<description>&lt;p&gt;We’ve all seen it: the patient whose chart is &amp;#8220;flagged&amp;#8221; with a penicillin allergy, but when you dig into the history, the story doesn&amp;#8217;t quite add up. Maybe it was a stomach ache in the 90s, or maybe they’re just carrying a &amp;#8220;inherited&amp;#8221; allergy from a parent.&lt;/p&gt; &lt;p&gt;In this episode of EM Pulse, we sit down with ED Clinical Pharmacist &lt;b&gt;Haley Burhans&lt;/b&gt; to discuss why these labels are more than just a nuisance—they’re a clinical liability—and how a simple tool can empower you to fix them on the fly.&lt;/p&gt; &lt;p&gt;&lt;b&gt;The Hidden Danger of the &amp;#8220;Safe&amp;#8221; Choice&lt;/b&gt;&lt;/p&gt; &lt;p&gt;Choosing a non-beta-lactam antibiotic because of a questionable allergy label feels like the path of least resistance, but the data tells a different story. We explore how &amp;#8220;playing it safe&amp;#8221; can actually lead to:&lt;/p&gt; &lt;ul&gt; &lt;li&gt;&lt;b&gt;Worse Outcomes:&lt;/b&gt; Why second line antibiotics often mean higher treatment failure rates.&lt;/li&gt; &lt;li&gt;&lt;b&gt;The &amp;#8220;Superbug&amp;#8221; Factor:&lt;/b&gt; The surprising link between penicillin allergy labels and the rise of MRSA and VRE in our communities.&lt;/li&gt; &lt;li&gt;&lt;b&gt;The C. diff Connection:&lt;/b&gt; Why alternative choices might be setting your patient up for a much more difficult recovery.&lt;/li&gt; &lt;/ul&gt; &lt;p&gt;&lt;b&gt;The Solution: The PEN-FAST Score&lt;/b&gt;&lt;/p&gt; &lt;p&gt;How do you move from &amp;#8220;I think this might not be a true allergy&amp;#8221; to &amp;#8220;I am confident this antibiotic is safe&amp;#8221;? Haley introduces the &lt;b&gt;PEN-FAST score&lt;/b&gt;, a validated scoring tool designed to risk-stratify patients based on a few key historical questions.&lt;/p&gt; &lt;ul&gt; &lt;li&gt;&lt;b&gt;The Mnemonic:&lt;/b&gt; We break down the PEN-&lt;b&gt;FAST&lt;/b&gt; acronym so you know exactly which three questions to ask to risk-stratify your patient in seconds.&lt;/li&gt; &lt;li&gt;&lt;b&gt;IgE vs. The Rest:&lt;/b&gt; Learn to distinguish between the &amp;#8220;true&amp;#8221; dangerous hypersensitivity and the delayed reactions that shouldn&amp;#8217;t stop you from using the best drug for the job.&lt;/li&gt; &lt;li&gt;&lt;b&gt;The “Amoxicillin Rash”:&lt;/b&gt; We dive into this common pediatric &amp;#8220;gotcha.&amp;#8221;, why many kids end up with a lifelong allergy label after a routine ear infection, and why it often has nothing to do with the drug itself.&lt;/li&gt; &lt;/ul&gt; &lt;p&gt;&lt;b&gt;The Bottom Line:&lt;/b&gt; Patients with low PEN-FAST scores are considered low risk, making an oral challenge under observation in the ED a reasonable option. Higher scores may require shared decision-making or referral.&lt;/p&gt; &lt;p&gt;&lt;b&gt;Why the ED is the Perfect Place for a &amp;#8220;Challenge&amp;#8221;&lt;/b&gt;&lt;/p&gt; &lt;p&gt;Delabeling isn&amp;#8217;t just for the allergist&amp;#8217;s office. We argue that the Emergency Department is actually the &lt;b&gt;ideal&lt;/b&gt; setting to challenge these allergies.&lt;/p&gt; &lt;ul&gt; &lt;li&gt;&lt;b&gt;The &amp;#8220;Oral Challenge&amp;#8221;:&lt;/b&gt; Learn the practical steps for performing a trial dose in the department.&lt;/li&gt; &lt;li&gt;&lt;b&gt;Safety First:&lt;/b&gt; Why your environment and expertise make you uniquely qualified to handle the &amp;#8220;what-ifs&amp;#8221; better than anyone else.&lt;/li&gt; &lt;/ul&gt; &lt;p&gt;&lt;b&gt;Key Takeaways&lt;/b&gt;&lt;/p&gt; &lt;ul&gt; &lt;li&gt;&lt;b&gt;Question the Label:&lt;/b&gt; The vast majority of reported penicillin allergies are inaccurate due to patients outgrowing the allergy or misinterpreting common side effects as allergic reactions.&lt;/li&gt; &lt;li&gt;&lt;b&gt;History is Everything:&lt;/b&gt; Dig deeper than just &amp;#8220;rash.&amp;#8221; Ask about the timing relative to the dose, specific appearance (hives vs. flat rash), and what treatment was required (epinephrine vs. antihistamines).&lt;/li&gt; &lt;li&gt;&lt;b&gt;Use PEN-FAST:&lt;/b&gt; Utilize this tool to objectify the risk.