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Burn MS, Xu X, Kwah J, Liao J, Son M. The Cost of Developing and Implementing an Antepartum Referral Program for Penicillin Allergy Evaluation at a Single Academic Tertiary Care Hospital. Am J Perinatol 2024; 41:1290-1297. [PMID: 38423122 DOI: 10.1055/a-2278-9279] [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: 03/02/2024]
Abstract
OBJECTIVE Approximately 10% of pregnant individuals report a penicillin allergy, yet most are not truly allergic. Allergy verification during pregnancy is safe and recommended; however, many hospitals lack the infrastructure to execute testing. Our aim was to evaluate the cost of developing and implementing a penicillin allergy referral program for pregnant individuals at an academic institution and to compare costs of care between patients who were referred and not referred through the program. STUDY DESIGN We conducted an economic analysis of our institution's antepartum penicillin allergy referral program. We prospectively collected detailed resource utilization data and conducted the analysis from the program's perspective, accounting for costs related to program development, allergy verification, antibiotic cost, and delivery hospitalization. Costs were compared between patients who were referred for evaluation versus patients who were not referred using bivariate tests as well as quantile regression adjusting for baseline differences. A sensitivity analysis was performed for allergy testing cost. All cost estimates were inflation adjusted to 2021 U.S. dollars. RESULTS The startup cost of program development and educational initiatives was $19,920, or 86 per patient. The median allergy evaluation cost was $397 (interquartile range: $303-663). There was no significant difference in maternal (median: $13,579 vs. 13,999, p = 0.94) or neonatal (median: $3,565 vs. 3,577, p = 0.55) delivery hospitalization cost or antibiotic cost (median: $1.57 vs. 3.87, p = 0.10) between referred and nonreferred patients. Overall, the total cost per person did not differ significantly between study groups (median: $18,931 vs. 18,314, p = 0.69). CONCLUSION The cost of developing a penicillin allergy referral program in pregnancy was modest and did not significantly alter short-term cost of care with potential for long-term cost benefit. Verification of a reported penicillin allergy is an integral part of antibiotic stewardship, and the pregnancy period should be utilized as an important opportunity to perform this evaluation. KEY POINTS · The cost of developing and implementing an antepartum penicillin allergy referral program is modest.. · Program cost did not significantly alter short-term cost with a potential for long-term cost benefit.. · Penicillin allergy verification is an important part of antibiotic stewardship and should be expanded..
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Affiliation(s)
- Martina S Burn
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, Minnesota
| | - Xiao Xu
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Jason Kwah
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jane Liao
- Department of Internal 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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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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Epstein-Rigbi N, Ziv S, Bulanenkova M, Bouganim R, Tal-Jasper R, Marchaim D. Beta-lactam antibiotics administration among adult inpatients with a beta-lactam allergy label: incidence, predictors, and outcomes. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e68. [PMID: 38698943 PMCID: PMC11062790 DOI: 10.1017/ash.2024.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/31/2024] [Accepted: 04/04/2024] [Indexed: 05/05/2024]
Abstract
Background A beta-lactam antibiotics (BLA) allergy label is common, resulting in disadvantageous outcomes due to the usage of second-line antimicrobial agents. Noncontrolled case-series analyses report low rates of hypersensitivity reactions, following intentional/non-intentional BLA challenges among labeled inpatients. The study aims were to explore predictors and outcomes associated with hypersensitivity reactions following BLA challenge among BLA-allergic labeled inpatients. Methods Retrospective cohort study (2019-2020) of adult (≥18 years) inpatients (Shamir Medical Center, Israel), labeled as allergic to ≥1 BLA, who received ≥1 dose/s of BLA during their stay. Independent predictors to develop allergic reactions and the independent associations of allergic reactions with clinical outcomes were queried by logistic and Cox regressions. Results Of 9,670 inpatients (14,088 hospitalizations), 3,570 (37%) were labeled as allergic to ≥1 BLA. Of those, 1,171 (33%) patients received ≥1 BLA. The majority were women (67%), and the mean age was 69.3 ± 19.4 years. Only 30 patients (2.6%) developed a reaction, all mild. Independent predictors to develop an allergic reaction were documented reactions in the past, atopic background, antihistamines administration prior to the BLA challenge, and high risk for cross-reactivity, based on the BLA side chains, between the labeled and the challenged agents. Reaction upon the BLA challenge was not independently associated with any worse outcome. Conclusions Despite the commonality of allergy labeling, and the commonality of BLA administration to labeled inpatients, hypersensitivity reactions were mild and rare. Interventional stewardship strategies for active BLA de-labeling among low-risk patients should be promoted, to improve patients' and institutional health and fiscal outcomes.
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Affiliation(s)
- Naama Epstein-Rigbi
- The Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (Assaf Harofeh) Medical Center, Beer Yaacov, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Sharon Ziv
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Marina Bulanenkova
- Department of Geriatrics, Shmuel Harofeh Medical Center, Beer Yaacov, Israel
| | - Ruth Bouganim
- Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Beer Yaacov, Israel
| | - Ruthy Tal-Jasper
- Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Beer Yaacov, Israel
| | - Dror Marchaim
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Beer Yaacov, Israel
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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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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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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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Joerger T, Taylor MG, Palazzi DL, Gerber JS. The epidemiology of cephalosporin allergy labels in pediatric primary care. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e215. [PMID: 38156211 PMCID: PMC10753463 DOI: 10.1017/ash.2023.487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 12/30/2023]
Abstract
Background Recent studies have sought to understand the epidemiology and impact of beta-lactam allergy labels on children; however, most of these studies have focused on penicillin allergy labels. Fewer studies assess cephalosporin antibiotic allergy labels in children. The objective of this study was to determine the prevalence, factors associated with, and impact of cephalosporin allergy labels in children cared for in the primary care setting. Methods Cephalosporin allergy labels were reviewed among children in a dual center, retrospective, birth cohort who were born between 2010 and 2020 and followed in 90 pediatric primary care practices. Antibiotic prescriptions for acute otitis media were compared in children with and without cephalosporin allergies. Results 334,465 children comprised the birth cohort and 2,877 (0.9%) were labeled as cephalosporin allergic during the study period at a median age of 1.6 years. Third-generation cephalosporins were the most common class of cephalosporin allergy (83.0%). Cephalosporin allergy labels were more common in children with penicillin allergy labels than those without (5.8% vs. 0.6%). Other factors associated with a cephalosporin allergy label included white race, private insurance, presence of a chronic condition, and increased health care utilization. Children with third-generation cephalosporin allergy labels received more amoxicillin/clavulanate (28.8% vs. 10.2%) and macrolides (10.4% vs. 1.9%) and less amoxicillin (55.8% vs. 70.9%) for treatment of acute otitis media than non-allergic peers p < 0.001. Conclusions One in 100 children is labeled as cephalosporin allergic, and these children receive different antibiotics for the treatment of acute otitis media compared to non-allergic peers.
