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Understanding Penicillin Allergy, Cross-reactivity, and Antibiotic Selection in the Preoperative Setting. J Am Acad Orthop Surg 2022; 30:e1-e5. [PMID: 34669610 PMCID: PMC8928301 DOI: 10.5435/jaaos-d-21-00422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/08/2021] [Indexed: 02/01/2023] Open
Abstract
Penicillin allergies are reported by 8% to 15% of the US population, but up to 95% of these allergies do not correspond to a true allergy when tested. Recent studies have demonstrated that having a penicillin allergy label (PAL) results in a 50% increased odds of surgical site infection among patients reporting a penicillin allergy entirely attributable to the use of a beta-lactam alternative antibiotic (primarily clindamycin or vancomycin). This study provides a review of the prevalence of PAL, the cross-reactivity with cefazolin, immunogenic components of cefazolin and penicillin, and current guidelines for preoperative antibiotic selection in patients with PALs. On understanding these principles, a new set of guidelines and a risk stratification tool are proposed for assessing allergies and determining appropriate antibiotic choice, dosage, and timing in the orthopaedic preoperative setting.
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102
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Gaberino CL, Chiu AM, Mahatme SS. The effects of beta-lactam allergy relabeling on antibiotic prescribing practices. Ann Allergy Asthma Immunol 2021; 128:307-313. [PMID: 34890777 DOI: 10.1016/j.anai.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/05/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Beta-lactam antibiotic allergy labels are highly prevalent but rarely indicate an allergic intolerance. These patient-reported allergies lead to broad-spectrum antibiotic use, conferred resistance, increased expense, and adverse effects. OBJECTIVE To implement and assess the impact of a history-based clinical guideline that directs antibiotic management and beta-lactam allergy relabeling for patients reporting beta-lactam allergies. METHODS Patients with beta-lactam allergy labels were identified by our trained multidisciplinary team in diverse clinical settings. This quality improvement project was conducted to evaluate the safety and impact of the guideline on antibiotic use by comparing prescribing practices before and after guideline implementation. RESULTS A total of 79 patients with beta-lactam allergies were identified (penicillins-90%, cephalosporins-10%). After guideline implementation, outcomes of allergy relabeling included the following: (1) complete removal, indicating an unlikely true allergy (27%); (2) updated to detail successfully tolerated beta-lactam courses (48%); or (3) no change made to current label (25%). Beta-lactam antibiotic courses before and after guideline implementation compared with total antibiotic courses: allergy removed (44% vs 70%; P < .001), allergy updated (32% vs 68%; P < .001), and no change (27% vs 41%; P = .08). Compared with before guideline implementation, beta-lactam antibiotics were 3 times more likely to be prescribed after allergy assessment (odds ratio, 3.22; 95% confidence interval, 2.4-4.3; P < .05). CONCLUSION The implementation of the beta-lactam allergy clinical guideline resulted in most patients' allergy labels being removed or advantageously updated. These allergy label changes correlated with a substantial increase in the percentage of beta-lactam antibiotics prescribed. After guideline implementation, beta-lactam antibiotics had a 3-fold increased odds of being prescribed independent of allergy label outcome.
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Affiliation(s)
- Courtney L Gaberino
- Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Asriani M Chiu
- Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; Division of Asthma, Allergy, and Clinical Immunology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sheran S Mahatme
- Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
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103
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Desy J, Coderre S, Veale P, Busche K, Woloschuk W, McLaughlin K. Can we predict failure in licensure exams from medical students' undergraduate academic performance? CANADIAN MEDICAL EDUCATION JOURNAL 2021; 12:6-13. [PMID: 35003426 PMCID: PMC8740250 DOI: 10.36834/cmej.68172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND In 2015, the Medical Council of Canada increased the minimum pass level for the Medical Council of Canada Qualifying Examination Part I, and students had a higher rate of failure than in previous years. The purpose of this study was to predict students at an increased odds of examination failure to allow for early, targeted interventions. METHODS We divided our dataset into a derivation cohort and two validation cohorts and used multiple logistic regression to predict licensing examination failure. We then performed receiver operating characteristics and a sensitivity analysis using different cutoffs for explanatory variables to identify the cutoff threshold with the best predictive value at identifying students at increased odds of failure. RESULTS After multivariate analysis, only pre-clerkship GPA was a significant independent predictor of failure (OR 0.76, 95% CI [0.66, 0.88], p < 0.001). The probability of failure increased steeply when the pre-clerkship GPA fell below 80% and 76% was found to be the most efficient cutoff for predicting failure (OR 9.37, 95% CI [3.08, 38.41]). CONCLUSIONS Pre-clerkship performance can predict students at increased odds of licensing examination failure. Further studies are needed to explore whether early interventions for at-risk students alter their examination performance.
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Affiliation(s)
- Janeve Desy
- Office of Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Sylvain Coderre
- Office of Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Pamela Veale
- Office of Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Kevin Busche
- Office of Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Wayne Woloschuk
- Office of Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Kevin McLaughlin
- Office of Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Alberta, Canada
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104
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Minaldi E, Phillips EJ, Norton A. Immediate and Delayed Hypersensitivity Reactions to Beta-Lactam Antibiotics. Clin Rev Allergy Immunol 2021; 62:449-462. [PMID: 34767158 DOI: 10.1007/s12016-021-08903-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 12/16/2022]
Abstract
Beta-lactam antibiotics are the most commonly reported drug allergy in adults and children. More than 95% of those with reported allergy labels to beta lactams are not confirmed when subjected to allergy testing. Beta lactam antibiotics are associated with a wide spectrum of immediate and delayed drug hypersensitivity reactions. The latency period to symptoms and clinical presentation aids in the causality assessment. Risk stratification based on diagnosis and timing then allows for appropriate management and evaluation. Skin prick testing, intradermal testing and oral challenge are well established for evaluation of immediate reactions. Delayed intradermal testing, patch testing and oral challenge can also be considered for evaluation of mild to moderate delayed reactions. Cross-reactivity between beta-lactams appears to be driven most commonly by a shared R1 side-chain. Standardized algorithms, protocols and pathways are needed for widespread implementation of a pragmatic and effective approach to patients reporting beta lactam allergy.