&lt;/li&gt; &lt;li&gt;&lt;b&gt;Document Tolerance:&lt;/b&gt; Even if you don&amp;#8217;t fully delete the allergy label, if you successfully treat the patient with another beta-lactam (like ceftriaxone), document that tolerance clearly to aid future clinicians.&lt;/li&gt; &lt;li&gt;&lt;b&gt;Cephalosporins are likely safe:&lt;/b&gt; Later-generation cephalosporins generally have very low cross-reactivity and are usually safe options even in truly allergic patients&lt;/li&gt; &lt;/ul&gt; &lt;p&gt;How do you handle documented penicillin allergies? Do you use the PEN-FAST tool? Share your experience with us on social media &lt;a href="http://twitter.com/empulsepodcast"&gt;@empulsepodcast&lt;/a&gt; or at &lt;a href="http://ucdavisem.com"&gt;ucdavisem.com&lt;/a&gt;&lt;/p&gt; &lt;p&gt;&lt;b&gt;Hosts:&lt;/b&gt;&lt;b&gt;&lt;/b&gt;&lt;/p&gt; &lt;p&gt;&lt;a href="http://Twitter.com/julmagana"&gt;Dr. Julia Magaña&lt;/a&gt;, Professor of Pediatric Emergency Medicine at UC Davis&lt;/p&gt; &lt;p&gt;&lt;a href="https://health.ucdavis.edu/boldly-learning/featured/sarah-medeiros.html"&gt;Dr. Sarah Medeiros&lt;/a&gt;, Professor of Emergency Medicine at UC Davis&lt;/p&gt; &lt;p&gt;&lt;b&gt;Guests:&lt;/b&gt;&lt;/p&gt; &lt;p&gt;&lt;a href="https://www.linkedin.com/in/haley-burhans?utm_source=share&amp;#38;utm_campaign=share_via&amp;#38;utm_content=profile&amp;#38;utm_medium=ios_app"&gt;Haley Burhans, PharmD&lt;/a&gt;, Emergency Medicine Clinical Pharmacist at UC Davis&lt;/p&gt; &lt;p&gt;&lt;b&gt;Resources:&lt;/b&gt;&lt;/p&gt; &lt;p&gt;&lt;a href="https://www.mdcalc.com/calc/10422/penicillin-allergy-decision-rule-pen-fast"&gt;PEN-FAST Score on MDCalc&lt;/a&gt;&lt;/p&gt; &lt;p&gt;&lt;a href="https://www.aaaai.org/Aaaai/media/Media-Library-PDFs/Allergist%20Resources/Statements%20and%20Practice%20Parameters/Penicillin-Allergy-Position-Statement_Approved-08-31-2023.pdf"&gt;Penicillin Allergy Evaluation Should Be Performed Proactively in Patients with a Penicillin Allergy Label&lt;/a&gt; – A Position Statement of the American Academy of Allergy, Asthma &amp;#38; Immunology&lt;/p&gt; &lt;p&gt;&lt;a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC8019188/"&gt;Staicu ML, Vyles D, Shenoy ES, Stone CA, Banks T, Alvarez KS, Blumenthal KG. Penicillin Allergy Delabeling: A Multidisciplinary Opportunity. J Allergy Clin Immunol Pract. 2020 Oct;8(9):2858-2868.e16. doi: 10.1016/j.jaip.2020.04.059. PMID: 33039010; PMCID: PMC8019188.&lt;/a&gt;&lt;/p&gt; &lt;p&gt;&lt;a href="https://pubmed.ncbi.nlm.nih.gov/36990206/"&gt;Yang C, Graham JK, Vyles D, Leonard J, Agbim C, Mistry RD. Parental perspective on penicillin allergy delabeling in a pediatric emergency department. Ann Allergy Asthma Immunol. 2023 Jul;131(1):82-88. doi: 10.1016/j.anai.2023.03.023. Epub 2023 Mar 27. PMID: 36990206.&lt;/a&gt;&lt;/p&gt; &lt;p style="text-align: center;"&gt;***&lt;/p&gt; &lt;p&gt;Thank you to the &lt;a href="http://www.ucdmc.ucdavis.edu/emergency/"&gt;UC Davis Department of Emergency Medicine&lt;/a&gt; for supporting this podcast and to Orlando Magaña at &lt;a href="http://www.orlandomagana.com/"&gt;OM Productions&lt;/a&gt; for audio production services.&lt;/p&gt; &lt;p&gt;&amp;#160;&lt;/p&gt; &lt;p&gt;&lt;a href="https://ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM.png"&gt;&lt;img fetchpriority="high" decoding="async" class="aligncenter wp-image-8792 size-large" src="https://ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM-814x1024.png" alt="" width="814" height="1024" srcset="https://i0.wp.com/ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM.png?resize=814%2C1024&amp;#38;ssl=1 814w, https://i0.wp.com/ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM.png?resize=238%2C300&amp;#38;ssl=1 238w, https://i0.wp.com/ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM.png?resize=768%2C967&amp;#38;ssl=1 768w, https://i0.wp.com/ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM.png?resize=1220%2C1536&amp;#38;ssl=1 1220w, https://i0.wp.com/ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM.png?w=1292&amp;#38;ssl=1 1292w" sizes="(max-width: 814px) 100vw, 814px" /&gt;&lt;/a&gt;&lt;/p&gt;</description>

