151
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Iammatteo M, Keskin T, Jerschow E. Evaluation of periprocedural hypersensitivity reactions. Ann Allergy Asthma Immunol 2017; 119:349-355.e2. [DOI: 10.1016/j.anai.2017.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/08/2017] [Accepted: 07/11/2017] [Indexed: 12/18/2022]
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152
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Blumenthal KG, Li Y, Banerji A, Yun BJ, Long AA, Walensky RP. The Cost of Penicillin Allergy Evaluation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:1019-1027.e2. [PMID: 28958738 DOI: 10.1016/j.jaip.2017.08.006] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Unverified penicillin allergy leads to adverse downstream clinical and economic sequelae. Penicillin allergy evaluation can be used to identify true, IgE-mediated allergy. OBJECTIVE To estimate the cost of penicillin allergy evaluation using time-driven activity-based costing (TDABC). METHODS We implemented TDABC throughout the care pathway for 30 outpatients presenting for penicillin allergy evaluation. The base-case evaluation included penicillin skin testing and a 1-step amoxicillin drug challenge, performed by an allergist. We varied assumptions about the provider type, clinical setting, procedure type, and personnel timing. RESULTS The base-case penicillin allergy evaluation costs $220 in 2016 US dollars: $98 for personnel, $119 for consumables, and $3 for space. In sensitivity analyses, lower cost estimates were achieved when only a drug challenge was performed (ie, no skin test, $84) and a nurse practitioner provider was used ($170). Adjusting for the probability of anaphylaxis did not result in a changed estimate ($220); although other analyses led to modest changes in the TDABC estimate ($214-$246), higher estimates were identified with changing to a low-demand practice setting ($268), a 50% increase in personnel times ($269), and including clinician documentation time ($288). In a least/most costly scenario analyses, the lowest TDABC estimate was $40 and the highest was $537. CONCLUSIONS Using TDABC, penicillin allergy evaluation costs $220; even with varied assumptions adjusting for operational challenges, clinical setting, and expanded testing, penicillin allergy evaluation still costs only about $540. This modest investment may be offset for patients treated with costly alternative antibiotics that also may result in adverse consequences.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass.
| | - Yu Li
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Brian J Yun
- Harvard Medical School, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Aidan A Long
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Mass
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153
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Are Cephalosporins Safe for Use in Penicillin Allergy without Prior Allergy Evaluation? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:82-89. [PMID: 28958745 DOI: 10.1016/j.jaip.2017.07.033] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 12/28/2022]
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154
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The Importance of Prolonged Provocation in Drug Allergy — Results From a Danish Allergy Clinic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1394-1401. [DOI: 10.1016/j.jaip.2017.02.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 01/19/2017] [Accepted: 02/17/2017] [Indexed: 11/24/2022]
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155
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Abstract
Ten percent of patients report penicillin allergy, but more than 90% of these individuals can tolerate penicillins. Skin testing remains the optimal method for evaluation of possible IgE-mediated penicillin allergy and is recommended by professional societies, as the harms for alternative antibiotics include antimicrobial resistance, prolonged hospitalizations, readmissions, and increased costs. Removal of penicillin allergy leads to decreased utilization of broad-spectrum antibiotics, such as fluoroquinolones and vancomycin. There is minimal allergic cross-reactivity between penicillins and cephalosporins. IgE-mediated allergy to cephalosporins is usually side-chain specific and may warrant graded challenge with cephalosporins containing dissimilar R1 or R2 group side chains.
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Affiliation(s)
- Daniel Har
- Division of Allergy and Immunology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Roland Solensky
- Division of Allergy and Immunology, The Corvallis Clinic, 3680 NW Samaritan Dr, Corvallis, OR 97330, USA; Oregon State University/Oregon Health & Science University College of Pharmacy, 1601 SW Jefferson Way, Corvallis, OR 97331, USA.
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156
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Knezevic B, Sprigg D, Seet J, Trevenen M, Trubiano J, Smith W, Jeelall Y, Vale S, Loh R, McLean-Tooke A, Lucas M. The revolving door: antibiotic allergy labelling in a tertiary care centre. Intern Med J 2017; 46:1276-1283. [PMID: 27530619 DOI: 10.1111/imj.13223] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 06/13/2016] [Accepted: 07/18/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients frequently report antibiotic allergies; however, only 10% of labelled patients have a true allergy. AIM We investigated the documentation of antibiotic 'allergy' labels (AAL) and the effect of labelling on clinical outcomes, in a West Australian adult tertiary hospital. METHODS Retrospective cross-sectional analysis of patients captured in the 2013 and 2014 National Antimicrobial Prescribing Surveys was carried out. Data were collected on documented antibiotic adverse drug reactions, antibiotic cost, prescribing appropriateness, prevalence of multi-drug resistant organisms, length of stay, intensive care admission and readmissions. RESULTS Of the 687 patients surveyed, 278 (40%) were aged 70 or above, 365 (53%) were male and 279 (41%) were prescribed antibiotics. AAL were recorded in 122 (18%) patients and the majority were penicillin labels (n = 87; 71%). Details of AAL were documented for 80 of 141 (57%) individual allergy labels, with 61 describing allergic symptoms. Patients with beta-lactam allergy labels received fewer penicillins (P = 0.0002) and more aminoglycosides (P = 0.043) and metronidazole (P = 0.021) than patients without beta-lactam labels. Five patients received an antibiotic that was contraindicated according to their allergy status. Patients with AAL had significantly more hospital readmissions within 4 weeks (P = 0.001) and 6 months (P = 0.025) of discharge, compared with unlabelled patients. The majority (81%) of readmitted labelled patients had major infections. CONCLUSIONS AAL are common, but poorly documented in hospital records. Patients with AAL are significantly more likely to require alternative antibiotics and hospital readmissions. There may be a role for antibiotic allergy delabelling to mitigate the clinical and economic burdens for patients with invalid allergy labels.
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Affiliation(s)
- B Knezevic
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia.
| | - D Sprigg
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - J Seet
- Department of Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - M Trevenen
- Department of Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Centre for Applied Statistics, University of Western Australia, Perth, Western Australia, Australia
| | - J Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
| | - W Smith
- Department of Immunology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Y Jeelall
- School of Medicine and Pharmacology, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - S Vale
- Drug Allergy Working Party, Australasian Society of Clinical Immunology and Allergy, Sydney, New South Wales, Australia
| | - R Loh
- Department of Clinical Immunology, Princess Margaret Hospital, Perth, Western Australia, Australia.,Pathwest Laboratory, Queen Elizabeth II Campus, Perth, Western Australia, Australia
| | - A McLean-Tooke
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia.,Pathwest Laboratory, Queen Elizabeth II Campus, Perth, Western Australia, Australia
| | - M Lucas
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia.,Pathwest Laboratory, Queen Elizabeth II Campus, Perth, Western Australia, Australia.,Department of Clinical Immunology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
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157
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Sundquist BK, Bowen BJ, Otabor U, Celestin J, Sorum PC. Proactive penicillin allergy testing in primary care patients labeled as allergic: outcomes and barriers. Postgrad Med 2017; 129:915-920. [DOI: 10.1080/00325481.2017.1370360] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Britta K. Sundquist
- Department of Medicine, Division of Allergy, Asthma, and Immunology, Albany Medical College, Albany, NY, USA
| | - Brady J. Bowen
- Department of Medicine, Division of Internal Medicine/Pediatrics, Albany Medical College, Albany, NY, USA
| | - Uwa Otabor
- Department of Medicine, Division of Internal Medicine/Pediatrics, Albany Medical College, Albany, NY, USA
| | - Jocelyn Celestin
- Department of Medicine, Division of Allergy, Asthma, and Immunology, Albany Medical College, Albany, NY, USA
| | - Paul C. Sorum
- Department of Medicine, Division of Internal Medicine/Pediatrics, Albany Medical College, Albany, NY, USA
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158
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Dorman SM, Seth S, Khan DA. Risk of Allergic Reactions to Recurrent Intravenous Penicillin Administration in Penicillin Skin Test Negative Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:196-200. [PMID: 28803185 DOI: 10.1016/j.jaip.2017.06.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/14/2017] [Accepted: 06/16/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with a history of penicillin allergy who are found to be skin test negative to penicillin are able to tolerate repeated oral doses of penicillin with low rates of resensitization. However, the resensitization rate after repeated doses of intravenous penicillin is less clear. OBJECTIVE We sought to evaluate the risk of allergic reactions to repeated doses of intravenous penicillin in patients who previously reported penicillin allergy and were found to be penicillin skin test and oral challenge negative. METHODS A retrospective review was conducted between 2010 and 2016 of adult patients who were treated at our academically affiliated hospitals. Patients included in the review had negative penicillin allergy testing and were treated with 2 or more courses of intravenous penicillins. Charts were evaluated to identify any adverse drug reactions. RESULTS Thirty-two patients met our inclusion criteria. The index penicillin-associated reactions ranged from rash to hypotension and were, for the most part, remote as 75% had reported reactions more than 10 years previously. More than 50% of patients received 3 or more courses of intravenous penicillins. The most frequently repeated intravenous penicillin overall was piperacillin/tazobactam. Thirty-two patients received a total of 111 courses of intravenous penicillins and none developed an immediate hypersensitivity reaction. CONCLUSIONS In patients who report penicillin allergy and have negative penicillin allergy testing, repeated administration of intravenous penicillin antibiotics appears to be safe. Larger prospective studies should be performed to confirm these observations.
