Western Health, Footscray, Victoria, Australia.
Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.
J Med Ethics. 2023 Dec 14;50(1):39-44. doi: 10.1136/jme-2022-108648.
Antibiotic allergies are commonly reported among patients, but most do not experience reactions on rechallenge with the same agents. These reported allergies complicate management of infections in patients labelled as having penicillin allergy, including serious infections where penicillin-based antibiotics are the first-line (most effective and least toxic) treatment option. Allergy labels are rarely questioned in clinical practice, with many clinicians opting for inferior second-line antibiotics to avoid a perceived risk of allergy. Reported allergies thereby can have significant impacts on patients and public health, and present major ethical challenges. Antibiotic allergy testing has been described as a strategy to circumvent this dilemma, but it carries limitations that often make it less feasible in patients with acute infections or in community settings that lack access to allergy testing. This article provides an empirically informed ethical analysis of key considerations in this clinical dilemma, using bacteraemia in patients with penicillin allergies as a case study. We argue that prescribing first-line penicillin-based antibiotics to patients with reported allergies may often present a more favourable ratio of benefits to risks, and may therefore be more ethically appropriate than using second-line drugs. We recommend changes to policy-making, clinical research and medical education, in order to promote more ethically acceptable responses to antibiotic allergies than the status quo.
抗生素过敏在患者中很常见，但大多数患者在再次使用相同药物时不会出现过敏反应。这些报告的过敏反应使被标记为青霉素过敏的患者的感染管理变得复杂，包括严重感染，此时青霉素类抗生素是一线（最有效且毒性最低）治疗选择。在临床实践中，过敏标签很少受到质疑，许多临床医生选择效果较差的二线抗生素，以避免过敏的潜在风险。因此，报告的过敏反应会对患者和公共卫生产生重大影响，并带来重大的伦理挑战。抗生素过敏测试被描述为规避这一困境的策略，但它存在局限性，在急性感染患者或缺乏过敏测试的社区环境中，该测试往往不太可行。本文通过以青霉素过敏患者的菌血症为例，对这一临床困境中的关键考虑因素进行了基于经验的伦理分析。我们认为，给有报告过敏史的患者开一线青霉素类抗生素，可能通常会带来更有利的获益风险比，因此比使用二线药物更符合伦理。我们建议在政策制定、临床研究和医学教育方面做出改变，以促进对抗生素过敏做出比现状更具伦理可接受的反应。
