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Bailey P, Schacht L, Pazienza G, Kohn J, Yunusa I, Seal P, Crockett A, Justo JA. Cefoxitin for Intra-amniotic Infections and Endometritis: A Retrospective Comparison to Traditional Antimicrobial Therapy Regimens Within a Healthcare System. Clin Infect Dis 2024; 79:247-254. [PMID: 38297884 DOI: 10.1093/cid/ciae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/05/2024] [Accepted: 01/19/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Local institutional guidelines and order sets were updated in June 2023 to recommend first-line cefoxitin monotherapy for the treatment of intra-amniotic infections (IAIs) and endometritis. This study evaluated the clinical impact of this change. METHODS This was a retrospective, observational cohort study in an 11-campus health system comparing clinical outcomes of patients with chorioamnionitis, endometritis, or septic abortion receiving intravenous antimicrobial therapy before and after implementation of first-line cefoxitin monotherapy recommendations for the treatment of these infections. Primary outcome was a composite of serious clinical events postdelivery (ie, intensive care unit admission, death, hospital readmission related to IAI or endometritis within 30 days, additional surgery or procedures, or deep surgical site infection). Baseline characteristics between the pre- and post-cefoxitin groups were compared via Student's t tests for continuous variables and chi-square tests for categorical variables. Outcomes were evaluated via generalized linear modeling. RESULTS A total of 472 patients were enrolled, 350 (74%) in the pre-cefoxitin group and 122 (26%) in the post-cefoxitin group. Groups were significantly different by race, healthcare payor, and hospital campus. Cefoxitin was rarely used in the pre-cefoxitin group (n = 2, <0.1%) and commonly used in the post-cefoxitin group (n = 112, 91.8%). After controlling for group differences, odds of experiencing serious clinical event postdelivery in the post-cefoxitin group were noninferior to those in the pre-cefoxitin group (adjusted odds ratio, .37; 95% CI, .17-.76; P = .010). CONCLUSIONS Local institutional guidelines with predominant use of cefoxitin therapy were noninferior to traditional antimicrobial therapy regimens for the treatment of IAI.
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Affiliation(s)
- Pamela Bailey
- Division of Infectious Diseases, Prisma Health Midlands, Columbia, South Carolina, USA
- University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Lance Schacht
- University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Grace Pazienza
- Department of Internal Medicine, Prisma Health Midlands, Columbia, South Carolina, USA
| | - Joseph Kohn
- Division of Infectious Diseases, Prisma Health Midlands, Columbia, South Carolina, USA
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, USA
| | - Ismaeel Yunusa
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, USA
| | - Patricia Seal
- University of South Carolina School of Medicine, Columbia, South Carolina, USA
- Department of Obstetrics/Gynecology, Prisma Health Midlands, Columbia, South Carolina, USA
| | - Amy Crockett
- Prisma Health/University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA
| | - Julie Ann Justo
- Division of Infectious Diseases, Prisma Health Midlands, Columbia, South Carolina, USA
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, USA
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Bodega-Azuara J, Belles Medall MD, Edo-Peñarrocha J, Puplá-Bartoll A, Ferrando Piqueres R, Torres-Górriz MC, Germán-Sánchez A, Enrique E. Beta-lactam allergy in patients: an antibiotic stewardship challenge. Eur J Hosp Pharm 2024; 31:307-313. [PMID: 36564160 PMCID: PMC11265552 DOI: 10.1136/ejhpharm-2022-003304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 12/12/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patients are commonly reported as being allergic to beta-lactam (BL) antibiotics. However, many patients with this reported allergy are able to receive BL treatments because they do not have true allergies. In many cases these are simply intolerances due to side effects reported as an allergy. Delabelling these patients leads to better clinical outcomes, optimal antibiotic usage, decreased bacterial resistance and reduced healthcare costs. Therefore, the aims of this study were to identify incorrectly labelled BL allergies in hospitalised patients and to assess antibiotic use in delabelled patients in order to establish a quality indicator to optimise antimicrobial treatments. METHODS A prospective study was conducted in which hospitalised patients treated with antimicrobial drugs and labelled as 'BL-allergic' were identified by clinical pharmacists. An allergist assessed whether patients were suitable candidates for a skin test or oral challenge. The Allergy Service removed 'BL-allergic' labels if negative results were obtained. Delabelled patients were followed up by clinical pharmacists to study the use of BL antibiotics as a result of the delabelling programme. RESULTS A total of 176 suspected allergic patients were identified and 91 (51.7%) were tested either by a skin test or oral challenge based on the patient indicators. Seven (16.4%) patients tested were allergic to BL antibiotics, 76 (83.5%) were totally delabelled and eight (0.1%) were partially delabelled. Thirty-two (38.1%) delabelled patients required antibiotic treatment in another inpatient or outpatient setting, of whom 27 (84.3%) patients with a new infectious episode received BL treatments while five (15.7%) continued to receive antimicrobial treatments without BL. CONCLUSION After the implementation of a protocol to detect incorrect BL allergy labels, 83.5% of the patients in this cohort were completely delabelled. This shows that there is a clear opportunity to optimise the use of antibiotics by delabelling 'BL-allergic' patients.
