testing.
“One significant strength to this study was the variety of patients that we were able to test, starting with orthopedic pre-operative patients, expanding to infectious disease and wound care providers, and ultimately family medicine providers,” Linn said.
A protocol was developed incorporating recommendations from the American Academy of Allergy, Asthma & Immunology, physician preferences, and pharmacist collaboration to create a patient-specific protocol to identify and triage eligible patients for penicillin skin testing. Pharmacists received specific training to perform the testing as well.
The appointment consisted of three parts. First, patients received the scratch test, utilizing histamine, normal saline, benzylpenicilloyl G polylysine (Pre-Pen), and penicillin G 10,000 units/mL. If they were negative to the scratch test, patients proceeded to the intradermal injections using those same ingredients, minus the histamine.
“One surprising finding was the minimal positive reactions during the scratch and intradermal steps of testing,” said Linn.
They anticipated having a handful of patients who tested positive during the skin testing portion—either the scratch or intradermal test, he said.
Patient satisfaction
While the research team did not specifically measure patient satisfaction, Linn said they anecdotally noticed that patients were receptive to the testing and wanted definitive answers to their long-standing allergy status.
“This helped to facilitate clinic expansion to other disciplines and increase referral volume through patient feedback to their providers,” he said.
When developing the testing protocol, Linn noted that the Florida Board of Pharmacy said testing had to occur within the walls of the hospital with emergency services nearby.
“This also contributed to increased patient comfort due to allergy uncertainty compared to an offsite outpatient clinic,” he said.
Pharmacists also had the opportunity to provide patient education on more than just the testing process, but also on education for new medications, diabetes counseling, supplement information, and more.
“This was in part [due] to the amount of time the pharmacist was able to spend with the patient and opens new opportunities for further services the clinic could provide,” said Linn. ■