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Affiliation(s)
- Torsten Joerger
- Department of Pediatrics, Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Margaret G. Taylor
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA
| | - Debra L. Palazzi
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA
| | - Jeffrey S. Gerber
- Department of Pediatrics, Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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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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Ali SB, Le TTA, Ahmadie A, Yuson C, Kette F, Hissaria P, Smith WB. The role of major and minor determinants in penicillin allergy testing: Time to revisit an old friend? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100132. [PMID: 37781672 PMCID: PMC10509867 DOI: 10.1016/j.jacig.2023.100132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/09/2023] [Accepted: 03/29/2023] [Indexed: 10/03/2023]
Abstract
Background Skin testing is an important step in evaluation of penicillin allergic reactions. It includes testing to the following: amoxicillin, benzyl penicillin, and products generated in vivo after penicillin administration, the major determinant hapten penicilloyl-polylysine (PPL) and the minor determinant mixture (MDM). Although PPL and MDM are available as a commercial kit, their supply and cost remain problematic. Objective We aimed to evaluate the performance and utility of PPL and MDM in penicillin allergy testing. Methods A retrospective audit over a 5-year period was undertaken for those with penicillin testing in a tertiary immunology unit. Results In all, 214 patients were identified. Of those patients, 151 (70.6%) were female and the average age was 58 years. Unspecified penicillin was the most common index drug (n = 127 [59.3%]), followed by amoxicillin (n =3 [24.8%]) and amoxicillin-clavulanic acid (n = 21 [9.7%]). The result of skin testing was positive in 23 patients (10.7%); skin prick testing was positive in 10 patients (4.7%), and intradermal testing (IDT) was positive in 13 patients (6.1%), the majority of whom had identified amoxicillin or amoxicillin-clavulanic acid as the index drug (n = 22 [95.7%]). The result of testing to PPL and/or MDM was positive with IDT only (n=5 [23.8%]). PPL and MDM positivity coexisted with a positive reaction to amoxicillin IDT in 2 patients, 1 of whom passed an amoxicillin challenge. Additionally, 2 positive tests to PPL were present with a negative result for MDM; of these 2 positive results, 1 was positive to amoxicillin IDT. In only 1 case were the results of testing for MDM and PPL both positive, with negative results to all native β-lactams tested; the patient tolerated an amoxicillin challenge. Overall, the negative predictive value for both skin prick testing and IDT was 89.5%. Conclusion Benzyl penicillin and amoxicillin alone may be sufficient for in vivo testing in suspected individuals with penicillin allergy.
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Affiliation(s)
- Syed B. Ali
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
| | - Thanh-Thao Adriana Le
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
| | - Aida Ahmadie
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
| | - Chino Yuson
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
| | - Frank Kette
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
| | - Pravin Hissaria
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
- Department of Immunopathology, SA Pathology, Adelaide, Australia
| | - William B. Smith
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
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Chadha S, Troost JP, Shivers PL. Does thePenicillin Allergy Label Affect Outcomes of Complicated Odontogenic Infections? J Oral Maxillofac Surg 2023; 81:1301-1310. [PMID: 37507104 DOI: 10.1016/j.joms.2023.07.001] [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: 12/29/2022] [Revised: 05/31/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023]
Abstract
PURPOSE Penicillins are a potent antibiotic in managing odontogenic infections, but 10% of the population is labelled as allergic to these drugs. This has limited their use and resulted in increased utilization of health care resources as well as complications associated with alternative antibiotics. The purpose of the study was to measure the association between patients labeled as penicillin allergic and treatment outcomes in a sample of patients treated for complicated odontogenic infections. Additionally, we sought to investigate antibiotic resistance patterns in these patients. MATERIALS AND METHODS A retrospective cohort study was performed at the Michigan Medicine health care system to include patients who were treated for complicated odontogenic infections by oral and maxillofacial surgery between 2016 and 2020. Complicated odontogenic infection was defined as any odontogenic infection requiring admission and surgical management in the operating room. The primary predictor variable was the penicillin allergy label, which was determined by chart review and not confirmed with formal testing. Outcomes were measures of disease severity. The primary outcome variable was hospital length of stay. Secondary outcome variables were ICU admission (yes/no), repeat computed tomography scan(s), repeat surgery (yes/no), and re-admission (yes/no). Co-variates included were age, sex (male/female), tobacco use status, diabetes, immunocompromised state, number of spaces involved, white blood cell count upon admission and insurance status. For our secondary aim, the primary predictor variable was again penicillin allergy and outcome variable was antibiotic resistance as determined by wound culture results following surgical intervention. Negative binomial regression and logistic regression analyses were performed. P < .05 was considered significant. RESULTS A total of 150 patients met the inclusion criteria and of those 17.3% reported as penicillin allergic. Patients labelled as penicillin allergic did not differ significantly from patients without penicillin allergy label in terms of treatment outcomes. Age, diabetes, and immunosuppression were associated with an increased length of stay. Patients labelled as penicillin allergic were at significantly higher risk for antibiotic resistance (relative risk = 2.34; 95% confidence interval, 1.66 to 3.32; P < .001), specifically clindamycin resistance (relative risk = 3.17; 95% confidence interval, 1.93 to 5.18; P < .001). CONCLUSIONS Penicillin allergy was significantly associated with clindamycin resistance. There were similar outcomes amongst patients with and without a penicillin allergy label despite antibiotic differences. Delabeling efforts for patients with a reported penicillin allergy must be considered and local nomograms for antibiotic selection should be used by providers when seeking alternative antibiotics.
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Affiliation(s)
- Sagar Chadha
- Resident, Department of Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, MI
| | - Jonathan P Troost
- Lead Statistician, Michigan Institute for Clinical Health and Research, Ann Arbor, MI
| | - Paul L Shivers
- Clinical Instructor, Department of Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, MI.