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Affiliation(s)
- Julia Bodega-Azuara
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | | | - Josep Edo-Peñarrocha
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | - Aarón Puplá-Bartoll
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | - Raul Ferrando Piqueres
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | | | - Adrián Germán-Sánchez
- Allergology, Hospital General Universitari de Castello, Castellon de la Plana, Spain
| | - Ernesto Enrique
- Allergology, Hospital General Universitari de Castello, Castellon de la Plana, Spain
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Powell N, Elkhalifa S, Sandoe J. Penicillin allergy de-labelling by non-allergists: a comparison of testing protocols. JAC Antimicrob Resist 2023; 5:dlad134. [PMID: 38115860 PMCID: PMC10729857 DOI: 10.1093/jacamr/dlad134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
Optimizing penicillin allergy de-labelling (PADL) to ensure patients with an incorrect penicillin allergy record are de-labelled with minimal patient harm is important for antibiotic stewardship. The heterogeneity of inclusion and exclusion criteria in the published penicillin allergy testing protocols risks suboptimal delivery of PADL. We compared the similarities and the differences between non-allergist-delivered PADL testing protocols and make suggestions for harmonization. The observed variation in testing practice has two broad elements: (i) definitions and terminology; and (ii) differences in the acceptability of perceived risk. All direct drug provocation testing (DDPT) protocols included patients with benign delayed rash as eligible for testing, although the remoteness of the rash, and the terminology used to describe the rash, differed. Patients with features of potential IgE reactions were excluded from most DDPT protocols, but not all of them. There was differing advice on how to manage patients who had subsequently tolerated penicillin since the index reaction and differences in which patients were considered ineligible for DDPT due to acuity of illness, comorbidities and concomitant medications. Standardization of the terminology used in penicillin allergy testing protocols and consensus on inclusion and exclusion criteria are required for safe and efficient PADL delivery at scale by non-allergists.
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Affiliation(s)
- Neil Powell
- School of Biomedical Sciences, University of Plymouth, Plymouth, UK
- Pharmacy Department, Royal Cornwall Hospital Trust, Truro, UK
| | - Shuayb Elkhalifa
- Allergy and Immunology Department, Respiratory Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Jonathan Sandoe
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
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Vyas L, Raja K, Morrison S, Beggs D, Attalla MS, Patel M, Philips M. Beta-lactam comprehensive allergy management program in a community medical center. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e189. [PMID: 38028889 PMCID: PMC10654959 DOI: 10.1017/ash.2023.461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 12/01/2023]
Abstract
Objective The Beta-lactam Comprehensive Allergy Management Program (CAMP) was implemented to facilitate complete beta-lactam allergy history documentation in the electronic medical record (EMR) and increase beta-lactam utilization. The study objective was to assess the rate of complete allergy histories and days of antimicrobial therapy (DOT) before versus after CAMP implementation. Design Quasi-experimental study with interrupted time-series analysis. Setting Non-teaching, urban, and community medical center within a multi-hospital health system. Patients Adult inpatients with a beta-lactam allergy receiving antimicrobial therapy. Methods The multidisciplinary CAMP team screened, interviewed, and collected allergy history details of adult inpatients with a beta-lactam allergy receiving antimicrobial therapy starting January 4, 2021. Patients were stratified as high, moderate, or low risk of IgE-mediated allergy and referred to an allergist for skin testing or drug challenge. The EMR was updated with interview details and drug challenge or skin test results. The primary endpoint was rate of complete allergy history documentation before (12/1/18-4/1/19) compared to after (1/4/21-5/1/21) program implementation. The secondary endpoint was days of inpatient beta-lactam therapy. Implementation logistics, de-labeling rate, and antimicrobial therapy changes were evaluated. Results The program evaluated 392 individuals, with 184 and 208 patients comprising the pre- and post-intervention groups, respectively. The post-intervention period was associated with an increase of 19.8% in complete allergy histories (0.359 PPc; R 2 0.26; p = 0.002) and 9.34 beta-lactam DOT per 1,000-days-present (1.106 PPc; R 2 0.194; p = 0.009). Conclusion Implementation of a comprehensive beta-lactam allergy management program was associated with higher rates of complete beta-lactam allergy history and beta-lactam use.
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Affiliation(s)
- Lakhini Vyas
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
| | - Karan Raja
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
- Ernest Mario School of Pharmacy, Rutgers University, New Brunswick, NJ, USA
| | - Susan Morrison
- Department of Medicine, Clara Maass Medical Center, Belleville, NJ, USA
| | - Donald Beggs
- Department of Medicine, Clara Maass Medical Center, Belleville, NJ, USA
| | - Mark S. Attalla
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
| | - Mitesh Patel
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
| | - Mona Philips
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
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Powell N, Stephens J, Kohl D, Owens R, Ahmed S, Musicha C, Upton M, Kent B, Tonkin-Crine S, Sandoe J. The effectiveness of interventions that support penicillin allergy assessment and delabeling of adult and pediatric patients by nonallergy specialists: a systematic review and meta-analysis. Int J Infect Dis 2023; 129:152-161. [PMID: 36450321 PMCID: PMC10017351 DOI: 10.1016/j.ijid.2022.11.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Penicillin allergy records are often incorrect and may result in harm. We aimed to systematically review the effectiveness and safety of nonallergist health care worker delivery of penicillin allergy delabeling. METHODS We searched EMBASE/MEDLINE/CINAHL (Ovid), PsycInfo, Web of Science, and Cochrane CENTRAL from inception to January 21, 2022 and unpublished studies and gray literature. The proportion of patients allergic to penicillin delabeled and harmed was calculated using random-effects models. RESULTS Overall, 5019 patients were delabeled. Using allergy history alone, 14% (95% confidence interval [CI], 9-21%) of 4350 assessed patients were delabeled without reported harm. Direct drug provocation testing resulted in delabeling in 27% (95% CI, 18-37%) of 4207 assessed patients. Of the 1373 patients tested, 98% were delabeled (95% CI, 97-99%), and nonserious harm was reported in 1% (95% CI, 0-2%). Using skin testing, followed by drug provocation testing, 41% (95% CI, 24-59%) of 2890 assessed patients were delabeled. Of the 1294 tested patients, 95.0% (95% CI, 90-99%) were delabeled, and the reported harm was low (0%; (95% CI 0-1%). CONCLUSION Penicillin allergy delabeling by nonallergists is efficacious and safe. The proportion of assessed patients who can be delabeled increases with the complexity of testing method, but substantial numbers can be delabeled without skin testing.
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Affiliation(s)
- Neil Powell
- Pharmacy Department, Royal Cornwall Hospital, Truro, United Kingdom TR1 3LJ / School of Biomedical Sciences, University of Plymouth, Plymouth, United Kingdom.
| | - Jennie Stephens
- Intensive Care Department, Royal Cornwall Hospital, Truro, United Kingdom
| | - Declan Kohl
- School of Biomedical Sciences, University of Leeds, Leeds, United Kingdom
| | - Rhys Owens
- Core Medical Trainee, Royal Cornwall Hospital, Truro, United Kingdom
| | - Shadia Ahmed
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Crispin Musicha
- Medical Statistics, Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - Mathew Upton
- School of Biomedical Sciences, University of Plymouth, Plymouth, United Kingdom
| | - Bridie Kent
- School of Nursing and Midwifery, University of Plymouth, Plymouth, United Kingdom
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jonathan Sandoe
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
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Kufel WD, Blaine BE, Ruehl R, Avery LM. Instruction and Simulation to Improve Pharmacy Students' Knowledge and Confidence Regarding Assessment of Penicillin Allergies. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2022; 86:8688. [PMID: 34301577 PMCID: PMC10159444 DOI: 10.5688/ajpe8688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/30/2021] [Indexed: 05/06/2023]
Abstract
Objective. To evaluate pharmacy students' knowledge of and confidence regarding penicillin allergy assessment and skin testing (PAAST) before and after a focused didactic instruction and simulation (FDIS).Methods. A multicenter, quasi-experimental, cross-sectional survey study was performed among pharmacy students before and after FDIS on PAAST at two schools of pharmacy. The FDIS on PAAST consisted of an infectious disease faculty-led seminar, student-led penicillin allergy counseling interviews, penicillin skin testing simulation, and case studies to assess penicillin allergy scenarios and management. An anonymous, voluntary, electronic survey was distributed to students (n=159) before and after the FDIS. The pre- and post-intervention survey contained 10 PAAST knowledge-based questions and multi-step, five-point Likert scale statements related to students' confidence in PAAST. The post-intervention survey also evaluated students' perceptions of the FDIS on PAAST. Descriptive statistics were performed, and the Student t test was used to compare pre- and post-intervention responses.Results. One hundred forty-three surveys were completed, resulting in a survey response rate of 90%. Students' PAAST knowledge scores (mean±SD) increased overall following the FDIS on PAAST (6.67±1.51 vs 7.81±1.39). Knowledge scores increased considerably for questions related to penicillin allergy consequences, cross-reactivity, and correct steps of PAAST. Pharmacy students' PAAST confidence scores (mean±SD) also improved following the interactive instruction and simulation (2.30±0.7 vs 3.22±0.67) with considerable confidence increases in penicillin skin testing. Pharmacy students' perceptions of the FDIS on PAAST were also positive overall.Conclusion. Pharmacy students' knowledge and confidence of PAAST improved following FDIS. This may be an effective strategy to implement PAAST education during pharmacy school.
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Affiliation(s)
- Wesley D Kufel
- Binghamton University, School of Pharmacy and Pharmaceutical Sciences, Binghamton, New York
- State University of New York, Upstate Medical University, Syracuse, New York
- State University of New York, Upstate University Hospital, Syracuse, New York
| | | | - Rachel Ruehl
- Good Samaritan TriHealth Hospital, Cincinnati, Ohio
| | - Lisa M Avery
- Saint John Fisher College, Wegmans School of Pharmacy, Rochester, New York
- Saint Joseph's Health, Syracuse, New York
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Overview of Beta-Lactam Allergy and the Role of the Pharmacist in Management. ALLERGIES 2021. [DOI: 10.3390/allergies1020011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Unverified beta-lactam allergies are a substantial public health problem, as the majority of patients labeled as beta-lactam allergic do not have clinically significant allergies that may hinder the use beta-lactam therapy when indicated. Outdated or inaccurate beta-lactam or penicillin allergies can result in serious consequences, including suboptimal antibiotic therapy, increased risk of adverse effects, and use of broader spectrum antibiotics than indicated, which may contribute to antimicrobial resistance. The purpose of this review is to provide an overview of beta-lactam allergy and highlight the role of pharmacists in managing beta-lactam allergies. Studies have shown that pharmacists can play a vital role in allergy assessment, penicillin skin testing, beta-lactam desensitization, evaluation of beta-lactam cross-reactivity and recommending appropriate antibiotic therapy in patients with beta-lactam allergies.
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Jones BM, Bland CM. Pharmacists implementing penicillin allergy assessment and skin testing programs for
delabeling—What
are we waiting for? JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Bruce M. Jones
- University of Georgia College of Pharmacy Savannah Georgia
- Clinical Pharmacy Specialist, St. Joseph’s/Candler Health System Savannah Georgia USA
| | - Christopher M. Bland
- University of Georgia College of Pharmacy Savannah Georgia
- Clinical Pharmacy Specialist, St. Joseph’s/Candler Health System Savannah Georgia USA
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