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Ali SB, Hughes T, Smith A. Penicillin or cephalosporin antibiotic allergy label: Influence on length of stay and hospital readmission. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100272. [PMID: 38817345 PMCID: PMC11137559 DOI: 10.1016/j.jacig.2024.100272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/04/2024] [Accepted: 02/15/2024] [Indexed: 06/01/2024]
Abstract
Background A penicillin or cephalosporin antibiotic (PCA) allergy label (PCAAL) has negative implications for both the patient and health care alike. Objective A retrospective study was undertaken to evaluate the influence of a PCAAL on length of stay (LOS) and hospital readmissions. Methods Over 4 weeks, inpatients with a PCAAL who were referred to the allergy service or opportunistically reviewed were grouped in the categories delabeled (group 1a) or advice not followed (ie, label carriage) (group 1b). Comparator groups without a PCAAL were identified, those either on a PCA (the PCA group [group 2]) or on a non-PCA (the non-PCA group [group 3]). Results The study population comprised 77 patients as follows: group 1a (n = 19), group 1b (n = 6), group 2 (n = 36), and group 3 (n = 16). Those in group 1a were significantly older (median age 78 years) than those in group 1b (median age 53 years [P = .013]) or group 3 (median age 59 years [P = .013]).There was a trend toward lower LOS in group 1a (10 days) than in group 1b (11.5 days [P = not significant]). Group 2 had a significantly lower LOS (6 days) than either both group 1a (10 days [P = .043]) or group 3 (15 days [P = .002]). Group 3 had the highest rate of patients readmitted within 30 days (n = 5 [71.4%]). Conclusion A PCAAL carries influence on both LOS and readmissions, thus identifying the prompt need for allergy review to provide specific recommendations: delabeling and transition to an appropriate antibiotic. The significantly older group of those with a PCAAL who received a PCA after delabeling (ie, a 20-year age difference) may also be a signal that more elderly and comorbid patients benefit from this intervention the most.
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Affiliation(s)
- Syed B. Ali
- Department of Clinical Immunology and Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine, Flinders University, Bedford Park, Australia
| | - Tiffany Hughes
- Department of Clinical Immunology and Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine, Flinders University, Bedford Park, Australia
| | - Anthony Smith
- Department of Clinical Immunology and Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine, Flinders University, Bedford Park, Australia
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Green EA, Fogarty K, Ishmael FT. Penicillin Allergy: Mechanisms, Diagnosis, and Management. Med Clin North Am 2024; 108:671-685. [PMID: 38816110 DOI: 10.1016/j.mcna.2023.08.009] [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] [Indexed: 06/01/2024]
Abstract
Allergy to penicillin can occur via any of the 4 types of Gel-Coombs hypersensitivity reactions, producing distinct clinical histories and physical examination findings. Treatments include penicillin discontinuation, and depending on the type of reaction, epinephrine, antihistamines, and/or glucocorticoids. Most beta-lactams may be safely used in penicillin-allergic patients, with the possible exception of first-generation and second-generation cephalosporins. Penicillin testing includes skin testing, patch testing, and graded challenge. The selection of the type of testing depends on the clinical setting, equipment availability, and type of hypersensitivity reaction. Desensitization may be used in some cases where treatment with penicillins is essential.
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Affiliation(s)
- Estelle A Green
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Kelan Fogarty
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Faoud T Ishmael
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA; Mount Nittany Health, 1850 East Park Avenue, State College, PA 16803, USA.
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3
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Huang M, Okocha O, Selzer A. Perioperative management of penicillin allergy - the essential partnership between physicians and patients in advancing antibiotic stewardship. J Clin Anesth 2024; 94:111426. [PMID: 38422955 DOI: 10.1016/j.jclinane.2024.111426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/13/2023] [Accepted: 02/23/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Misha Huang
- Department of Medicine Division of Infectious Diseases at the University of Colorado
| | | | - Angela Selzer
- Department of Anesthesiology at the University of Colorado.
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4
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Porto JR, Lavu MS, Hecht CJ, McNassor R, Burkhart RJ, Kamath AF. Is Penicillin Allergy a Clinical Problem? A Systematic Review of Total Joint Arthroplasty Procedures With Implications for Patient Safety and Antibiotic Stewardship. J Arthroplasty 2024; 39:1616-1623. [PMID: 38040064 DOI: 10.1016/j.arth.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Patients undergoing total joint arthroplasty (TJA) who report penicillin allergy (PA) are frequently administered second-line antibiotics, although recent evidence suggests that this may be unnecessary and could increase infection risk. Many institutions have aimed to improve antibiotic deployment via allergy testing and screening; however, there is little standardization to this process. This review aimed to evaluate (1) antibiotic selection in patients who report PA and assess the impact of screening and testing interventions, (2) rates of allergic reactions in patients who report PA, and (3) the association between reported PA and screening or testing programs and odds of surgical site infection or periprosthetic joint infection. METHODS PubMed, EBSCOhost, and Google Scholar electronic databases were searched on February 4, 2023 to identify all studies published since January 1, 2000 that evaluated the impact of PA on patients undergoing TJA (PROSPERO study protocol registration: CRD42023394031). Articles were included if full-text manuscripts in English were available, and the study analyzed the impact of PA and related interventions on TJA patients. There were 11 studies evaluating 1,276,663 patients included. Interventions were compared via presentation of key findings regarding rates of clinically relevant or high-risk PA reported upon screenings or testings, cephalosporin utilizations, allergic reactions, and postoperative infections (surgical site infection and periprosthetic joint infection). RESULTS All 6 studies found that PA screening and testing markedly increase the use of first-line antibiotics. Testing showed low rates of true allergy (0.7 to 3%) and allergic reaction frequency for patients who have reported PA receiving cephalosporins was between 0% and 2%. Although there were mixed findings across studies, there was a trend toward second-line antibiotic prophylaxis being associated with a slightly higher rate of infection in PA patients. CONCLUSIONS Using PA screening and testing can promote antibiotic stewardship by safely increasing the use of first-line antibiotics in patients who have a reported PA. LEVEL OF EVIDENCE Level III, Therapeutic Study.
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Affiliation(s)
- Joshua R Porto
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Monish S Lavu
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christian J Hecht
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ryan McNassor
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, Michigan
| | - Robert J Burkhart
- Department of Orthopaedic Surgery, University Hospitals, Cleveland, Ohio
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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5
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Rose MT, Holmes NE, Eastwood GM, Vogrin S, James F, De Luca JF, Bellomo R, Warrillow SJ, Phung M, Barnes SL, Murfin B, Rogers B, Lambros B, Collis B, Peel TN, Slavin MA, Trubiano JA. Oral challenge vs routine care to assess low-risk penicillin allergy in critically ill hospital patients (ORACLE): a pilot safety and feasibility randomised controlled trial. Intensive Care Med 2024; 50:913-921. [PMID: 38739277 PMCID: PMC11164790 DOI: 10.1007/s00134-024-07448-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/14/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE Critically ill patients are vulnerable to penicillin allergy labels that may be incorrect. The validity of skin testing in intensive care units (ICUs) is uncertain. Many penicillin allergy labels are low risk, and validated tools exist to identify those amenable to direct oral challenge. This pilot randomised controlled trial explored the feasibility, safety, and validity of direct enteral challenge for low-risk penicillin allergy labels in critical illness. METHODS Consenting patients with a low-risk penicillin allergy label (PAL) (PEN-FAST risk assessment score < 3) in four ICUs (Melbourne, Australia) were randomised 1:1 to penicillin (250 mg amoxicillin or implicated penicillin) direct enteral challenge versus routine care (2-h post-randomisation observation for each arm). Repeat challenge was performed post -ICU in the intervention arm. Patients were reviewed at 24 h and 5 days after each challenge/observation. RESULTS We screened 533 patients. 130 (24.4%) were eligible and 80/130 (61.5%) enrolled (age median 64.5 years (interquartile range, IQR 53.5, 74), PEN-FAST median 1 (IQR 0,1)), with 40 (50%) randomised to direct enteral challenge. A positive challenge rate of 2.5% was identified. No antibiotic-associated serious adverse events were identified. 32/40 (80%) received a repeat challenge (zero positive). Post-randomisation, 13 (32%) of the intervention arm and 4 (10%) of the control arm received penicillin (odds ratio, OR 4.33 [1.27, 14.78] p = 0.019). CONCLUSION These findings support the safety, validity, and feasibility of direct enteral challenge for critically ill patients with PEN-FAST assessed low-risk penicillin allergy. The absence of false negative results was confirmed by subsequent negative repeat challenges. A relatively low recruitment to screened ratio suggests that more inclusive eligibility criteria and integration of allergy assessment into routine ICU processes are needed to optimise allergy delabelling in critical illness.
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Affiliation(s)
- Morgan T Rose
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia.
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia.
| | - Natasha E Holmes
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, Austin Health/University of Melbourne, Melbourne, VIC, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Sara Vogrin
- Department of Medicine (St Vincent's Hospital), University of Melbourne, Melbourne, VIC, Australia
| | - Fiona James
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Joseph F De Luca
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Parkville, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Stephen J Warrillow
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, The University of Melbourne, Parkville, VIC, Australia
| | - Michelle Phung
- Pharmacy Department, Monash Health, Clayton, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, VIC, Australia
| | - Sara L Barnes
- Monash Lung Sleep Allergy and Immunology, Monash Health, Clayton, VIC, Australia
| | - Brendan Murfin
- Intensive Care Unit, Monash Health, Clayton, VIC, Australia
| | - Ben Rogers
- Monash Infectious Diseases, Monash Health, Clayton, VIC, Australia
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Belinda Lambros
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Brennan Collis
- Department of Infectious Diseases, Alfred Health, Melbourne, VIC, Australia
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Health, Melbourne, VIC, Australia
- Department of Infectious Diseases, Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Monica A Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Immunocompromised Host Infection Service, Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
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Oseni LA, Tryfonos A, Basta C, Vastardi MA, Hammerschlag MR. Pediatric Residents Knowledge of Penicillin Allergy. Clin Pediatr (Phila) 2024:99228241254703. [PMID: 38767311 DOI: 10.1177/00099228241254703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Penicillin allergy knowledge has not been evaluated specifically in the pediatric resident population. An anonymous electronic survey was distributed to all the pediatric residents in a single residency program to ascertain knowledge of penicillin allergies and allergy history taking skills. Responses among each resident class were compared using the Fisher exact test, 2-tailed. A total of 46 (52%) of 88 pediatric residents completed the survey. Only 63% reported to have had prior penicillin allergy education. All residents incorrectly identified low-risk symptoms as high-risk symptoms. The knowledge of penicillin allergy was poor across all training levels with no improvement over the duration of training. There is large support in the literature for de-labeling penicillin allergy in patients. Pediatric residents evaluate patients in childhood when most of the allergy labeling occurs. We need to consider strategies for incorporating penicillin allergy education in pediatric residency training.
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Affiliation(s)
- Lauretta A Oseni
- Division of Hospital Medicine, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
| | - Anna Tryfonos
- Department of Pediatrics, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
| | - Caroline Basta
- Division of Allergy and Immunology, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
| | - Maria-Anna Vastardi
- Division of Allergy and Immunology, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
| | - Margaret R Hammerschlag
- Division of Infectious Diseases, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
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7
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Lillis RA, Barbee LA, McNeil CJ, Newman L, Fortenberry JD, Alvarez-Arango S, Zenilman JM. Randomized Multicenter Trial for the Validation of an Easy-to-Administer Algorithm to Define Penicillin Allergy Status in Sexually Transmitted Infection Clinic Outpatients. Clin Infect Dis 2024; 78:1131-1139. [PMID: 38325290 DOI: 10.1093/cid/ciae064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Approximately 15% of patients in sexually transmitted infection (STI) clinics report penicillin allergies, complicating treatment for syphilis and gonorrhea. Nonetheless, >90% do not have a penicillin allergy when evaluated. We developed and validated an algorithm to define which patients reporting penicillin allergy can be safely treated at STI clinics with these drugs. METHODS Randomized controlled trial to assess feasibility and safety of penicillin allergy evaluations in STI clinics. Participants with reported penicillin allergy answered an expert-developed questionnaire to stratify risk. Low-risk participants underwent penicillin skin testing (PST) followed by amoxicillin 250 mg challenge or a graded oral challenge (GOC)-amoxicillin 25 mg followed by 250 mg. Reactions were recorded, and participant/provider surveys were conducted. RESULTS Of 284 participants, 72 (25.3%) were deemed high risk and were excluded. Of 206 low-risk participants, 102 (49.5%) underwent PST without reactions and 3 (3%) had mild reactions during the oral challenge. Of 104 (50.5%) participants in the GOC, 95 (91.3%) completed challenges without reaction, 4 (4.2%) had mild symptoms after 25 mg, and 4 (4.2%) after 250-mg doses. Overall, 195 participants (94.7%) successfully completed the study and 11 (5.3%) experienced mild symptoms. Of 14 providers, 12 (85.7%) completed surveys and 11 (93%) agreed on the safety/effectiveness of penicillin allergy assessment in STI clinics. CONCLUSIONS An easy-to-administer risk-assessment questionnaire can safely identify patients for penicillin allergy evaluation in STI clinics by PST or GOC, with GOC showing operational feasibility. Using this approach, 67% of participants with reported penicillin allergy could safely receive first-line treatments for gonorrhea or syphilis. Clinical Trials Registration. Clinicaltrials.gov (NCT04620746).