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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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Palacios Cañas AA, Meneses Sotomayor JV, Clar Castelló M, Gómez Torrijos E, Borja Segade JM, García Rodríguez R. [Reproducibilidad clínica de reacciones de hipersensibilidad a fármacos en pruebas de exposición controlada]. REVISTA ALERGIA MÉXICO 2023; 70:113-120. [PMID: 37933921 DOI: 10.29262/ram.v70i3.1199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/19/2023] [Indexed: 11/08/2023] Open
Abstract
Objective To assess the reproducibility of symptoms in drug challenge tests. Methods The study included patients with positive cutaneous or challenge test throughout 2019. For each patient, clinical suspicion according to Karch-Lasagna algorithm was registered. Primary outcome was the reproducibility of symptoms in the provocation tests using a paired analysis of data with McNemar test. Results Eighty-nine patients were included, 16 of them presented more than one positive test. Thirty were skin tests positive and 75 reacted to provocation tests. Eighty nine percent of patients who reacted in challenge test were probably or possibly reactors according to Karch-Lasagna scale. Symptoms of initial reaction did not differ from those triggered in challenge tests. Conclusions Karch-Lasagna scale is useful in predicting the response to drug provocation tests. In most of the positive studies, results were suggested by clinical history and no differences were found between symptoms triggered in challenge test and that referred to in the previous reaction.
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13
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Heo E, Jeong Y, Heo KN, Kim H, Kang HR, Park SK, Lee JY. Impact of β-lactam allergies on antibiotic use, clinical outcomes, and economic costs in patients receiving surgical prophylactic antibiotics. J Hosp Infect 2023; 139:249-250. [PMID: 37286106 DOI: 10.1016/j.jhin.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023]
Affiliation(s)
- E Heo
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Y Jeong
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - K N Heo
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - H Kim
- Regional Pharmacovigilance Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - H R Kang
- Regional Pharmacovigilance Center, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - S K Park
- College of Pharmacy, The Catholic University of Korea, Bucheon, Republic of Korea
| | - J Y Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea.
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14
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Sunagawa SW, Bergman SJ, Kreikemeier E, Watkins AB, Alexander BT, Miller MM, Schroeder D, Stohs EJ, Van Schooneveld TC, May SM. Use of a beta-lactam graded challenge process for inpatients with self-reported penicillin allergies at an academic medical center. FRONTIERS IN ALLERGY 2023; 4:1161683. [PMID: 37588449 PMCID: PMC10425280 DOI: 10.3389/falgy.2023.1161683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/29/2023] [Indexed: 08/18/2023] Open
Abstract
Background The Antimicrobial Stewardship Program (ASP) at Nebraska Medicine collaborated with a board-certified allergist to develop a penicillin allergy guidance document for treating inpatients with self-reported allergy. This guidance contains an algorithm for evaluating and safely challenging penicillin-allergic patients with beta-lactams without inpatient allergy consults being available. Methods Following multi-disciplinary review, an order set for beta-lactam graded challenges (GC) was implemented in 2018. This contains recommended monitoring and detailed medication orders to challenge patients with various beta-lactam agents. Inpatient orders for GC from 3/2018-6/2022 were retrospectively reviewed to evaluate ordering characteristics, outcomes of the challenge, and whether documentation of the allergy history was updated. All beta-lactam challenges administered to inpatients were included, and descriptive statistics were performed. Results Overall, 157 GC were administered; 13 with oral amoxicillin and 144 with intravenous (IV) beta-lactams. Ceftriaxone accounted for the most challenges (43%). All oral challenges were recommended by an Infectious Diseases consult service, as were a majority of IV challenges (60%). Less than one in five were administered in an ICU (19%). Almost all (n = 150, 96%) were tolerated without any adverse event. There was one reaction (1%) of hives and six (4%) involving a rash, none of which had persistent effects. Allergy information was updated in the electronic health record after 92% of the challenges. Conclusion Both intravenous and oral beta-lactam graded challenges were implemented successfully in a hospital without a regular inpatient allergy consult service. They were well-tolerated, administered primarily in non-ICU settings, and were often ordered by non-specialist services. In patients with a self-reported penicillin allergy, these results demonstrate the utility and safety of a broadly adopted beta-lactam GC process.
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Affiliation(s)
- Shawnalyn W. Sunagawa
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, NE, United States
| | - Scott J. Bergman
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, NE, United States
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Emily Kreikemeier
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, NE, United States
| | - Andrew B. Watkins
- Department of Pharmacy, St. Dominic Jackson Memorial Hospital, Jackson, MS, United States
| | - Bryan T. Alexander
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, NE, United States
| | - Molly M. Miller
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, NE, United States
| | - Danny Schroeder
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, NE, United States
| | - Erica J. Stohs
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | | | - Sara M. May
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, United States
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15
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Redmond M, Scherzer R, Hardy C, Macias C, Samora J, Stukus D. In-Office Amoxicillin to Increase Graded-Dose Challenges at Initial Evaluation for Penicillin Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2190-2195. [PMID: 37088373 DOI: 10.1016/j.jaip.2023.04.006] [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: 10/16/2022] [Revised: 03/13/2023] [Accepted: 04/02/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND More than 90% of pediatric patients labeled with a penicillin allergy can tolerate subsequent treatment courses without reaction. Graded-dose challenges (GDCs) are an important tool to clarify reported penicillin allergy. OBJECTIVE To increase the use of same-day amoxicillin GDCs among patients with a low-risk penicillin allergy history who presented for outpatient allergy office evaluation from 2% to 15% and sustain for 6 months. METHODS New patients evaluated in an academic pediatric allergy clinic with a documented penicillin allergy were included, regardless of reason for referral. The percentage of these patients who were administered a GDC to amoxicillin at the initial evaluation was assessed over time. Multiple interventions were implemented to increase same-day GDC: amoxicillin, previously only available from pharmacy, was made available in clinic, and penicillin-allergic patients were scheduled earlier in the clinic session. RESULTS The baseline rate of new patients with penicillin allergy who received a GDC increased from 2% to 18% after amoxicillin was stocked in the allergy clinic. GDCs further increased to 34% after penicillin-allergic patients were scheduled at a time conducive to challenge. CONCLUSIONS Amoxicillin availability in the clinic setting increased the percentage of eligible patients who completed same-day GDCs. Scheduling adjustments further increased the ability to conduct GDCs. Proactive penicillin allergy delabeling efforts can be assisted through practical approaches in the outpatient setting.