EM Pulse Podcast™

UC Davis Department of Emergency Medicine

Penicillin Allergy Delabeling

FEB 17, 202616 MIN
EM Pulse Podcast™

Penicillin Allergy Delabeling

FEB 17, 202616 MIN

Description

<p>We’ve all seen it: the patient whose chart is &#8220;flagged&#8221; with a penicillin allergy, but when you dig into the history, the story doesn&#8217;t quite add up. Maybe it was a stomach ache in the 90s, or maybe they’re just carrying a &#8220;inherited&#8221; allergy from a parent.</p> <p>In this episode of EM Pulse, we sit down with ED Clinical Pharmacist <b>Haley Burhans</b> to discuss why these labels are more than just a nuisance—they’re a clinical liability—and how a simple tool can empower you to fix them on the fly.</p> <p><b>The Hidden Danger of the &#8220;Safe&#8221; Choice</b></p> <p>Choosing a non-beta-lactam antibiotic because of a questionable allergy label feels like the path of least resistance, but the data tells a different story. We explore how &#8220;playing it safe&#8221; can actually lead to:</p> <ul> <li><b>Worse Outcomes:</b> Why second line antibiotics often mean higher treatment failure rates.</li> <li><b>The &#8220;Superbug&#8221; Factor:</b> The surprising link between penicillin allergy labels and the rise of MRSA and VRE in our communities.</li> <li><b>The C. diff Connection:</b> Why alternative choices might be setting your patient up for a much more difficult recovery.</li> </ul> <p><b>The Solution: The PEN-FAST Score</b></p> <p>How do you move from &#8220;I think this might not be a true allergy&#8221; to &#8220;I am confident this antibiotic is safe&#8221;? Haley introduces the <b>PEN-FAST score</b>, a validated scoring tool designed to risk-stratify patients based on a few key historical questions.</p> <ul> <li><b>The Mnemonic:</b> We break down the PEN-<b>FAST</b> acronym so you know exactly which three questions to ask to risk-stratify your patient in seconds.</li> <li><b>IgE vs. The Rest:</b> Learn to distinguish between the &#8220;true&#8221; dangerous hypersensitivity and the delayed reactions that shouldn&#8217;t stop you from using the best drug for the job.</li> <li><b>The “Amoxicillin Rash”:</b> We dive into this common pediatric &#8220;gotcha.&#8221;, why many kids end up with a lifelong allergy label after a routine ear infection, and why it often has nothing to do with the drug itself.</li> </ul> <p><b>The Bottom Line:</b> Patients with low PEN-FAST scores are considered low risk, making an oral challenge under observation in the ED a reasonable option. Higher scores may require shared decision-making or referral.</p> <p><b>Why the ED is the Perfect Place for a &#8220;Challenge&#8221;</b></p> <p>Delabeling isn&#8217;t just for the allergist&#8217;s office. We argue that the Emergency Department is actually the <b>ideal</b> setting to challenge these allergies.</p> <ul> <li><b>The &#8220;Oral Challenge&#8221;:</b> Learn the practical steps for performing a trial dose in the department.</li> <li><b>Safety First:</b> Why your environment and expertise make you uniquely qualified to handle the &#8220;what-ifs&#8221; better than anyone else.</li> </ul> <p><b>Key Takeaways</b></p> <ul> <li><b>Question the Label:</b> The vast majority of reported penicillin allergies are inaccurate due to patients outgrowing the allergy or misinterpreting common side effects as allergic reactions.</li> <li><b>History is Everything:</b> Dig deeper than just &#8220;rash.&#8221; Ask about the timing relative to the dose, specific appearance (hives vs. flat rash), and what treatment was required (epinephrine vs. antihistamines).</li> <li><b>Use PEN-FAST:</b> Utilize this tool to objectify the risk.