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Affiliation(s)
- Ellen Minaldi
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Allison Norton
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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105
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Steenvoorden L, Bjoernestad EO, Kvesetmoen TA, Gulsvik AK. De-labelling penicillin allergy in acutely hospitalized patients: a pilot study. BMC Infect Dis 2021; 21:1083. [PMID: 34670500 PMCID: PMC8527685 DOI: 10.1186/s12879-021-06794-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background Penicillin allergy prevalence is internationally reported to be around 10%. However, the majority of patients who report a penicillin allergy do not have a clinically significant hypersensitivity. Few patients undergo evaluation, which leads to overuse of broad-spectrum antibiotics. The objective of this study was to monitor prevalence and implement screening and testing of hospitalized patients. Methods All patients admitted to the medical department in a local hospital in Oslo, Norway, with a self-reported penicillin allergy were screened using an interview algorithm to categorize the reported allergy as high-risk or low-risk. Patients with a history of low-risk allergy underwent a direct graded oral amoxicillin challenge to verify absence of a true IgE-type allergy. Results 257 of 5529 inpatients (4.6%) reported a penicillin allergy. 191 (74%) of these patients underwent screening, of which 86 (45%) had an allergy categorized as low-risk. 54 (63%) of the low-risk patients consented to an oral test. 98% of these did not have an immediate reaction to the amoxicillin challenge, and their penicillin allergy label could thus be removed. 42% of the patients under treatment with antibiotics during inclusion could switch to treatment with penicillins immediately after testing, in line with the national recommendations for antibiotic use. Conclusions The prevalence of self-reported penicillin allergy was lower in this Norwegian population, than reported in other studies. Screening and testing of hospitalized patients with self-reported penicillin allergy is a feasible and easy measure to de-label a large proportion of patients, resulting in immediate clinical and environmental benefit. Our findings suggest that non-allergist physicians can safely undertake clinically impactful allergy evaluations.
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Affiliation(s)
- Linde Steenvoorden
- Department of Medicine, Diakonhjemmet Hospital, Postboks 23 Vinderen, 0319, Oslo, Norway
| | - Erik Oeglaend Bjoernestad
- Department of Medicine, Diakonhjemmet Hospital, Postboks 23 Vinderen, 0319, Oslo, Norway. .,Department of Hematology, Oslo University Hospital, Oslo, Norway.
| | - Thor-Agne Kvesetmoen
- Department of Medicine, Diakonhjemmet Hospital, Postboks 23 Vinderen, 0319, Oslo, Norway
| | - Anne Kristine Gulsvik
- Department of Medicine, Diakonhjemmet Hospital, Postboks 23 Vinderen, 0319, Oslo, Norway
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106
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Arikoglu T, Kont AO, Demirhan A, Yuksek BC, Tokmeci N, Kuyucu S. Risk stratification in beta-lactam allergy. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00295-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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107
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Roistacher DM, Heller JA, Ferraro NF, August M. Is Penicillin Allergy a Risk Factor for Surgical Site Infection After Oral and Maxillofacial Surgery? J Oral Maxillofac Surg 2021; 80:93-100. [PMID: 34547269 DOI: 10.1016/j.joms.2021.08.147] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE The selection of perioperative antibiotics for prevention of surgical site infection (SSI) is often limited by the presence of a reported penicillin allergy. The purpose of this study was to determine if oral and maxillofacial surgery patients who report allergy to penicillin are at an increased risk of developing SSI. METHODS A retrospective cohort study was performed of patients who underwent oral and maxillofacial surgical procedures in the operating room setting at a single institution between 2011 and 2018. The following categories of procedures were investigated: dentoalveolar, orthognathic, orthognathic with third molar extraction, pathology and reconstruction, and temporomandibular joint. The primary predictor and outcome variables were reported penicillin allergy and surgical site infection, respectively. Bivariate and multiple logistic regression analysis were performed. P < .05 was considered to be significant. RESULTS The cohort was composed of 2,058 patients of which 318 (15.5%) reported allergy to penicillin. Beta-lactam antibiotics were administered less frequently to penicillin allergic patients perioperatively compared with those without penicillin allergy (7.9 vs 97.1%, P < .001), while clindamycin was more commonly administered (76.4 vs 2.5%, P < .001). Clindamycin was associated with a higher SSI rate compared with beta-lactam antibiotics (5.6 vs 1.4%, P < .001). Penicillin allergy was significantly associated with SSI at an adjusted odds ratio of 2.61 (95% CI 1.51 to 4.49, P = .001). After holding perioperative antibiotic usage equal between the 2 groups, penicillin allergy per se was no longer associated with SSI (P = .901), suggesting that the outcome was mediated by antibiotic selection. CONCLUSIONS Penicillin allergy was associated with development of SSI due to receipt of non-beta-lactam antibiotics as perioperative prophylaxis. Formal allergy evaluation should be considered for patients with putative penicillin allergy.
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Affiliation(s)
- Daniel M Roistacher
- Resident, Oral and Maxillofacial Surgery, Mount Sinai Health System, New York, NY.
| | | | - Nalton F Ferraro
- Instructor, Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, MA
| | - Meredith August
- Attending Surgeon, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA
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108
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Chua KYL, Vogrin S, Bury S, Douglas A, Holmes NE, Tan N, Brusco NK, Hall R, Lambros B, Lean J, Stevenson W, Devchand M, Garrett K, Thursky K, Grayson ML, Slavin MA, Phillips EJ, Trubiano JA. The Penicillin Allergy Delabeling Program: A Multicenter Whole-of-Hospital Health Services Intervention and Comparative Effectiveness Study. Clin Infect Dis 2021; 73:487-496. [PMID: 32756983 DOI: 10.1093/cid/ciaa653] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/23/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Penicillin allergies are associated with inferior patient and antimicrobial stewardship outcomes. We implemented a whole-of-hospital program to assess the efficacy of inpatient delabeling for low-risk penicillin allergies in hospitalized inpatients. METHODS Patients ≥ 18 years of age with a low-risk penicillin allergy were offered a single-dose oral penicillin challenge or direct label removal based on history (direct delabeling). The primary endpoint was the proportion of patients delabeled. Key secondary endpoints were antibiotic utilization pre- (index admission) and post-delabeling (index admission and 90 days). RESULTS Between 21 January 2019 and 31 August 2019, we assessed 1791 patients reporting 2315 antibiotic allergies, 1225 with a penicillin allergy. Three hundred fifty-five patients were delabeled: 161 by direct delabeling and 194 via oral penicillin challenge. Ninety-seven percent (194/200) of patients were negative upon oral penicillin challenge. In the delabeled patients, we observed an increase in narrow-spectrum penicillin usage (adjusted odds ratio [OR], 10.51 [95% confidence interval {CI}, 5.39-20.48]), improved appropriate antibiotic prescribing (adjusted OR, 2.13 [95% CI, 1.45-3.13]), and a reduction in restricted antibiotic usage (adjusted OR, 0.38 [95% CI, .27-.54]). In the propensity score analysis, there was an increase in narrow-spectrum penicillins (OR, 10.89 [95% CI, 5.09-23.31]) and β-lactam/β-lactamase inhibitors (OR, 6.68 [95% CI, 3.94-11.35]) and a reduction in restricted antibiotic use (OR, 0.52 [95% CI, .36-.74]) and inappropriate prescriptions (relative risk ratio, 0.43 [95% CI, .26-.72]) in the delabeled group compared with the group who retained their allergy label. CONCLUSIONS This health services program using a combination of direct delabeling and oral penicillin challenge resulted in significant impacts on the use of preferred antibiotics and appropriate prescribing.