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Affiliation(s)
- Margaret Redmond
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio.
| | - Rebecca Scherzer
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio
| | - Charles Hardy
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Charlie Macias
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Julie Samora
- Department of Orthopedics, Nationwide Children's Hospital, Columbus, Ohio
| | - David Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio
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16
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Kuder MM, McDonnell JC, Weller K, Li M, Wang X, Lang DM. Relationship of Reaction History to Positive Penicillin Skin Tests. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1869-1875. [PMID: 36948489 DOI: 10.1016/j.jaip.2023.03.007] [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: 06/28/2022] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Previous data suggest that up to one-third of patients classified as allergic based on positive penicillin skin tests have a vague reaction history. Direct oral challenge (DOC) has been recommended for patients with a low-risk reaction history. A variety of published models stratify reaction risk to guide the use of DOC. OBJECTIVE To reassess the proportion of penicillin skin test-positive patients with vague or low-risk reaction histories and evaluate the relationship between the reaction risk history and the likelihood of positive skin test results. METHODS We identified patients who underwent penicillin allergy evaluation over a 5-year period. We recorded drug reaction history, demographic variables, skin testing, and challenge results. Matched controls whose skin tests were negative were identified for skin test-positive patients. Drug reaction histories were assigned a risk category based on 2 previously published risk stratification models. We used logistic regression to investigate whether reaction history risk was associated with positive skin test results. RESULTS Penicillin skin testing was performed in 3382 patients; 207 (6.1%) were positive. Positive skin tests were more frequent in outpatients (P < .001), younger patients (P < .001), and female patients (P < .001). Percentages of each risk category in each model were similar in cases versus matched controls. The likelihood for positive skin tests increased with a high-risk reaction history in one stratification model. CONCLUSION Our data confirm that a substantial proportion of patients who self-report penicillin allergy and have positive skin test results have a low-risk history and imply that penicillin skin testing is associated with a poor positive predictive value.
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Affiliation(s)
- Margaret M Kuder
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - John C McDonnell
- Center of Pediatric Allergy and Immunology, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Katherine Weller
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Manshi Li
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Xiafeng Wang
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Snider JB, Mithal LB, Kwah JH, Rhodes NJ, Son M. Antibiotic choice for Group B Streptococcus prophylaxis in mothers with reported penicillin allergy and associated newborn outcomes. BMC Pregnancy Childbirth 2023; 23:400. [PMID: 37254067 PMCID: PMC10228028 DOI: 10.1186/s12884-023-05697-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/10/2023] [Indexed: 06/01/2023] Open
Abstract
OBJECTIVE To evaluate the choice of antibiotic used for intrapartum Group B Streptococcus (GBS) prophylaxis in pregnant individuals with reported penicillin allergies compared to those without reported penicillin allergies and investigate whether there are associated differences in neonatal outcomes. STUDY DESIGN This retrospective cohort study included mother-infant dyads of GBS positive pregnant individuals who labored and delivered newborns ≥ 35 weeks of gestation at a high-volume urban hospital (2005-2018). The type of antibiotic administered to the mothers for GBS prophylaxis (beta-lactam prophylaxis defined as penicillin-class drug or cefazolin; alternative prophylaxis defined as vancomycin or clindamycin) was compared between those with a penicillin allergy documented in their medical record versus those who did not. Neonatal outcomes included number of postnatal blood draws, antibiotic administration, neonatal intensive care unit (NICU) admission, bacteremia, and hospital length of stay and were compared between groups. Bivariable and multivariable analyses were performed. RESULTS Of 11,334 mother-infant pairs, 1170 (10.3%) mothers had a penicillin allergy documented in their medical record. Of them, 49 (4.2%) received a penicillin, 259 (22.1%) received cefazolin, 449 (38.4%) received clindamycin, and 413 (35.3%) received vancomycin. Patients with a reported penicillin allergy were significantly more likely to receive alternative GBS prophylaxis compared to those without penicillin allergy (73.7% vs. 0.2%, p < 0.01). Neonates of patients who received alternative GBS prophylaxis were significantly more likely to undergo a postnatal lab draw compared to neonates of patients who received beta-lactam antibiotics (20.8% vs. 17.3%, OR 1.25 (95% CI 1.08-1.46)). This significant association persisted after adjusting for potential confounders (aOR 1.23, 95% CI 1.06-1.43). There were no other significant differences seen in other newborn outcomes. CONCLUSION Pregnant individuals who report a penicillin allergy were more likely to receive alternative antibiotics for GBS prophylaxis compared to those without a penicillin allergy. This was associated with an increased frequency of postnatal blood draws among neonates of mothers with a reported penicillin allergy. Administration of alternative intrapartum antibiotic prophylaxis with vancomycin or clindamycin is common in individuals with self-reported penicillin allergy, and maternal alternative antibiotic administration may impact neonatal care, particularly via increased lab draws.
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Affiliation(s)
- Josephine B Snider
- Department of Pediatrics, Division of Hospital-Based Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Leena B Mithal
- Department of Pediatrics, Division of Infectious Diseases, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jason H Kwah
- Department of Medicine, Section of Rheumatology, Allergy, and Immunology, School of Medicine, Yale University, New Haven, CT, USA
| | - Nathaniel J Rhodes
- Midwestern University Chicago College of Pharmacy,Center of Pharmacometric Excellence, Midwestern University, Downers Grove, IL, USA
| | - Moeun Son
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Section of Maternal-Fetal Medicine, School of Medicine, Yale University, 333 Cedar Street, P.O. Box 208063, New Haven, CT, 06520, USA.