</li> <li><b>Document Tolerance:</b> Even if you don&#8217;t fully delete the allergy label, if you successfully treat the patient with another beta-lactam (like ceftriaxone), document that tolerance clearly to aid future clinicians.</li> <li><b>Cephalosporins are likely safe:</b> Later-generation cephalosporins generally have very low cross-reactivity and are usually safe options even in truly allergic patients</li> </ul> <p>How do you handle documented penicillin allergies? Do you use the PEN-FAST tool? Share your experience with us on social media <a href="http://twitter.com/empulsepodcast">@empulsepodcast</a> or at <a href="http://ucdavisem.com">ucdavisem.com</a></p> <p><b>Hosts:</b><b></b></p> <p><a href="http://Twitter.com/julmagana">Dr. Julia Magaña</a>, Professor of Pediatric Emergency Medicine at UC Davis</p> <p><a href="https://health.ucdavis.edu/boldly-learning/featured/sarah-medeiros.html">Dr. Sarah Medeiros</a>, Professor of Emergency Medicine at UC Davis</p> <p><b>Guests:</b></p> <p><a href="https://www.linkedin.com/in/haley-burhans?utm_source=share&#38;utm_campaign=share_via&#38;utm_content=profile&#38;utm_medium=ios_app">Haley Burhans, PharmD</a>, Emergency Medicine Clinical Pharmacist at UC Davis</p> <p><b>Resources:</b></p> <p><a href="https://www.mdcalc.com/calc/10422/penicillin-allergy-decision-rule-pen-fast">PEN-FAST Score on MDCalc</a></p> <p><a href="https://www.aaaai.org/Aaaai/media/Media-Library-PDFs/Allergist%20Resources/Statements%20and%20Practice%20Parameters/Penicillin-Allergy-Position-Statement_Approved-08-31-2023.pdf">Penicillin Allergy Evaluation Should Be Performed Proactively in Patients with a Penicillin Allergy Label</a> – A Position Statement of the American Academy of Allergy, Asthma &#38; Immunology</p> <p><a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC8019188/">Staicu ML, Vyles D, Shenoy ES, Stone CA, Banks T, Alvarez KS, Blumenthal KG. Penicillin Allergy Delabeling: A Multidisciplinary Opportunity. J Allergy Clin Immunol Pract. 2020 Oct;8(9):2858-2868.e16. doi: 10.1016/j.jaip.2020.04.059. PMID: 33039010; PMCID: PMC8019188.</a></p> <p><a href="https://pubmed.ncbi.nlm.nih.gov/36990206/">Yang C, Graham JK, Vyles D, Leonard J, Agbim C, Mistry RD. Parental perspective on penicillin allergy delabeling in a pediatric emergency department. Ann Allergy Asthma Immunol. 2023 Jul;131(1):82-88. doi: 10.1016/j.anai.2023.03.023. Epub 2023 Mar 27. PMID: 36990206.</a></p> <p style="text-align: center;">***</p> <p>Thank you to the <a href="http://www.ucdmc.ucdavis.edu/emergency/">UC Davis Department of Emergency Medicine</a> for supporting this podcast and to Orlando Magaña at <a href="http://www.orlandomagana.com/">OM Productions</a> for audio production services.</p> <p>&#160;</p> <p><a href="https://ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM.png"><img fetchpriority="high" decoding="async" class="aligncenter wp-image-8792 size-large" src="https://ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM-814x1024.png" alt="" width="814" height="1024" srcset="https://i0.wp.com/ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM.png?resize=814%2C1024&#38;ssl=1 814w, https://i0.wp.com/ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM.png?resize=238%2C300&#38;ssl=1 238w, https://i0.wp.com/ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM.png?resize=768%2C967&#38;ssl=1 768w, https://i0.wp.com/ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM.png?resize=1220%2C1536&#38;ssl=1 1220w, https://i0.wp.com/ucdavisem.com/wp-content/uploads/2026/02/Screenshot-2026-02-17-at-11.54.46-AM.png?w=1292&#38;ssl=1 1292w" sizes="(max-width: 814px) 100vw, 814px" /></a></p>