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Affiliation(s)
| | - Sharon Seth
- Texas Regional Allergy & Asthma Center, Southlake, Texas
| | - David A Khan
- Division of Allergy & Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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159
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Geng B, Eastman JJ, Mori K, Braskett M, Riedl MA. Utility of minor determinants for skin testing in inpatient penicillin allergy evaluation. Ann Allergy Asthma Immunol 2017; 119:258-261. [PMID: 28743423 DOI: 10.1016/j.anai.2017.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/09/2017] [Accepted: 06/13/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Most patients with a history of penicillin allergy can tolerate penicillin. Skin testing can identify tolerant patients, but not all known allergenic determinants are commercially available. Protocols exist that use only available reagents, but the sensitivity and safety of these protocols, particularly for hospitalized patients, are controversial. OBJECTIVE To determine the number of hospitalized patients referred for penicillin skin testing who showed unique positivity to the minor determinants penicilloate and penilloate. METHODS A retrospective chart review was conducted of all inpatients who underwent penicillin skin testing at 1 institution. Patients were referred by their treating physician. All patients underwent skin prick testing to benzylpenicilloyl polylysine (major determinant), penicillin G, penicilloate, penilloate (minor determinants), amoxicillin, and positive and negative controls. If the result was negative, then intradermal testing was done with the same penicillin determinants and the negative control. A 4-mm wheal with flare was considered a positive reaction. RESULTS Inpatient penicillin skin testing was done in 528 subjects. Any positive test reaction was found in 107 subjects (20%). Three subjects (3%) reacted to penilloate only, 25 (23%) reacted to penicilloate only, 2 (2%) reacted to penicillin G only, and 8 (8%) reacted to amoxicillin only. Sixty-eight subjects (64%) reacted to a compound other than the major determinant. CONCLUSION This study found a high rate of exclusively positive skin test reactions to the minor determinants penicilloate and penilloate. Because patients with positive test reactions are at increased risk of reaction to drug challenge, these data support the use of these reagents for penicillin skin testing in hospitalized patients.
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Affiliation(s)
- Bob Geng
- Division of Rheumatology, Allergy and Immunology, University of California-San Diego, La Jolla, California.
| | - Jacqueline J Eastman
- Division of Rheumatology, Allergy and Immunology, University of California-San Diego, La Jolla, California
| | - Karen Mori
- Faculty of Medicine, University of Campinas, Campinas, São Paulo, Brazil
| | - Melinda Braskett
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, California
| | - Marc A Riedl
- Division of Rheumatology, Allergy and Immunology, University of California-San Diego, La Jolla, California
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160
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Romano A, Valluzzi RL, Caruso C, Maggioletti M, Gaeta F. Non-immediate Cutaneous Reactions to Beta-Lactams: Approach to Diagnosis. Curr Allergy Asthma Rep 2017; 17:23. [PMID: 28382604 DOI: 10.1007/s11882-017-0691-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Non-immediate cutaneous reactions (i.e., occurring at least 1 h after the initial drug administration), particularly maculopapular exanthemas and urticarial eruptions, are common during beta-lactam treatments. A T cell-mediated pathogenic mechanism has been demonstrated in some cutaneous reactions, such as maculopapular exanthema, fixed drug eruption, acute generalized exanthematous pustulosis, and drug-induced hypersensitivity syndrome. In the diagnostic work-up, patch testing is useful, together with delayed-reading intradermal testing. Patch tests are a simple and safe diagnostic tool, which in the case of severe reactions should be used as the first line of investigation. However, patch tests are less sensitive than intradermal tests, which are preferable in subjects with mild reactions. Lymphocyte transformation or activation tests and enzyme-linked immunosorbent spot assays can be used as complementary tests. In selected cases of mild or moderate reactions, displaying negative results in the aforesaid allergy tests, a graded challenge with the implicated beta-lactam can be performed.
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Affiliation(s)
- Antonino Romano
- Allergy Unit, Presidio Columbus, Via G. Moscati, 31, 00168, Rome, Italy. .,IRCCS Oasi Maria S.S, Troina, Italy.
| | - Rocco Luigi Valluzzi
- Allergy Unit, Presidio Columbus, Via G. Moscati, 31, 00168, Rome, Italy.,Department of Pediatrics, Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Vatican City, Italy
| | - Cristiano Caruso
- Allergy Unit, Presidio Columbus, Via G. Moscati, 31, 00168, Rome, Italy
| | | | - Francesco Gaeta
- Allergy Unit, Presidio Columbus, Via G. Moscati, 31, 00168, Rome, Italy
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161
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Macy E, Romano A, Khan D. Practical Management of Antibiotic Hypersensitivity in 2017. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:577-586. [DOI: 10.1016/j.jaip.2017.02.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 02/17/2017] [Accepted: 02/22/2017] [Indexed: 12/19/2022]
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162
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Aberer W. Penicillin Allergy: Mono-, Double-, and Multiple-Drug Hypersensitivity, or Even No Sensitivity? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:703-704. [DOI: 10.1016/j.jaip.2017.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 03/02/2017] [Indexed: 12/17/2022]
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163
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Tucker MH, Lomas CM, Ramchandar N, Waldram JD. Amoxicillin challenge without penicillin skin testing in evaluation of penicillin allergy in a cohort of Marine recruits. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:813-815. [DOI: 10.1016/j.jaip.2017.01.023] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/17/2017] [Accepted: 01/26/2017] [Indexed: 11/26/2022]
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164
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Confino-Cohen R, Rosman Y, Meir-Shafrir K, Stauber T, Lachover-Roth I, Hershko A, Goldberg A. Oral Challenge without Skin Testing Safely Excludes Clinically Significant Delayed-Onset Penicillin Hypersensitivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:669-675. [DOI: 10.1016/j.jaip.2017.02.023] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 02/15/2017] [Accepted: 02/28/2017] [Indexed: 11/28/2022]
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165
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The Effect of Penicillin Allergy Testing on Future Health Care Utilization: A Matched Cohort Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:705-710. [PMID: 28366717 DOI: 10.1016/j.jaip.2017.02.012] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 01/21/2017] [Accepted: 02/22/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND The effect that penicillin allergy testing has on future health care utilization is uncertain. OBJECTIVE Determine whether penicillin allergy testing affects future overall health care utilization as measured by outpatient department (OPD) visits, emergency department (ED) visits, and hospital days. METHODS Potential cases and control subjects were penicillin allergic Kaiser Permanente Southern California members who had at least 2 visits between 2010 and 2012 and at least 1 year of continuous health plan coverage before their index visit. RESULTS It was possible to match 308 (73.2%) of the potential cases to 1251 unique controls, on the basis of age, sex, weighted Charlson comorbidity index, drug class allergies, OPD visits, ED visits, and hospital days during the years before their index visit. Cases and controls were then followed for an average of 3.6 and 4.0 years, respectively. Based on results analyzed using a generalized linear mixed model, cases were estimated to have 0.09 fewer OPD visits (P < .001), 0.13 fewer ED visits (P = .29), and 0.55 fewer hospital days (P < .001) per health plan coverage year during follow-up compared with controls. Cases were exposed to more penicillins and first- and second-generation cephalosporins and less clindamycin and macrolides. CONCLUSIONS Penicillin allergy testing, primarily done in the setting of an outpatient Allergy consultation, was associated with significantly less health care utilization during 3.6+ years of follow-up and greater use of narrow-spectrum antibiotics. Penicillin allergy testing has a favorable cost-benefit ratio for the incremental cost of testing versus future health care utilization and improves antibiotic stewardship.