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Affiliation(s)
- Kyra Y L Chua
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Australia
| | - Susan Bury
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Pharmacy, Austin Health, Heidelberg, Australia
| | - Abby Douglas
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Natasha E Holmes
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Nixon Tan
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Natasha K Brusco
- Alpha Crucis Group, Health Economics, Langwarrin, Australia.,Rehabilitation, Ageing and Independent Living Research Centre, Monash University, Frankston, Australia
| | - Rebecca Hall
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Belinda Lambros
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Jacinta Lean
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Wendy Stevenson
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Misha Devchand
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Pharmacy, Austin Health, Heidelberg, Australia
| | - Kent Garrett
- Department of Pharmacy, Austin Health, Heidelberg, Australia
| | - Karin Thursky
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia.,National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Melbourne, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Parkville, Australia
| | - M Lindsay Grayson
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia
| | - Monica A Slavin
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Parkville, Australia
| | - Elizabeth J Phillips
- Department of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia
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109
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Van Gerwen OT, Camino AF, Bourla LN, Legendre D, Muzny CA. Management of Trichomoniasis in the Setting of 5-Nitroimidazole Hypersensitivity. Sex Transm Dis 2021; 48:e111-e115. [PMID: 33137011 PMCID: PMC8081757 DOI: 10.1097/olq.0000000000001326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
ABSTRACT Metronidazole and other 5-nitroimidazoles are the mainstay of Trichomonas vaginalis treatment, with few efficacious and safe treatment options available outside of this class. Patients with trichomoniasis and a history of a clinically confirmed hypersensitivity reaction to 5-nitroimidazoles present a management challenge for clinicians. The first step in managing such patients is metronidazole desensitization. In situations where this cannot be performed or tolerated, treatment with alternative regimens outside of the 5-nitroimidazole class, such as intravaginal boric acid or paromomycin, may be possible.
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Affiliation(s)
- Olivia T. Van Gerwen
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Lorelei N. Bourla
- Saratoga Hospital Medical Group, Allergy and Clinical Immunology, Saratoga Springs, New York
| | | | - Christina A. Muzny
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
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110
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Abstract
PURPOSE OF REVIEW Drug allergy management has previously not been emphasized in the elderly. However, the geriatric population poses several unique characteristics, challenges for drug allergy testing and considerations in the management. Especially in the era of COVID-19, the elderly population is a vulnerable cohort and reviewing the management during this unprecedented time is both timely and relevant. RECENT FINDINGS In recent years, larger scale studies focusing on the epidemiology and prevalence trends of drug allergies among older adults has been summarized in this review. Emphasis on anaphylaxis in the older adults has been studied. SUMMARY There are many implications of these findings. Epidemiological studies are useful in realizing the burden and spectrum of drug allergies on our healthcare system. It has allowed us to identify certain barriers in drug allergy management and develop ways to overcome these challenges through. Lastly, we have proposed an approach to drug allergy management based on previous studies as well as from our perspective and local experience.
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Affiliation(s)
- Jane C Y Wong
- Division of Rheumatology & Clinical Immunology, Department of Medicine, Queen Mary Hospital, Pok Fu Lam, Hong Kong
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111
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Caballero ML, Krantz MS, Quirce S, Phillips EJ, Stone CA. Hidden Dangers: Recognizing Excipients as Potential Causes of Drug and Vaccine Hypersensitivity Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:2968-2982. [PMID: 33737254 PMCID: PMC8355062 DOI: 10.1016/j.jaip.2021.03.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 12/18/2022]
Abstract
Excipients are necessary as a support to the active ingredients in drugs, vaccines, and other products, and they contribute to their stability, preservation, pharmacokinetics, bioavailability, appearance, and acceptability. For both drugs and vaccines, these are rare reactions; however, for vaccines, they are the primary cause of immediate hypersensitivity. Suspicion for these "hidden dangers" should be high, in particular, when anaphylaxis has occurred in association with multiple chemically distinct drugs. Common excipients implicated include gelatin, carboxymethylcellulose, polyethylene glycols, and products related to polyethylene glycols in immediate hypersensitivity reactions and propylene glycol in delayed hypersensitivity reactions. Complete evaluation of a suspected excipient reaction requires detailed information from the product monograph and package insert to identify all ingredients that are present and to understand the function and structure for these chemicals. This knowledge helps develop a management plan that may include allergy testing to identify the implicated component and to give patients detailed information for future avoidance of relevant foods, drugs, and vaccines. Excipient reactions should be particularly considered for specific classes of drugs where they have been commonly found to be the culprit (eg, corticosteroids, injectable hormones, immunotherapies, monoclonal antibodies, and vaccines). We provide a review of the evidence-based literature outlining epidemiology and mechanisms of excipient reactions and provide strategies for heightened recognition and allergy testing.
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Affiliation(s)
| | - Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, IdiPAZ, Madrid, Spain; Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Elizabeth J Phillips
- Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt School of Medicine, Nashville, Tenn; Institute of Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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112
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Abstract
PURPOSE OF REVIEW Understand how the clinical history has been used to risk stratify patients reporting a beta-lactam allergy, both in clinical care pathways and predictive models. RECENT FINDINGS Drug allergy clinical care pathways have emerged as a safe and effective method of stratifying patients with a reported beta-lactam allergy into risk categories, with 'low-risk' patients able to proceed straight to direct challenges or test doses. These methods have streamlined antibiotic stewardship policies and penicillin allergy de-labeling. However, how to define 'low-risk' has been subject to much debate. New research has developed predictive models that utilize the clinical history to assess a patient's true risk of beta-lactam allergy. SUMMARY The clinical history has long been an essential part of drug allergy evaluation and has proven invaluable within the past decade in the development of drug allergy clinical pathways. Evidence-based predictive models that use the clinical history to assess a patient's true risk of beta-lactam allergy offer tremendous promise, but differ in crucial areas such as the populations they study, the predictor variables they use, and the ultimate accuracy they attain. These models highlight key aspects of the drug allergy history and pave the way for future large-scale research.