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Affiliation(s)
- Rebecca A Lillis
- Section of Infectious Diseases, Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | - Lindley A Barbee
- Division of Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Candice J McNeil
- Section of Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Lori Newman
- National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - J Dennis Fortenberry
- Division of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Santiago Alvarez-Arango
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonathan M Zenilman
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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8
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Lockhart PB, Durkin MJ, Blumenthal KG, Paumier TM, Baddour LM. Evaluation of patients labeled with a penicillin allergy to promote antimicrobial stewardship in dental practice. J Am Dent Assoc 2024:S0002-8177(24)00143-0. [PMID: 38703160 DOI: 10.1016/j.adaj.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/29/2024] [Accepted: 03/11/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Approximately 10% of the US population self-reports a penicillin allergy history or are labeled as penicillin allergic. However, from 90% through 99% of these patients are not allergic on formal evaluation. CASE DESCRIPTION Patients labeled as penicillin allergic receive broader-spectrum and sometimes less-effective antibiotics, thereby contributing to increased treatment failures, antibiotic resistance, and adverse drug reactions. Self-reported penicillin allergy can be eliminated or classified as low-, medium-, or high-risk after a careful review of patient history. This allows these patients to be delabeled; that is, having any reference to their penicillin allergy history or of having an allergy to penicillin eliminated from their health records. PRACTICAL IMPLICATIONS Oral health care professionals are ideally placed to partner in both antibiotic stewardship interventions by means of recognizing pervasive mislabeling and aiding in the process of delabeling.
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9
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Gonzalez-Estrada A, Park MA, Accarino JJO, Banerji A, Carrillo-Martin I, D'Netto ME, Garzon-Siatoya WT, Hardway HD, Joundi H, Kinate S, Plager JH, Rank MA, Rukasin CRF, Samarakoon U, Volcheck GW, Weston AD, Wolfson AR, Blumenthal KG. Predicting Penicillin Allergy: A United States Multicenter Retrospective Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1181-1191.e10. [PMID: 38242531 DOI: 10.1016/j.jaip.2024.01.010] [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: 04/04/2023] [Revised: 12/29/2023] [Accepted: 01/07/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND Using the reaction history in logistic regression and machine learning (ML) models to predict penicillin allergy has been reported based on non-US data. OBJECTIVE We developed ML positive penicillin allergy testing prediction models from multisite US data. METHODS Retrospective data from 4 US-based hospitals were grouped into 4 datasets: enriched training (1:3 case-control matched cohort), enriched testing, nonenriched internal testing, and nonenriched external testing. ML algorithms were used for model development. We determined area under the curve (AUC) and applied the Shapley Additive exPlanations (SHAP) framework to interpret risk drivers. RESULTS Of 4777 patients (mean age 60 [standard deviation: 17] years; 68% women, 91% White, and 86% non-Hispanic) evaluated for penicillin allergy labels, 513 (11%) had positive penicillin allergy testing. Model input variables were frequently missing: immediate or delayed onset (71%), signs or symptoms (13%), and treatment (31%). The gradient-boosted model was the strongest model with an AUC of 0.67 (95% confidence interval [CI]: 0.57-0.77), which improved to 0.87 (95% CI: 0.73-1) when only cases with complete data were used. Top SHAP drivers for positive testing were reactions within the last year and reactions requiring medical attention; female sex and reaction of hives/urticaria were also positive drivers. CONCLUSIONS An ML prediction model for positive penicillin allergy skin testing using US-based retrospective data did not achieve performance strong enough for acceptance and adoption. The optimal ML prediction model for positive penicillin allergy testing was driven by time since reaction, seek medical attention, female sex, and hives/urticaria.
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Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Miguel A Park
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - John J O Accarino
- Division of Rheumatology, Allergy, and Immunology, 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
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Michael E D'Netto
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - W Tatiana Garzon-Siatoya
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Heather D Hardway
- Digital Innovation Lab, Department of Health Sciences Research, Mayo Clinic, Jacksonville, Fla
| | - Hajara Joundi
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Susan Kinate
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz
| | - Jessica H Plager
- Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Section of Allergy, Immunology, Division of Pulmonary, Phoenix Children's Hospital, Phoenix, Ariz
| | - Christine R F Rukasin
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Section of Allergy, Immunology, Division of Pulmonary, Phoenix Children's Hospital, Phoenix, Ariz
| | - Upeka Samarakoon
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - Alexander D Weston
- Digital Innovation Lab, Department of Health Sciences Research, Mayo Clinic, Jacksonville, Fla
| | - Anna R Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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10
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Gray MP, Kellum JA, Kirisci L, Boyce RD, Kane-Gill SL. Long-Term Outcomes Associated With β-Lactam Allergies. JAMA Netw Open 2024; 7:e2412313. [PMID: 38758551 PMCID: PMC11102016 DOI: 10.1001/jamanetworkopen.2024.12313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/19/2024] [Indexed: 05/18/2024] Open
Abstract
Importance β-lactam (BL) allergies are the most common drug allergy worldwide, but most are reported in error. BL allergies are also well-established risk factors for adverse drug events and antibiotic-resistant infections during inpatient health care encounters, but the understanding of the long-term outcomes of patients with BL allergies remains limited. Objective To evaluate the long-term clinical outcomes of patients with BL allergies. Design, Setting, and Participants This longitudinal retrospective cohort study was conducted at a single regional health care system in western Pennsylvania. Electronic health records were analyzed for patients who had an index encounter with a diagnosis of sepsis, pneumonia, or urinary tract infection between 2007 and 2008. Patients were followed-up until death or the end of 2018. Data analysis was performed from January 2022 to January 2024. Exposure The presence of any BL class antibiotic in the allergy section of a patient's electronic health record, evaluated at the earliest occurring observed health care encounter. Main Outcomes and Measures The primary outcome was all-cause mortality, derived from the Social Security Death Index. Secondary outcomes were defined using laboratory and microbiology results and included infection with methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, or vancomycin-resistant Enterococcus (VRE) and severity and occurrence of acute kidney injury (AKI). Generalized estimating equations with a patient-level panel variable and time exposure offset were used to evaluate the odds of occurrence of each outcome between allergy groups. Results A total of 20 092 patients (mean [SD] age, 62.9 [19.7] years; 12 231 female [60.9%]), of whom 4211 (21.0%) had BL documented allergy and 15 881 (79.0%) did not, met the inclusion criteria. A total of 3513 patients (17.5%) were Black, 15 358 (76.4%) were White, and 1221 (6.0%) were another race. Using generalized estimating equations, documented BL allergies were not significantly associated with the odds of mortality (odds ratio [OR], 1.02; 95% CI, 0.96-1.09). BL allergies were associated with increased odds of MRSA infection (OR, 1.44; 95% CI, 1.36-1.53), VRE infection (OR, 1.18; 95% CI, 1.05-1.32), and the pooled rate of the 3 evaluated antibiotic-resistant infections (OR, 1.33; 95% CI, 1.30-1.36) but were not associated with C difficile infection (OR, 1.04; 95% CI, 0.94-1.16), stage 2 and 3 AKI (OR, 1.02; 95% CI, 0.96-1.10), or stage 3 AKI (OR, 1.06; 95% CI, 0.98-1.14). Conclusions and Relevance Documented BL allergies were not associated with the long-term odds of mortality but were associated with antibiotic-resistant infections. Health systems should emphasize accurate allergy documentation and reduce unnecessary BL avoidance.
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Affiliation(s)
- Matthew P. Gray
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - John A. Kellum
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Levent Kirisci
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Richard D. Boyce
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sandra L. Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
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11
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Azmy V, Lundsberg LS, Culhane J, Kwah J, Partridge C, Son M. Pregnant Patients with a Documented History of Penicillin Allergy and Associated Maternal and Neonatal Outcomes at a Tertiary Care Center. Am J Perinatol 2024; 41:e2051-e2057. [PMID: 37211008 DOI: 10.1055/a-2096-5002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Pregnant individuals are likely to need antibiotics during the peripartum period. For pregnant individuals who report a history of penicillin allergy, non-β-lactam antibiotics are often administered. Compared with first-line β-lactam antibiotics, alternative antibiotics can be less effective, more toxic, and more costly. It remains unclear if being labeled with a penicillin allergy is associated with adverse maternal and neonatal outcomes. STUDY DESIGN We conducted a retrospective cohort study of all pregnant patients who delivered a viable singleton between 24 and 42 weeks of gestation at a large academic hospital from 2013 to 2021. We compared patients who had a documented penicillin allergy history in their electronic medical record versus those who did not and examined whether there were significant differences in maternal outcomes and neonatal outcomes. Bivariable and multivariable analyses were performed. RESULTS Of 41,943 eligible deliveries included in the analysis, 4,705 (11.2%) patients had a penicillin allergy history documented in their electronic medical record and 37,238 (88.8%) did not. Even after adjusting for potential confounders, patients with a documented penicillin allergy had a higher risk of postpartum endometritis (adjusted odds ratio [aOR]: 1.46; 95% confidence interval [CI]: 1.01-2.11) and a higher risk of their neonates having a postnatal hospital stay lasting more than 72 hours (aOR: 1.10; 95% CI: 1.02-1.18). There were no significant differences seen in the other maternal and neonatal outcomes in both bivariable and multivariable analyses. CONCLUSION Pregnant patients who are labeled as having a penicillin allergy are more likely to have postpartum endometritis, and neonates born to mothers who are labeled as having a penicillin allergy are more likely to have a postnatal hospital stay lasting more than 72 hours. There were no other significant differences seen in pregnant patients and their newborns whether they were labeled as having a penicillin allergy history or not. However, pregnant individuals with a penicillin allergy documented in their medical record were significantly more likely to receive alternative non-β lactam antibiotics, and may have benefitted from having more details of their allergy history available as well as proper allergy verification with testing. KEY POINTS · It is unclear whether pregnant individuals labeled with penicillin allergies have worse obstetric outcomes.. · These individuals were significantly more likely to have endometritis and their newborns hospitalized for >72 hours.. · They were significantly more likely to receive alternative non-β lactam antibiotics than those without documented allergies..
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Affiliation(s)
- Veronica Azmy
- Section of Rheumatology, Allergy and Clinical Immunology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer Culhane
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Jason Kwah
- Section of Rheumatology, Allergy and Clinical Immunology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Moeun Son
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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12
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Sobrino-García M, Muñoz-Bellido FJ, Moreno-Rodilla E, Martín-Muñoz R, García-Iglesias A, Dávila I. Delabeling of allergy to beta-lactam antibiotics in hospitalized patients: a prospective study evaluating cost savings. Int J Clin Pharm 2024:10.1007/s11096-024-01737-7. [PMID: 38642250 DOI: 10.1007/s11096-024-01737-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/04/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Patients with a penicillin allergy label are at risk of an associated increase in adverse antibiotic events and hospitalization costs. AIM We aimed to study the economic savings derived from the correct diagnosis and delabeling inpatients with suspected beta-lactam allergy, considering the acquisition cost of antimicrobials prescribed during a patient's hospital stay. METHOD We prospectively evaluated patients admitted to the University Hospital of Salamanca who had been labeled as allergic to beta-lactams and performed a delabeling study. Subsequently, cost differences between antibiotics administered before and after the allergy study and those derived from those patients who received alternative antibiotics during admission and those who switched to beta-lactams after the allergy study were calculated. RESULTS One hundred seventy-seven inpatients labeled as allergic to beta-lactams underwent a delabeling study; 34 (19.2%) were confirmed to have allergy to beta-lactams. Of the total number of patients, 136 (76.8%) received antibiotics during their hospitalization, involving a mean (SD) cost of €203.07 (318.42) and a median (IQR) cost of €88.97 (48.86-233.56). After delabeling in 85 (62.5%) patients, the antibiotic treatment was changed to beta-lactams. In this group of patients, the mean cost (SD) decreased from €188.91 (351.09) before the change to 91.31 (136.07) afterward, and the median cost (IQR) decreased from €72.92 (45.82-211.99) to €19.24 (11.66-168). The reduction was significant compared to the median cost of patients whose treatment was not changed to beta-lactams (p<0.001). CONCLUSION Delabeling hospitalized patients represents a cost-saving measure for treating patients labeled as allergic to beta-lactams.
