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Performance of the PEN-FAST clinical decision rule in older adults, immunocompromised patients and delayed penicillin allergy
Journal article   Open access   Peer reviewed

Performance of the PEN-FAST clinical decision rule in older adults, immunocompromised patients and delayed penicillin allergy

Morgan T. Rose, Sara Vogrin, Elizabeth J. Phillips and Jason A. Trubiano
The Journal of Allergy and Clinical Immunology In Practice, Vol.14(10), pp.2414-2416
2026
DOI: https://doi.org/10.1016/j.jaip.2026.07.016
PMID: 42486188
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Published1.58 MBDownloadView
Open Access CC BY V4.0

Abstract

As the original authors of the PEN-FAST penicillin allergy clinical decision rule,1 we have received frequent questions since publication regarding its applicability across certain patient populations and penicillin allergy phenotypes. PEN-FAST is a validated clinical decision rule that uses 4 criteria to identify low-risk penicillin allergy phenotypes that may be eligible for evaluation with direct penicillin challenge without prior skin testing. With a scoring range of 0 to 5, a PEN-FAST score of less than 3 is used to identify low-risk allergy phenotypes. Despite global implementation among broad stakeholder groups2 and external validation in immediate hypersensitivity3,4 and specialty populations (eg, pregnancy), clinicians ask whether PEN-FAST retains its negative predictive value (NPV) in immunocompromised hosts, older adults, and delayed (nonimmediate) reactions. To address these clinical questions, we performed subgroup analyses based on age, immune status, and reaction phenotype using the PEN-FAST development cohort published in JAMA Internal Medicine.1 In brief, the initial PEN-FAST was developed to identify predictors of positive allergy testing results in a prospective cohort of 622 participants (development cohort) and externally validated in 3 retrospective data sets from independent international clinical sites. Using the same development cohort, we have now performed additional subgroup analyses evaluating the distribution of PEN-FAST scores and its diagnostic performance within each subgroup. This includes sensitivity, specificity, positive and negative predictive values, and area under receiver-operating characteristics curve, using a cutoff of less than 3 to classify as low risk as suggested in the main study. Performance was compared between subgroups using Fisher exact test and χ2 test. All results are reported with 95% CI. Analysis was performed using Stata 18 (StataCorp LLC, College Station, Tex).

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