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Affiliation(s)
| | - Allen Judd
- Division of Rheumatology, Allergy and Immunology, Department of Medicine
| | - Kimberly Blumenthal
- Medical Practice Evaluation Center
- The Mongan Institute, Massachusetts General Hospital
- Harvard Medical School, Boston, Massachusetts, USA
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113
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Piotin A, Godet J, Trubiano JA, Grandbastien M, Guénard-Bilbault L, de Blay F, Metz-Favre C. Predictive factors of amoxicillin immediate hypersensitivity and validation of PEN-FAST clinical decision rule. Ann Allergy Asthma Immunol 2021; 128:27-32. [PMID: 34271183 DOI: 10.1016/j.anai.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/12/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The challenge of delabeling amoxicillin allergy is an important issue for patients and clinicians, especially when anaphylaxis is reported. A recent study has proposed a clinical decision rule, PEN-FAST, to identify low-risk penicillin allergies. OBJECTIVE To validate the PEN-FAST clinical decision rule in a population with high risk of suspected immediate amoxicillin allergy and to identify clinical predictive factors of amoxicillin immediate hypersensitivity. METHODS We retrospectively analyzed medical records of patients with a suspected immediate amoxicillin allergy who carried out an allergologic evaluation by a specialist in the Allergy Unit of Strasbourg University Hospital from 2015 to 2020. RESULTS A total of 142 adult patients (88 women [62.0%]; median age, 52 [interquartile range, 40.3-62.0] years) were analyzed. Most of them reported anaphylaxis (68.8%). Internal validation of PEN-FAST score revealed a good discrimination with area under the curve of 0.86 (95% confidence interval, 0.79-0.92). A cutoff of less than 3 points for PEN-FAST was used to classify 29 from 142 patients at low risk of allergy, of whom only 2 (6.9%) received positive results of allergy testing. The negative predictive value for successful delabeling was 0.93 (95% confidence interval, 0.77-0.99). Predictive clinical features for immediate amoxicillin hypersensitivity were time since reaction (P < .001), time elapsed between drug intake and first symptom (P < .001), severity grade reaction (P < .001), and treatment or hospitalization required (P < .001). CONCLUSION PEN-FAST has been validated to identify low-risk penicillin allergies in our European cohort of patients mainly reporting anaphylaxis. This is the first reported external validation of a penicillin allergy clinical decision rule internationally.
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Affiliation(s)
- Anays Piotin
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France.
| | - Julien Godet
- Public Health Department, Strasbourg University Hospital, Strasbourg, France
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Australia; Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Manon Grandbastien
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France
| | | | - Frédéric de Blay
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France; EA 3070 Federation of Translational Medicine, FHU Homicare, University of Strasbourg, Strasbourg, France
| | - Carine Metz-Favre
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France
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114
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Krishna MT, Vedanthan PK, Vedanthan R, El Shabrawy RM, Madhan R, Nguyen HL, Kudagammana T, Williams I, Karmacharya B, Hariharan S, Krishnamurthy K, Sumantri S, Elliott R, Mahesh PA, Marriott JF. Is spurious penicillin allergy a major public health concern only in high-income countries? BMJ Glob Health 2021; 6:bmjgh-2021-005437. [PMID: 34016579 PMCID: PMC8141433 DOI: 10.1136/bmjgh-2021-005437] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 12/24/2022] Open
Affiliation(s)
- Mamidipudi Thirumala Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, West Midlands, UK .,Institute of Immunology and Immunotherapy, University of Birmingham, Edgbaston Campus, Birmingham, UK
| | | | - Rajesh Vedanthan
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | | | - Ramesh Madhan
- Department of Phamacy Practice, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
| | - Hoa L Nguyen
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Thushara Kudagammana
- Department of Paediatrics, Faculty of Medicine, University of Peradeniya, Peradeniya, Central, Sri Lanka
| | - Iestyn Williams
- Health Services Management Centre, University of Birmingham, Birmingham, West Midlands, UK
| | - Biraj Karmacharya
- Departments of Public Health and Community Programs, Dhulikhel Hospital Kathmandu University Hospital, Kathmandu, Nepal
| | - Seetharaman Hariharan
- Department of Clinical Surgical Sciences, The University of the West Indies St Augustine Campus, St Augustine, Tunapuna-Piarco, Trinidad and Tobago
| | | | - Stevent Sumantri
- Department of Internal Medicine, Universitas Pelita Harapan, Tangerang, Banten, Indonesia
| | - Rachel Elliott
- Division of Population Health, Health Services Research and Primary care, The University of Manchester, Manchester, UK
| | - Padukudru Anand Mahesh
- Department of Respiratory Medicine, JSS Medical College, JSSAHER, Mysore, Karnataka, India
| | - John F Marriott
- The School of Pharmacy, University of Birmingham, Birmingham, UK
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Zhang BY, Paquette V, McClymont E, Barlas A, Wong T, Watt M, Mak R, Elwood C. Implementing a penicillin allergy delabeling service for the obstetric population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2501-2502.e2. [DOI: 10.1016/j.jaip.2021.01.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 12/31/2022]
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Penicillin Allergy Delabeling: A Multidisciplinary Opportunity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2858-2868.e16. [PMID: 33039010 DOI: 10.1016/j.jaip.2020.04.059] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022]
Abstract
The penicillin allergy label has been consistently linked with deleterious effects that span the health care spectrum, including suboptimal clinical outcomes, the emergence of bacterial resistance, and increased health care expenditures. These risks have recently motivated professional organizations and public health institutes to advocate for the implementation of penicillin allergy delabeling initiatives; however, the burden of delabeling millions of patients is too expansive for any one discipline to bear alone. This review presents the unique perspectives and roles of various stakeholder groups involved in penicillin allergy diagnosis, assessment, and delabeling; we emphasize opportunities, barriers, and promising areas of innovation. We summarize penicillin allergy methods and tools that have proven successful in delabeling efforts. A multidisciplinary approach to delabeling patients with reported penicillin allergy, bolstered by evidence-based clinical practices, is recommended to reduce the risks that associate with the penicillin allergy label.