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Affiliation(s)
- Miriam Sobrino-García
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain
| | - Francisco J Muñoz-Bellido
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain.
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain.
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Castilla y León, Spain.
- Red de Enfermedades Inflamatorias - Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain.
- Servicio de Alergología, Hospital Universitario de Salamanca, Paseo de La Transición Española, 37007, Salamanca, Spain.
| | - Esther Moreno-Rodilla
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Castilla y León, Spain
- Red de Enfermedades Inflamatorias - Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain
| | - Rita Martín-Muñoz
- Hospital Pharmacy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
| | - Aránzazu García-Iglesias
- Admission and Clinical Documentation Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
| | - Ignacio Dávila
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Castilla y León, Spain
- Red de Enfermedades Inflamatorias - Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain
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13
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Wong JCY, Kan AKC, Chik TSH, Chu MY, Li TCM, Mak HWF, Chiang V, Li PH. Prospective, Multicenter, Head-to-Head Comparison Between Allergists Versus Nonallergists in Low-Risk Penicillin Allergy Delabeling: Effectiveness, Safety, and Quality of Life (HK-DADI2). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00394-5. [PMID: 38631522 DOI: 10.1016/j.jaip.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/03/2024] [Accepted: 04/06/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Penicillin "allergy" labels are prevalent but frequently misdiagnosed. Mislabelled allergies are associated with adverse outcomes and increased antimicrobial resistance. With an urgent need to delabel the overwhelming number of mislabeled allergies, nonallergist evaluations have been advocated for low-risk individuals. Despite growing interest in non-allergist-led initiatives, evidence on their effectiveness, safety, and impact by direct comparisons is lacking. OBJECTIVE To assess the comparative outcomes of penicillin allergy evaluations conducted by allergists versus nonallergists. METHODS A prospective, multicenter, pragmatic study was conducted at 4 tertiary hospitals (1 allergist- vs 3 non-allergist-led) for low-risk penicillin allergy patients in Hong Kong-the Hong Kong Drug Allergy Delabelling Initiative 2 (HK-DADI2). RESULTS Among 228 low-risk patients who underwent testing (32.9% by allergists, 67.1% by nonallergists), only 14 (6.1%) had positive penicillin allergy testing results. Delabeling rates (94.1% vs 93.3%; P = .777), positive skin test results (2.6% vs 2.7%; P > .99), and drug provocation test results (3.3% vs 2.7%; P = 1.000) were similar between allergists and nonallergists. There were no systemic reactions in either cohort. All patients had significant improvements in health-related quality of life (Drug Hypersensitivity Quality of Life Questionnaire scores -5.00 vs -8.33; P = .072). Nonallergist evaluations had shorter waiting times (0.57 vs 15.7 months; P < .001), whereas allergists required fewer consultations with higher rate of completing evaluations within a single visit (odds ratio, 0.04; P < .001). CONCLUSIONS With training and support, nonallergists can independently evaluate low-risk penicillin allergies. Compared with allergists, evaluation of low-risk penicillin allergy by nonallergists can be comparably effective, safe, and impactful on quality of life. More multidisciplinary partnerships to empower nonallergists to conduct allergy evaluations should be encouraged.
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Affiliation(s)
- Jane C Y Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Andy K C Kan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Thomas S H Chik
- Division of Infectious Diseases, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | - M Y Chu
- Division of Infectious Diseases, Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Timothy C M Li
- Division of Infectious Diseases, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong
| | - Hugo W F Mak
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
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Ravikumar R, Arora NS, Hanson R, Barhitte L, Nagel J, Aitken SL, Bashaw L, Gandhi T, Spranger E, Marshall VD, Eschenauer GA. A novel 2-step process for the management of inpatient beta-lactam allergy labels. Ann Allergy Asthma Immunol 2024; 132:525-531.e1. [PMID: 38151095 DOI: 10.1016/j.anai.2023.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/22/2023] [Accepted: 12/22/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Inpatient beta-lactam allergy labels may increase the unnecessary use of aztreonam and non-beta-lactam antibiotics, which can then lead to more adverse events and increased health care costs, OBJECTIVE: To assess the impact of a novel 2-step process (medication history review followed by risk stratification) on rates of beta-lactam delabeling, aztreonam use, and desensitizations on pediatric, adult, and obstetrics inpatients at a tertiary academic center. METHODS We prospectively collected data on 700 patients who received inpatient consultation from the Beta-Lactam Allergy Evaluation Service between August 2021 and July 2022. Patients were delabeled either by medication review alone, drug challenge alone if with a low-risk history, or penicillin skin test followed by drug challenge if with a high-risk history. Generalized linear regression modeling was used to compare aztreonam days of therapy in the intervention year with the 2 prior years. Drug desensitizations were assessed by electronic chart review. RESULTS Most of the patients (n = 656 of 700, 94%) had more than or equal to 1 beta-lactam allergy label removed, clarified, or both; 77.9% of these patients (n = 511 of 656) had 587 beta-lactam allergy labels removed. Nearly one-third (n = 149, 27.6%) had 162 allergy labels removed solely by medication history review. All 114 penicillin skin tests performed had negative results, and 98% (8 of 381) of the patients who underwent any drug challenge passed. Only 5.7% of the delabeled patients were relabeled. There was a 27% reduction in aztreonam use (P = .007). Beta-lactam desensitizations were reduced by 80%. CONCLUSION A full-time inpatient beta-lactam allergy service using medication history review and risk stratification can safely and effectively remove inpatient beta-lactam allergy labels, reduce aztreonam use, and decrease beta-lactam desensitizations.
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Affiliation(s)
- Rajan Ravikumar
- Division of Allergy and Clinical Immunology, Michigan Medicine, Ann Arbor, Michigan.
| | - Nonie S Arora
- Department of Internal Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Rebecca Hanson
- Division of Allergy and Clinical Immunology, Michigan Medicine, Ann Arbor, Michigan
| | - Lauren Barhitte
- Division of Allergy and Clinical Immunology, Michigan Medicine, Ann Arbor, Michigan
| | - Jerod Nagel
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan
| | - Samuel L Aitken
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan
| | - Linda Bashaw
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Tejal Gandhi
- Division of Infectious Diseases, Michigan Medicine, Ann Arbor, Michigan
| | | | - Vincent D Marshall
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Gregory A Eschenauer
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan
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15
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Carter EJ, Zavez K, Rogers SC, deMayo R, Harel O, Gerber JS, Aseltine RH. Documented Penicillin Allergies on Antibiotic Selection at Pediatric Emergency Department Visits. Pediatr Emerg Care 2024; 40:283-288. [PMID: 37549307 DOI: 10.1097/pec.0000000000003023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Penicillin or amoxicillin are the recommended treatments for the most common pediatric bacterial illnesses. Allergies to penicillin are commonly reported among children but rarely true. We evaluated the impact of reported penicillin allergies on broad-spectrum antibiotic use overall and for the treatment of common respiratory infections among treat-and-release pediatric emergency department (ED) visits. METHODS Retrospective cohort study of pediatric patients receiving antibiotics during a treat-and-release visit at a large, pediatric ED in the northeast from 2014 to 2016. Study exposure was a reported allergy to penicillin in the electronic medical record. Study outcomes were the selection of broad-spectrum antibiotics and alternative (second-line) antibiotic therapy for the treatment of acute otitis media (AOM) and group A streptococcus (GAS) pharyngitis. We used unadjusted and adjusted generalized estimating equation models to analyze the impact of reported penicillin allergies on the selection of broad-spectrum antibiotics. We used unadjusted and adjusted logistic regression models to determine the probability of children with a documented penicillin allergy receiving alternative antibiotic treatments for AOM and GAS. RESULTS Among 12,987 pediatric patients, 810 (6.2%) had a documented penicillin allergy. Penicillin allergies increased the odds of children receiving a broad spectrum versus narrow spectrum antibiotic (adjusted odds ratio, 13.55; 95% confidence interval (CI), 11.34-16.18). In our adjusted logistic regression model, the probability of children with a documented penicillin allergy receiving alternative antibiotic treatment for AOM was 0.97 (95% CI, 0.94-0.99) and for GAS was 0.97 (95% CI, 0.92-0.99). CONCLUSIONS Antibiotic stewardship efforts in pediatric EDs may consider the delabeling of penicillin allergies particularly among children receiving antibiotics for an acute respiratory infection as a target for intervention.
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Affiliation(s)
- Eileen J Carter
- From the University of Connecticut School of Nursing, Storrs, CT
| | - Katherine Zavez
- University of Connecticut Department of Statistics, Storrs, CT
| | - Steven C Rogers
- Pediatric Emergency Medicine, Connecticut Children's, Hartford, CT
| | - Richelle deMayo
- Department of Informatics, Connecticut Children's Medical Center, Hartford, CT
| | - Ofer Harel
- University of Connecticut Department of Statistics, Storrs, CT
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16
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Providencia R, Aali G, Zhu F, Leas BF, Orrell R, Ahmad M, Bray JJH, Pelone F, Nass P, Marijon E, Cassandra M, Celermajer DS, Shokraneh F. Penicillin Allergy Testing and Delabeling for Patients Who Are Prescribed Penicillin: A Systematic Review for a World Health Organization Guideline. Clin Rev Allergy Immunol 2024; 66:223-240. [PMID: 38696031 DOI: 10.1007/s12016-024-08988-2] [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] [Accepted: 03/16/2024] [Indexed: 06/23/2024]
Abstract
Secondary prevention with penicillin aims to prevent further episodes of acute rheumatic fever and subsequent development of rheumatic heart disease (RHD). Penicillin allergy, self-reported by 10% of the population, can affect secondary prevention programs. We aimed to assess the role for (i) routine penicillin allergy testing and the (ii) safety of penicillin allergy delabeling approaches in this context. We searched MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, WHO ICTRP, ISRCTN, and CPCI-S to identify the relevant reports. We found 2419 records, but no studies addressed our initial question. Following advice from the WHO-Guideline committee and experts, we identified 6 manuscripts on allergy testing focusing on other populations showing that the prevalence of allergy confirmed by testing was low and the incidence of life-threatening reactions to BPG was very low (< 1-3/1000 individuals treated). A subsequent search addressed penicillin allergy delabeling. This found 516 records, and 5 studies addressing the safety of direct oral drug challenge vs. skin testing followed by drug administration in patients with suspected penicillin allergy. Immediate allergic reactions of minor severity were observed for a minority of patients and occurred less frequently in the direct drug challenge group: 2.3% vs. 11.5%; RR = 0.25, 95%CI 0.15-0.45, P < 0.00001, I2 = 0%. No anaphylaxis or deaths were observed. Severe allergic reactions to penicillin are extremely rare and can be recognized and dealt by trained healthcare workers. Confirmation of penicillin allergy diagnosis or delabeling using direct oral drug challenge or penicillin skin testing seems to be safe and is associated with a low rate of adverse reactions.
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Affiliation(s)
- Rui Providencia
- University College London, London, UK.
- Barts Heart Centre, London, UK.
| | - Ghazaleh Aali
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Oxford, UK
| | - Fang Zhu
- Department of Biostatistics, Systematic Review Consultants LTD, Oxford, UK
| | - Brian F Leas
- Department of Biostatistics, Systematic Review Consultants LTD, Oxford, UK
| | - Rachel Orrell
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Oxford, UK
| | - Mahmood Ahmad
- University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | | | | | - Petra Nass
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Oxford, UK
| | - Eloi Marijon
- European Georges Pompidou Hospital, Paris, France
| | | | | | - Farhad Shokraneh
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Oxford, UK
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17
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Meehl S, Salathe C, Cooley C, Jordan-Villegas A, Laham FR, Madala A, Cowart M. Beta-Lactam Allergy De-labeling in a Pediatric Hospital. J Pediatr Pharmacol Ther 2024; 29:169-174. [PMID: 38596425 PMCID: PMC11001211 DOI: 10.5863/1551-6776-29.2.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/15/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVE To assess the ability to de-label pediatric patients of their beta-lactam allergy by using a newly implemented institutional protocol and to identify potential barriers to the de-labeling process. METHODS All patients with reported allergies to prespecified beta-lactam antibiotics were eligible for a -beta-lactam allergy interview. Following the interview, patients were grouped into 4 risk categories-no risk, low risk, moderate risk, and high risk-and assessed for intervention eligibility. Potential interventions included de-labeling based on the interview alone or proceeding to an oral amoxicillin challenge with or without penicillin allergy skin testing. RESULTS Of the 62 patients eligible for beta-lactam allergy interviews, 40% (n = 25) were de-labeled. Among de-labeled patients, 60% (n = 15) were de-labeled on the basis of the interview alone. Additionally, no failures were documented in patients who underwent an oral amoxicillin challenge or penicillin skin testing. Barriers to performing oral amoxicillin challenges or penicillin skin testing included concomitant systemic steroid or antihistamine use, refusal of intervention, and insufficient resources to perform penicillin skin testing. CONCLUSIONS There was a high frequency of patients de-labeled of their beta-lactam allergies in this study. Increased education to patients, parents, and providers on the de-labeling process, as well as increased personnel available to coordinate and perform de-labeling interventions, may result in more beta-lactam allergy de-labeling.
