Xiang Y Y, Heriot G S,Jamrozik E. Ethics of antibiotic allergy. J Med Ethics 2023; DOI: 10.1136/jme-2022-108648.

Some re-thinking required.

Approximately 10% of hospitalised patients report penicillin allergy. Only 5% of these have true allergy after testing. Thus only 1% of people have confirmed allergy and only 0.0001 to 0.0005% of these will have an anaphylactic reaction. For patients presenting with a bacterial infection which warrants antibiotic treatment, and with a history of penicillin allergy, the doctor has two choices (ignoring the option for allergy testing) - prescribe first line penicillin-based treatment and risk allergic reaction OR prescribe second line antibiotics, and risk a lower chance of cure, associated with adverse drug reactions, longer treatment durations, greater healthcare costs and increased prevalence of resistant bacteria.

The authors argue that allergy history is a weak predictor of harms to patients whereas use of second line treatments is associated with well-described harms. Therefore, one might expect that doctors would prescribe first line treatments even in the presence of an allergy history. However, that doesn't seem to happen, possibly due to lack of awareness of the relevant data, professional norms and medico-legal issues and cognitive bias from both the doctor and the patient. The authors recommend changes to clinical practice, medical education and clinical guidelines.