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Delabeling Delayed Drug Hypersensitivity: How Far Can You Safely Go? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2878-2895.e6. [PMID: 33039012 DOI: 10.1016/j.jaip.2020.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/01/2020] [Accepted: 07/08/2020] [Indexed: 12/17/2022]
Abstract
Delayed immune-mediated adverse drug reactions (IM-ADRs) are defined as reactions occurring more than 6 hours after dosing. They include heterogeneous clinical phenotypes that are typically T-cell-mediated reactions with distinct mechanisms across a wide spectrum of severity from benign exanthems through to life-threatening cutaneous or organ-specific diseases. For mild reactions such as benign exanthem, considerations for delabeling are similar to immediate reactions and may include a graded or single-dose drug challenge with or without preceding skin or patch testing. Evaluation of challenging cases such as the patient who is on multiple drugs at the time a severe delayed IM-ADR occurs should prioritize clinical ascertainment of the most likely phenotype and implicated drug(s). Although not widely available and validated, procedures such as patch testing, delayed intradermal skin testing, and laboratory-based functional drug assays or genetic (human leukocyte antigen) testing may provide valuable information to further help risk stratify patients and identify the likely implicated and/or cross-reactive drug(s). The decision to use a drug challenge as a diagnostic or delabeling tool in a patient with a severe delayed IM-ADR should weigh the risk-benefit ratio, balancing the severity and priority for the treatment of the underlying, and the availability of alternative efficacious and safe treatments.
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Turner NA, Wrenn R, Sarubbi C, Kleris R, Lugar PL, Radojicic C, Moehring RW, Anderson DJ. Evaluation of a Pharmacist-Led Penicillin Allergy Assessment Program and Allergy Delabeling in a Tertiary Care Hospital. JAMA Netw Open 2021; 4:e219820. [PMID: 33983399 PMCID: PMC8120333 DOI: 10.1001/jamanetworkopen.2021.9820] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Penicillin allergies are frequently mislabeled, which may contribute to use of less-preferred alternative antibiotics. OBJECTIVE To evaluate a pharmacist-led allergy assessment program's association with antimicrobial use and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS A pharmacist-led allergy assessment program was launched in 2 phases (June 1, 2015, and November 2, 2016) at a single-center tertiary referral hospital. The longitudinal cross-sectional study included all study period adult admissions; hospitalwide outcomes were assessed by segmented regression. Individual outcomes were assessed within an embedded propensity score-matched case-control study of inpatients undergoing comprehensive allergy assessment following self-report of penicillin allergy. Analysis occurred from March 1, 2020, to February 29, 2020. EXPOSURES The longitudinal study analyzed hospital-level outcomes over 3 periods: preintervention (15 months), phase 1 (structured allergy history alone, 16 months), and phase 2 (comprehensive assessment including penicillin skin testing, 52 months). The case-control study defined cases as individuals undergoing comprehensive allergy assessment. MAIN OUTCOMES AND MEASURES Hospital-level outcomes included antibiotic days of therapy per 1000 patient-days and hospital-acquired Clostridioides difficile infection (CDI) incidence per 10 000 patient-days. Individual outcomes included antibiotic selection, overall survival, and CDI-free survival. RESULTS Longitudinal analysis spanned 2014-2020 (median admissions, 46 416 per year; interquartile range [IQR], 46 001-50 091 per year). Hospitalwide, allergy histories were temporally associated with decreased use of nonpenicillin alternative antibiotics (rate ratio, 0.87; 95% CI, 0.79-0.97) and high-CDI-risk antibiotics (rate ratio, 0.91; 95% CI, 0.85-0.98). Penicillin skin testing was temporally associated with lower hospital-acquired CDI rates (rate ratio, 0.61; 95% CI, 0.43-0.86). The embedded case-control study included 272 cases and 819 controls. Median age was 63 years (interquartile range, 51-73 years), 553 (50.7%) patients were women, and 229 (21.0%) patients were Black. Allergy-assessed patients were less likely to receive high-CDI-risk antibiotics at discharge (odds ratio, 0.66; 95% CI, 0.44-0.98). Estimated reductions in mortality (hazard ratio, 0.77; 95% CI, 0.55-1.07) and hospital-acquired CDI risk (hazard ratio, 0.53; 95% CI, 0.18-1.55) were not statistically significant. CONCLUSIONS AND RELEVANCE Pharmacist-led allergy assessments may be associated with reduced high-CDI-risk antibiotic use at both hospitalwide and individual levels. Although individual reductions in mortality and CDI risk did not achieve significance, divergence of survival curves suggest longer-term benefits of allergy delabeling warrant future study.
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Affiliation(s)
- Nicholas A. Turner
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Rebekah Wrenn
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | | | - Renee Kleris
- Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Patricia L. Lugar
- Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Christine Radojicic
- Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Rebekah W. Moehring
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Deverick J. Anderson
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
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Skin Testing for Penicillin Allergy: a Review of the Literature. Curr Allergy Asthma Rep 2021; 21:21. [PMID: 33738621 DOI: 10.1007/s11882-021-00997-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Self-reported penicillin allergies are frequently reported, though more than 95% of those are not truly allergic when challenged. These patients are more likely to receive alternative antibiotic regimens resulting in the use of broad-spectrum antibiotics that may be less effective, more toxic, and/or more expensive than preferred agents. Given the significant burden on patient outcomes and the healthcare system, the ability to reconcile an allergy and broaden future antibiotic options is essential. RECENT FINDINGS This is a narrative review describing risk stratification for penicillin skin testing, practical advice for implementation, and future directions. A summary of studies within the last 5 years is provided. The trend over the past several years has been to offer oral drug challenges to low-risk patients and skin testing to high-risk patients with a reported penicillin allergy. This review provides support for risk stratification assessment of reported penicillin allergy to optimize antibiotic use and prevent emergence of antimicrobial resistance.