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Affiliation(s)
- Shawn Meehl
- Department of Pharmacy (SM, CS, MC, CC), Arnold Palmer Hospital for Children, Orlando, FL
| | - Christina Salathe
- Department of Pharmacy (SM, CS, MC, CC), Arnold Palmer Hospital for Children, Orlando, FL
| | - Chelsea Cooley
- Department of Pharmacy (SM, CS, MC, CC), Arnold Palmer Hospital for Children, Orlando, FL
| | - Alejandro Jordan-Villegas
- Department of Infectious Diseases and Antimicrobial Stewardship (FRL, AJ-V), Arnold Palmer Hospital for Children, Orlando, FL
| | - Federico R. Laham
- Department of Infectious Diseases and Antimicrobial Stewardship (FRL, AJ-V), Arnold Palmer Hospital for Children, Orlando, FL
| | - Akshita Madala
- Department of Pediatric Residency Program (AM), Arnold Palmer Hospital for Children, Orlando, FL
| | - Mallory Cowart
- Department of Pharmacy (SM, CS, MC, CC), Arnold Palmer Hospital for Children, Orlando, FL
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Dutra KJ, Lazenby GB, Goje O, Soper DE. Cefazolin as the mainstay for antibiotic prophylaxis in patients with a penicillin allergy in obstetrics and gynecology. Am J Obstet Gynecol 2024:S0002-9378(24)00448-4. [PMID: 38527607 DOI: 10.1016/j.ajog.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/20/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024]
Abstract
Cefazolin is the most common antibiotic used for prophylaxis in obstetrics and gynecology. Among those with a penicillin allergy, alternative antibiotics are often chosen for prophylaxis, given fears of cross-reactivity between penicillin and cefazolin. Alternative antibiotics in this setting are associated with adverse sequelae, including surgical site infection, induction of bacterial resistance, higher costs to the healthcare system, and possible Clostridium difficile infection. Given the difference in R1 side chains between penicillin and cefazolin, cefazolin use is safe and should be recommended for patients with a penicillin allergy, including those who experience Immunoglobulin E-mediated reactions such as anaphylaxis. Cefazolin should only be avoided in those who experience a history of a severe, life-threatening delayed hypersensitivity reaction manifested as severe cutaneous adverse reactions (Steven-Johnson Syndrome), hepatitis, nephritis, serum sickness, and hemolytic anemia in response to penicillin administration. In addition, >90% of those with a documented penicillin allergy do not have true allergies on skin testing. Increased referral for penicillin allergy testing should be incorporated into routine obstetric care and preoperative assessment to reduce suboptimal antibiotic prophylaxis use. More education is needed among providers surrounding penicillin allergy assessment and cross-reactivity among penicillins and cephalosporins to optimize antibiotic prophylaxis in obstetrics and gynecology.
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Affiliation(s)
- Karley J Dutra
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC.
| | - Gweneth B Lazenby
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
| | - Oluwatosin Goje
- Department of Subspecialties, Obstetrics and Gynecology Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - David E Soper
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
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19
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Anderson AM, Coallier S, Mitchell RE, Dumkow LE, Wolf LM. Full-dose challenge of moderate, severe, and unknown beta-lactam allergies in the emergency department. Acad Emerg Med 2024. [PMID: 38511401 DOI: 10.1111/acem.14893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 01/26/2024] [Accepted: 02/16/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVE This study aims to assess the outcome of challenging documented moderate, severe, or unknown beta-lactam allergies with full dose administration of a beta-lactam antibiotic in emergency department (ED) patients admitted for acute bacterial infection. METHODS A single-center, retrospective, descriptive study of adult patients challenged with a full dose of beta-lactam in the ED from January 2021 to December 2022 was conducted. Included patients had at least one documented moderate, severe, or unknown beta-lactam allergy in the electronic medical record (EMR) without documentation of prior tolerance. Patient demographics, prior beta-lactam antibiotic reaction, beta-lactam administered in the ED, inpatient beta-lactam continuation, adverse drug reactions, and updates to allergy profiles were collected. Descriptive statistics for data analysis were performed using SPSS Version 22. RESULTS Of the 184 ED encounters with full-dose beta-lactam challenges, five (2.7%) patients with documented moderate, severe, or unknown beta-lactam allergies experienced an allergic reaction after the challenge; one (0.5%) patient had an allergic reaction in the ED, and the remaining four (2.2%) occurred after admission. No anaphylactic reactions occurred. All allergic reactions were limited to mild rash or itching. Most patients (98.9%) were challenged with a cephalosporin. A beta-lactam was continued in 86.4% of cases, and the allergy profile was updated for future utilization in 73.4% of patients. CONCLUSIONS This study suggests that full-dose challenge of moderate, severe, or unknown beta-lactam allergies can be safely accomplished in the ED. This approach avoids unnecessary penicillin allergy skin testing and reduces utilization of suboptimal alternative antibiotic regimens.
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Affiliation(s)
- Adam M Anderson
- Grand River Emergency Medical Group, Grand Rapids, Michigan, USA
| | - Stephanie Coallier
- Trinity Health-West Michigan Emergency Medicine Residency, Muskegon, Michigan, USA
| | - Reid E Mitchell
- Trinity Health-West Michigan Emergency Medicine Residency, Muskegon, Michigan, USA
| | - Lisa E Dumkow
- Department of Pharmacy, Trinity Health Grand Rapids Hospital, Grand Rapids, Michigan, USA
| | - Lauren M Wolf
- Department of Pharmacy, Trinity Health Grand Rapids Hospital, Grand Rapids, Michigan, USA
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20
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Han N, Oh OH, Oh J, Kim Y, Lee Y, Cha WC, Yu YM. The Application of Knowledge-Based Clinical Decision Support Systems to Detect Antibiotic Allergy. Antibiotics (Basel) 2024; 13:244. [PMID: 38534679 DOI: 10.3390/antibiotics13030244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 02/29/2024] [Accepted: 03/05/2024] [Indexed: 03/28/2024] Open
Abstract
Prevention of drug allergies is important for patient safety. The objective of this study was to evaluate the outcomes of antibiotic allergy-checking clinical decision support system (CDSS), K-CDSTM. A retrospective chart review study was performed in 29 hospitals and antibiotic allergy alerts data were collected from May to August 2022. A total of 15,535 allergy alert cases from 1586 patients were reviewed. The most frequently prescribed antibiotics were cephalosporins (48.5%), and there were more alerts of potential cross-reactivity between beta-lactam antibiotics than between antibiotics with the same ingredients or of the same class. Regarding allergy symptoms, dermatological disorders were the most common (38.8%), followed by gastrointestinal disorders (28.4%). The 714 cases (4.5%) of immune system disorders included 222 cases of anaphylaxis and 61 cases of severe cutaneous adverse reactions. Alerts for severe symptoms were reported in 6.4% of all cases. This study confirmed that K-CDS can effectively detect antibiotic allergies and prevent the prescription of potentially allergy-causing antibiotics among patients with a history of antibiotic allergies. If K-CDS is expanded to medical institutions nationwide in the future, it can prevent an increase in allergy recurrence related to drug prescriptions through cloud-based allergy detection CDSSs.
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Affiliation(s)
- Nayoung Han
- Jeju Research Institute of Pharmaceutical Sciences, College of Pharmacy, Jeju National University, Jeju 63243, Republic of Korea
| | - Ock Hee Oh
- FirstDIS Ltd., Seoul 07343, Republic of Korea
| | - John Oh
- Kakao Healthcare Corp., Seongnam 13529, Republic of Korea
| | - Yoomi Kim
- Korea Health Information Service, Seoul 04512, Republic of Korea
| | - Younghee Lee
- Department of Pharmacy, Ajou University Hospital, Suwon 16499, Republic of Korea
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul 06355, Republic of Korea
| | - Yun Mi Yu
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon 21983, Republic of Korea
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21
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Mir A, Lanoue D, Zanichelli V, van Walraven C, Olynych T, Nott C, MacFadden D. Introduction of a penicillin allergy de-labelling program with direct oral challenge and its effects on utilization of beta-lactam antimicrobials: a multicenter retrospective parallel cohort study. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2024; 20:20. [PMID: 38444037 PMCID: PMC10913637 DOI: 10.1186/s13223-024-00877-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/31/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Self-reported penicillin allergy labels are common and often inaccurate after assessment. These labels can lead to reduced use of first-line beta-lactam antibiotics and worse outcomes. We measured the impact of a previously performed inpatient proactive systematic penicillin allergy de-labelling program on subsequent antibiotic use. This prior program included assessment, risk-stratification, and low risk direct oral amoxicillin challenge. METHODS We performed a retrospective comparison of parallel cohorts from two separate tertiary care hospital campuses in Ottawa, Canada across two penicillin de-labelling intervention periods across April 15th to April 30th, 2021, and February 15th to March 8th, 2022. Outcomes, including penicillin allergy labelling and antibiotic use, were collected for the index admission and the subsequent 6-month period. Descriptive statistics and multivariate regression analyses were performed. RESULTS A total of 368 patients with penicillin allergy label were included across two campuses and study periods. 24 (13.8%) patients in the intervention groups had sustained penicillin allergy label removal at 30 days from admission vs. 3 (1.5%) in the non-intervention group (p < 0.001). In the 6-months following admission, beta-lactams were prescribed more frequently in the intervention groups vs. the non-intervention groups for all patients (28 [16.1%] vs.15 [7.7%], p = 0.04) and were prescribed more frequently amongst those who received at least one antibiotic (28/46 [60.9%] vs.15/40 [37.5%], p = 0.097). In a multivariate regression analysis, the intervention groups were found to be associated with an increased odds of beta-lactam prescribing in all patients (OR 2.49, 95%CI 1.29-5.02) and in those prescribed at least one antibiotic (OR 2.44, 95%CI 1.00-6.15). No drug-related adverse events were reported. CONCLUSIONS Proactive penicillin allergy de-labelling for inpatients was associated with a reduction in penicillin allergy labels and increased utilization of beta-lactams in the subsequent 6-months.
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Affiliation(s)
- Adhora Mir
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada.
- The University of Ottawa, Ottawa, Canada.
| | - Derek Lanoue
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | | | - Carl van Walraven
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
- The University of Ottawa, Ottawa, Canada
| | | | - Caroline Nott
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
- The University of Ottawa, Ottawa, Canada
| | - Derek MacFadden
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
- The University of Ottawa, Ottawa, Canada
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22
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Anton-Vazquez V, Ferretti F, Kaya D, Mishra S, Kerneis S, Eden C, Doan H, Leung HF, Baltazar J, Starkey S, Uwagwu J, Dall'Antonia M, Cepeda J. Impact of penicillin allergy records on antimicrobial prescribing in hospitalised patients. Clin Med (Lond) 2024; 24:100024. [PMID: 38382835 DOI: 10.1016/j.clinme.2024.100024] [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] [Indexed: 02/23/2024]
Abstract
BACKGROUND The overdiagnosis of penicillin allergy and misclassification of non-truly allergic reactions is a growing public health problem, associated with the overuse of broad-spectrum and restricted antimicrobials. We aimed to evaluate the impact of penicillin allergy status on antimicrobial prescribing. METHODS A retrospective study of inpatients with a documented penicillin allergy receiving antimicrobials was conducted from 1 April to 1 July 2021. Antimicrobial prescribing and clinical characteristics were compared between patients with an active penicillin allergy label and those whose label was removed following antimicrobial stewardship team review. Antimicrobials were classified in two categories: i) 'Access' (recommended), ii) 'Watch and Reserve' (restricted) according to WHO AWaRe classification, a tool to guide appropriate antibiotic use. RESULTS 437 patients with a documented penicillin allergy receiving antimicrobials were included. 353 patients with an active penicillin allergy label, more frequently received antimicrobials from the 'Watch and Reserve list' (283;80% vs 30;37%; p<0.001). In contrast, 84 patients who were de-labelled received more often antimicrobials from the 'Access list' (53;63% vs 64;18%; p<0.001). CONCLUSIONS Penicillin allergy reviews and de-labelling strategies may reduce the use of restricted antimicrobials under the 'Watch and Reserve list'. This practice should be encouraged and reinforced in all hospitals.
