E-Consults Streamline Evaluations of Penicillin Allergy

SAN DIEGO — Bypassing referrals to allergists and using electronic consults to reassess if patients are allergic to penicillin may be faster and more convenient than usual care, according to research presented at the American Academy of Allergy, Asthma, and Immunology (AAAAI) 2025 Annual Meeting.

Among 534 adult patients who received an e-consult at Oregon Health and Science University (OHSU), Portland, Oregon, 90% were evaluated within 72 hours. Before the implementation of e-consults, patients were referred by their doctor for an appointment with an allergist, with wait times averaging 243 days, said Nithya Koka, MD, an allergy and immunology fellow at OHSU, who led the study.

Primary care clinicians requesting an e-consult by an allergist received a questionnaire to review with the patient. Patients were asked if they had been hospitalized for their penicillin allergy, what type of symptoms they have with a reaction, and what other antibiotics they had taken, as forms of penicillin are often administered without the patient realizing it.

After receiving the answers, allergists had up to 72 hours to determine if a patient needed an appointment for testing.

Almost three fourths of patients who required in-person testing or supervised exposure waited a week or less for their appointment.

Since the trial ended, e-consults for penicillin have remained in place in the Oregon system.

Koka said confirmation of a penicillin allergy is often time sensitive.

“A patient might need penicillin if they have an upcoming surgery or to treat an infection,” she said.

The American Academy of Allergy, Asthma, and Immunology recommends confirming penicillin allergies and cites that studies showing 9 out of 10 people with a label are not allergic to the drug. Roughly 80% of patients with a true allergy to penicillin lose their sensitivity after 10 years.

“Many diagnoses of penicillin allergy are made in childhood and may have been misdiagnosed, such as a viral rash being mistaken for a drug rash, or there was an allergy that has waned over time,” said Catherine Monteleone, MD, a professor of medicine in the Division of Infectious Diseases, Allergy, and Immunology at Robert Wood Johnson Medical School in New Brunswick, New Jersey.

Patients with an allergy label for penicillin are often treated with less effective or more expensive antibiotics, Monteleone said. As a result, they may experience longer hospital stays, higher medical costs, and an increased risk of developing acute heart failure.

Unnecessary labeling can stay in electronic records for years, affecting health outcomes and quality of life, said Renee Crawford, DO, a pediatrician and chief resident at Phoenix Children’s Hospital, Phoenix. She described a teenage patient in the intensive care unit who arrived after a weeks-long stay at another hospital. Without penicillin, the boy’s illness had progressed, causing him to miss school and important activities.

The teen had received the penicillin label as an infant but had only ever experienced a rash, Crawford said. After determining he was low risk for an allergic reaction, she prescribed him the drug, and he did not experience adverse effects.

A seamless experience may help clinicians de-label more patients more quickly, Monteleone said.

“Using e-consults when in-person consults are not possible or may be delayed is helpful as it is often necessary to decide on treatment with an antibiotic in a timely manner,” she said. “It is helpful to patients, and if done quickly, it is more likely that they will complete the testing.”

Monteleone, Koka, and Crawford reported no disclosures. Koka reported receiving no funding.

Brittany Vargas is a journalist covering medicine, mental health, and wellness.