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166
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Blumenthal KG, Wickner PG, Hurwitz S, Pricco N, Nee AE, Laskowski K, Shenoy ES, Walensky RP. Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship. J Allergy Clin Immunol 2017; 140:154-161.e6. [PMID: 28254470 DOI: 10.1016/j.jaci.2017.02.005] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/13/2017] [Accepted: 02/07/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Reported penicillin allergy rarely reflects penicillin intolerance. Failure to address inpatient penicillin allergies results in more broad-spectrum antibiotic use, treatment failures, and adverse drug events. OBJECTIVE We aimed to determine the optimal approach to penicillin allergies among medical inpatients. METHODS We evaluated internal medicine inpatients reporting penicillin allergy in 3 periods: (1) standard of care (SOC), (2) penicillin skin testing (ST), and (3) computerized guideline application with decision support (APP). The primary outcome was use of a penicillin or cephalosporin, comparing interventions to SOC using multivariable logistic regression. RESULTS There were 625 patients: SOC, 148; ST, 278; and APP, 199. Of 278 ST patients, 179 (64%) were skin test eligible; 43 (24%) received testing and none were allergic. In the APP period, there were 292 unique Web site views; 112 users (38%) completed clinical decision support. Although ST period patients did not have increased odds of penicillin or cephalosporin use overall (adjusted odds ratio [aOR] 1.3; 95% CI, 0.8-2.0), we observed significant increased odds of penicillin or cephalosporin use overall in the APP period (aOR, 1.8; 95% CI, 1.1-2.9) and in a per-protocol analysis of the skin tested subset (aOR, 5.7; 95% CI, 2.6-12.5). CONCLUSIONS Both APP and ST-when completed-increased the use of penicillin and cephalosporin antibiotics among inpatients reporting penicillin allergy. While the skin tested subset showed an almost 6-fold impact, the computerized guideline significantly increased penicillin or cephalosporin use overall nearly 2-fold and was readily implemented.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and the Massachusetts General Professional Organization, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Paige G Wickner
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Shelley Hurwitz
- Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | | | | | - Karl Laskowski
- Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Erica S Shenoy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Infection Control Unit, Massachusetts General Hospital, Boston, Mass
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Mass
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167
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Narayanan PP, Jeffres MN. Feasibility, Benefits, and Limitations of a Penicillin Allergy Skin Testing Service. Ann Pharmacother 2017; 51:504-510. [PMID: 28152605 DOI: 10.1177/1060028017690854] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To critically examine the feasibility, benefits, and limitations of an inpatient penicillin skin testing service and how pharmacists can be utilized. DATA SOURCES A PubMed search was performed from July 2016 through September 2016 using the following search terms: penicillin skin testing, penicillin allergy, β-lactam allergy. Additional references were identified from a review of literature citations. STUDY SELECTION AND DATA EXTRACTION All English-language studies assessing the use of penicillin skin testing as well as management and clinical outcomes of patients with a β-lactam allergy were evaluated. DATA SYNTHESIS The prevalence of people self-identifying as penicillin allergic ranges from 10% to 20% in the United States. Being improperly labeled as penicillin allergic is associated with higher health care costs, worse clinical outcomes, and an increased prevalence of multidrug-resistant infections. Penicillin skin testing can be a tool used to clarify penicillin allergies and has been demonstrated to be a successful addition to antimicrobial stewardship programs in multiple health care settings. Prior to implementing a penicillin skin testing service, institutions will need to perform a feasibility analysis of who will supply labor and accept the financial burden as well as identify if the positive benefits of a penicillin skin testing service overcome the limitations of this diagnostic test. CONCLUSION We conclude that institutions with high percentages of patients receiving non-β-lactams because of penicillin allergy labels would likely benefit the most from a penicillin skin testing service.
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Affiliation(s)
| | - Meghan N Jeffres
- 2 University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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168
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Segura-Egea JJ, Gould K, Şen BH, Jonasson P, Cotti E, Mazzoni A, Sunay H, Tjäderhane L, Dummer PMH. Antibiotics in Endodontics: a review. Int Endod J 2017; 50:1169-1184. [DOI: 10.1111/iej.12741] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/19/2016] [Indexed: 12/20/2022]
Affiliation(s)
- J. J. Segura-Egea
- Department of Endodontics; School of Dentistry; University of Sevilla; Sevilla Spain
| | - K. Gould
- Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne UK
| | | | - P. Jonasson
- Department of Endodontology; Institute of Odontology; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - E. Cotti
- Department of Conservative Dentistry and Endodontics; University of Cagliari; Cagliari, Sardinia Italy
| | - A. Mazzoni
- Department of Biomedical and Neuromotor Sciences; DIBINEM; University of Bologna; Bologna Italy
| | - H. Sunay
- Department of Endodontology; Dental Faculty of Istanbul Kemerburgaz University; Istanbul Turkey
| | - L. Tjäderhane
- Department of Oral and Maxillofacial Diseases; Helsinki University Hospital; University of Helsinki; Helsinki Finland
- Research Unit of Oral Health Sciences; Medical Research Center Oulu (MRC Oulu); Oulu University Hospital and University of Oulu; Oulu Finland
| | - P. M. H. Dummer
- School of Dentistry; College of Biomedical & Life Sciences; Cardiff University; Cardiff UK
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169
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Oliver WD, Heil EL, Thom KA, Martinez JP, Hayes BD. Allergy profile should be updated after uneventful administration of a penicillin or penicillin-related antibiotic to a patient with penicillin allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:184-186. [DOI: 10.1016/j.jaip.2016.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 08/04/2016] [Accepted: 08/23/2016] [Indexed: 10/20/2022]
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170
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Staicu ML, Brundige ML, Ramsey A, Brown J, Yamshchikov A, Peterson DR, Baran A, Laguio-Vila M. Implementation of a penicillin allergy screening tool to optimize aztreonam use. Am J Health Syst Pharm 2016; 73:298-306. [PMID: 26896502 DOI: 10.2146/ajhp150288] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
PURPOSE The implementation of a penicillin allergy screening tool to optimize the use of aztreonam is described. METHODS This study was conducted at a 528-bed tertiary referral community teaching facility and compared the use of aztreonam in patients before and after the implementation of a multipronged intervention consisting of a penicillin allergy screening tool (PAST), education, order set decision support, and prospective review of aztreonam orders by the antimicrobial stewardship team and clinical pharmacists. Patients for whom aztreonam was prescribed at any time during their presentation to the hospital January 1-June 30, 2013 (preintervention period), and September 1, 2013-February 28, 2014 (postintervention period) were eligible for inclusion. Primary outcomes included total and inappropriate aztreonam usage. Secondary outcomes included cost avoidance and safety. RESULTS A total of 496 aztreonam orders were reviewed. The total number of days of therapy (DOT) with aztreonam significantly decreased from 9.5 per 1,000 patient-days in the preintervention group to 4.4 per 1,000 patient-days in the postintervention group (p < 0.0001). The number of inappropriate aztreonam DOT decreased from 4.0 per 1,000 patient days to 0.8 per 1,000 patient-days (p < 0.0001). The median number of inappropriate aztreonam doses decreased significantly in the postintervention period, as did inappropriate aztreonam DOT (p < 0.0001 for both comparisons). An estimated cost avoidance of $60,000-$100,000 was realized, depending on the alternative antibiotic selected. CONCLUSION Implementation of the PAST and provider and pharmacist education reduced the use of aztreonam by promoting the first-line use of β-lactam alternatives.
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Affiliation(s)
- Mary L Staicu
- Pharmacy Department, Rochester General Hospital, Rochester, NY.
| | | | - Allison Ramsey
- Allergy and Immunology, Rochester General Hospital, Rochester, NY
| | - Jack Brown
- Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY
| | | | | | - Andrea Baran
- University of Rochester Medical Center, Rochester, NY
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171
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Abrams EM, Wakeman A, Gerstner TV, Warrington RJ, Singer AG. Prevalence of beta-lactam allergy: a retrospective chart review of drug allergy assessment in a predominantly pediatric population. Allergy Asthma Clin Immunol 2016; 12:59. [PMID: 27956906 PMCID: PMC5129666 DOI: 10.1186/s13223-016-0165-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/31/2016] [Indexed: 12/03/2022] Open
Abstract
Background Research suggests that 90% of patients labeled beta-lactam allergic are able to tolerate penicillins following further assessment. This study aims to define and describe the frequency of true beta-lactam allergy following allergy patient evaluation in a predominantly pediatric population. Methods 306 primary care patients referred between January 2010 and June 2015 were assessed for a suspected beta-lactam allergy. Patient demographics, history and test results were extracted from electronic medical records. Testing performed was based on specialist recommendation following review of patient history. Results 34% of the study participants had intradermal testing. Oral challenge was given to 96.7% of the sample. 96% of patients with a prior history of beta-lactam allergy were advised that they could re-introduce beta-lactam antibiotics following evaluation. Conclusions Among patients with a documented beta-lactam allergy or a recent history of a reaction there is a low rate of ‘true’ beta-lactam allergy. Consistent evaluation of beta-lactam antibiotic allergies can reduce rates of broad spectrum antibiotic prescribing, among other harmful consequences.