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Affiliation(s)
| | | | - Deniz Kaya
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Shashwat Mishra
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Sven Kerneis
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Charlotte Eden
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Hong Doan
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Hiu Fung Leung
- Antimicrobial pharmacy, Lewisham & Greenwich NHS Trust, London, UK
| | | | - Sarah Starkey
- Medical Microbiology, Lewisham & Greenwich NHS Trust, London, UK
| | - Juliet Uwagwu
- Medical Microbiology, Lewisham & Greenwich NHS Trust, London, UK
| | | | - Jorge Cepeda
- Medical Microbiology, Lewisham & Greenwich NHS Trust, London, UK
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23
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Merz LE, Huang GX, Mehta GD, Lynch DM, Maliborski N, Besz K, Wickner P, Cutler C, Castells M. Development of a Pipeline for Removing Allergy Labels in Patients Undergoing Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2024; 30:322.e1-322.e10. [PMID: 38134971 DOI: 10.1016/j.jtct.2023.12.012] [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: 10/16/2023] [Revised: 12/07/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
Penicillin allergy is reported by 10% to 20 % of patients, but when evaluated only 1% to 2% may have a true allergy. Patients undergoing hematopoietic stem cell transplantation (HSCT) have a high likelihood of requiring beta-lactam antibiotics due to increased infection risk, which can be limited by a penicillin allergy label. When a penicillin allergy is recorded, alternatives are needed, including more expensive broader-spectrum antibiotics, with increases in drug-resistant bacteria, longer hospital stays, higher expenditures, and increases in nosocomial infections, such as Clostridium difficile colitis. This group of patients already undergoes extensive pretreatment testing and would especially benefit from allergy delabeling. This study aimed to develop a self-sustaining, low-cost pipeline between an HSCT clinic and an allergy clinic to identify and successfully delabel low-risk patients who endorse an allergy to penicillin, amoxicillin, amoxicillin-clavulanate, piperacillin-tazobactam, or ampicillin before admission to the hospital. We developed a survey to triage allergy risk, identified key stakeholders in building the pipeline, and underwent 4 plan, do, study, act (PDSA) cycles. Changes were made in each of the PDSA cycles to minimize cost and uncompensated provider time, as well as to increase patient retention throughout the pipeline by increasing appointment availability and decreasing reliance on patients to independently progress through the pathway. Of the 410 patients with planned HSCT who were screened over 11 months, 89 (21.7%) were listed as having a penicillin and/or beta lactam allergy. All but 1 (66 of 67; 98.5%) of the participants completed the survey accurately when confirmed by an allergist, and the survey was 100% accurate in predicting delabeling success in low-risk patients. Of eligible patients, 43.8% (n = 39) were successfully delabeled before their transplant date, and 97.4% of these (n = 38) have undergone HSCT to date. This pipeline is maintained by approximately 5 hours of work per week (1 hour of allergy physician time, 4 hours of nurse and/or clinical coordinator time), with no other direct costs. There is an estimated direct savings of at least $1914.93 per patient delabeled. We successfully designed and implemented a pipeline between the HSCT clinic and the allergy clinic as a quality improvement initiative to identify and address high rates of reported beta-lactam allergies. We identified and addressed patient-based factors, logistical, temporal, and financial barriers that impacted patient retention and sustainability. This model is expected to yield significant and sustained cost savings for the healthcare system as well as to improve patient outcomes, and this hypothesis is currently undergoing formal analysis. We anticipate that this model can be used to create a similar pipeline in other healthcare systems for HSCT recipients, as well as patients in other clinical settings, such as oncology and chimeric antigen receptor T cell therapy.
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Affiliation(s)
- Lauren E Merz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - George X Huang
- Division of Allergy and Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Geneva D Mehta
- Division of Allergy and Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Donna-Marie Lynch
- Division of Allergy and Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Natalia Maliborski
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kylie Besz
- Division of Allergy and Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Paige Wickner
- Division of Allergy and Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Corey Cutler
- Division of Transplantation and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mariana Castells
- Division of Allergy and Immunology, Brigham and Women's Hospital, Boston, Massachusetts.
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24
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Krishna MT, Bhogal R, Ng BY, Kildonaviciute K, Jani YH, Williams I, Sandoe JAT, Pollard R, Jones N, Dunsmure L, Powell N, Hullur C, Balaji A, Moriarty C, Jackson B, Warner A, Daniels R, West R, Thomas C, Misbah SA, Savic L. A multicentre observational study to investigate feasibility of a direct oral penicillin challenge in de-labelling 'low risk' patients with penicillin allergy by non-allergy healthcare professionals (SPACE study): Implications for healthcare systems. J Infect 2024; 88:106116. [PMID: 38331329 PMCID: PMC10961940 DOI: 10.1016/j.jinf.2024.01.015] [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: 10/25/2023] [Revised: 01/17/2024] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE The huge burden of inaccurate penicillin allergy labels (PALs) is an important driver of antimicrobial resistance. This is magnified by insufficient allergy specialists and lack of 'point-of-care' tests. We investigated the feasibility of non-allergy healthcare professionals (HCPs) delivering direct oral penicillin challenges (DPCs) for penicillin allergy de-labelling. METHODS This prospective observational study was conducted in three hospitals in England across three settings (acute medical, pre-surgical and haematology-oncology). Patients with a PAL were screened and stratified as low risk/high risk. Low risk patients (non-immune mediated symptoms, benign rash, tolerated amoxicillin since and family history) underwent a DPC. RESULTS N = 2257 PALs were screened, 1054 were eligible; 643 were approached, 373 declined, 270 consented and 259 risk stratified (low risk = 155; high risk = 104). One hundred and twenty-six low risk patients underwent DPC, 122 (96.8%) were de-labelled with no serious allergic reactions. Conversion rate from screening-to-consent was 12% [3.3% and 17.9% in acute and elective settings respectively; odds ratios for consent were 3.42 (p < 0.001) and 5.53 (p < 0.001) in haematology-oncology and pre-surgical setting respectively. Common reasons for failure to progress in the study included difficulty in reaching patients, clinical instability/medical reasons, lacking capacity to consent and psychological factors. INTERPRETATION DPCs can be delivered by non-allergy HCPs. A high proportion of patients with PALs did not progress in the study pathway. Strategies to deliver DPC at optimal points of the care pathway are needed to enhance uptake. Elective settings offer greater opportunities than acute settings for DPC. The safety and simplicity of DPCs lends itself to adoption by healthcare systems beyond the UK, including in resource-limited settings.
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Affiliation(s)
- Mamidipudi Thirumala Krishna
- Institute of Immunology and Immunotherapy, University of Birmingham and Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Rashmeet Bhogal
- Department of Pharmacy, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bee Yean Ng
- Department of Pharmacy, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Yogini H Jani
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust and UCL School of Pharmacy, London, UK
| | - Iestyn Williams
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Jonathan A T Sandoe
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rachel Pollard
- Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicola Jones
- Department of Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Louise Dunsmure
- Department of Pharmacy, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Neil Powell
- Department of Pharmacy, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Chidanand Hullur
- Department of Anaesthesia, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ariyur Balaji
- Acute Medicine Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Catherine Moriarty
- Theatres and Anaesthetics Research Team, St James' University Hospital, Leeds Teaching Hospitals, Leeds, UK
| | - Beverley Jackson
- Theatres and Anaesthetics Research Team, St James' University Hospital, Leeds Teaching Hospitals, Leeds, UK
| | | | | | - Robert West
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Caroline Thomas
- Department of Anaesthesia, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Siraj A Misbah
- Department of Clinical Immunology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Louise Savic
- Department of Anaesthesia, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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25
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Nürnberg H, Khatamzas E, Denkinger C, Krause T, Oetken L, Rauer S, Rapp A, Hoppe-Tichy T, Morath B. Effectiveness, barriers and facilitating factors of strategies for active delabelling of patients with penicillin allergy labels: a systematic review protocol. BMJ Open 2024; 14:e077927. [PMID: 38413160 PMCID: PMC10900358 DOI: 10.1136/bmjopen-2023-077927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 01/31/2024] [Indexed: 02/29/2024] Open
Abstract
INTRODUCTION Up to 15% of adult patients in the clinical setting report to be allergic to penicillin. However, in most cases, penicillin allergy is not confirmed. Due to the negative aspects associated with erroneous penicillin allergy, the implementation of active delabelling processes for penicillin allergy is an important part of antibiotic stewardship programmes. Depending on the clinical setting, different factors need to be considered during implementation. This review examines the effectiveness of different delabelling interventions and summarises components and structures that facilitate, support or constrain structured penicillin allergy delabelling. METHODS AND ANALYSIS This review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The databases MEDLINE (via PubMed), EMBASE and Cochrane Library were searched for studies reporting on any intervention to identify, assess or rule out uncertain penicillin allergy. To improve completeness, two further databases are also searched for grey literature. Study design, intervention type, professional groups involved, effectiveness, limitations, barriers, facilitating factors, clinical setting and associated regulatory factors will be extracted and analysed. In addition, exclusion criteria for participation in the delabelling intervention and criteria for not delabelling penicillin allergy will be summarised. In case of failed protocols, these are highlighted and quantitatively analysed if possible. Two independent reviewers will perform the screening process and data extraction. Discordant decisions will be resolved through review by a third reviewer. Bias assessment of the individual studies will be performed using the Newcastle Ottawa Scale. ETHICS AND DISSEMINATION Because individual patient-related data are not analysed, an ethical approval is not required. The review will be published in a peer-reviewed scientific journal.
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Affiliation(s)
- Hannah Nürnberg
- Hospital Pharmacy, University Hospital Heidelberg, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Elham Khatamzas
- Division of Infectious Diseases and Tropical Medicine, University Hospital Heidelberg, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Claudia Denkinger
- Division of Infectious Diseases and Tropical Medicine, University Hospital Heidelberg, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Tabea Krause
- Hospital Pharmacy, University Hospital Heidelberg, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Lars Oetken
- Hospital Pharmacy, University Hospital Heidelberg, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Sophie Rauer
- Hospital Pharmacy, University Hospital Heidelberg, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Amelie Rapp
- Hospital Pharmacy, University Hospital Heidelberg, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Torsten Hoppe-Tichy
- Hospital Pharmacy, University Hospital Heidelberg, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Benedict Morath
- Hospital Pharmacy, University Hospital Heidelberg, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
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26
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Felix MMR, Kuschnir FC, Boechat JL, Castells M. Recent findings on drug hypersensitivity in children. FRONTIERS IN ALLERGY 2024; 5:1330517. [PMID: 38384771 PMCID: PMC10879301 DOI: 10.3389/falgy.2024.1330517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/24/2024] [Indexed: 02/23/2024] Open
Abstract
Drug hypersensitivity reactions (DHR) in children have a significant impact on clinical practice and public health. Both under-diagnosis (due to under-reporting) and over-diagnosis (due to the overuse of the term "allergy") are potential issues. The aim of this narrative review is to describe the most recent findings of DHR in children/adolescents and gaps regarding epidemiology, antibiotic allergy, antiepileptic hypersensitivity, vaccine allergy, and severe cutaneous adverse reactions (SCAR) in this age group.
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Affiliation(s)
- Mara Morelo Rocha Felix
- Department of General Medicine, School of Medicine and Surgery, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fábio Chigres Kuschnir
- Department of Pediatrics, Faculty of Medicine, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - José Laerte Boechat
- Clinical Immunology Service, Internal Medicine Department, Faculty of Medicine, Universidade Federal Fluminense, Niterói, Brazil
- Basic and Clinical Immunology Unit, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Mariana Castells
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States
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27
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Jones NK, Tom B, Simillis C, Bennet J, Gourgiotis S, Griffin J, Blaza H, Nasser S, Baker S, Gouliouris T. Impact of penicillin allergy labels on surgical site infections in a large UK cohort of gastrointestinal surgery patients. JAC Antimicrob Resist 2024; 6:dlae022. [PMID: 38372001 PMCID: PMC10873540 DOI: 10.1093/jacamr/dlae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/26/2024] [Indexed: 02/20/2024] Open
Abstract
Objectives Studies in the USA, Canada and France have reported higher surgical site infection (SSI) risk in patients with a penicillin allergy label (PAL). Here, we investigate the association between PALs and SSI in the UK, a country with distinct epidemiology of infecting pathogens and range of antimicrobial regimens in routine use. Methods Electronic health records and national SSI surveillance data were collated for a retrospective cohort of gastrointestinal surgery patients at Cambridge University Hospitals NHS Foundation Trust from 1 January 2015 to 31 December 2021. Univariable and multivariable logistic regression were used to examine the effects of PALs and the use of non-β-lactam-based prophylaxis on likelihood of SSI, 30 day post-operative mortality, 7 day post-operative acute kidney injury and 60 day post-operative infection/colonization with antimicrobial-resistant bacteria or Clostridioides difficile. Results Our data comprised 3644 patients and 4085 operations; 461 were undertaken in the presence of PALs (11.3%). SSI was detected after 435/4085 (10.7%) operations. Neither the presence of PALs, nor the use of non-β-lactam-based prophylaxis were found to be associated with SSI: adjusted OR (aOR) 0.90 (95% CI 0.65-1.25) and 1.20 (0.88-1.62), respectively. PALs were independently associated with increased odds of newly identified MRSA infection/colonization in the 60 days after surgery: aOR 2.71 (95% CI 1.13-6.49). Negative association was observed for newly identified infection/colonization with third-generation cephalosporin-resistant Gram-negative bacteria: aOR 0.38 (95% CI 0.16-0.89). Conclusions No evidence was found for an association between PALs and the likelihood of SSI in this large UK cohort, suggesting significant international variation in the impact of PALs on surgical patients.
