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Kouma MA, Guastadisegni JM, Yang L, Maxwell DN, Storey DF, Arasaratnam RJ. Challenges and opportunities related to penicillin allergy in the Veterans Health Administration: a narrative review. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e174. [PMID: 38028897 PMCID: PMC10644167 DOI: 10.1017/ash.2023.448] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 12/01/2023]
Abstract
The presence of a penicillin allergy label in a patient's medical chart is associated with negative clinical and economic outcomes. Given that less than 10% of reported reactions are truly immunoglobulin E-mediated, removal of unverified penicillin allergy labels is a public health priority and an area of ongoing implementation research. The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States, with almost 9 million veterans currently enrolled. However, studies analyzing the impact of the penicillin allergy label in this population are limited to single facilities and largely focus on short-term outcomes of allergy documentation correction, usage of β-lactams, and avoidance of antibiotic-related side effects. Broader, national VHA studies focusing on health outcomes and costs are lacking. As with non-VHA facilities, penicillin allergy evaluations are limited owing to the absence of formal allergy/immunology services at most VHA facilities. Pharmacy-driven screening and referral for clinic-based penicillin skin testing is a promising and frequently discussed modality in the literature, but its scalability within the VHA is not yet proven. Broader, evidence-based strategies that can be adapted to the available resources of individual VHA facilities, including those without on-site access to allergy providers, are needed.
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Affiliation(s)
- Marcus A. Kouma
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | | | - Linda Yang
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | - Daniel N. Maxwell
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donald F. Storey
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Reuben J. Arasaratnam
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
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2
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Kanannejad Z, Pourvali A, Esmaeilzadeh H, Shokouhi Shoormasti R, Reza Fazlollahi M, Fallahpour M, Zaremehrjardi F. Diagnosis and selection of alternative antibiotics in beta-lactams hypersensitivity reactions: Current recommendations and challenges. Int Immunopharmacol 2023; 122:110573. [PMID: 37413935 DOI: 10.1016/j.intimp.2023.110573] [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: 05/03/2023] [Revised: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023]
Abstract
Beta-lactam (BLM) antibiotics, including amino-penicillin and cephalosporins, are typically the first-choice treatment for bacterial infections. However, adverse reactions to these antibiotics are frequently reported, causing non-allergist physicians to select alternative broad-spectrum antibiotics that can have harmful consequences. Patients with unclear histories of hypersensitivity reactions to BLMs should undergo an allergy workup to establish a firm diagnosis, particularly when different drugs are prescribed simultaneously. However, finding the safest, most precise, and cost-effective methods for confirming BLMs hypersensitivity and selecting the most appropriate alternative BLM is uncertain, particularly in severe delayed reactions. This review aims to provide data and recommendations on the availability and validity of skin tests (STs), drug provocation test (DPT) protocols, based on the latest published literature and guideline. To make the process more practical, we focused on cross-reactivity between BLMs and diagnostic tests. There are two main novel aspects of this document: 1) For T-cell-mediated reactions, patient stratification into high, moderate, and low-risk groups based on the mortality and morbidity of adverse drug reactions. 2) For IgE-mediated reactions, stratification of individuals with isolated limited urticarial without anaphylaxis in a low-risk group and removal of the extensive limitation.
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Affiliation(s)
- Zahra Kanannejad
- Allergy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Pourvali
- Department of Pediatrics, School of Medicine, Arak University of Medical Sciences, Arak, Iran
| | - Hossein Esmaeilzadeh
- Allergy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Allergy and Clinical Immunology, Namazi Hospital, Shiraz, Iran.