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18
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Holmes MD, Vo N, Rafeq R, Byrne D, King M. Administration of β-lactam antibiotics to patients with reported penicillin allergy in the emergency department. Am J Emerg Med 2023; 68:119-123. [PMID: 36972634 DOI: 10.1016/j.ajem.2023.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND β-lactam antibiotics are amongst the most commonly prescribed medications in the Emergency Department (ED) due to their role in empiric sepsis therapy; however, inferior therapeutic options are often utilized due to a reported allergy; penicillin (PCN) being most frequent. In the United States, 10% of the population endorses an allergic reaction to PCN while <1% experience IgE-mediated reactions. This study aimed to evaluate the frequency and outcome of patients in the ED whose PCN allergies were challenged with β-lactam antibiotics. METHODS We conducted a retrospective chart review of patients in the ED at an academic medical center aged ≥18, and who received a β-lactam despite a reported PCN allergy between January 2015 and December 2019. Patients who did not receive a β-lactam or did not report a PCN allergy prior to administration were excluded. The primary outcome was the frequency of IgE-mediated reactions in response to β-lactam administration. A secondary outcome assessed the frequency of continuation of β-lactams upon admission from the ED. RESULTS 819 patients were included (66% female) with prior reported PCN reactions: hives (22.5%), rash (15.4%), swelling (6.2%), anaphylaxis (3.5%), other (12.1%), or undocumented on medical electronic record (40.3%). No patients experienced an IgE-mediated reaction to the β-lactam administered in the ED. Previously reported allergies had no effect on the continuation of β-lactams when admitted or discharged (OR: 1, 95% CI: 0.7-1.44). Patients who had a history of an IgE-mediated penicillin allergy were frequently continued (77%) on a β-lactam after leaving the ED via admission or discharge. CONCLUSION β-lactam administration in patients with previously reported PCN allergies did not result in any IgE-mediated reactions nor in an increase in adverse reactions. Our data contributes to the body of evidence that supports the administration of β-lactams to patients with documented PCN allergies.
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Affiliation(s)
- Matthew D Holmes
- Cooper Medical School of Rowan University, 401 Broadway, Camden, NJ 08103, USA.
| | - Nina Vo
- Philadelphia College of Pharmacy, University of the Sciences, 600 South 43rd, Philadelphia, PA 19104, USA
| | - Rachel Rafeq
- Cooper University Health Care, 1 Cooper Plaza, Camden, NJ 08103, USA.
| | - Dana Byrne
- Cooper Medical School of Rowan University, 401 Broadway, Camden, NJ 08103, USA; Cooper University Health Care, 1 Cooper Plaza, Camden, NJ 08103, USA
| | - Madeline King
- Philadelphia College of Pharmacy, University of the Sciences, 600 South 43rd, Philadelphia, PA 19104, USA; Cooper University Health Care, 1 Cooper Plaza, Camden, NJ 08103, USA
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De Luca JF, James F, Vogrin S, Chua K, Fletcher L, Nazareth J, Guha R, Hardidge A, Douglas N, Carruthers J, Stewardson A, Cheng AC, Johnson D, Douglass J, Peel T, Trubiano J. Study protocol for PREPARE: a phase II feasibility/safety randomised controlled trial on PeRiopErative Penicillin AlleRgy TEsting. BMJ Open 2023; 13:e067653. [PMID: 36828661 PMCID: PMC9972415 DOI: 10.1136/bmjopen-2022-067653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/23/2023] [Indexed: 02/26/2023] Open
Abstract
INTRODUCTION Patient-reported antibiotic allergy labels (AALs) are common. These labels have been demonstrated to have a negative impact on use of appropriate antibiotics and patient-related health outcomes. These patients are more likely to receive suboptimal antibiotics, have increased rates of surgical site infections and are more likely to be colonised with multidrug-resistant organisms. Increasing recognition that antibiotic allergy forms a key part of good antimicrobial stewardship has led to calls for greater access to antibiotic allergy assessment.PREPARE is a pilot randomised controlled trial of beta-lactam allergy assessment and point of care delabelling in perioperative patients utilising a validated antibiotic allergy assessment tool that has been repurposed into a smartphone application. The aim of the study is to assess the feasibility and safety of this approach in the perioperative outpatient setting. METHODS AND ANALYSIS Adult participants requiring elective surgery and are likely to require prophylactic intravenous antibiotics will be recruited. During the intervention phase, participants will be randomised to the intervention or control arm, with control patients receiving usual standard of care. Those randomised to intervention undertake a risk assessment via the smartphone application, with those deemed low risk proceeding to direct oral provocation with either a penicillin or cephalosporin. Study outcomes will be evaluated in the postintervention phase, 30 and 90 days after surgery.Feasibility of intervention delivery and recruitment will be reported as proportions with respective 95% CIs. Participants who experience an antibiotic adverse event will be reported by group with respective 95% CIs and compared using modified Poisson regression model with robust SE estimation. ETHICS AND DISSEMINATION This protocol has received approval from the Austin Health human research and ethics committee, Heidelberg, Victoria, Australia (HREC/17/Austin/575). Results will be disseminated via publication in peer-reviewed journals as well as presentation at international conferences. TRIAL REGISTRATION NUMBER ACTRN12620001295932.
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Affiliation(s)
- Joseph F De Luca
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Fiona James
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Sara Vogrin
- St Vincent's Department of Medicine, The University of Melbourne, Fitzroy, Victoria, Australia
| | - Kyra Chua
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Luke Fletcher
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Justin Nazareth
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Ranjan Guha
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew Hardidge
- Department of Orthopaedic Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Ned Douglas
- Department of Anaesthesia, Melbourne Health, Parkville, Victoria, Australia
| | - John Carruthers
- Department of Anaesthesia, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew Stewardson
- Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
- Infectious Diseases, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine Clinical Trials Centre, Monash University, Melbourne, Victoria, Australia
| | - Douglas Johnson
- Department of General Medicine, Melbourne Health, Parkville, Victoria, Australia
- Department of Medicine RMH, The University of Melbourne, Parkville, Victoria, Australia
| | - Jo Douglass
- Department of Medicine RMH, The University of Melbourne, Parkville, Victoria, Australia
| | - Trisha Peel
- Infectious Diseases, Monash University, Melbourne, Victoria, Australia
- Infectious Diseases, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
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Cate JJM, Burn M, Kwah J, Liao J, Illuzzi J, Reddy U, Son M. Survey of Obstetric Providers to Assess the Knowledge and Management of a Reported Penicillin Allergy in Pregnant Women. Am J Perinatol 2023; 40:1-8. [PMID: 35709740 DOI: 10.1055/a-1877-9970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Penicillin allergy is the most commonly reported drug allergy in the United States; however, less than 10% of individuals labeled with a penicillin allergy are truly allergic. A reported penicillin allergy in pregnancy is associated with adverse maternal and perinatal outcomes. Despite recommendations for penicillin allergy testing in pregnancy, limited literature regarding obstetric providers' comfort and knowledge in addressing penicillin allergy and referral patterns exists. The objective of this study is to survey obstetric providers to assess their clinical practice patterns and baseline penicillin allergy knowledge, identify potential knowledge gaps in the management of pregnant patients with reported penicillin allergy, and measure the impact of an educational intervention on provider knowledge and practice patterns. STUDY DESIGN An anonymous, electronic 23-question survey administered to all obstetric providers at a single academic medical center assessed obstetric provider characteristics, self-reported antibiotic practice patterns, and antibiotic allergy knowledge before (June 19, 2020) and after (September 16, 2020) a penicillin allergy educational intervention, which consisted of multiple small-group educational sessions and a culminating departmental educational session. Discrete knowledge comparison by provider type and experience level of pre- and postintervention was performed using chi-square tests. RESULTS Of 277 obstetric providers invited, 124 (45%) responded preintervention and 62 (22%) postintervention. In total, 27% correctly identified the percentage of patients labeled penicillin allergic who would tolerate penicillins, 45% identified cephalosporin cross-reactivity, 59% understood penicillin allergies can wane, and 54% identified penicillin skin testing (PST) as a valid allergy verification tool. Among 48 respondents who attended educational sessions and responded postintervention, their knowledge of penicillin allergy waning (79% preeducation vs. 98% posteducation, p < 0.01) and PST as a valid tool for penicillin allergy verification (50% preeducation vs. 83% posteducation, p < 0.01) improved. CONCLUSION Knowledge gaps related to penicillin allergy exist among obstetric providers. Educational initiatives may improve provider knowledge, help in the identification of patients requiring penicillin allergy evaluation, and reduce referral barriers. KEY POINTS · Obstetric providers lack adequate knowledge of penicillin allergy.. · Educational interventions can improve discrete knowledge.. · Limited knowledge is a barrier to allergy referral for penicillin allergy delabeling..