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Bhogal R, Hussain A, Balaji A, Bermingham WH, Marriott JF, Krishna MT. The role of a clinical pharmacist in spurious Penicillin allergy: a narrative review. Int J Clin Pharm 2021; 43:461-475. [PMID: 33439428 DOI: 10.1007/s11096-020-01226-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/30/2020] [Indexed: 12/31/2022]
Abstract
Background A label of penicillin allergy is held by 6-10% of the general population and 15-20% of inpatients. > 90% of these labels are found to be spurious after formal allergy assessment. Carrying an unnecessary label of penicillin allergy is not benign. Such patients may receive second line, more expensive antibiotics, representing a significant impediment to antimicrobial stewardship. Aim of the review To (a) Explain the burden of spurious penicillin allergy, and evaluate the safety of direct oral penicillin challenge in 'low risk' patients (b) appraise the place for a clinical pharmacist-led penicillin allergy de-labelling programme. Method Narrative review. Search engines: PubMed, Google Scholar and Cochrane reviews. Search criteria: English language; search terms: penicillin allergy, antimicrobial stewardship, antimicrobial resistance, clostridium difficile, vancomycin resistant enterococci, risk stratification, clinical pharmacist and direct oral provocation test Results Penicillin allergy labels are associated with: longer hospital stay, higher readmission rates, enhanced risk of surgical site infections, risk of Clostridioides difficile infection and Methicillin resistant Staphylococcus aureus infection, a delay in the first dose of an antibiotic in sepsis and higher healthcare costs. A direct oral penicillin challenge in 'low risk' patients has proven to be safe. Discussion Recent studies including those led by a clinical pharmacist have demonstrated safety of a direct oral penicillin challenge in 'low risk' patients. This intervention needs validation within individual health services. Conclusion Direct oral penicillin challenge reduces the adverse impact of spurious penicillin allergy. A pharmacist-led penicillin allergy de-labelling program needs further validation in prospective multi-centre studies.
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Affiliation(s)
- Rashmeet Bhogal
- Department of Pharmacy, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B9 5SS, UK.
| | - Abid Hussain
- Birmingham Public Health Laboratory, National Infection Service, Public Health England, Birmingham, UK
| | - Ariyur Balaji
- Department of Acute Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - William H Bermingham
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John F Marriott
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Mamidipudi T Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, UK
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
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Abstract
Introduction: Nosocomial pneumonia unfortunately remains a frequent event for which appropriate antibiotic treatment is central to improving outcomes. Physicians must choose an early and appropriate empirical treatment, basing their decision on the safety profile and possible side effects. Areas covered: In this review, we analyzed the safety profiles of the most common antimicrobials for treating nosocomial pneumonia. Beta-lactams are used most often for these infections, with a high percentage (6% to 25%) of patients reporting allergy or hypersensitivity reactions; however, exhaustive evaluation is key because it seems possible to de-label as many as 90% by proper assessment. Combinations including a beta-lactam are recommended in patients with risk factors for drug-resistant microorganisms and septic shock. Although aminoglycosides are safe for 3-5 days of therapy, renal function should be monitored. Fluoroquinolones must also be used with care given the risk of collagen degradation and cardiovascular events, mainly aneurysm or aortic dissection. Linezolid or vancomycin are both viable for the treatment of methicillin-resistant Staphylococcus aureus, but linezolid seems to be the superior option. Antibiotic stewardships programs must be developed for each center. Expert opinion: Choosing the most appropriate antimicrobial based on information from national and international guidelines, local microbiology data, and stewardship programs may reduce the use of broad-spectrum antibiotics. Daily assessment for the emergence of adverse events related to antimicrobial use is essential.
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Quoi de neuf en thérapeutique dermatologique ? Ann Dermatol Venereol 2020; 147:12S43-12S50. [DOI: 10.1016/s0151-9638(20)31107-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Kern WV, Horn S, Fink G. Aktuelle Entwicklungen im Bereich Antibiotic Stewardship. Dtsch Med Wochenschr 2020; 145:1758-1763. [DOI: 10.1055/a-0982-8842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Was ist neu?
Antibiotikaverbrauch in Deutschland In Deutschland wurden in den letzten Jahren sowohl im Krankenhausbereich als auch im ambulanten Setting immer weniger Fluorchinolone verordnet. Auch der Verbrauch der Cephalosporine ging etwas zurück.
Renaissance von Aminoglykosiden? Die inzwischen relativ seltenen Substanzen können aufgrund einer recht guten Resistenzlage bei Harnwegsinfektionen als geeignete Alternative – allerdings nur parenteral – eingesetzt werden. Bei akuten schweren Infektionen ist eine einmalige Gabe, z. B. von Tobramycin, initial zusätzlich zu einem geeigneten Betalactam ebenfalls eine Option, aber keine klare Empfehlung.
Antibiotikaeinsatz in der Hämatologie/Onkologie Bei Fieber und Neutropenie gilt nach wie vor die initiale empirische Gabe von Piperacillin-Tazobactam oder einem pseudomonasaktiven Carbapenem als Standard. Diese Betalactame sollten mit verlängerter Infusionsdauer, z. B. über 4 h, verabreicht werden. Linezolid ist ein Reservemedikament und sollte auch bei hämatoonkologischen Patienten nicht empirisch, sondern nur in der gezielten Therapie verwendet werden.
Penicillinallergie Die anamnestische Angabe einer Penicillinallergie sollte durch genaues Hinterfragen differenziert werden. Patienten können so bezüglich ihres Risikos für allergische Reaktionen gruppiert werden – oft besteht kein oder ein sehr geringes Risiko bei einer (erneuten) Behandlung mit Penicillinderivaten. Niedrigrisikopatienten dürfen ohne weitergehende allergologische Untersuchungen reexponiert werden.
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Affiliation(s)
- Winfried V. Kern
- Abteilung Infektiologie, Klinik für Innere Medizin II, Universitätsklinikum Freiburg
| | - Stephan Horn
- Abteilung Infektiologie, Klinik für Innere Medizin II, Universitätsklinikum Freiburg
| | - Geertje Fink
- Abteilung Infektiologie, Klinik für Innere Medizin II, Universitätsklinikum Freiburg
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Penicillin Allergy Assessment in Pregnancy: Safety and Impact on Antibiotic Use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1338-1346. [PMID: 33212237 DOI: 10.1016/j.jaip.2020.10.063] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Penicillin and other beta-lactam antibiotics are recommended for group B Streptococcus and cesarean section prophylaxis, but approximately 10% of pregnant patients report a penicillin allergy. OBJECTIVE To assess the safety and impact of penicillin allergy evaluation in pregnant patients. METHODS In this retrospective study of obstetrician-ordered Allergy/Immunology (AI) electronic consultations (e-consults) from September 20, 2017 through December 31, 2019, we reviewed the electronic health record for e-consult recommendation; patient demographic, obstetric, and allergy histories; and peripartum antibiotic utilization with indication. For patients whose electronic consultation recommended an in-person AI evaluation, testing outcomes were determined, and multivariable logistic regression models were used to compare antibiotic use between patients who did and did not receive an in-person AI evaluation. RESULTS Of 389 obstetrician-ordered e-consults, 363 (93%) recommended an in-person AI evaluation; of these, 222 (61%) patients received an in-person AI evaluation. Of 220 (99%) patients skin tested, 209 (95%) had their penicillin allergy label safely removed. Compared with patients who did not receive an in-person AI evaluation despite it being recommended (n = 141), patients with in-person AI evaluation (n = 222) had reduced peripartum vancomycin (adjusted odds ratio [aOR], 0.07; 95% CI, 0.01-0.33), clindamycin (aOR, 0.17; 95% CI, 0.08-0.34), and gentamicin (aOR, 0.39; 95% CI, 0.19-0.78) use and increased penicillin (aOR, 18.0; 95% CI, 6.30-51.2) use. The fully AI evaluated patients had increased first-line antibiotic prophylaxis for group B Streptococcus (aOR, 26.9; 95% CI, 6.32-114) and cesarean section (aOR, 1.94; 95% CI, 1.06-3.52). CONCLUSIONS In a sample of 220 pregnant patients with penicillin allergy histories and in-person AI evaluation, penicillin allergy testing was safe and associated with significantly reduced broad-spectrum antibiotic use and increased first-line beta-lactam antibiotic use.
