Contribution of Penicillin Allergy Labels to Second-Line Broad-Spectrum Antibiotic Prescribing for Pediatric Respiratory Tract Infections

INTRODUCTION: Antibiotic allergies are overdiagnosed. This may lead to unnecessary use of second-line broader-spectrum agents in place of narrower-spectrum guideline-recommended first-line therapies especially for uncomplicated respiratory tract infections. The extent to which this occurs for children with respiratory tract infections is unknown. METHODS: We included outpatient encounters for patients < 18 years with acute respiratory tract infections (sinusitis, bronchitis, bronchiolitis, upper respiratory tract infection, pharyngitis, otitis media). Patients were classified as penicillin allergic based on the presence of an allergy label in the electronic medical record. First-line guideline-recommended antibiotics included penicillin, amoxicillin or amoxicillin-clavulanate; all others were considered second line. The percentage of patients treated with first-line versus second-line antibiotics was compared between those with and without penicillin allergy. Additionally, we calculated the contribution of penicillin allergy to overall use of second-line antibiotics. RESULTS: Among 17,578 eligible encounters for respiratory tract infections, 1332 (8%) included patients with a penicillin allergy label. Overall, second-line antibiotics were prescribed in 15% of encounters. Second-line antibiotics were prescribed in 91% of encounters for penicillin-allergic patients, compared with 8% of encounters for non-allergic patients (P < 0.001). Patients with penicillin allergy labels accounted for 47% of all second-line antibiotic prescriptions. CONCLUSION: In a large population of pediatric outpatient encounters for acute respiratory tract infections, patients labeled with a penicillin allergy accounted for nearly half of second-line antibiotics, which are often broader spectrum. Efforts to de-label children with penicillin allergies have the potential to reduce broader-spectrum antibiotic use.