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Affiliation(s)
- Jennifer J M Cate
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Martina Burn
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Jason Kwah
- Section of Rheumatology, Allergy, and Immunology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jane Liao
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jessica Illuzzi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Uma Reddy
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Moeun Son
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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21
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[Efficiency of the allergological study in the diagnosis of allergic reactions to beta-lactams]. Semergen 2023; 49:101866. [PMID: 36434940 DOI: 10.1016/j.semerg.2022.101866] [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: 08/17/2022] [Revised: 09/14/2022] [Accepted: 10/08/2022] [Indexed: 11/24/2022]
Abstract
AIMS Assessing the rate of β-lactams-allergic patients who are still labelled as such in their medical records after being performed an allergic test; as well as the rate of no allergic patients who were prescribed one of these antibiotics; and pondering whether the allergic test is hence cost-effective. METHODS This is a retrospective study developed from 2019 to 2021 focusing on patients suspected of β-lactams allergy (n=688). By means of an allergy test, it was cleared out if they were actually allergic. Later, we checked if the patient was still labelled as allergic in their medical record. Tracking through the digital health services card, we followed up if the antibiotic was ever prescribed again, and if the drug was then dispensed to the patient. RESULTS 11.3% of the patients showed hypersensitivity to β-lactams. Nonetheless, 33.1% of the patients were still considered allergic to these antibiotics in their medical record even though not being such. 32% of the patients - who had their allergy confirmed - had been labelled without the general practitioner's acknowledgment, and 32.8% had even been prescribed a β-lactam again. CONCLUSIONS Discarding any allergy to β-lactams is as important as registering the allergy on medical records after testing the patient. A remarkable quantity of non-allergic patients is still addressed as actual allergic, in spite not being such. Labelling patients as β-lactams allergic may have consequences, short-term and long-term, for the patient but also for the health service budget.
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22
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Beta-lactam hypersensitivity diagnosis in ambulatory and hospitalized settings require different approaches. Ann Allergy Asthma Immunol 2023; 130:84-92.e1. [PMID: 36122888 DOI: 10.1016/j.anai.2022.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Data on beta-lactam hypersensitivity (BLH) are mainly focused on immediate or mild nonimmediate reactions in the ambulatory setting, but limited in patients with concurrent illness and moderate-to-severe nonimmediate reactions in the hospitalized setting. OBJECTIVE To investigate the entire spectrum of BLH in Thai tertiary hospital. METHODS Clinical characteristics of 357 patients with suspected BLH were evaluated in a 7-year period. Culprit drug identification was performed in 335 patients by combined skin testing, in vitro testing, or drug provocation tests. RESULTS The predominant BLH presentations were non-immunoglobulin (Ig)E-mediated reactions with severe cutaneous adverse reactions of 18.9%, and BLH status was definitively confirmed in 18.1%. The most common verified culprits were cephalosporins (34.8%), particularly in hypersensitivity type IV reactions. Natural penicillins were the main implicated drugs in 48.5% of ambulatory patients. In contrast, cephalosporins and carbapenems were the main implicated drugs in hospitalized patients. Non-IgE-mediated anaphylaxis and serum sickness-like reaction remained diagnostically challenged. New generations of beta-lactams, hospitalized patients, recent allergic history, and underlying malignancies or autoimmune diseases were associated with increased BLH risk. CONCLUSION At present, cephalosporins are the leading causes of BLH, particularly in non-IgE-mediated reactions. More research on the verification of non-IgE hypersensitivity reactions from new generations of beta-lactams should be better emphasized. CLINICAL TRIAL REGISTRATION The registry was approved by the Ethics and Research Committee of the Faculty of Medicine, Chulalongkorn University, and listed on ClinicalTrials.gov (Identifier: NCT01667055; https://www. CLINICALTRIALS gov/ct2/show/NCT01667055).