| | - Raheleh Shokouhi Shoormasti
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical, Sciences, Tehran, Iran
| | - Mohammad Reza Fazlollahi
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical, Sciences, Tehran, Iran
| | - Morteza Fallahpour
- Department of Allergy and Clinical Immunology, Rasoole- Akaram Medical Research Development Center (RCRDC), School of Medicine, Iran University of Medical Science, Tehran, Iran
| | - Fatemeh Zaremehrjardi
- Allergist and Clinical Immunologist, Clinical Research Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Iran
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3
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Gillespie C, Sitter K, McConeghy KW, Strymish J, Gupta K, Hartmann CW, Borzecki AM. Facilitators and Barriers to Verifying Penicillin Allergies in a Veteran Nursing Home Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2848-2854.e3. [PMID: 37352930 DOI: 10.1016/j.jaip.2023.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Unconfirmed penicillin allergies are common and may contribute to adverse outcomes, especially in frail older patients. Evidence-based clinical pathways for evaluating penicillin allergies have been effectively and safely applied in selected settings, but not in nursing home populations. OBJECTIVE To identify potential facilitators and barriers to implementing a strategy to verify penicillin allergies in Veterans Health Administration nursing homes, known as Community Living Centers (CLCs). METHODS We conducted semistructured interviews with staff, patients, and family members at 1 CLC to assess their understanding of penicillin allergies and receptiveness to verifying the allergy. We also asked staff about the proposed allergy assessment strategy, including willingness to delabel by history and feasibility of performing oral challenges or skin testing on their unit. RESULTS From 24 interviews (11 front-line staff, 4 leadership, 3 patients, 6 family members), we identified several facilitators or barriers. Staff recognized the importance of allergy verification and were willing to support and assist in implementing verification strategies. The CLC residents were willing to have their allergy status verified. However, some family members expressed reluctance to verifying their relative's allergy status owing to safety concerns. Front-line staff also expressed concern over having the necessary resources, including time and expertise, to implement the strategy. Staff suggested involving clinical pharmacists and educating staff, patients, and family members as ways to overcome these barriers. CONCLUSIONS Concerns about safety and staff resources are important potential barriers to implementing verification strategies. Involvement of pharmacists and education of both staff and patients and family members will be important components of any successful intervention.
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Affiliation(s)
- Chris Gillespie
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass.
| | - Kailyn Sitter
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass
| | - Kevin W McConeghy
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, RI; Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI
| | - Judith Strymish
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Infectious Diseases, VA Boston Healthcare System, Boston, Mass
| | - Kalpana Gupta
- Division of Infectious Diseases, VA Boston Healthcare System, Boston, Mass; Center for Healthcare Organization and Implementation Research (CHOIR), Boston Campus, VA Boston Healthcare System, Boston, Mass; Department of General Internal Medicine, Boston University School of Medicine, Boston, Mass
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass; Zuckerberg College of Health Sciences, Department of Public Health, University of Massachusetts Lowell, Lowell, Mass
| | - Ann M Borzecki
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass; Department of General Internal Medicine, Boston University School of Medicine, Boston, Mass; School of Public Health, Department of Health Law, Policy and Management, Boston University School of Public Health, Boston University, Boston, Mass
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4
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Norvell MR, Porter M, Ricco MH, Koonce RC, Hogan CA, Basler E, Wong M, Jeffres MN. Cefazolin vs Second-line Antibiotics for Surgical Site Infection Prevention After Total Joint Arthroplasty Among Patients With a Beta-lactam Allergy. Open Forum Infect Dis 2023; 10:ofad224. [PMID: 37363051 PMCID: PMC10289809 DOI: 10.1093/ofid/ofad224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/20/2023] [Indexed: 06/28/2023] Open
Abstract
Background Cefazolin is a first-line agent for prevention of surgical site infections (SSIs) after total joint arthroplasty. Patients labeled allergic to beta-lactam antibiotics frequently receive clindamycin or vancomycin perioperatively due to the perceived risk of a hypersensitivity reaction after exposure to cefazolin. Methods This single-system retrospective review included patients labeled allergic to penicillin or cephalosporin antibiotics who underwent a primary total hip and/or knee arthroplasty between January 2020 and July 2021. A detailed chart review was performed to compare the frequency of SSI within 90 days of surgery and interoperative hypersensitivity reactions (HSRs) between patients receiving cefazolin and patients receiving clindamycin and/or vancomycin. Results A total of 1128 hip and/or knee arthroplasties from 1047 patients were included in the analysis (cefazolin n = 809, clindamycin/vancomycin n = 319). More patients in the clindamycin and/or vancomycin group had a history of cephalosporin allergy and allergic reactions with immediate symptoms. There were fewer SSIs in the cefazolin group compared with the clindamycin and/or vancomycin group (0.9% vs 3.8%; P < .001) including fewer prosthetic joint infections (0.1% vs 1.9%). The frequency of interoperative HSRs was not different between groups (cefazolin = 0.2% vs clindamycin/vancomycin = 1.3%; P = .06). Conclusions The use of cefazolin as a perioperative antibiotic for infection prophylaxis in total joint arthroplasty in patients labeled beta-lactam allergic is associated with decreased postoperative SSI without an increase in interoperative HSR.