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Affiliation(s)
- Elissa M Abrams
- Section of Allergy and Immunology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | | | - Tom V Gerstner
- Section of Allergy and Immunology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Richard J Warrington
- Section of Allergy and Immunology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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172
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Chen JR, Tarver SA, Alvarez KS, Tran T, Khan DA. A Proactive Approach to Penicillin Allergy Testing in Hospitalized Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:686-693. [PMID: 27888034 DOI: 10.1016/j.jaip.2016.09.045] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 09/23/2016] [Accepted: 09/28/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Penicillin allergy testing is underutilized in inpatients despite its potential to immediately impact antibiotic treatment. Although most tested patients are able to tolerate penicillin, limited availability and awareness of this tool leads to the use of costly and harmful substitutes. OBJECTIVE We established an inpatient service at a large academic hospital to identify and test patients with a history of penicillin allergy with the goals of removing inaccurate diagnoses, reducing the use of beta-lactam alternatives, and educating patients and clinicians about the procedure. METHODS Eligible inpatients were flagged daily through the electronic medical record and prioritized via a specialized algorithm. A trained clinical pharmacist performed penicillin skin tests and challenges preemptively or by provider request. Clinical characteristics and antibiotic use were analyzed in tested patients. RESULTS A total of 1203 applicable charts were detected by our system leading to 252 direct evaluations over 18 months. Overall, 228 subjects (90.5%) had their penicillin allergy removed. Of these, 223 were cleared via testing and 5 by discovery of prior penicillin tolerance. Among patients testing negative, 85 (38%) subsequently received beta-lactams, preventing 504 inpatient days and 648 outpatient days on alternative agents. CONCLUSIONS Penicillin allergy testing using a physician-pharmacist team model effectively removes reported allergies in hospitalized patients. The electronic medical record is a valuable asset for locating and stratifying individuals who benefit most from intervention. Proactive testing substantially reduces unnecessary inpatient and outpatient use of beta-lactam alternatives that may otherwise go unaddressed.
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Affiliation(s)
- Justin R Chen
- Division of Allergy & Immunology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Tex
| | - Scott A Tarver
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Tex
| | - Kristin S Alvarez
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Tex
| | - Trang Tran
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Tex
| | - David A Khan
- Division of Allergy & Immunology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Tex.
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173
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McConeghy KW, Caffrey AR, Morrill HJ, Trivedi AN, LaPlante KL. Are non-allergic drug reactions commonly documented as medication “allergies”? A national cohort of Veterans' admissions from 2000 to 2014. Pharmacoepidemiol Drug Saf 2016; 26:472-476. [DOI: 10.1002/pds.4134] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 08/04/2016] [Accepted: 10/19/2016] [Indexed: 01/11/2023]
Affiliation(s)
- Kevin W. McConeghy
- Center of Innovation in Long Term Services and Supports, Veterans Affairs Medical Center; Providence VA Medical Center; Providence RI USA
- Infectious Diseases Research Program; Veterans Affairs Medical Center; Providence RI USA
| | - Aisling R. Caffrey
- Center of Innovation in Long Term Services and Supports, Veterans Affairs Medical Center; Providence VA Medical Center; Providence RI USA
- Infectious Diseases Research Program; Veterans Affairs Medical Center; Providence RI USA
- Department of Health Services, Policy and Practice, School of Public Health; Brown University; Providence RI USA
- Department of Pharmacy Practice, College of Pharmacy; University of Rhode Island; North Kingston RI USA
| | - Haley J. Morrill
- Center of Innovation in Long Term Services and Supports, Veterans Affairs Medical Center; Providence VA Medical Center; Providence RI USA
- Infectious Diseases Research Program; Veterans Affairs Medical Center; Providence RI USA
- Department of Pharmacy Practice, College of Pharmacy; University of Rhode Island; North Kingston RI USA
| | - Amal N. Trivedi
- Center of Innovation in Long Term Services and Supports, Veterans Affairs Medical Center; Providence VA Medical Center; Providence RI USA
- Department of Health Services, Policy and Practice, School of Public Health; Brown University; Providence RI USA
| | - Kerry L. LaPlante
- Center of Innovation in Long Term Services and Supports, Veterans Affairs Medical Center; Providence VA Medical Center; Providence RI USA
- Infectious Diseases Research Program; Veterans Affairs Medical Center; Providence RI USA
- Department of Pharmacy Practice, College of Pharmacy; University of Rhode Island; North Kingston RI USA
- Warren-Albert School of Medicine; Brown University; Providence RI USA
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174
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Trubiano JA, Worth LJ, Urbancic K, Brown TM, Paterson DL, Lucas M, Phillips E. Return to sender: the need to re-address patient antibiotic allergy labels in Australia and New Zealand. Intern Med J 2016; 46:1311-1317. [PMID: 27527526 PMCID: PMC5096978 DOI: 10.1111/imj.13221] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/04/2016] [Accepted: 08/08/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND/AIM Antibiotic allergies are frequently reported and have significant impacts upon appropriate prescribing and clinical outcomes. We surveyed infectious diseases physicians, allergists, clinical immunologists and hospital pharmacists to evaluate antibiotic allergy knowledge and service delivery in Australia and New Zealand. METHODS An online multi-choice questionnaire was developed and endorsed by representatives of the Australasian Society of Clinical Immunology and Allergy (ASCIA) and the Australasian Society of Infectious Diseases (ASID). The 37-item survey was distributed in April 2015 to members of ASCIA, ASID, the Society of Hospital Pharmacists of Australia and the Royal Australasian College of Physicians. RESULTS Of 277 respondents, 94% currently use or would utilise antibiotic allergy testing (AAT) and reported seeing up to 10 patients/week labelled as antibiotic-allergic. Forty-two per cent were not aware of or did not have AAT available. Most felt that AAT would aid antibiotic selection, antibiotic appropriateness and antimicrobial stewardship (79, 69 and 61% respectively). Patients with the histories of immediate hypersensitivity were more likely to be referred than those with delayed hypersensitivities (76 vs 41%, P = 0.0001). Lack of specialist physicians (20%) and personal experience (17%) were barriers to service delivery. A multidisciplinary approach was a preferred AAT model (53%). Knowledge gaps were identified, with the majority overestimating rates of penicillin/cephalosporin (78%), penicillin/carbapenem (57%) and penicillin/monobactam (39%) cross-reactivity. CONCLUSIONS A high burden of antibiotic allergy labelling and demand for AAT is complicated by a relative lack availability or awareness of AAT services in Australia and New Zealand. Antibiotic allergy education and deployment of AAT, accessible to community and hospital-based clinicians, may improve clinical decisions and reduce antibiotic allergy impacts. A collaborative approach involving infectious diseases physicians, pharmacists and allergists/immunologists is required.
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Affiliation(s)
- J A Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.
| | - L J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - K Urbancic
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
- Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia
| | - T M Brown
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - D L Paterson
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - M Lucas
- Department of Clinical Immunology, Pathwest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - E Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
- Department of Medicine, Vanderbilt Medical Center, Nashville, Tennessee, USA
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175
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Involvement of Histamine and RhoA/ROCK in Penicillin Immediate Hypersensitivity Reactions. Sci Rep 2016; 6:33192. [PMID: 27619816 PMCID: PMC5020415 DOI: 10.1038/srep33192] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 08/22/2016] [Indexed: 12/17/2022] Open
Abstract
The mechanism of penicillin immediate hypersensitivity reactions has not been completely elucidated. These reactions are generally considered to be mediated by IgE, but penicillin-specific IgE could not be detected in most cases. This study demonstrated that penicillin was able to cause vascular hyperpermeability in a mouse model mimicking clinical symptoms of penicillin immediate hypersensitivity reactions. The first exposure to penicillin also induced immediate edema and exudative reactions in ears and lungs of mice in a dose-dependent manner. Vasodilation was noted in microvessels in ears. These reactions were unlikely to be immune-mediated reactions, because no penicillin-specific IgE was produced. Furthermore, penicillin treatment directly elicited rapid histamine release. Penicillin also led to F-actin reorganization in human umbilical vein endothelial cells and increased the permeability of the endothelial monolayer. Activation of the RhoA/ROCK signaling pathway was observed in ears and lungs of mice and in endothelial cells after treatment with penicillin. Both an anti-histamine agent and a ROCK inhibitor attenuated penicillin immediate hypersensitivity reactions in mice. This study presents a novel mechanism of penicillin immediate hypersensitivity reactions and suggests a potential preventive approach against these reactions.
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176
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Petroni DH, Aitken ML, Ham E, Chung S, Menalia L, Altman MC, Ayars AG. Approach to the evaluation of adverse antibiotic reactions in patients with cystic fibrosis. Ann Allergy Asthma Immunol 2016; 117:378-381. [PMID: 27590641 DOI: 10.1016/j.anai.2016.07.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 07/24/2016] [Accepted: 07/30/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Adverse drug reactions (ADRs) to antibiotics in patients with cystic fibrosis (CF) are common and often mislabeled as allergies. The labeling of an antibiotic reaction as an allergy can lead to the use of antibiotics that are less efficacious, are more expensive, or have a greater risk of adverse effects. OBJECTIVE To establish a safe approach for the evaluation of ADRs to antibiotics in patients with CF to help clarify future use of these medications. METHODS Patients with CF whose antibiotic allergies were causing difficulty in their medical management were referred for an allergy evaluation that consisted of a thorough drug allergy history and antibiotic testing if appropriate. If the history was not consistent with a true hypersensitivity reaction (HSR) and test results were negative, the patient underwent a challenge to the offending agent(s) to rule out an HSR. Challenges were only performed if the medication was indicated for future use. RESULTS A total of 17 patients (mean age, 32.4 years) underwent a thorough allergy evaluation. A total of 17 antibiotic challenges were performed in 11 patients without a reaction consistent with an HSR or severe delayed reaction. Only 2 medications had a history consist with an HSR, and it was recommended that they undergo a desensitization procedure if the drug was required. CONCLUSION If treatment with appropriate antibiotics becomes difficult in patients with CF because of drug allergies, then referral to an allergist can help safely identify treatment options. Our findings suggest that a thorough evaluation by an allergy specialist can lead to more appropriate treatment options in patients with CF.