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23
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Niu T, Zhang Y, Li Z, Bian Y, Zhang J, Wang Y. The association between penicillin allergy and surgical site infection after orthopedic surgeries: a retrospective cohort study. Front Cell Infect Microbiol 2023; 13:1182778. [PMID: 37153141 PMCID: PMC10160653 DOI: 10.3389/fcimb.2023.1182778] [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: 03/09/2023] [Accepted: 04/03/2023] [Indexed: 05/09/2023] Open
Abstract
Background Cephalosporins are used as first-line antimicrobial prophylaxis for orthopedics surgeries. However, alternative antibiotics are usually used in the presence of penicillin allergy (PA), which might increase the risk of surgical site infection (SSI). This study aimed to analyze the relationship between SSI after orthopedic surgeries and PA among surgical candidates and related alternative antibiotic use. Methods In this single-center retrospective cohort study, we compared inpatients with and without PA from January 2015 to December 2021. The primary outcome was SSI, and the secondary outcomes were SSI sites and perioperative antibiotic use. Moreover, pathogen characteristics of all SSIs were also compared between the two cohorts. Results Among the 20,022 inpatient records, 1704 (8.51%) were identified with PA, and a total of 111 (0.55%) SSI incidents were reported. Compared to patients without PA, patients with PA had higher postoperative SSI risk (1.06%, 18/1704 vs. 0.51%, 93/18318), shown both in multivariable regression analysis (odds ratio [OR] 2.11; 95% confidence interval [CI], 1.26-3.50; p= 0.004) and propensity score matching (OR 1.84; 95% CI, 1.05-3.23; p= 0.034). PA was related to elevated deep SSI risk (OR 2.79; 95% CI, 1.47-5.30; p= 0.002) and had no significant impact on superficial SSI (OR 1.39; 95% CI, 0.59-3.29; p= 0.449). The PA group used significantly more alternative antibiotics. Complete mediation effect of alternative antibiotics on SSI among these patients was found in mediation analysis. Pathogen analysis revealed gram-positive cocci as the most common pathogen for SSI in our study cohort, while patients with PA had higher infection rate from gram-positive rods and gram-negative rods than non-PA group. Conclusion Compared to patients without PA, patients with PA developed more SSI after orthopedic surgeries, especially deep SSI. The elevated infection rate could be secondary to the use of alternative prophylactic antibiotics.
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Affiliation(s)
- Tong Niu
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuelun Zhang
- Medical Research Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ziquan Li
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yanyan Bian
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yipeng Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Yipeng Wang,
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24
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Outcomes of Beta-Lactam Allergic and Non-Beta-Lactam Allergic Patients with Intra-Abdominal Infection: A Case-Control Study. Antibiotics (Basel) 2022; 11:antibiotics11121786. [PMID: 36551442 PMCID: PMC9774689 DOI: 10.3390/antibiotics11121786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 12/13/2022] Open
Abstract
Background: In the case of intra-abdominal infections (IAI) in beta-lactam (BL) allergic patients, empiric antimicrobial therapy without BL is recommended; however, data regarding the outcome with alternative regimens are scarce. This study aimed to compare the outcomes of BL allergic (BLA) patients with IAI to those who were non-BLA (NBLA). Method: We conducted a case−control study in a French teaching hospital, between 1 January 2016 and 31 August 2021. BLA patients with IAI treated with fluoroquinolone or aztreonam and metronidazole were matched with controls treated with BL, on age, sex, disease severity, IAI localization, and healthcare-associated infection (HAI) status. We compared rates of therapeutic failures, adverse events, and HAI, and then assessed factors associated with therapeutic failure using a logistic regression model. Results: The therapeutic failure rate was 14% (p > 0.99) in both groups of 43 patients, and there was no significant difference in the adverse events rate (p > 0.99) and HAI rate (p = 0.154). Factors independently associated with therapeutic failure were higher BMI (OR 1.16; 95%CI [1.00−1.36]; p = 0.041), longer hospital length of stay (OR 1,20; 95%CI [1.08−1.41]; p = 0.006), and inadequate empiric antimicrobial therapy (OR 11.71; 95%CI [1.43−132.46]; p = 0.025). Conclusion: The outcomes of BLA patients with IAI treated without BL were the same as those for NBLA patients treated with BL.
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25
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Ham YY, Joshi S, Sukerman E. Delabeling penicillin and other antibiotic allergies in solid organ transplantation patients. Transpl Infect Dis 2022; 24:e13897. [DOI: 10.1111/tid.13897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Young Yoon Ham
- Department of Pharmacy Oregon Health & Science University Portland Oregon USA
| | - Shyam Joshi
- Division of Allergy and Clinical Immunology Oregon Health & Science University Portland Oregon USA
| | - Ellie Sukerman
- Division of Infectious Diseases Oregon Health & Science University Portland Oregon USA
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26
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Motzer AR, Holaday E, Axelrod P, Mishkin A. Effects of reported beta‐lactam allergies on pneumonia outcomes in lung transplant recipients. Transpl Infect Dis 2022; 24:e13906. [DOI: 10.1111/tid.13906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/03/2022] [Accepted: 06/08/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Andrew R. Motzer
- Lewis Katz School of Medicine at Temple University Philadelphia Pennsylvania USA
| | - Eric Holaday
- Virtua Medical Group Mount Laurel New Jersey USA
| | - Peter Axelrod
- Lewis Katz School of Medicine at Temple University Philadelphia Pennsylvania USA
| | - Aaron Mishkin
- Lewis Katz School of Medicine at Temple University Philadelphia Pennsylvania USA
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27
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Mowrer C, Lyden E, Matthews S, Abbas A, Bergman S, Alexander BT, Van Schooneveld TC, Stohs EJ. Beta-lactam allergies, surgical site infections, and prophylaxis in solid organ transplant recipients at a single center: A retrospective cohort study. Transpl Infect Dis 2022; 24:e13907. [PMID: 36254522 PMCID: PMC9787036 DOI: 10.1111/tid.13907] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Beta-lactam allergies (BLAs) are common in hospitalized patients, including transplant recipients. BLA is associated with decreased use of preferred surgical site infection (SSI) prophylaxis and increased SSIs, but this has not been studied in the transplant population. METHODS We reviewed adult heart, kidney, and liver transplant recipients between January 1, 2016 and December 31, 2019 to characterize reported BLA and collect SSI prophylaxis regimens at time of transplant. We compared the use of preferred SSI prophylaxis and SSI incidence based on reported BLA status. Post hoc we collected antibiotic days of therapy (DOT) (excluding pneumocystis prophylaxis) in the 30-day period posttransplant for patients without SSI. We utilized descriptive statistics for comparisons. RESULTS Of 691 patients included (116 heart, 400 kidney, and 175 liver transplant recipients), 118 (17%) reported BLA. Rash and hives were the two most reported BLA reactions (36% and 24%), categorized as potential T-cell mediated and IgE mediated, respectively. Preferred SSI prophylaxis was prescribed in 13 (11%) patients with BLA and 573 (92%) without BLA (p < .001). No difference could be detected in SSI incidence between BLA and non-BLA patients (4.2 vs. 4.3%, p = 1.0). Of 659 without SSI, 169 (25.6%) received antibiotics within 30 days of transplant; mean antibiotic DOT for BLA and non-BLA patients were 3.5 ± 8.0 versus 2.3 ± 5.8, p = .12. CONCLUSION BLA transplant recipients received nonpreferred SSI prophylaxis more frequently than non-BLA recipients, but there was no difference in 30-day SSIs between the groups. One-fourth of solid organ transplant recipients received systemic antibiotics within 30 days of transplant.