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Affiliation(s)
- Miranda R Norvell
- Correspondence: Meghan N. Jeffres, PharmD, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy and Pharmaceutical Sciences, Mail Stop C 238, 12850 E. Montview Blvd, V20-1212, Aurora, CO 80045 (); or Miranda R. Norvell, PharmD, Barnes-Jewish Hospital, Department of Pharmacy, One Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, St Louis, MO 63110-1026 ()
| | - Melissa Porter
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Madison H Ricco
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ryan C Koonce
- Department of Orthopedic Surgery, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Craig A Hogan
- Department of Orthopedic Surgery, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Eric Basler
- Department of Orthopedic Surgery, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Megan Wong
- UCHealth University of Colorado Hospital, Aurora, Colorado, USA
| | - Meghan N Jeffres
- Correspondence: Meghan N. Jeffres, PharmD, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy and Pharmaceutical Sciences, Mail Stop C 238, 12850 E. Montview Blvd, V20-1212, Aurora, CO 80045 (); or Miranda R. Norvell, PharmD, Barnes-Jewish Hospital, Department of Pharmacy, One Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, St Louis, MO 63110-1026 ()
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Liu HH, Mutneja H, Buckley M, Cushinotto L. Trends in Antimicrobial Allergies in Patients Seen in Infectious Disease Consultation During Selected Periods 2007–2016. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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6
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Appaneal HJ, Shireman TI, Lopes VV, Mor V, Dosa DM, LaPlante KL, Caffrey AR. Poor clinical outcomes associated with suboptimal antibiotic treatment among older long-term care facility residents with urinary tract infection: a retrospective cohort study. BMC Geriatr 2021; 21:436. [PMID: 34301192 PMCID: PMC8299613 DOI: 10.1186/s12877-021-02378-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment. METHODS We conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013-2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment. RESULTS Among 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01-1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54-2.44). CONCLUSION In this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA. .,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA. .,College of Pharmacy, University of Rhode Island, Kingston, RI, USA. .,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Theresa I Shireman
- Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA
| | - Vincent Mor
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - David M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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7
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Abstract
Sulfonamides, particularly antimicrobial sulfonamides, have been implicated as a common cause of a spectrum of hypersensitivity reactions. Immediate IgE-mediated reactions have been reported but are much less common than delayed cutaneous reactions. Delayed cutaneous reactions range from benign exanthems to severe cutaneous reactions such as Stevens Johnson syndrome, toxic epidermal necrolysis, or drug reaction with eosinophilia and systemic symptoms. Sulfonamides can be subclassified as antimicrobial sulfonamides and non-antimicrobial sulfonamides, which are also distinguished by key structural differences, resulting in very low risk of cross-reactivity between these two subclasses. Immediate and delayed skin testing and in vitro testing remain limited as options in evaluating antimicrobial sulfonamide hypersensitivity. Drug challenges continue to play an important role in the evaluation of both immediate and delayed reactions, with a growing body of evidence for the safety of direct challenges regardless of human immunodeficiency virus infection status. While numerous "desensitization" protocols have been described for the management of antimicrobial sulfonamide hypersensitivity, there is limited evidence that such procedures are successful because of an induction of tolerance.
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Affiliation(s)
- Timothy G Chow
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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8
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Wu P, Nelson SD, Zhao J, Stone CA, Feng Q, Chen Q, Larson EA, Li B, Cox NJ, Stein CM, Phillips EJ, Roden DM, Denny JC, Wei WQ. DDIWAS: High-throughput electronic health record-based screening of drug-drug interactions. J Am Med Inform Assoc 2021; 28:1421-1430. [PMID: 33712848 DOI: 10.1093/jamia/ocab019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/08/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We developed and evaluated Drug-Drug Interaction Wide Association Study (DDIWAS). This novel method detects potential drug-drug interactions (DDIs) by leveraging data from the electronic health record (EHR) allergy list. MATERIALS AND METHODS To identify potential DDIs, DDIWAS scans for drug pairs that are frequently documented together on the allergy list. Using deidentified medical records, we tested 616 drugs for potential DDIs with simvastatin (a common lipid-lowering drug) and amlodipine (a common blood-pressure lowering drug). We evaluated the performance to rediscover known DDIs using existing knowledge bases and domain expert review. To validate potential novel DDIs, we manually reviewed patient charts and searched the literature. RESULTS DDIWAS replicated 34 known DDIs. The positive predictive value to detect known DDIs was 0.85 and 0.86 for simvastatin and amlodipine, respectively. DDIWAS also discovered potential novel interactions between simvastatin-hydrochlorothiazide, amlodipine-omeprazole, and amlodipine-valacyclovir. A software package to conduct DDIWAS is publicly available. CONCLUSIONS In this proof-of-concept study, we demonstrate the value of incorporating information mined from existing allergy lists to detect DDIs in a real-world clinical setting. Since allergy lists are routinely collected in EHRs, DDIWAS has the potential to detect and validate DDI signals across institutions.
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Affiliation(s)
- Patrick Wu
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Scott D Nelson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,HealthIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Juan Zhao
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - QiPing Feng
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Qingxia Chen
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Eric A Larson
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Bingshan Li
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Vanderbilt Genetics Institute, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nancy J Cox
- Vanderbilt Genetics Institute, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C Michael Stein
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Elizabeth J Phillips
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dan M Roden
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Joshua C Denny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,All of Us Research Program, National Institutes of Health, Bethesda, Maryland, USA
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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9
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Liao S, Rhodes J, Jandarov R, DeVore Z, Sopirala MM. Out of Sight-Out of Mind: Impact of Cascade Reporting on Antimicrobial Usage. Open Forum Infect Dis 2020; 7:ofaa002. [PMID: 32055636 PMCID: PMC7008474 DOI: 10.1093/ofid/ofaa002] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/03/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There is a paucity of data evaluating the strategy of suppressing broader-spectrum antibiotic susceptibilities on utilization. Cascade reporting (CR) is a strategy of reporting antimicrobial susceptibility test results in which secondary (eg, broader-spectrum, costlier) agents may only be reported if an organism is resistant to primary agents within a particular drug class. Our objective was to evaluate the impact of ceftriaxone-based cascade reporting on utilization of cefepime and clinical outcomes in patients with ceftriaxone-susceptible Escherichia and Klebsiella clinical cultures. METHODS We compared post-CR (July 2014-June 2015) with baseline (July 2013-June 2014), evaluating utilization of cefepime, cefazolin, ceftriaxone, ampicillin derivatives, fluoroquinolones, piperacillin/tazobactam, ertapenem, and meropenem; new Clostridium difficile infection; and length of stay (LOS) after the positive culture, 30-day readmission, and in-hospital all-cause mortality. RESULTS Mean days of therapy (DOT) among patients who received any antibiotic for cefepime decreased from 1.229 days during the baseline period to 0.813 days post-CR (adjusted relative risk, 0.668; P < .0001). Mean DOT of ceftriaxone increased from 0.864 days to 0.962 days, with an adjusted relative risk of 1.113 (P = .004). No significant differences were detected in other antibiotics including ertapenem and meropenem, demonstrating the direct association of the decrease in cefepime utilization with CR based on ceftriaxone susceptibility. Average LOS in the study population decreased from 14.139 days to 10.882 days from baseline to post-CR and was found to be statistically significant (P < .0001). CONCLUSIONS In conclusion, we demonstrated significant association of decreased cefepime utilization with the implementation of a CR based on ceftriaxone susceptibility. We demonstrated the safety of deescalation, with LOS being significantly lower during the post-CR period than in the baseline period, with no change in in-hospital mortality.