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Affiliation(s)
- Daniel H Petroni
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington.
| | - Moira L Aitken
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Erin Ham
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
| | - Sarah Chung
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Lori Menalia
- Cystic Fibrosis Clinic, Medical Subspecialties Clinic, University of Washington Medical Center, Seattle, Washington
| | - Matthew C Altman
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
| | - Andrew G Ayars
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
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177
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Romano A, Gaeta F, Arribas Poves MF, Valluzzi RL. Cross-Reactivity among Beta-Lactams. Curr Allergy Asthma Rep 2016; 16:24. [PMID: 26898316 DOI: 10.1007/s11882-016-0594-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Penicillins and cephalosporins are the major classes of beta-lactam (BL) antibiotics in use today and one of the most frequent causes of hypersensitivity reactions to drugs. Monobactams, carbapenems, oxacephems, and beta-lactamase inhibitors constitute the four minor classes of BLs. This review takes into account mainly the prospective studies which evaluated cross-reactivity among BLs in subjects with a well-demonstrated hypersensitivity to a certain class of BLs by performing allergy tests with alternative BLs and, in case of negative results, administering them. In subjects with either IgE-mediated or T-cell-mediated hypersensitivity, cross-reactivity among BLs, particularly among penicillins and among cephalosporins, as well as between penicillins and cephalosporins, seems to be mainly related to structural similarities among their side-chain determinants. Specifically, in penicillin-allergic subjects, cross-reactivity between penicillins and cephalosporins may exceed 30% when they are administered cephalosporins with identical side chains to those of responsible penicillins. In these subjects, a few prospective studies have demonstrated a rate of cross-reactivity between penicillins and both carbapenems and aztreonam lower than 1%. With regard to subjects with an IgE-mediated hypersensitivity to cephalosporins, in a single study, about 25% of the 98 subjects with such hypersensitivity had positive results to penicillins, 3% to aztreonam, 2% to imipenem/cilastatin, and 1% to meropenem. The cross-reactivity related to the selective recognition of the BL ring by IgE or T lymphocytes, which entails positive responses to all BLs tested, appears to be exceptional. Some studies concerning cross-reactivity among BLs have found patterns of allergy-test positivity which cannot be explained by either the common BL ring or by similar or identical side chains, thus indicating the possibility of coexisting sensitivities to different BLs because of prior exposures to them.
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Affiliation(s)
- Antonino Romano
- Allergy Unit, Complesso Integrato Columbus, Via G. Moscati, 31, 00168, Rome, Italy. .,IRCCS Oasi Maria S.S., Troina, Italy.
| | - Francesco Gaeta
- Allergy Unit, Complesso Integrato Columbus, Via G. Moscati, 31, 00168, Rome, Italy
| | | | - Rocco Luigi Valluzzi
- Allergy Unit, Complesso Integrato Columbus, Via G. Moscati, 31, 00168, Rome, Italy
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178
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Blumenthal KG, Shenoy ES, Huang M, Kuhlen JL, Ware WA, Parker RA, Walensky RP. The Impact of Reporting a Prior Penicillin Allergy on the Treatment of Methicillin-Sensitive Staphylococcus aureus Bacteremia. PLoS One 2016; 11:e0159406. [PMID: 27438379 PMCID: PMC4954694 DOI: 10.1371/journal.pone.0159406] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 07/02/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia is a morbid infection with mortality benefit from receipt of parenteral β-lactam therapy. A substantial portion of MSSA bacteremia patients report penicillin allergy, but infrequently have true allergy. OBJECTIVE To determine the frequency and predictors of optimal and adequate therapy in patients with MSSA bacteremia. DESIGN Retrospective cohort. PARTICIPANTS Adult inpatients with MSSA bacteremia, January 2009 through October 2013. MAIN MEASURES The primary measure was a trial of optimal therapy (OT), defined as ≥3 inpatient days or discharge on any first-line agents (nafcillin, oxacillin, cefazolin, or penicillin G, if susceptible). The secondary measure was completion of adequate therapy (AT), defined as ≥10 inpatient days or discharge on an agent appropriate for MSSA bacteremia. Data were electronically gathered with key variables manually validated through chart review. Log-binomial regression models were used to determine the frequency and predictors of outcomes. KEY RESULTS Of 456 patients, 346 (76%) received a trial of OT. Patients reporting penicillin allergy (13%) were less likely to receive OT trial than those without penicillin allergy (47% vs. 80%, p <0.001). Adjusting for other factors, penicillin allergy was the largest negative predictor of OT trial (RR 0.64 [0.49, 0.83]). Infectious Disease (ID) consultation was the largest positive predictor of OT trial across all patients (RR 1.34 [1.14, 1.57]). Allergy/Immunology consultation was the single most important predictor of OT trial among patients reporting penicillin allergy (RR 2.33 [1.44, 3.77]). Of 440 patients, 391 (89%) completed AT, with ID consultation the largest positive predictor of the outcome (RR 1.28 [1.15, 1.43]). CONCLUSIONS Nearly 25% of patients with MSSA bacteremia did not receive OT trial and about 10% did not receive AT completion. Reported penicillin allergy reduced, and ID consult increased, the likelihood of OT. Allergy evaluation, coupled with ID consultation, may improve outcomes in MSSA bacteremic patients.
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Affiliation(s)
- Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Erica S. Shenoy
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Mingshu Huang
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - James L. Kuhlen
- Acadia Allergy and Immunology, Department of Medicine, University of South Carolina School of Medicine, Greenville, South Carolina, United States of America
| | - Winston A. Ware
- Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Robert A. Parker
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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179
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Blumenthal KG, Shenoy ES. Editorial Commentary: Fortune Favors the Bold: Give a Beta-Lactam! Clin Infect Dis 2016; 63:911-3. [DOI: 10.1093/cid/ciw467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/03/2016] [Indexed: 11/13/2022] Open
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180
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Confino-Cohen R, Rosman Y, Lachover I, Meir Shafrir K, Goldberg A. The Importance of Amoxicillin and Amoxicillin-Clavulanate Determinants in the Diagnosis of Immediate Allergic Reactions to β-Lactams. Int Arch Allergy Immunol 2016; 170:62-6. [DOI: 10.1159/000446961] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 05/17/2016] [Indexed: 11/19/2022] Open
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181
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Penicillin skin testing in hospitalized patients with β-lactam allergies. Ann Allergy Asthma Immunol 2016; 117:67-71. [DOI: 10.1016/j.anai.2016.04.021] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 04/14/2016] [Accepted: 04/21/2016] [Indexed: 11/20/2022]
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182
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Blumenthal KG, Park MA, Macy EM. Redesigning the allergy module of the electronic health record. Ann Allergy Asthma Immunol 2016; 117:126-31. [PMID: 27315742 DOI: 10.1016/j.anai.2016.05.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 05/16/2016] [Accepted: 05/19/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Professional Organization, Boston, Massachusetts.
| | - Miguel A Park
- Allergy and Immunology, Mayo Clinic, Rochester, Minnesota
| | - Eric M Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, California
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183
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van Dijk SM, Gardarsdottir H, Wassenberg MWM, Oosterheert JJ, de Groot MCH, Rockmann H. The High Impact of Penicillin Allergy Registration in Hospitalized Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:926-31. [PMID: 27131826 DOI: 10.1016/j.jaip.2016.03.009] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/07/2016] [Accepted: 03/23/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Suspected penicillin allergy (Pen-A) is often not verified or excluded by diagnostic testing. OBJECTIVE To assess the prevalence and impact of Pen-A registration in a Dutch University Medical Center. METHODS In a prospective matched cohort study, all admitted patients (July 2013-July 2014) who underwent a pharmacotherapeutic interview were selected. Patients with a registered Pen-A were matched on age, sex, and department of admission with up to 3 patients without a registered Pen-A. Relative risks (RRs) of receiving a reserve antibiotic, death during hospitalization, and rehospitalization were compared in the 2 cohorts. The number and type of antibiotics prescribed during admission and duration of hospitalization were compared. RESULTS Of 17,959 patients, 1010 (5.6%) patients (66.7% women; median age, 55 years) had a Pen-A registration. These patients had a higher risk of receiving reserve antibiotics (RR, 1.38; 95% CI, 1.22-1.56) and of being rehospitalized within 12 weeks (RR, 1.28; 95% CI, 1.10-1.49). A significantly larger proportion of Pen-A registered patients received reserve antibiotics such as tetracyclines (1.8% vs 0.8%), macrolides/lincosamides/streptogramins (12.5% vs 4.9%), and quinolones (7.9% vs 4.3%) or received 2 or more types of antibiotics during hospitalization (21.7% vs 16.9%). CONCLUSIONS Prevalence of Pen-A registration in hospitalized patients is high, has high impact on antibiotic prescribing, and is associated with a higher risk of readmission. Verification of the Pen-A in hospitalized patients might restrict the use of reserve antibiotics and improve patient outcome.