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Affiliation(s)
- Clayton Mowrer
- Division of Infectious DiseasesDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Elizabeth Lyden
- Department of BiostatisticsCollege of Public HealthUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Stephen Matthews
- Infection Control and EpidemiologyNebraska MedicineOmahaNebraskaUSA
| | - Anum Abbas
- Division of Infectious DiseasesDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Scott Bergman
- Department of Pharmaceutical and Nutritional CareNebraska MedicineOmahaNebraskaUSA
| | - Bryan T. Alexander
- Department of Pharmaceutical and Nutritional CareNebraska MedicineOmahaNebraskaUSA
| | - Trevor C. Van Schooneveld
- Division of Infectious DiseasesDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Erica J. Stohs
- Division of Infectious DiseasesDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
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28
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Kinn PM, Ince D. Outpatient and peri-operative antibiotic stewardship in solid organ transplantation. Transpl Infect Dis 2022; 24:e13922. [PMID: 36254519 PMCID: PMC9788159 DOI: 10.1111/tid.13922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/27/2022] [Accepted: 07/01/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The consequences of inappropriate antimicrobial use including resistance are increasingly recognized as a global public health threat and many steps have been taken over the last few decades to advance antimicrobial stewardship initiatives with most organ transplant centers currently part of institutions with active antimicrobial stewardship programs. METHODS A review of the literature was conducted and articles were categorized according to the topic and relevance in the judgment of the two authors. RESULTS A summary review of the currently available literature was created with a focus on periprocedural and outpatient antimicrobial stewardship. Limitations in the data were significant and discussed in the review. CONCLUSION The principles of antimicrobial stewardship remain important throughout all phases starting with periprocedural prophylactic antimicrobial selection all the way through to discharge and subsequent healthcare encounters. Despite the broad advances in stewardship initiatives and the rapidly progressing supportive data overall there continue to be significant opportunities for additional research within various special patient populations including recipients of solid organ transplantation (SOT). The recent white paper published in the American Journal of Transplantation called to action the transplant and stewardship communities to have an increased focus and awareness of the issues that antimicrobial overuse can present in the SOT patient population. This is an important step that will hopefully generate more data in this group of patients that arguably faces the greatest vulnerability to the consequences of increased antimicrobial resistance.
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Affiliation(s)
- Patrick Michael Kinn
- Department of Pharmaceutical CareUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | - Dilek Ince
- Department of Internal MedicineDivision of Infectious DiseasesUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
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29
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DesBiens MT, Calderwood MS, Reigh EL. Expanding Penicillin Allergy Evaluation in Hospitalized Patients. Am J Med 2022; 135:958-963.e13. [PMID: 35339433 DOI: 10.1016/j.amjmed.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/08/2021] [Accepted: 12/08/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Martha T DesBiens
- Department of Medicine, Section of Infectious Disease, Nuvance Health, Southbury, Conn; The Robert Larner M.D. College of Medicine at The University of Vermont, Burlington; Department of Medicine, Section of Infectious Disease & International Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - Michael S Calderwood
- Department of Medicine, Section of Infectious Disease & International Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Erin L Reigh
- Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Medicine, Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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30
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Jiang Z, Zhang H, Xiao H, Xiao X, Meng J. Negative impact of penicillin allergy labels on antibiotic use in hospitalized patients in Chinese Mainland. World Allergy Organ J 2022; 15:100677. [PMID: 36090383 PMCID: PMC9428801 DOI: 10.1016/j.waojou.2022.100677] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/07/2022] [Accepted: 07/20/2022] [Indexed: 01/06/2023] Open
Abstract
Background Penicillin allergy labels have gained increasing global attention. However, to date, there are no data on the influence of penicillin allergy labels on patients in Chinese mainland. Methods This retrospective study reviewed the electronic health record (EHR) of hospitalized patients between June 1, 2018 and May 31, 2019. Patients with a penicillin allergy record were included in the allergy group. Every allergy patient was matched with 4 control patients by using propensity score-based matching to make sure the following were balanced: age, sex, date of admission, and the main diagnosis. We estimated the prevalence of penicillin allergy labels and compared the antibiotic prescription patterns and other clinical outcomes between the 2 groups. Results A total of 5691 patients and 22 585 patients were included in the allergy group and control group, respectively. The prevalence of penicillin allergy labels among the hospitalized patients in this study was 4.00%. Compared to the control group, significantly fewer patients in the allergy group were prescribed penicillins and most cephalosporins, while a larger proportion of allergy patients received clindamycin (10.02% vs 5.41%, p < 0.001) and some higher-class antibiotics, such as monobactams (1.81% vs 0.54%, p < 0.001), carbapenems (5.80% vs 4.98%, p = 0.014), macrolides (0.60% vs 0.25%, p < 0.001), and quinolones (17.62% vs 12.40%, p < 0.001). Allergy patients also had longer hospital stays and a greater need to consult infection specialists. Conclusion The prevalence of penicillin allergy labels was 4.00% in Chinese hospitalized patients. Penicillin allergy labels could cause irrational antibiotic prescribing, prolonged hospital stays, and greater consultation needs.
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Affiliation(s)
- Zihan Jiang
- Department of Otorhinolaryngology, West China Hospital, Sichuan University, Chengdu, China
| | - Hongting Zhang
- West China School of Nursing, Sichuan University/Department of Otorhinolaryngology, West China Hospital, Sichuan University, Chengdu, China
- Allergy Center, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Xiao
- Department of Otorhinolaryngology, West China Hospital, Sichuan University, Chengdu, China
- Allergy Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiong Xiao
- Department of Epidemiology and Biostatistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Juan Meng
- Department of Otorhinolaryngology, West China Hospital, Sichuan University, Chengdu, China
- Allergy Center, West China Hospital, Sichuan University, Chengdu, China
- Corresponding author. Department of Otorhinolaryngology/Allergy Center, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu 610041, China.
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Kwah JH, Burn MS, Liao J, Cate J, Son M. Outpatient penicillin allergy evaluation during pregnancy and associated clinical outcomes. