Penicillin allergy management in India and Sri Lanka: current challenges

Data regarding Penicillin allergy labels (PALs) from India and Sri Lanka are sparse. Emerging data suggests that the proportion of patients declaring an unverified PAL in secondary care in India and Sri Lanka (1-4%) is lesser than that reported in High Income Countries (15-20%). However, even this relatively small percentage translates into a large absolute number, as this part of the world accounts for approximately 25% of the global population. There is a huge unmet need for allergy specialists in India and Sri Lanka. Penicillin allergy management is further compromised by unavailability of skin test reagents, lack of formal training in drug allergy, pre-emptive, non-standardised and unregulated skin testing by untrained operators and a weak health service framework. This has an adverse impact on antimicrobial stewardship, particularly in the management of rheumatic fever, rheumatic heart disease, bacterial endocarditis, syphilis and other sexually transmitted infections. This narrative review highlights the burden of PALs in India and Sri Lanka, as well as gaps in the published literature. It describes current challenges and a pragmatic, cautious and staged bespoke mitigation approach to improve and standardise antimicrobial stewardship in accordance with the World Health Organization AWaRe guidance.