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Affiliation(s)
- Savannah M van Dijk
- Department of Dermatology and Allergology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Helga Gardarsdottir
- Division of Laboratory and Pharmacy, Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Marjan W M Wassenberg
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mark C H de Groot
- Division of Laboratory and Pharmacy, Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heike Rockmann
- Department of Dermatology and Allergology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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184
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Shah NS, Ridgway JP, Pettit N, Fahrenbach J, Robicsek A. Documenting Penicillin Allergy: The Impact of Inconsistency. PLoS One 2016; 11:e0150514. [PMID: 26981866 PMCID: PMC4794183 DOI: 10.1371/journal.pone.0150514] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/15/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Allergy documentation is frequently inconsistent and incomplete. The impact of this variability on subsequent treatment is not well described. OBJECTIVE To determine how allergy documentation affects subsequent antibiotic choice. DESIGN Retrospective, cohort study. PARTICIPANTS 232,616 adult patients seen by 199 primary care providers (PCPs) between January 1, 2009 and January 1, 2014 at an academic medical system. MAIN MEASURES Inter-physician variation in beta-lactam allergy documentation; antibiotic treatment following beta-lactam allergy documentation. KEY RESULTS 15.6% of patients had a reported beta-lactam allergy. Of those patients, 39.8% had a specific allergen identified and 22.7% had allergic reaction characteristics documented. Variation between PCPs was greater than would be expected by chance (all p<0.001) in the percentage of their patients with a documented beta-lactam allergy (7.9% to 24.8%), identification of a specific allergen (e.g. amoxicillin as opposed to "penicillins") (24.0% to 58.2%) and documentation of the reaction characteristics (5.4% to 51.9%). After beta-lactam allergy documentation, patients were less likely to receive penicillins (Relative Risk [RR] 0.16 [95% Confidence Interval: 0.15-0.17]) and cephalosporins (RR 0.28 [95% CI 0.27-0.30]) and more likely to receive fluoroquinolones (RR 1.5 [95% CI 1.5-1.6]), clindamycin (RR 3.8 [95% CI 3.6-4.0]) and vancomycin (RR 5.0 [95% CI 4.3-5.8]). Among patients with beta-lactam allergy, rechallenge was more likely when a specific allergen was identified (RR 1.6 [95% CI 1.5-1.8]) and when reaction characteristics were documented (RR 2.0 [95% CI 1.8-2.2]). CONCLUSIONS Provider documentation of beta-lactam allergy is highly variable, and details of the allergy are infrequently documented. Classification of a patient as beta-lactam allergic and incomplete documentation regarding the details of the allergy lead to beta-lactam avoidance and use of other antimicrobial agents, behaviors that may adversely impact care quality and cost.
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Affiliation(s)
- Nirav S. Shah
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
- * E-mail:
| | - Jessica P. Ridgway
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Natasha Pettit
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - John Fahrenbach
- Department of Clinical Analytics, Northshore University HealthSystem, Evanston, Illinois, United States of America
| | - Ari Robicsek
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
- Department of Clinical Analytics, Northshore University HealthSystem, Evanston, Illinois, United States of America
- Department of Medicine, Northshore University HealthSystem, Evanston, Illinois, United States of America
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185
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Use of Cefazolin for Group B Streptococci Prophylaxis in Women Reporting a Penicillin Allergy Without Anaphylaxis. Obstet Gynecol 2016; 127:577-583. [DOI: 10.1097/aog.0000000000001297] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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186
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Rosenfield L, Kalicinsky C, Warrington R. A retrospective comparison of false negative skin test rates in penicillin allergy, using pencilloyl-poly-lysine and minor determinants or Penicillin G, followed by open challenge. Allergy Asthma Clin Immunol 2015; 11:34. [PMID: 26594228 PMCID: PMC4654886 DOI: 10.1186/s13223-015-0098-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/07/2015] [Indexed: 12/04/2022] Open
Abstract
Background A history of penicillin allergy in patients is common, but only 10–15 % are truly allergic. While the gold standard for diagnosing penicillin allergy is challenge, it is not recommended that this be done without first carrying out diagnostic skin testing. This is carried out with the major determinant benzylpenicilloyl (PPL) and the minor determinant mixture (MDM), consisting of penilloate, penicilloate and Penicillin G. However, since availability of the MDM is limited, Penicillin G alone has been used. Methods A retrospective chart review was carried out on patients tested for penicillin allergy in the Clinical Immunology and Allergy Clinic at the Health Sciences Centre, Winnipeg, Canada between 2005 and 2013. A total of 521 patients charts were reviewed, of whom 240 had skin testing, ImmunoCap® for IgE to Penicillin G and V and had oral challenges with penicillin, amoxicillin or cloxacillin. Results 17/240 (7.5 %) were skin test positive, 8 to PPL, 4 to MDM and 5 to Penicillin G. One was also positive on ImmunoCap® testing. Three patients had negative skin tests but weakly positive ImmunoCap®. 222 patients with negative skin tests and serological tests were challenged. Of these, 12 patients reacted to challenge. Three of the challenges were equivocal. Of the nine patients with definite positive challenges, three were tested with Penicillin G and six with MDM. Therefore the false negative rates for testing were 2.3 % with PPL and Penicillin G and 6.97 % for PPL and MDM. The difference was not significant (p = 0.0856). Conclusions In this group of patients with a history of penicillin allergy tested with the major determinant of benzyl penicillin and either MDM or Penicillin G, there was no difference in the rate of false negative testing, based on oral penicillin challenges. Therefore, Penicillin G can be safely used as an alternative to MDM in diagnosing penicillin allergy.
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Affiliation(s)
- Lana Rosenfield
- Section of Clinical Immunology and Allergy, Department of Internal Medicine, Health Sciences Centre and University of Manitoba, Winnipeg, MB Canada
| | - Chrystyna Kalicinsky
- Section of Clinical Immunology and Allergy, Department of Internal Medicine, Health Sciences Centre and University of Manitoba, Winnipeg, MB Canada
| | - Richard Warrington
- Section of Clinical Immunology and Allergy, Department of Internal Medicine, Health Sciences Centre and University of Manitoba, Winnipeg, MB Canada
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187
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Arroliga ME, Vazquez-Sandoval A, Dvoracek J, Arroliga AC. Penicillin skin testing is a safe method to guide β-lactam administration in the intensive care unit. Ann Allergy Asthma Immunol 2015; 116:86-7. [PMID: 26596409 DOI: 10.1016/j.anai.2015.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 10/13/2015] [Accepted: 10/18/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Mercedes E Arroliga
- Division of Allergy and Immunology, Baylor Scott and White Health, Temple, Texas.
| | - Alfredo Vazquez-Sandoval
- Division of Pulmonary/Critical Care/Sleep Medicine, Baylor Scott and White Health, Temple, Texas
| | - John Dvoracek
- Division of Allergy and Immunology, Baylor Scott and White Health, Temple, Texas
| | - Alejandro C Arroliga
- Division of Pulmonary/Critical Care/Sleep Medicine, Baylor Scott and White Health, Temple, Texas
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188
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Solensky R, Macy E. Minor Determinants Are Essential for Optimal Penicillin Allergy Testing: A Pro/Con Debate. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:883-7. [DOI: 10.1016/j.jaip.2015.05.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 05/14/2015] [Accepted: 05/15/2015] [Indexed: 10/23/2022]
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189
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Mirakian R, Leech SC, Krishna MT, Richter AG, Huber PAJ, Farooque S, Khan N, Pirmohamed M, Clark AT, Nasser SM. Management of allergy to penicillins and other beta-lactams. Clin Exp Allergy 2015; 45:300-27. [PMID: 25623506 DOI: 10.1111/cea.12468] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 10/29/2014] [Accepted: 11/07/2014] [Indexed: 12/15/2022]
Abstract
The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and an expert panel have prepared this guidance for the management of immediate and non-immediate allergic reactions to penicillins and other beta-lactams. The guideline is intended for UK specialists in both adult and paediatric allergy and for other clinicians practising allergy in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking, the panel reached consensus. During the development of the guideline, all BSACI members were consulted using a Web-based process and all comments carefully considered. Included in the guideline are epidemiology of allergic reactions to beta-lactams, molecular structure, formulations available in the UK and a description of known beta-lactam antigenic determinants. Sections on the value and limitations of clinical history, skin testing and laboratory investigations for both penicillins and cephalosporins are included. Cross-reactivity between penicillins and cephalosporins is discussed in detail. Recommendations on oral provocation and desensitization procedures have been made. Guidance for beta-lactam allergy in children is given in a separate section. An algorithm to help the clinician in the diagnosis of patients with a history of penicillin allergy has also been included.
