Allergy, asthma & immunology research · 2026
Real-World Performance of Non-Allergist-Led Penicillin Allergy Delabeling: Prospective Head-to-Head Comparison of APAAACI vs. PENFAST.
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Chung Freya Kl, Shi Weihong, Chong Man Yui, Lee Elaine, Yim Jackie Sh, Chiang Valerie, Li Philip H
Аннотация
PURPOSE: Although around 90% of penicillin allergies are mislabelled, delabeling initiatives have been hindered by limited access to drug allergy services. Asia Pacific Association of Allergy, Asthma, and Clinical Immunology (APAAACI) and PENFAST risk-stratification tools can facilitate non-allergist delabeling, but their comparative real-world performance remains unknown. The purpose of this study was to prospectively evaluate APAAACI and PENFAST against allergist assessment and drug provocation testing (DPT) outcomes.
METHODS: In a blinded, head-to-head study, 103 adults with penicillin allergy labels underwent independent risk stratification using both APAAACI and PENFAST tools, followed by allergist evaluation and allergy testing (skin tests, in vitro tests, and DPT). We assessed diagnostic performance (area under the curve [AUC]-receiver operating characteristic, accuracy, sensitivity, specificity, positive and negative predictive values [NPVs]) and agreement (Cohen's κ) of these tools.
RESULTS: Overall, allergist assessment demonstrated the highest AUC of 0.82 (95% confidence interval [CI], 0.69-0.95), outperforming APAAACI (AUC, 0.79; 95% CI, 0.66-0.92; P = 0.012) and PENFAST (AUC, 0.75; 95% CI, 0.62-0.89; P = 0.010). Both APAAACI and PENFAST demonstrated high sensitivity (0.88) and NPV (APAAACI, 0.99; PENFAST, 0.98), missing only one non-severe DPT-positive case. APAAACI showed excellent agreement with allergist assessment (κ = 0.96, P < 0.001) versus moderate agreement for PENFAST (κ = 0.43). Allergist evaluation had superior specificity (0.77 vs. 0.71 [APAAACI] and 0.63 [PENFAST]) and overall accuracy (0.78 vs. 0.72 and 0.65).
CONCLUSIONS: APAAACI and PENFAST can both effectively identify low-risk patients labelled with penicillin allergy when used by non-allergists, with comparable sensitivity to allergist assessment. APAAACI's stronger agreement with allergist assessment may suggest particular utility in Asian populations. These tools can significantly improve access to delabeling in settings lacking specialist allergy services.
METHODS: In a blinded, head-to-head study, 103 adults with penicillin allergy labels underwent independent risk stratification using both APAAACI and PENFAST tools, followed by allergist evaluation and allergy testing (skin tests, in vitro tests, and DPT). We assessed diagnostic performance (area under the curve [AUC]-receiver operating characteristic, accuracy, sensitivity, specificity, positive and negative predictive values [NPVs]) and agreement (Cohen's κ) of these tools.
RESULTS: Overall, allergist assessment demonstrated the highest AUC of 0.82 (95% confidence interval [CI], 0.69-0.95), outperforming APAAACI (AUC, 0.79; 95% CI, 0.66-0.92; P = 0.012) and PENFAST (AUC, 0.75; 95% CI, 0.62-0.89; P = 0.010). Both APAAACI and PENFAST demonstrated high sensitivity (0.88) and NPV (APAAACI, 0.99; PENFAST, 0.98), missing only one non-severe DPT-positive case. APAAACI showed excellent agreement with allergist assessment (κ = 0.96, P < 0.001) versus moderate agreement for PENFAST (κ = 0.43). Allergist evaluation had superior specificity (0.77 vs. 0.71 [APAAACI] and 0.63 [PENFAST]) and overall accuracy (0.78 vs. 0.72 and 0.65).
CONCLUSIONS: APAAACI and PENFAST can both effectively identify low-risk patients labelled with penicillin allergy when used by non-allergists, with comparable sensitivity to allergist assessment. APAAACI's stronger agreement with allergist assessment may suggest particular utility in Asian populations. These tools can significantly improve access to delabeling in settings lacking specialist allergy services.