May 24, 2023

Protocol aims to delabel low-risk drug allergies

In 2017, Allison Norton, MD, associate professor of Clinical Pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt, started a protocol for low-risk drug allergies.

By Jessica Pasley

In 2017, Allison Norton, MD, associate professor of Clinical Pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt, started a protocol for low-risk drug allergies.

Allison Norton, MD, is the director of the Pediatric Drug Allergy Clinic.(Photo by Erin O. Smith)

Her goal — to identify and safely de-label children who were unlikely to be truly allergic to antibiotics.

Norton is also director of the Pediatric Drug Allergy Clinic at Vanderbilt Health One Hundred Oaks, which has impacted the lives of hundreds of patients.

Patricia Easley is thankful that Norton’s protocol grew into an actual clinic. Her 6-year-old granddaughter, Paislee Walker, has frequent strep infections and was referred to the clinic.

“For most of Paislee’s life, we have listed amoxicillin as an allergy,” said Easley. “When she was a baby, her mom told us that she broke out in a rash after taking it.

“It’s been listed ever since. But a recent bout of strep and our inability to locate an antibiotic she could take had me thinking. What if she isn’t really allergic?”

That same questioning led Norton to explore drug allergy challenges after observing that reported reactions for drug allergies were not consistent with what experts in her field understood as an allergy.

“I noticed that many of the complaints about children with drug allergies were similar to complaints associated with an infection,” said Norton. “If a child has a rash with strep throat, the problem was that they were given an antibiotic to treat the infection and blaming the antibiotic, not the infection for the cause of the rash. Families would then avoid that antibiotic thinking it was the cause.

“Carrying these labels can unfortunately affect children’s health and are related to worse outcomes, especially when children are hospitalized.”

Recently Norton and her colleagues reviewed data from 460 challenges performed at the Vanderbilt Allergy Clinic at One Hundred Oaks and determined that the protocol is efficient and safe at identifying low risk drug allergies with 99% pass rate for de-labeling. The findings were presented as an oral abstract by Grace Koo, MD, assistant professor of Medicine, at the February meeting of the American Academy of Allergy Asthma and Immunology. A manuscript of the findings is in the works.

“The benefit of the protocol is that if the child is likely to pass, they can go straight to challenge with observation in our office and avoid painful skin testing, which is costly, time consuming and unnecessary given the probability that they will pass,” said Norton.

The typical scenario is as follows: children often develop ear infections as a consequence of a viral infection. Because the ear infection is bacterial, antibiotics are introduced. During this timeframe, the skin is often recruited to deal with the initial viral infection causing a rash. The child is then labeled allergic.

Because children are more likely to develop a rash with infections than adults, these labels are placed early and can be lifelong if not challenged. Studies support that 75% of children are labeled with an antibiotic allergy occurs by the age of 3, which is the most common timeframe for viral and ear infections.

“Our practice will hopefully change this,” said Norton. “The paradigm shift in how we treat and evaluate these children will change and this will be the standard of care. I think we will find that most children are rarely allergic.”

The clinic sees patients as young as 6 months and stocks antibiotics that allows the team to administer a same-day antibiotic challenge. Within hours, a family can know if the label is accurate or not. Norton said that while the majority of these can be done the same day, there are exceptions. There are instances when testing prior to challenge or a longer challenge duration is necessary for the safety of the patient.

She also acknowledges that the entire team, from medical assistants to nurses, is essential in this process.

“It’s really a simple process,” said Easley. “We went to the clinic. They put us in a room. Fully checked her out before starting the challenge. She got a small amount of the antibiotic, waited 15 minutes, checked her again and gave her a bit more.

“We waited 50 minutes. They did their final check to absolutely make sure there was no rash or any allergic symptoms and they cleared her,” she said. “It was awesome and a huge relief. This makes it so much easier to get medications at a much more affordable price.”