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Affiliation(s)
- R Mirakian
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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190
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Gerace KS, Phillips E. Penicillin allergy label persists despite negative testing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:815-6. [DOI: 10.1016/j.jaip.2015.05.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/23/2015] [Accepted: 05/04/2015] [Indexed: 11/15/2022]
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191
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Blanca-Lopez N, Perez-Alzate D, Ruano F, Garcimartin M, de la Torre V, Mayorga C, Somoza ML, Perkins J, Blanca M, Canto MG, Torres MJ. Selective immediate responders to amoxicillin and clavulanic acid tolerate penicillin derivative administration after confirming the diagnosis. Allergy 2015; 70:1013-9. [PMID: 25913298 DOI: 10.1111/all.12636] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND An increasing number of patients show immediate selective hypersensitivity reactions to clavulanic acid (CLV) and amoxicillin (AX), probably due to their increased prescription. The maintenance of this response should be established. OBJECTIVE To assess that the immediate hypersensitivity selective response to AX or to CLV is maintained after repeated administration of penicillin G (PG)/penicillin V (PV) and AX. METHODS Patients with proven immediate hypersensitivity to AX (Group A) or CLV (Group B) were included. Diagnosis was performed using skin tests with major and minor determinants of PG (PPL/MDM), AX and CLV and by drug provocation test (DPT) if required. Selectivity was established by confirming tolerance to PG/PV (Group A) and to PG/PV and AX (Group B). The maintenance of the selective response was verified by repeating DPT, 15 days after the initial investigation, with the same procedure. RESULTS Of 51 patients, 78% belonged to Group A and 22% to Group B. Most had anaphylaxis. In Group A, 72% were skin test positive; 28% required DPT. In Group B, 63% were skin test positive; 37% required DPT. Only two AX-selective cases developed positive responses after re-provocation with PG/PV. No cases selective for CLV developed a positive response to PG, PV or AX. DISCUSSION The selective response to AX appears consistent, and a response to penicillin determinants only develops in a minority of cases. For the case of CLV, the selective response appears not to be modified by exposure to penicillin determinants, meaning that patients with CLV allergy can take penicillin derivatives safely.
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Affiliation(s)
| | | | - F. Ruano
- Allergy Service; Hospital Infanta Leonor; Madrid Spain
| | | | | | - C. Mayorga
- Allergy Service; Hospital Infanta Leonor; Madrid Spain
| | - M. L. Somoza
- Allergy Service; Hospital Infanta Leonor; Madrid Spain
| | - J. Perkins
- Allergy Service; Hospital Infanta Leonor; Madrid Spain
| | - M. Blanca
- Allergy Unit; IBIMA; Regional University Hospital of Malaga; Málaga Spain
| | - M. G. Canto
- Allergy Service; Hospital Infanta Leonor; Madrid Spain
| | - M. J. Torres
- Allergy Unit; IBIMA; Regional University Hospital of Malaga; Málaga Spain
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192
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Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy. Ann Allergy Asthma Immunol 2015; 115:294-300.e2. [PMID: 26070805 DOI: 10.1016/j.anai.2015.05.011] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/27/2015] [Accepted: 05/16/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Self-reported penicillin allergy infrequently reflects an inability to tolerate penicillins. Inpatients reporting penicillin allergy receive alternative antibiotics that might be broader spectrum, more toxic, or less effective. OBJECTIVE To develop and assess a clinical guideline for the general inpatient provider that directs taking a history and prescribing antibiotics for patients with penicillin or cephalosporin allergy. METHODS A guideline was implemented to assist providers with assessing allergy history and prescribing antibiotics for patients with reported penicillin or cephalosporin allergy. The guideline used a standard 2-step graded challenge or test dose. A quasi-experimental study was performed to assess safety, feasibility, and impact on antibiotic use by comparing treatment 21 months before guideline implementation with 12 months after guideline implementation. RESULTS Significantly more test doses to β-lactam antibiotics were performed monthly after vs before guideline implementation (median 14.5, interquartile range 13-16.25, vs 2, interquartile range 1-3.25, P < .001). Seven adverse drug reactions occurred during guideline-driven test doses, with no significant difference in rate (3.9% vs 6.1%, P = .44) or severity (P > .5) between periods. Guideline-driven test doses decreased alternative antimicrobial therapy after the test dose, including vancomycin (68.3% vs 37.2%, P < .001), aztreonam (11.5% vs 0.5%, P < .001), aminoglycosides (6.0% vs 1.1%, P = .004), and fluoro quinolones (15.3% vs 3.3%, P < .001). CONCLUSION The implementation of an inpatient antibiotic prescribing guideline for patients with penicillin or cephalosporin allergy was associated with an almost 7-fold increase in the number of test doses to β-lactams without increased adverse drug reactions. Patients assessed with guideline-driven test doses were observed to have significantly decreased alternative antibiotic exposure.
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193
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Blumenthal KG, Parker RA, Shenoy ES, Walensky RP. Improving Clinical Outcomes in Patients With Methicillin-Sensitive Staphylococcus aureus Bacteremia and Reported Penicillin Allergy. Clin Infect Dis 2015; 61:741-9. [PMID: 25991471 DOI: 10.1093/cid/civ394] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/09/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia is a morbid infection. First-line MSSA therapies (nafcillin, oxacillin, cefazolin) are generally avoided in the 10% of patients reporting penicillin (PCN) allergy, but most of these patients are not truly allergic. We used a decision tree with sensitivity analyses to determine the optimal evaluation and treatment for patients with MSSA bacteremia and reported PCN allergy. METHODS Our model simulates 3 strategies: (1) no allergy evaluation, give vancomycin (Vanc); (2) allergy history-guided treatment: if history excludes anaphylactic features, give cefazolin (Hx-Cefaz); and (3) complete allergy evaluation with history-appropriate PCN skin testing: if skin test negative, give cefazolin (ST-Cefaz). Model outcomes included 12-week MSSA cure, recurrence, and death; allergic reactions including major, minor, and potentially iatrogenic; and adverse drug reactions. RESULTS Vanc results in the fewest patients achieving MSSA cure and the highest rate of recurrence (67.3%/14.8% vs 83.4%/9.3% for Hx-Cefaz and 84.5%/8.9% for ST-Cefaz) as well as the greatest frequency of allergic reactions (3.0% vs 2.4% for Hx-Cefaz and 1.7% for ST-Cefaz) and highest rates of adverse drug reactions (5.2% vs 4.6% for Hx-Cefaz and 4.7% for ST-Cefaz). Even in a "best case for Vanc" scenario, Vanc yields the poorest outcomes. ST-Cefaz is preferred to Hx-Cefaz although sensitive to input variations. CONCLUSIONS Patients with MSSA bacteremia and a reported PCN allergy should have the allergy addressed for optimal treatment. Full allergy evaluation with skin testing seems to be preferred, although more data are needed.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine Medical Practice Evaluation Center, Massachusetts General Hospital Harvard Medical School
| | - Robert A Parker
- Medical Practice Evaluation Center, Massachusetts General Hospital Harvard Medical School Biostatistics Center, Department of Medicine, Massachusetts General Hospital, Boston
| | - Erica S Shenoy
- Medical Practice Evaluation Center, Massachusetts General Hospital Harvard Medical School Infection Control Unit Division of Infectious Disease, Department of Medicine
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital Harvard Medical School Division of Infectious Disease, Department of Medicine
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194
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Thornhill MH, Dayer MJ, Prendergast B, Baddour LM, Jones S, Lockhart PB. Incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis. J Antimicrob Chemother 2015; 70:2382-8. [PMID: 25925595 DOI: 10.1093/jac/dkv115] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 04/01/2015] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Antibiotic prophylaxis (AP) administration prior to invasive dental procedures has been a leading focus of infective endocarditis prevention. However, there have been long-standing concerns about the risk of adverse drug reactions as a result of this practice. The objective of this study was to identify the incidence and nature of adverse reactions to amoxicillin and clindamycin prophylaxis to prevent infective endocarditis. METHODS We obtained AP prescribing data for England from January 2004 to March 2014 from the NHS Business Services Authority, and adverse drug reaction data from the Medicines and Healthcare Products Regulatory Agency's Yellow Card reporting scheme for prescriptions of the standard AP protocol of a single 3 g oral dose of amoxicillin or a single 600 mg oral dose of clindamycin for those allergic to penicillin. RESULTS The reported adverse drug reaction rate for amoxicillin AP was 0 fatal reactions/million prescriptions (in fact 0 fatal reactions for nearly 3 million prescriptions) and 22.62 non-fatal reactions/million prescriptions. For clindamycin, it was 13 fatal and 149 non-fatal reactions/million prescriptions. Most clindamycin adverse drug reactions were Clostridium difficile infections. CONCLUSIONS AP adverse drug reaction reporting rates in England were low, particularly for amoxicillin, and lower than previous estimates. This suggests that amoxicillin AP is comparatively safe for patients without a history of amoxicillin allergy. The use of clindamycin AP was, however, associated with significant rates of fatal and non-fatal adverse drug reactions associated with C. difficile infections. These were higher than expected and similar to those for other doses, durations and routes of clindamycin administration.
