The evaluation of penicillin allergy in dialysis patients.

Patients on hemodialysis and peritoneal dialysis are at high risk of developing infections and consume a large amount of antibiotics [1]. A label of penicillin allergy often leads to unnecessary avoidance of β-lactams and to the use of alternative classes of antibiotics [2]. However, according to recent studies penicillin allergy is grossly overdiagnosed [3]. In developed countries, approximately 10% of the population reports a penicillin allergy, with higher rates reported by older and hospitalized patients. When appropriately tested, more than 95% of those suspected of having a penicillin allergy actually tolerate penicillin [3]. The use of alternative antibiotic regimens may lead to treatment failure and increases the risk of antimicrobial resistance and Clostridioides difficile infection [4]. In a study comparing cephalosporins and vancomycin in the treatment of methicillin-susceptible Staphylococcus aureus bacteremia among hemodialysis patients, the risk of treatment failure was three times more likely when vancomycin was used [5]. Traditionally, removing the penicillin allergy label has required a thorough allergological evaluation, including skin testing, thus making it difficult to implement for larger patient groups. A recent review by The American Academy of Allergy, Asthma, and Immunology (AAAAI), the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) suggests a direct amoxicillin challenge to be safe and effective in patients defined as low risk for penicillin allergy [3].