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Affiliation(s)
- Nick K Jones
- Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Brian Tom
- MRC Biostatistics Unit, Cambridge University, Cambridge, UK
| | - Constantinos Simillis
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - John Bennet
- Department of General Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stavros Gourgiotis
- Department of General Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jo Griffin
- Department of Infection, Prevention and Control, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Helen Blaza
- Department of Infection, Prevention and Control, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen Baker
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Theodore Gouliouris
- Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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28
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Brillant-Marquis F, Proulx É, Ratnarajah K, Lavoie A, Gauthier A, Gagnon R, Boursiquot JN, Verreault N, Marois L, Bédard MA, Boivin M, Bédard PM, Ouakki M, De Serres G, Drolet JP. Safety of Direct Drug Provocation for the Evaluation of Penicillin Allergy in Low-Risk Adults. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:451-457.e2. [PMID: 38572700 DOI: 10.1016/j.jaip.2023.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/08/2023] [Accepted: 10/17/2023] [Indexed: 04/05/2024]
Abstract
BACKGROUND About 10% of patients have a penicillin allergy label, but less than 5% of them are actually allergic. Unnecessary penicillin avoidance is associated with serious medical consequences. Given the growing number of these labels, it is imperative that our diagnostic strategy for penicillin allergy be as efficient as possible. The validity of traditionally used skin tests (STs) has been questioned, whereas drug provocation testing (DPT), the criterion standard, without previous ST appears very safe in most cases. OBJECTIVE To evaluate the safety of direct DPT without consideration for ST results and the validity of ST in the diagnosis of penicillin allergy. METHODS In this prospective cohort study without a control group, we recruited patients consulting an allergist for penicillin allergy. Patients underwent ST followed by DPT regardless of ST results. Patients with anaphylaxis to penicillin within the past 5 years or a severe delayed reaction were excluded, as were those with significant cardiorespiratory comorbidity. RESULTS None of the 1002 recruited patients had a serious reaction to DPT. Ten (1.0%) had a mild immediate reaction, of whom only 1 (0.1%) was considered likely IgE-mediated. The positive and negative predictive values of ST for an immediate reaction were 3.6% and 99.1%, respectively. CONCLUSIONS In a low-risk adult population reporting penicillin allergy, ST has very poor positive predictive value. Direct DPT without ST is safe and appears to be an ideal diagnostic strategy to remove penicillin allergy labels that could be implemented in first-line practice.
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Affiliation(s)
- Frédéric Brillant-Marquis
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Émilie Proulx
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Kayadri Ratnarajah
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Aubert Lavoie
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Amélie Gauthier
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Rémi Gagnon
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Jean-Nicolas Boursiquot
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Nina Verreault
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Louis Marois
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Marc-Antoine Bédard
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Martine Boivin
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Pierre-Michel Bédard
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Manale Ouakki
- Institut National de Santé Publique du Québec, Québec City, Québec, Canada
| | - Gaston De Serres
- Institut National de Santé Publique du Québec, Québec City, Québec, Canada
| | - Jean-Philippe Drolet
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada.
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Pongdee T, Brunner WM, Kanuga MJ, Sussman JH, Wi CI, Juhn YJ. Rural Health Disparities in Allergy, Asthma, and Immunologic Diseases: The Current State and Future Direction for Clinical Care and Research. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:334-344. [PMID: 38013156 PMCID: PMC11089647 DOI: 10.1016/j.jaip.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/06/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Abstract
Rural health disparities are well documented and continue to jeopardize the long-term health and wellness for the millions of individuals who live in rural America. The disparities observed between urban and rural residents encompass numerous morbidity and mortality measures for several chronic diseases and have been referred to as the "rural mortality penalty." Although the unmet health needs of rural communities are widely acknowledged, little is known about rural health disparities in allergies, asthma, and immunologic diseases. Furthermore, the intersection between rural health disparities and social determinants of health has not been fully explored. To achieve a more complete understanding of the factors that perpetuate rural health disparities, greater research efforts followed by improved practice and policy are needed that account for the complex social context within rural communities rather than a general comparison between urban and rural environments or focusing on biomedical factors. Moreover, research efforts must prioritize community inclusion throughout rural areas through meaningful engagement of stakeholders in both clinical care and research. In this review, we examine the scope of health disparities in the rural United States and the impact of social determinants of health. We then detail the current state of rural health disparities in the field of allergy, asthma, and immunology. To close, we offer future considerations to address knowledge gaps and unmet needs for both clinical care and research in addressing rural health disparities.
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Affiliation(s)
- Thanai Pongdee
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn.
| | - Wendy M Brunner
- Center for Rural Community Health, Bassett Research Institute, Bassett Medical Center, Cooperstown, NY
| | - Mansi J Kanuga
- Division of Allergic Diseases, Mayo Clinic Health System, Red Wing, Minn
| | | | - Chung-Il Wi
- Precision Population Science Lab, Mayo Clinic, Rochester, Minn; Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn
| | - Young J Juhn
- Precision Population Science Lab, Mayo Clinic, Rochester, Minn; Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn; Office of Mayo Clinic Health System Research, Mayo Clinic Health System, Rochester, Minn.
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Lanoue D, Mir A, van Walraven C, Olynych T, Nott C, MacFadden DR. Resource utilization and cost assessment of a proactive penicillin allergy de-labeling program for low-risk inpatients. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2024; 20:7. [PMID: 38254221 PMCID: PMC10804656 DOI: 10.1186/s13223-023-00864-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 12/05/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Resource utilization and costs can impede proactive assessment and de-labeling of penicillin allergy among inpatients. METHODS Our pilot intervention was a proactive penicillin allergy de-labeling program for new inpatients with penicillin allergy. Patients deemed appropriate for a challenge with a low-risk penicillin allergy history were administered 250 mg amoxicillin and monitored for 1 h. We performed an explorative economic evaluation using various healthcare professional wages. RESULTS Over two separate 2-week periods between April 2021 and March 2022, we screened 126 new inpatients with a penicillin allergy. After exclusions, 55 were appropriate for formal assessment. 19 completed the oral challenge, and 12 were directly de-labeled, resulting in a number needed to screen of 4 and a number needed to assess of 1.8 to effectively de-label one patient. The assessor's median time in the hospital per day de-labeling was 4h08 with a range of (0h05, 6h45). A single-site annual implementation would result in 715 penicillin allergy assessments with 403 patients de-labeled assuming 20,234 annual weekday admissions and an 8.9% penicillin allergy rate. Depending on the assessor used, the annual cost of administration would be between $21,476 ($53.29 per effectively de-labeled patient) for a pharmacy technician and $61,121 ($151.67 per effectively de-labeled patient) for a Nurse Practitioner or Physician Assistant. CONCLUSION A proactive approach, including a direct oral challenge for low-risk in-patients with penicillin allergy, appears safe and feasible. Similar programs could be implemented at other institutions across Canada to increase access to allergy assessment.
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Affiliation(s)
- Derek Lanoue
- Division of Clinical Immunology and Allergy, McGill University, 1650 Cedar Ave., H3G1A4, Montreal, QC, Canada
| | | | - Carl van Walraven
- The Ottawa Hospital, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Caroline Nott
- The Ottawa Hospital, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Derek R MacFadden
- The Ottawa Hospital, Ottawa, ON, Canada.
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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Feldman K, Suppes SL, Goldman JL. Clarification of adverse drug reactions by a pharmacovigilance team results in increased antibiotic re-prescribing at a freestanding United States children's hospital. PLoS One 2024; 19:e0295410. [PMID: 38215178 PMCID: PMC10786368 DOI: 10.1371/journal.pone.0295410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/21/2023] [Indexed: 01/14/2024] Open
Abstract
Documentation of adverse drug reactions (ADRs) is a key factor in guiding future prescribing. However, incomplete documentation is common and often fails to distinguish implicated drugs as true allergies. This in turn leads to unnecessary avoidance of implicated drug classes and may result in sub-optimal prescribing. Pharmacovigilance (PV) programs utilize a systematic approach to clarify ADR documentation and are known to improve patient safety. Yet it remains unclear if PV alters prescribing. Or, if the existence of the ADR documentation itself continues to prompt avoidance of implicated drugs. To address this, our work presents a retrospective cohort study assessing if clarification of antibiotic ADRs by a hospital-wide PV team was associated with future, safe, re-prescribing at a freestanding pediatric hospital in the midwestern United States. First, we compared the likelihood of future prescribing in an antibiotic class with an active ADR, as compared to alternative drug classes, between PV-clarified and non-clarified patients. Second, we assessed differences in adverse event rates 30-days after future prescribing based on PV clarification status. For robustness, analyses were performed on patients with ADRs in four antibiotic classes: penicillin-based beta-lactams (n = 45,642), sulfonamides/trimethoprim (n = 5,329), macrolides (n = 3,959), and glycopeptides (n = 622). Results illustrate that clarification of an ADR by PV was associated with an increased odds of future prescribing in the same drug class (Odds Ratio [95%-CI]): penicillin-based beta-lactams (1.59 [1.36-1.89]), sulfonamides/trimethoprim (2.29 [0.89-4.91]), macrolides (0.77 [0.33-1.61]), and glycopeptide (1.85 [1.12-3.20]). Notably, patients clarified by PV experienced no increase in the rate of adverse events within 30-days following the prescribing of antibiotics in the same class as an active ADR. Overall, this study provides strong evidence that PV reviews safely increase the rate of re-prescribing antibiotics even in the presence of an existing implicated drug ADR.
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Affiliation(s)
- Keith Feldman
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, United States of America
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States of America
| | - Sarah L. Suppes
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, United States of America
| | - Jennifer L. Goldman
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, United States of America
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States of America
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Undeberg MR, Bowers DR, Chau CN, McKeirnan KC. A Pharmacist's Role in a Case of Allergy Labeling and Acute Bacterial Rhinosinusitis Treatment. PHARMACY 2024; 12:8. [PMID: 38251402 PMCID: PMC10801492 DOI: 10.3390/pharmacy12010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/07/2023] [Accepted: 12/29/2023] [Indexed: 01/23/2024] Open
Abstract
This case report describes a pharmacist's intervention with a 58-year-old female who presented with recurrent rhinosinusitis symptoms and limited treatment options due to a complicated allergy history. Using guidelines for treatment of acute bacterial rhinosinusitis coupled with a thorough antibiotic allergy assessment, the pharmacist developed a treatment plan that was acceptable to both the patient and the provider. Pharmacists can play an essential role in verification of allergies to both medications and non-pharmaceutical products, which further ensures patient safety as well as optimization of appropriate treatment methods.
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Affiliation(s)
- Megan R. Undeberg
- Pharmacotherapy Department, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA 99202, USA; (D.R.B.); (C.N.C.); (K.C.M.)
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He K, Dawson M, Stroh C, Taylor KM, Quigley S, Jones S, Cramm SL, Rangel SJ. A Process Improvement Project to Increase Compliance With Cephalosporin-based Surgical Antimicrobial Prophylaxis in Children With Non-severe Penicillin Allergies. J Pediatr Surg 2024; 59:61-67. [PMID: 37839950 DOI: 10.1016/j.jpedsurg.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND/PURPOSE Cephalosporins are considered safe and first-line prophylaxis in children with non-severe penicillin allergies. However, use of second-line agents is common and is primarily driven by poor allergic response documentation and misunderstanding of cross-reactivity risk. The goal of this project was to improve compliance with cephalosporin prophylaxis through improved documentation and targeted educational efforts. METHODS A multidisciplinary working group including representatives from allergy, surgery, infectious disease, and pharmacy developed staged interventions to facilitate compliance with cephalosporin prophylaxis. These included: (1) caregiver outreach to clarify incomplete allergy documentation, (2) a decision-support algorithm for prophylaxis use in penicillin-allergic patients, (3) standardized educational resources for surgical faculty and rotating trainees, (4) email reminders with prophylaxis recommendations sent out prior to scheduled cases, and (5) EMR-based decision support during antibiotic ordering. Rates of complete allergy documentation and cephalosporin utilization were compared for general surgery procedures between a 12-month pre-intervention and 14-month post-intervention period. RESULTS 578 patients with penicillin allergies recorded in the EMR were included (301 pre-intervention and 277 post-intervention), 54.0% of which received prophylaxis. Compared to the pre-intervention period, complete documentation of allergic reactions increased from 57.1% to 84.2% (p < 0.001) following implementation of all interventions. Appropriate prophylaxis utilization increased from 34.5% to 88.5% following implementation of all interventions (p < 0.001), and evidence of a stepwise increase in appropriate utilization was evident with each intervention stage. Persistent compliance failures during the post-implementation period were most commonly associated with urgent and emergent add-on cases. No adverse events or allergic responses were reported before or after project implementation. CONCLUSIONS Compliance with cephalosporin prophylaxis significantly improved following a multidisciplinary effort targeting education, allergy documentation, and clinical support at the point of care. Ongoing efforts include postoperative audits within 24 h for noncompliant cases in order to identify barriers and improve compliance for urgent and emergent add-on cases. LEVEL OF EVIDENCE III. TYPE OF STUDY Prospective.