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Affiliation(s)
- Martin H Thornhill
- Unit of Oral and Maxillofacial Surgery and Medicine, University of Sheffield School of Clinical Dentistry, Claremont Crescent, Sheffield S10 2TA, UK Department of Oral Medicine, Carolinas Medical Center, Charlotte, NC 28203, USA
| | - Mark J Dayer
- Department of Cardiology, Taunton and Somerset NHS Trust, Taunton, Somerset TA1 5DA, UK
| | | | - Larry M Baddour
- Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Simon Jones
- School of Health Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - Peter B Lockhart
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, NC 28203, USA
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195
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Gerace KS, Karlin E, McKinnon E, Phillips E. Varying penicillin allergy testing practices in the United States: A time for consensus. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:791-3. [PMID: 25920344 DOI: 10.1016/j.jaip.2015.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 03/10/2015] [Accepted: 03/18/2015] [Indexed: 10/23/2022]
Affiliation(s)
| | - Eric Karlin
- Division of Clinical Immunology, Allergy and Rheumatology, New York Medical College, Valhalla, NY
| | - Elizabeth McKinnon
- Institute of Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Elizabeth Phillips
- Division of Infectious Diseases, Vanderbilt University, Nashville, Tenn.
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196
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Fox SJ, Park MA. Penicillin skin testing is a safe and effective tool for evaluating penicillin allergy in the pediatric population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 2:439-44. [PMID: 25017533 DOI: 10.1016/j.jaip.2014.04.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 03/30/2014] [Accepted: 04/30/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Penicillin skin testing has been validated in the evaluation of adult patients with penicillin allergy. However, the commercially available benzylpenicilloyl polylysine (Pre-Pen) is not indicated in the pediatric population. Moreover, the safety and validity of penicillin skin testing in the pediatric population has not been well studied. OBJECTIVE We describe the safety and validity of penicillin skin testing in the evaluation of children with a history of penicillin allergy. METHODS Children (<18 years) with a history of penicillin allergy were evaluated with penicillin skin tests and were reviewed for basic demographics, penicillin skin test results, adverse drug reaction to penicillin after penicillin skin test, and adverse reaction to penicillin skin test. By using the χ(2) test, we compared the differences in the proportion of children and adults with a positive penicillin skin test. P value (<.05) was considered statistically significant. The institutional review board approved the study, and all the subjects signed written informed consents. RESULTS A total of 778 children underwent penicillin skin testing; 703 of 778 patients had a negative penicillin skin test (90.4%), 66 had a positive test (8.5%), and 9 had an equivocal test (1.1%). Children were more likely to have a positive penicillin skin test (P < .0001) compared with adults (64 of 1759 [3.6%]); 369 of 703 patients with negative penicillin skin test (52%) were challenged with penicillin, and 14 of 369 patients (3.8%) had an adverse drug reaction. No adverse reactions to penicillin skin testing were observed. CONCLUSION Penicillin skin testing was safe and effective in the evaluation of children with a history of penicillin allergy.
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Affiliation(s)
| | - Miguel A Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn.
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197
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Abstract
Drug-induced anaphylaxis is a common cause of anaphylaxis and a leading cause of fatal anaphylaxis. Antibiotics, radiocontrast, and nonsteroidal anti-inflammatory drugs are commonly implicated drugs. Vocal cord dysfunction can mimic anaphylaxis and is often overlooked. β-Lactams are a common cause of anaphylaxis; however, skin testing and drug challenge can usually determine tolerability of other classes of β-lactams. Nonionic contrast agents cause anaphylaxis less frequently than ionic contrast, and immunoglobulin E-mediated mechanisms may have a role in some of these reactions. Skin testing with radiocontrast may have a role in evaluating patients with anaphylaxis to nonionic contrast.
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Affiliation(s)
- Merin Kuruvilla
- Atlanta ENT, 5555 Peachtree Dunwoody Rd, Suite 125, Atlanta, GA-30342, USA
| | - David A Khan
- Division of Allergy & Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8859, USA.
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198
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Bourke J, Pavlos R, James I, Phillips E. Improving the Effectiveness of Penicillin Allergy De-labeling. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:365-34.e1. [PMID: 25609352 DOI: 10.1016/j.jaip.2014.11.002] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Revised: 11/03/2014] [Accepted: 11/04/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Approximately 10-20% of hospitalized patients are labeled as penicillin allergic, and this is associated with significant health and economic costs. OBJECTIVES We looked at the effectiveness of penicillin allergy de-labeling in clinical practice with the aim of deriving risk stratification models to guide testing strategies. METHODS Consecutive patients aged 15 years or more, referred to a Western Australian public hospital drug allergy service between 2008 and 2013 for beta-lactam allergy, were included. Follow-up surveys were conducted. Results of skin prick testing and intradermal testing (SPT/IDT) and oral challenge (OC), and follow-up of post testing antibiotic usage were the main outcomes. RESULTS SPT/IDT was performed in 401 consecutive patients with immediate (IMM) (≤ 1 hour) (n = 151) and nonimmediate (NIM) (>1 hour) (n = 250) reactions. Of 341 patients, 42 (12.3%) were SPT/IDT+ to ≥ 1 penicillin reagents, including 35/114 (30.4%) in the IMM group and 7/227 (3.1%) in the NIM group (P < .0001). Of 355 SPT/IDT patients, 3 (0.8%), all in the IMM group, had nonserious positive OC reactions to single dose penicillin VK (SPT/IDT negative predictive value [NPV] 99.2%). Selective or unrestricted beta-lactam was recommended in almost 90% overall, including 238/250 (95.2%) in the NIM group and 126/151 (83.4%) in the IMM group (P = .0001). Of 182 patients, 137 (75.3%) were following the allergy label modifications (ALM) at the time of follow-up. CONCLUSIONS Penicillin SPT/IDT/OC safely de-labels penicillin-allergic patients and identifies selective beta-lactam allergies; however, incomplete adherence to ALM recommendations impairs effectiveness. Infrequent SPT/IDT+ and absent OC reactions in patients with NIM reactions suggest OC alone to be a safe and cost-effective de-labeling strategy that could improve the coverage of penicillin allergy de-labeling in lower risk populations.
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Affiliation(s)
- Jack Bourke
- Department of Clinical Immunology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Rebecca Pavlos
- Institute for Immunology & Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
| | - Ian James
- Institute for Immunology & Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
| | - Elizabeth Phillips
- Department of Clinical Immunology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia; Institute for Immunology & Infectious Diseases, Murdoch University, Perth, Western Australia, Australia; Vanderbilt University School of Medicine, Nashville, Tenn.
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199
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Gaeta F, Valluzzi RL, Alonzi C, Maggioletti M, Caruso C, Romano A. Tolerability of aztreonam and carbapenems in patients with IgE-mediated hypersensitivity to penicillins. J Allergy Clin Immunol 2014; 135:972-976. [PMID: 25457154 DOI: 10.1016/j.jaci.2014.10.011] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 10/01/2014] [Accepted: 10/08/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Studies performed on samples larger than 100 subjects with a documented IgE-mediated hypersensitivity to penicillins have demonstrated a cross-reactivity rate of approximately 1% between penicillins and both imipenem and meropenem, whereas a single study found a cross-reactivity rate of 6.2% with aztreonam in 16 such subjects. OBJECTIVE To assess the cross-reactivity and tolerability of aztreonam and 3 carbapenems (imipenem-cilastatin, meropenem, and ertapenem) in patients with documented IgE-mediated hypersensitivity to penicillins. METHODS A total of 212 consecutive subjects with immediate reactions to penicillins and positive results on skin tests to at least 1 penicillin reagent underwent skin tests with aztreonam and carbapenems; subjects with negative results were challenged with escalating doses of aztreonam and carbapenems. RESULTS All subjects displayed negative skin test results to both aztreonam and carbapenems; 211 accepted challenges and tolerated them. Challenges were not followed by full therapeutic courses. CONCLUSIONS These data indicate the tolerability of both aztreonam and carbapenems in penicillin-allergic subjects. In those who especially require these alternative β-lactams, however, we recommend pretreatment skin tests, both because rare cases of cross-reactivity have been reported and because negative results indicate tolerability.
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Affiliation(s)
| | | | | | | | | | - Antonino Romano
- Allergy Unit, Complesso Integrato Columbus, Rome, Italy; IRCCS Oasi Maria S.S., Troina, Italy.
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Abstract
Most children with a history of penicillin allergy are labeled allergic and denied treatment with penicillin and sometimes other beta-lactam antibiotics. Most of these children never were or are no longer allergic to penicillin. Penicillin skin testing and oral challenge can identify patients who are not currently allergic, allowing them to be treated with penicillin. Children with egg allergy are often denied influenza vaccination, because the vaccine contains a small amount of egg protein. However, recent studies have demonstrated that children with even severe egg allergy can safely receive the vaccine, reducing their risk of the morbidity and mortality associated with influenza.
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Affiliation(s)
- John M Kelso
- Division of Allergy, Asthma, and Immunology, Scripps Clinic, 3811 Valley Centre Drive, San Diego, CA 92130, USA.
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