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Affiliation(s)
- Siyun Liao
- Department of Pharmacy, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Judith Rhodes
- Department of Pathology, University of College of Medicine, Cincinnati, Ohio, USA
| | - Roman Jandarov
- Division of Biostatistics and Bioinformatics, Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Zachary DeVore
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Madhuri M Sopirala
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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10
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Macy E. Addressing the epidemic of antibiotic "allergy" over-diagnosis. Ann Allergy Asthma Immunol 2019; 124:550-557. [PMID: 31881269 DOI: 10.1016/j.anai.2019.12.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/04/2019] [Accepted: 12/16/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE An epidemic of antibiotic allergy is occurring. DATA SOURCES Articles published since 2008. STUDY SELECTIONS Articles on antibiotic allergy and stewardship. RESULTS A number of overlapping factors contribute. The most important factor is antibiotic overuse. Antibiotics are commonly used in situations in which no antibiotics are indicated. Thirty percent to 50% of ambulatory antibiotic use may be inappropriate. The duration of indicated antibiotic use is often excessive, which leads to more side effects. All antibiotic use can result in adverse reactions, and a fraction of these will be dutifully recorded as an allergy in the electronic health record (EHR). Most EHRs are not well structured to accurately convey information on expected side effects that have occurred, metabolic or other contraindications, dose-related or situational toxicities, personal preferences, clinically significant immunologically mediated hypersensitivity, and other reasons a particular patient may not want or should not be given a specific drug or type of drug in the future. As populations age, their accumulated baggage of reported antibiotic allergies increase. Suspected antibiotic allergy is rarely confirmed with appropriate testing or rechallenge. Patients then receive suboptimal antibiotic therapy and experience more side effects, treatment failures, and serious antibiotic-resistant infections. Reporting an antibiotic allergy in the EHR is nominally done to improve patient safety, but unfortunately, this is often not the actual result. CONCLUSION Audit and feedback, to help ensure adherence to Choosing Wisely recommendations and good antibiotic stewardship practices, can help reduce inappropriate antibiotic use. Restructuring EHRs to facilitate correct drug intolerance reporting, along with active antibiotic allergy delabeling programs, can help stem this epidemic.
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Affiliation(s)
- Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, California.
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11
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Chiriac AM, Macy E. Large Health System Databases and Drug Hypersensitivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2125-2131. [DOI: 10.1016/j.jaip.2019.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/09/2019] [Accepted: 04/09/2019] [Indexed: 12/26/2022]
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12
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Blanca-Lopez N, Jimenez-Rodriguez TW, Somoza ML, Gomez E, Al-Ahmad M, Perez-Sala D, Blanca M. Allergic reactions to penicillins and cephalosporins: diagnosis, assessment of cross-reactivity and management. Expert Rev Clin Immunol 2019; 15:707-721. [DOI: 10.1080/1744666x.2019.1619548] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - Maria L. Somoza
- Allergy Service, Infanta Leonor University Hospital, Madrid, Spain
| | - Enrique Gomez
- Roche Innovation Center Basel, F Hoffmann-La Roche AG, Basel, Switzerland
| | - Mona Al-Ahmad
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Dolores Perez-Sala
- Department of Structural and Chemical Biology, Centro de Investigaciones Biológicas, C.S.I.C, Madrid, Spain
| | - Miguel Blanca
- Allergy Service, Infanta Leonor University Hospital, Madrid, Spain
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Abstract
PURPOSE OF REVIEW We sought to review past and current literature on sulfonamide drug allergy and distill it in a practical manner to assist the clinician, specifically focusing on cross-reactivity and desensitization. RECENT FINDINGS There do not appear to be consistent genetic markers to reliably predict features of or the presence hypersensitivity reactions. Recent evidence continues to alleviate early concerns cross-reactivity between sulfonamide antibiotics and non-antibiotics. Sulfonamide drug allergy is frequently encountered by the practicing clinician. For sulfonamide antibiotics, delayed rash is the most common clinical manifestation. There is no current evidence to support avoidance of all non-antibiotic sulfonamides in those with a reported allergy to sulfonamide antibiotics, although certain scenarios require caution. Available evidence supports the cautious reintroduction of sulfonamide antibiotics via desensitization, which is usually well tolerated and should be considered in those with strong indications for trimethoprim-sulfamethoxazole and a reported sulfonamide allergy.
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Affiliation(s)
- Joshua M Dorn
- Mayo Clinic, Division of Allergic Diseases, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mollie Alpern
- Mayo Clinic, Division of Allergic Diseases, 200 First Street SW, Rochester, MN, 55905, USA
| | - Caitlin McNulty
- Mayo Clinic, Division of Allergic Diseases, 200 First Street SW, Rochester, MN, 55905, USA
| | - Gerald W Volcheck
- Mayo Clinic, Division of Allergic Diseases, 200 First Street SW, Rochester, MN, 55905, USA.
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