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Affiliation(s)
- Katherine He
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michele Dawson
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Crystal Stroh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristina M Taylor
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan Quigley
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Jones
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Calmels M, Guyard-Boileau B, Guerby P, Guilleminault L. Penicillin allergy de-labelling is safe during pregnancy. BJOG 2023. [PMID: 38151715 DOI: 10.1111/1471-0528.17742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/06/2023] [Accepted: 12/13/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Mathilde Calmels
- Department of Respiratory Medicine, Toulouse University Hospital, Faculty of Medicine, Toulouse, France
| | - Beatrice Guyard-Boileau
- Department of Gynaecology, Toulouse University Hospital, Faculty of Medicine, Toulouse, France
| | - Paul Guerby
- Department of Gynaecology, Toulouse University Hospital, Faculty of Medicine, Toulouse, France
| | - Laurent Guilleminault
- Department of Respiratory Medicine, Toulouse University Hospital, Faculty of Medicine, Toulouse, France
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), INSERM UMR1291, CNRS UMR5051, University Toulouse III, Toulouse, France
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Xiang YY, Heriot GS, Jamrozik E. Ethics of antibiotic allergy. JOURNAL OF MEDICAL ETHICS 2023; 50:39-44. [PMID: 37286334 PMCID: PMC7615378 DOI: 10.1136/jme-2022-108648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 04/01/2023] [Indexed: 06/09/2023]
Abstract
Antibiotic allergies are commonly reported among patients, but most do not experience reactions on rechallenge with the same agents. These reported allergies complicate management of infections in patients labelled as having penicillin allergy, including serious infections where penicillin-based antibiotics are the first-line (most effective and least toxic) treatment option. Allergy labels are rarely questioned in clinical practice, with many clinicians opting for inferior second-line antibiotics to avoid a perceived risk of allergy. Reported allergies thereby can have significant impacts on patients and public health, and present major ethical challenges. Antibiotic allergy testing has been described as a strategy to circumvent this dilemma, but it carries limitations that often make it less feasible in patients with acute infections or in community settings that lack access to allergy testing. This article provides an empirically informed ethical analysis of key considerations in this clinical dilemma, using Staphylococcus aureus bacteraemia in patients with penicillin allergies as a case study. We argue that prescribing first-line penicillin-based antibiotics to patients with reported allergies may often present a more favourable ratio of benefits to risks, and may therefore be more ethically appropriate than using second-line drugs. We recommend changes to policy-making, clinical research and medical education, in order to promote more ethically acceptable responses to antibiotic allergies than the status quo.
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Affiliation(s)
- Yu Yi Xiang
- Western Health, Footscray, Victoria, Australia
| | - George S Heriot
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Euzebiusz Jamrozik
- Ethox and Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
- Royal Melbourne Hospital Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Monash Bioethics Centre, Monash University, Melbourne, Victoria, Australia
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36
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Grant Day W, DeNora AB, Shields D, Otto A, Banks T, Dore MM. Clearance of Penicillin Allergy Through Direct Oral Challenge by Primary Care Physicians. J Gen Intern Med 2023; 38:3651-3653. [PMID: 37783980 PMCID: PMC10713884 DOI: 10.1007/s11606-023-08425-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/12/2023] [Indexed: 10/04/2023]
Affiliation(s)
- W Grant Day
- Department of Medicine, Naval Medical Readiness Training Command Portsmouth, Portsmouth, VA, USA.
| | - Allyson Burkhart DeNora
- Department of Medicine, Naval Medical Readiness Training Command Portsmouth, Portsmouth, VA, USA
| | - Daniel Shields
- Department of Medicine, Naval Medical Readiness Training Command Portsmouth, Portsmouth, VA, USA
| | - Ashley Otto
- Department of Medicine, Naval Medical Readiness Training Command Portsmouth, Portsmouth, VA, USA
| | - Taylor Banks
- Department of Allergy and Immunology, Naval Medical Readiness Training Command Portsmouth, Portsmouth, VA, USA
| | - Michael M Dore
- Department of Medicine, Duke University Medical Center, Durham, USA
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Baghdady N, Alothmany HN. Describing Self-Reported Penicillin Allergy Using a Penicillin Allergy Risk Tool (PEN-FAST) in an Outpatient Setting at a Tertiary Hospital in Saudi Arabia. Cureus 2023; 15:e51322. [PMID: 38288241 PMCID: PMC10823762 DOI: 10.7759/cureus.51322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2023] [Indexed: 01/31/2024] Open
Abstract
Introduction Penicillin is a widely used antibiotic and is frequently reported as a cause of allergic reactions. However, many individuals reporting penicillin allergies are later found to be tolerant. This study, conducted in an outpatient setting at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia, aimed to assess the prevalence of self-reported penicillin allergy and to evaluate further the risk of a positive penicillin allergy test using the PEN-FAST tool. Methods A cross-sectional study was conducted via in-person questionnaires with patients in the waiting area at the outpatient clinics of KAUH in Jeddah, Saudi Arabia. Results Among 140 participants, 4% reported a penicillin allergy, with most identifying their allergies based on symptoms. None of these allergies resulted in severe reactions. Notably, 50% reported nausea and itching as symptoms. The PEN-FAST tool categorized 33.3% as moderate risk and 50% as low to very low risk for a positive penicillin skin test. One participant was confirmed to be allergic via a skin prick test. Discussion and conclusion The prevalence of reported penicillin allergy was lower in our study than that previously reported. Evaluation of the PEN-FAST score demonstrated that this prevalence is even lower at 2%. While this single-center study offers valuable insights, further research in diverse healthcare settings is required to validate these findings and refine our understanding of penicillin allergies.
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Affiliation(s)
- Nour Baghdady
- Pharmacy Practice, King Abdulaziz University, Jeddah, SAU
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Wrenn RH, Trubiano JA. Penicillin Allergy Impact and Management. Infect Dis Clin North Am 2023; 37:793-822. [PMID: 37537003 DOI: 10.1016/j.idc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
There is international evidence that penicillin allergies are associated with inferior prescribing and patient outcomes. A host of tools now exist from assessment (risk assessment tools, clinical decision rules) to delabeling (the removal of a beta-lactam allergy via testing or medical reconciliation) to reduce the impact of these "labels" in the hospital and community setting, as a primary antimicrobial stewardship intervention.
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Affiliation(s)
- Rebekah H Wrenn
- Duke University Medical Center, Durham, NC, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA.
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Melbourne, Australia; Department of Infectious Diseases, University of Melbourne, at The Peter Doherty Institute for Infection and Immunity, Victoria 3000, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Sáenz de Santa María R, Bogas G, Labella M, Ariza A, Salas M, Doña I, Torres MJ. Approach for delabeling beta-lactam allergy in children. FRONTIERS IN ALLERGY 2023; 4:1298335. [PMID: 38033918 PMCID: PMC10684789 DOI: 10.3389/falgy.2023.1298335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023] Open
Abstract
A considerable number of pediatric patients treated with beta-lactam (BL) antibiotics develop delayed onset of skin rashes during the course of treatment. Although the most frequent cause of these symptoms is infectious, many cases are labeled as allergic reactions to these drugs. BL allergy labels could have a negative impact, as they imply avoidance of this group of drugs and the use of second-line antibiotics, leading to a potential increase in adverse effects and the utilization of less effective therapies. This constitutes a major public health concern and economic burden, as the use of broad-spectrum antibiotics can result in multidrug-resistant organisms and prolonged hospital stays. Therefore, it is crucial to delabel patients during childhood to avoid false labeling in adult life. Although the label of BL allergy is among the most frequent causes of allergy referral, its management remains controversial, and new diagnostic perspectives are changing the paradigm of managing BL allergies in children. Traditionally, drug provocation testing (DPT) was exclusively performed in patients who had previously obtained negative results from skin tests (STs). However, the sensitivity of STs is low, and the role of in vitro testing in the pediatric population is not well defined. Recent studies have demonstrated the safety of direct DPT without prior ST or serum tests for pediatric patients who report a low-risk reaction to BLs, which is cost-effective. However, there is still a debate on the optimal allergic workup to be performed in children with a benign immediate reaction and the management of children with severe cutaneous adverse drug reactions. In this review, we will discuss the impact of the label of BL allergy and the role of the different tools currently available to efficiently address BL allergy delabeling in children.
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Affiliation(s)
- R. Sáenz de Santa María
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - G. Bogas
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. Labella
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - A. Ariza
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. Salas
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - I. Doña
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. J. Torres
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
- Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
- Departamento de Medicina, Universidad de Málaga, Facultad de Medicina, Málaga, Spain
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Loprete J, Richardson R, Bramah V, Comben S, Li T, Beiglari L, O’Neill R, McEwan C, Carr A, Tong W. Delabeling, safety, and impact of β-lactam allergy testing: A systematic review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100160. [PMID: 37781667 PMCID: PMC10509936 DOI: 10.1016/j.jacig.2023.100160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 07/18/2023] [Accepted: 07/18/2023] [Indexed: 10/03/2023]
Abstract
Background To improve β-lactam delabeling outcomes, we need to understand current practice and the evidence base regarding its outcomes, safety, and impact. Objectives We sought to assess the existing published evidence reporting on the effectiveness of penicillin allergy testing and delabeling. Methods We conducted a systematic review of studies reporting β-lactam delabeling practices and outcomes after testing, including β-lactam use and patient understanding of the delabeling result. Searches of the PubMed, Scopus, and Embase databases; clinical trial registries; and websites of professional organizations were conducted. Data were extracted from the included studies in duplicate, with a third extraction if discrepancies remained. Results We included 284 publications (covering 98,316 participants); 173 were prospective studies, with no randomized controlled trials. The overall study quality was low. In all, 95.6% of individuals who underwent provocation testing were delabeled. Factors associated with successful delabeling could not be determined because of significant heterogeneity between studies. Anaphylaxis due to testing occurred in 0.3% of participants (95 of 31,667). Subjects who did not undergo skin testing (6,980 patients in 31 studies) before challenge had higher rates of provocation test positivity (8.8% vs 4.1% [P < .0001]) and anaphylaxis (15.9% vs 2.7% [P < .0001]) than those subjects who underwent skin testing (51,607 patients in 177 studies). Six studies (2.1%) followed patients after testing to assess their adherence to prescribing recommendations. In all, 136 participants (20.6%) were actively avoiding β-lactams despite delabeling. Conclusions The available data suggest that penicillin allergy testing is safe and effective in delabeling most individuals, but the evidence base is incomplete and more work is required to assess the role of skin testing and the impact that delabeling is having on prescribing habits.
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Affiliation(s)
| | | | | | | | - Timothy Li
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, China
| | | | - Robert O’Neill
- St. Vincent’s Hospital, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine and Health, St. Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | | | - Andrew Carr
- St. Vincent’s Hospital, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine and Health, St. Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Winnie Tong
- St. Vincent’s Hospital, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine and Health, St. Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
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Accarino JJO, Ramsey A, Samarakoon U, Phillips E, Gonzalez-Estrada A, Otani IM, Fu X, Banerji A, Stone CA, Khan DA, Blumenthal KG. Drug allergy in older adults: A study from the United States Drug Allergy Registry. Ann Allergy Asthma Immunol 2023; 131:628-636.e2. [PMID: 37557950 DOI: 10.1016/j.anai.2023.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/14/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Older adults have an increased risk of adverse drug reactions and negative effects associated with alternative antibiotic use. Although the number of antibiotic allergies reported increases with age, the characteristics and outcomes of older adults receiving drug allergy assessment are unknown. OBJECTIVE To assess the characteristics and outcomes of drug allergy evaluations in older adults. METHODS We considered patients aged above or equal to 65 years enrolled in the United States Drug Allergy Registry (USDAR), a US multisite prospective cohort (January 16, 2019 to February 28, 2022). Data were summarized using descriptive statistics. RESULTS Of 1678 USDAR participants from 5 sites, 406 older adults aged above or equal to 65 years (37% 65-69 years, 37% 70-74 years, 16% 75-79 years, and 10% ≥80 years) received 501 drug allergy assessments. USDAR older adults were primarily of female sex (69%), White (94%), and non-Hispanic (98%). Most USDAR older adults reported less than or equal to 1 infections per year (64%) and rated their general health as good, very good, or excellent (80%). Of 296 (59%) penicillin allergy assessments in USDAR older adults, 286 (97%) were disproved. Other drug allergy assessments included sulfonamide (n = 41, 88% disproved) and cephalosporin (n = 20, 95% disproved) antibiotics. All 41 drug allergy labels in USDAR participants aged above or equal to 80 years and all 80 penicillin allergy labels in USDAR men aged above or equal to 65 years were disproved. CONCLUSION Older adults represented a quarter of USDAR participants but were neither racially nor ethnically diverse and were generally healthy without considerable antibiotic need. Most older adults presented for antibiotic allergy assessments, the vast majority of which were disproved. Drug allergy assessments may be underutilized in the older adults who are most vulnerable to the harms of unconfirmed antibiotic allergy labels.