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How Does the Skeletal Oncology Research Group Algorithm's Prediction of 5-year Survival in Patients with Chondrosarcoma Perform on International Validation? Clin Orthop Relat Res 2020; 478:2300-2308. [PMID: 32433107 PMCID: PMC7491905 DOI: 10.1097/corr.0000000000001305] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Skeletal Oncology Research Group (SORG) machine learning algorithm for predicting survival in patients with chondrosarcoma was developed using data from the Surveillance, Epidemiology, and End Results (SEER) registry. This algorithm was externally validated on a dataset of patients from the United States in an earlier study, where it demonstrated generally good performance but overestimated 5-year survival. In addition, this algorithm has not yet been validated in patients outside the United States; doing so would be important because external validation is necessary as algorithm performance may be misleading when applied in different populations. QUESTIONS/PURPOSES Does the SORG algorithm retain validity in patients who underwent surgery for primary chondrosarcoma outside the United States, specifically in Italy? METHODS A total of 737 patients were treated for chondrosarcoma between January 2000 and October 2014 at the Italian tertiary care center which was used for international validation. We excluded patients whose first surgical procedure was performed elsewhere (n = 25), patients who underwent nonsurgical treatment (n = 27), patients with a chondrosarcoma of the soft tissue or skull (n = 60), and patients with peripheral, periosteal, or mesenchymal chondrosarcoma (n = 161). Thus, 464 patients were ultimately included in this external validation study, as the earlier performed SEER study was used as the training set. Therefore, this study-unlike most of this type-does not have a training and validation set. Although the earlier study overestimated 5-year survival, we did not modify the algorithm in this report, as this is the first international validation and the prior performance in the single-institution validation study from the United States may have been driven by a small sample or non-generalizable patterns related to its single-center setting. Variables needed for the SORG algorithm were manually collected from electronic medical records. These included sex, age, histologic subtype, tumor grade, tumor size, tumor extension, and tumor location. By inputting these variables into the algorithm, we calculated the predicted probabilities of survival for each patient. The performance of the SORG algorithm was assessed in this study through discrimination (the ability of a model to distinguish between a binary outcome), calibration (the agreement of observed and predicted outcomes), overall performance (the accuracy of predictions), and decision curve analysis (establishment on the ability of a model to make a decision better than without using the model). For discrimination, the c-statistic (commonly known as the area under the receiver operating characteristic curve for binary classification) was calculated; this ranged from 0.5 (no better than chance) to 1.0 (excellent discrimination). The agreement between predicted and observed outcomes was visualized with a calibration plot, and the calibration slope and intercept were calculated. Perfect calibration results in a slope of 1 and an intercept of 0. For overall performance, the Brier score and the null-model Brier score were calculated. The Brier score ranges from 0 (perfect prediction) to 1 (poorest prediction). Appropriate interpretation of the Brier score requires comparison with the null-model Brier score. The null-model Brier score is the score for an algorithm that predicts a probability equal to the population prevalence of the outcome for every patient. A decision curve analysis was performed to compare the potential net benefit of the algorithm versus other means of decision support, such as treating all or none of the patients. There were several differences between this study and the earlier SEER study, and such differences are important because they help us to determine the performance of the algorithm in a group different from the initial study population. In this study from Italy, 5-year survival was different from the earlier SEER study (71% [319 of 450 patients] versus 76% [1131 of 1487 patients]; p = 0.03). There were more patients with dedifferentiated chondrosarcoma than in the earlier SEER study (25% [118 of 464 patients] versus 8.5% [131 of 1544 patients]; p < 0.001). In addition, in this study patients were older, tumor size was larger, and there were higher proportions of high-grade tumors than the earlier SEER study (age: 56 years [interquartile range {IQR} 42 to 67] versus 52 years [IQR 40 to 64]; p = 0.007; tumor size: 80 mm [IQR 50 to 120] versus 70 mm [IQR 42 to 105]; p < 0.001; tumor grade: 22% [104 of 464 had Grade 1], 42% [196 of 464 had Grade 2], and 35% [164 of 464 had Grade 3] versus 41% [592 of 1456 had Grade 1], 40% [588 of 1456 had Grade 2], and 19% [276 of 1456 had Grade 3]; p ≤ 0.001). RESULTS Validation of the SORG algorithm in a primarily Italian population achieved a c-statistic of 0.86 (95% confidence interval 0.82 to 0.89), suggesting good-to-excellent discrimination. The calibration plot showed good agreement between the predicted probability and observed survival in the probability thresholds of 0.8 to 1.0. With predicted survival probabilities lower than 0.8, however, the SORG algorithm underestimated the observed proportion of patients with 5-year survival, reflected in the overall calibration intercept of 0.82 (95% CI 0.67 to 0.98) and calibration slope of 0.68 (95% CI 0.42 to 0.95). The Brier score for 5-year survival was 0.15, compared with a null-model Brier of 0.21. The algorithm showed a favorable decision curve analysis in the validation cohort. CONCLUSIONS The SORG algorithm to predict 5-year survival for patients with chondrosarcoma held good discriminative ability and overall performance on international external validation; however, it underestimated 5-year survival for patients with predicted probabilities from 0 to 0.8 because the calibration plot was not perfectly aligned for the observed outcomes, which resulted in a maximum underestimation of 20%. The differences may reflect the baseline differences noted between the two study populations. The overall performance of the algorithm supports the utility of the algorithm and validation presented here. The freely available digital application for the algorithm is available here: https://sorg-apps.shinyapps.io/extremitymetssurvival/. LEVEL OF EVIDENCE Level III, prognostic study.
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Chakravorty A, Binder E, Rawlins M, Trevenen M, Ingram PR, McKeogh A, Murray K, Dyer J, Lucas M. Antibiotic allergy labels and optimal antimicrobial stewardship. Intern Med J 2020; 52:396-402. [PMID: 32743883 DOI: 10.1111/imj.15003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although common, antimicrobial allergy labels (AAL) rarely reflect immunologically-mediated hypersensitivity and can lead to poorer outcomes from alternative antimicrobial agents. Antimicrobial stewardship programs are ideally placed to assess AAL early as a means of improving antimicrobial use. OBJECTIVES To quantify the prevalence of AAL in patients referred for antimicrobial stewardship review and assess their impact on antibiotic prescribing, patient mortality, hospital length of stay, readmission, and rates of multidrug-resistant infections. METHODS We conducted a retrospective analysis of adult patients referred for inpatient antimicrobial prospective audit and feedback rounds (PAFR) via an electronic referral system (eReferrals) over a 12-month period in 2015. Outcome data was collected for a period of 36 months following the initial review. RESULTS Of the 639 patient records reviewed, 630 met inclusion criteria; 103 (16%) had an AAL, of which 82 (13%) had reported allergies to β-lactam antibiotics. Those with AAL were significantly less likely to be receiving guideline-recommended antimicrobial therapy (50% versus 64%, p=0.0311), however there were no significant difference in mortality, hospital length of stay, readmission or increased incidence of multidrug-resistant infections. CONCLUSIONS Our cohort demonstrated that AAL was associated with reduced adherence to antibiotic guidelines. The lack of association with adverse outcomes may reflect limitations within the study including retrospective cohort study numbers and observational nature, further skewed by high rates of poor documentation. A clear opportunity exists for antimicrobial stewardship programs to incorporate allergy assessment, delabelling, challenge and referral into these rounds. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | | | | | - Michelle Trevenen
- Centre for Applied Statistics, The University of Western Australia, Perth, WA, Australia
| | - Paul Robert Ingram
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia.,Department of Pathology and Laboratory Medicine, The University of Western Australia, Perth, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, Australia
| | - Anna McKeogh
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
| | - Kevin Murray
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - John Dyer
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
| | - Michaela Lucas
- Department of Immunology, Sir Charles Gairdner Hospital, Perth, Australia.,Department of Immunology, PathWest Laboratory Medicine, Perth, Australia.,School of Medicine, The University of Western Australia, Perth, Australia
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Kohlhäufel M. [Not Available]. MMW Fortschr Med 2020; 162:26. [PMID: 32780392 DOI: 10.1007/s15006-020-0734-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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128
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Blumenthal KG, Kuper K, Schulz LT, Bhowmick T, Postelnick M, Lee F, Walensky RP. Association Between Penicillin Allergy Documentation and Antibiotic Use. JAMA Intern Med 2020; 180:1120-1122. [PMID: 32597920 PMCID: PMC7325068 DOI: 10.1001/jamainternmed.2020.2227] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This cohort study assesses the prevalence and association of documented penicillin allergy with inpatient antibiotic use in the US.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston.,The Mongan Institute, Massachusetts General Hospital, Boston.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Lucas T Schulz
- Department of Pharmacy, University of Wisconsin Health, Madison
| | - Tanaya Bhowmick
- Division of Allergy, Immunology, and Infectious Diseases, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Michael Postelnick
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
| | - Francesca Lee
- Division of Infectious Diseases, Department of Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas
| | - Rochelle P Walensky
- The Mongan Institute, Massachusetts General Hospital, Boston.,Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
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129
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Rose MT, Slavin M, Trubiano J. The democratization of de-labeling: a review of direct oral challenge in adults with low-risk penicillin allergy. Expert Rev Anti Infect Ther 2020; 18:1143-1153. [PMID: 32662696 DOI: 10.1080/14787210.2020.1792775] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Penicillin antibiotic allergy labels (AALs) are common and lead to significant negative health and health system outcomes. Direct oral challenge offers a rapid and cost-effective way of removing inaccurate AALs and improving outcomes. AREAS COVERED A narrative review (Medline, May 2020) of direct oral challenge in low-risk penicillin allergy in adults is described, and the evidence for the safety and efficacy of this approach in inpatients, outpatients, and special patient groups is presented. EXPERT OPINION Whilst the current literature demonstrates the safety and efficacy of direct oral challenge in de-labeling low-risk penicillin allergy in adults, novel approaches are needed to improve access to antibiotic allergy assessment and address the growing global need.
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Affiliation(s)
- Morgan Thomas Rose
- Department of Infectious Diseases, Austin Health , Melbourne, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Parkville, Australia.,Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre , Melbourne, Australia
| | - Monica Slavin
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Parkville, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne , Parkville, Australia
| | - Jason Trubiano
- Department of Infectious Diseases, Austin Health , Melbourne, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Parkville, Australia.,Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre , Melbourne, Australia.,Department of Medicine (Austin Health), University of Melbourne , Parkville, Australia
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130
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Livirya S, Pithie A, Chua I, Hamilton N, Doogue M, Isenman H. Oral amoxicillin challenge for low risk penicillin allergic patients. Intern Med J 2020; 52:295-300. [DOI: 10.1111/imj.14978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/05/2020] [Accepted: 07/05/2020] [Indexed: 11/26/2022]
Affiliation(s)
| | - Alan Pithie
- Consultant Infectious Diseases and General Medicine Physician, Christchurch Hospital New Zealand
| | - Ignatius Chua
- Consultant Clinical Immunologist, Christchurch Hospital New Zealand
| | - Niall Hamilton
- Infectious Disease Registrar, Auckland City Hospital New Zealand
| | - Matthew Doogue
- Consultant Clinical Pharmacology and General Medicine Physician, Christchurch Hospital New Zealand
- Associate Professor, University of Otago Christchurch New Zealand
| | - Heather Isenman
- Consultant Infectious Diseases and General Medicine Physician, Christchurch Hospital New Zealand
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131
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eo. [Not Available]. MMW Fortschr Med 2020; 162:10. [PMID: 32248496 DOI: 10.1007/s15006-020-0315-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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