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Affiliation(s)
- John J O Accarino
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Allison Ramsey
- Rochester Regional Health, Rochester, New York; Department of Allergy/Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Upeka Samarakoon
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth Phillips
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, UCSF Medical Center, San Francisco, California
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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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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Giamarellou H, Galani L, Karavasilis T, Ioannidis K, Karaiskos I. Antimicrobial Stewardship in the Hospital Setting: A Narrative Review. Antibiotics (Basel) 2023; 12:1557. [PMID: 37887258 PMCID: PMC10604258 DOI: 10.3390/antibiotics12101557] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
The increasing global threat of antibiotic resistance, which has resulted in countless fatalities due to untreatable infections, underscores the urgent need for a strategic action plan. The acknowledgment that humanity is perilously approaching the "End of the Miracle Drugs" due to the unjustifiable overuse and misuse of antibiotics has prompted a critical reassessment of their usage. In response, numerous relevant medical societies have initiated a concerted effort to combat resistance by implementing antibiotic stewardship programs within healthcare institutions, grounded in evidence-based guidelines and designed to guide antibiotic utilization. Crucial to this initiative is the establishment of multidisciplinary teams within each hospital, led by a dedicated Infectious Diseases physician. This team includes clinical pharmacists, clinical microbiologists, hospital epidemiologists, infection control experts, and specialized nurses who receive intensive training in the field. These teams have evidence-supported strategies aiming to mitigate resistance, such as conducting prospective audits and providing feedback, including the innovative 'Handshake Stewardship' approach, implementing formulary restrictions and preauthorization protocols, disseminating educational materials, promoting antibiotic de-escalation practices, employing rapid diagnostic techniques, and enhancing infection prevention and control measures. While initial outcomes have demonstrated success in reducing resistance rates, ongoing research is imperative to explore novel stewardship interventions.
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Affiliation(s)
- Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Lamprini Galani
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Theodoros Karavasilis
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Konstantinos Ioannidis
- Clinical Pharmacists, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece;
| | - Ilias Karaiskos
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
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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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Céspedes JA, Fernández-Santamaría R, Ariza A, Bogas G, Doña I, Rondón C, Salas M, Labella M, Frecha C, Mayorga C, Torres MJ, Fernández TD. Diagnosis of immediate reactions to amoxicillin: Comparison of basophil activation markers CD63 and CD203c in a prospective study. Allergy 2023; 78:2745-2755. [PMID: 36478407 DOI: 10.1111/all.15610] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Amoxicillin (AX) combined or not with clavulanic acid (CLV) is frequently involved in IgE-mediated reactions. Drug provocation test (DPT) is considered as the gold standard for diagnosis, although contraindicated in high-risk patients. Basophil activation test (BAT) can help diagnose immediate reactions to beta-lactams, although controversy exists regarding the best activation marker. We have performed a real-life study in a prospective cohort to analyze the real value of BAT as diagnostic tool and the best activation marker, CD63 and CD203c, for the evaluation of immediate reactions to these drugs. METHODS We prospectively evaluated patients with a clinical suspicion of immediate reactions after AX or AX-CLV administration during a 6-year period. The allergological work-up was done following the EAACI recommendations. BAT was performed in all patients using CD63 and CD203c as activation markers. RESULTS In AX-allergic patients, both activation markers, CD63 and CD203c, showed similar SE values (48.6% and 46.7%, respectively); however, specificity was of 81.1% and 94.6%, respectively, with CD203c showing good positive predictive value and like-hood ratio. In CLV-allergic patients, CD203c showed higher SE (50%) than CD63 (42.9%), maintaining the same value of SP (80%). Combining the results of both markers can slightly increase the sensitivity (51.4% for AX and 54.8% for CLV), although decreasing the specificity (79.7% and 73%, respectively). Interestingly, all patients with an anaphylactic shock showed a positive BAT to CLV using CD203c. CONCLUSIONS BAT using CD203c showed a good confirmatory power, especially for AX allergy. Placing BAT as a first step in the diagnostic procedure can help reduce the need of performing a complete allergological work-up in 46.6% of patients, diminishing the risk of reinducing allergic reactions.
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Affiliation(s)
- Jose A Céspedes
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
| | - Rubén Fernández-Santamaría
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
- RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
| | - Adriana Ariza
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
- RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- RETICS Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain
| | - Gador Bogas
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
- RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Inmaculada Doña
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
- RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- RETICS Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Carmen Rondón
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
- RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- RETICS Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - María Salas
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
- RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- RETICS Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Marina Labella
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Cecilia Frecha
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
| | - Cristobalina Mayorga
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
- RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- RETICS Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - María J Torres
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
- RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- RETICS Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
| | - Tahia D Fernández
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
- RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- RETICS Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain
- Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga, Málaga, Spain
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Ramsey A, Rozario C, Stern J. Direct challenges are the gold standard for most antibiotic allergy evaluations. Ann Allergy Asthma Immunol 2023; 131:427-433. [PMID: 37031773 DOI: 10.1016/j.anai.2023.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 04/11/2023]
Abstract
Antibiotic allergies are frequently encountered in clinical practice, and delabeling of these allergies has individual and public health benefits. This review focuses on the evidence supporting graded challenges without preceding skin testing in adult and pediatric patients to the major groups of antibiotics including penicillins, cephalosporins, sulfamethoxazole, fluoroquinolones, tetracyclines, macrolides, metronidazole, carbapenems, and aztreonam. The cost savings, time savings, and evidence for performing graded challenges outside of an allergy/immunology office are also reviewed for graded challenges to penicillins.
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Affiliation(s)
- Allison Ramsey
- Rochester Regional Health, Rochester, New York; Department of Medicine, University of Rochester, Rochester, New York.
| | - Cheryl Rozario
- Department of Medicine, University of Rochester, Rochester, New York
| | - Jessica Stern
- Department of Medicine, University of Rochester, Rochester, New York; Department of Pediatrics, University of Rochester, Rochester, New York
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Jacobs MW, Bremmer DN, Shively NR, Moffa MA, Trienski TL, Carr DR, Buchanan CA, Walsh TL. Analysis of a beta-lactam allergy assessment protocol challenging diverse reported allergies managed by an antimicrobial stewardship program. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e153. [PMID: 37771740 PMCID: PMC10523545 DOI: 10.1017/ash.2023.432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 09/30/2023]
Abstract
Objective To assess the safety and efficacy of a novel beta-lactam allergy assessment algorithm managed by an antimicrobial stewardship program (ASP) team. Design Retrospective analysis. Setting One quaternary referral teaching hospital and one tertiary care teaching hospital in a large western Pennsylvania health network. Patients or participants Patients who received a beta-lactam challenge dose under the beta-lactam allergy assessment algorithm. Interventions A beta-lactam allergy assessment protocol was designed and implemented by an ASP team. The protocol risk stratified patients' reported allergies to identify patients appropriate for a challenge with a beta-lactam antibiotic. This retrospective analysis assessed the safety and efficacy of this protocol among patients receiving a challenge dose from November 2017 to July 2021. Results Over a 45-month period, 119 total patients with either penicillin or cephalosporin allergies entered the protocol. Following a challenge dose, 106 (89.1%) patients were treated with a beta-lactam. Eleven patients had adverse reactions to a challenge dose, one of which required escalation of care to the intensive care unit. Of the patients with an unknown or low-risk reported allergy, 7/66 (10.6%) had an observed adverse reaction compared to 3/42 (7.1%) who had an observed reaction with a reported high-risk or anaphylactic allergy. Conclusions Our implemented protocol was safe and effective, with over 90% of patients tolerating the challenge without incident and many going on to receive indicated beta-lactam therapy. This protocol may serve as a framework for other inpatient ASP teams to implement a low-barrier allergy assessment led by ASP teams.
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Affiliation(s)
- Max W. Jacobs
- Medicine Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Derek N. Bremmer
- Department of Pharmacy, Allegheny Health Network, Pittsburgh, PA, USA
| | - Nathan R. Shively
- Division of Infectious Diseases, Allegheny Health Network, Pittsburgh, PA, USA
| | - Matthew A. Moffa
- Division of Infectious Diseases, Allegheny Health Network, Pittsburgh, PA, USA
| | | | - Dustin R. Carr
- Department of Pharmacy, Allegheny Health Network, Pittsburgh, PA, USA
| | | | - Thomas L. Walsh
- Division of Infectious Diseases, Allegheny Health Network, Pittsburgh, PA, USA
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Belmont AP, Su C, Kwah J. Cephalosporins can be safely administered to patients with verified penicillin allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2933-2935.e2. [PMID: 37245737 DOI: 10.1016/j.jaip.2023.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Ami P Belmont
- Section of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Chang Su
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Jason Kwah
- Section of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn.
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Lozo S, Wagner D, Shah N, Goldberg R, Gafni-Kane A, Solomonides A. Should Penicillin Allergy Testing Be Included as Part of Preoperative Testing? J Healthc Qual 2023; 45:255-260. [PMID: 37428901 DOI: 10.1097/jhq.0000000000000395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Penicillin allergy is the most commonly reported drug allergy in the United States. Patients labeled with penicillin allergy are at risk of receiving broad-spectrum antibiotics for surgical site infection prophylaxis, which can lead to increased antibiotic resistance, higher morbidity, suboptimal antibiotic therapy, and higher medical costs. This study aimed to determine the true prevalence of penicillin allergy among surgical patients and to decrease the unnecessary use of broad-spectrum antibiotics. METHODS A retrospective chart review was performed of patients who underwent urogynecologic surgery in 2017. In 2018, a quality initiative was started, and all patients reporting penicillin allergies were offered antibiotic allergy testing as part of their preoperative testing. RESULTS In 2017, 15% of patients reported penicillin allergy and 52% of them received surgical prophylaxis with broad-spectrum antibiotics. In 2018, 463 patients underwent surgery, 55 of whom reported penicillin allergy and were offered penicillin allergy testing. 35 (64%) agreed to proceed with testing, and of those tested, 33 (94%) tested negative for penicillin allergy. CONCLUSIONS 94% of patients with stated penicillin allergy who consented to allergy testing proved to have negative test. Penicillin allergy testing should be considered as part of preoperative management.
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50
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Hampton LL, DeBoy JT, Gunaratne A, Stallings AP, Bell T, Phillips MA, Kamath SS, Sterrett EC, Nazareth-Pidgeon KM. Improving the Documentation of Penicillin Allergy Labels Among Pediatric Inpatients. Hosp Pediatr 2023; 13:811-821. [PMID: 37565275 DOI: 10.1542/hpeds.2022-006730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Penicillin allergy is the most common medication allergy, and the penicillin allergy label is commonly over-applied without adequate reaction history inquiry or documentation. Because penicillin allergy labels are often applied in childhood and carried into adulthood, we sought to increase the completeness of reaction history documentation from 20% to 70% for pediatric hospital medicine patients and from 20% to 50% for all other pediatric inpatients within 12 months. As a secondary outcome, we also aimed to increase the proportion of delabeling unnecessary penicillin labels to 20% for all pediatric inpatients. METHODS To address our aims, our quality improvement initiative included education for pediatric faculty and staff, development and implementation of a clinical pathway for allergy risk stratification, and electronic health record optimizations. Statistical process control charts were used to track the impact of the interventions facilitated by an automated dashboard. RESULTS Within 12 months of interventions, the completeness of allergy labels improved from 20% to 64% among patients admitted to the pediatric hospital medicine service and improved from 20% to 45% for all other pediatric inpatients. The frequency of penicillin allergy delabeling remained unchanged; however, 98 patients were risk stratified and 34 received outpatient allergy referrals for further testing. The number of adverse drug reactions to penicillin, a balancing measure, did not change during the study period. CONCLUSIONS We increased the completeness of penicillin allergy documentation using a standardized workflow facilitated by a multidisciplinary clinical pathway. With ongoing efforts, more penicillin delabeling in low-risk patients is anticipated.
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Affiliation(s)
- Laura L Hampton
- Division of Hospital Medicine, Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, Georgia
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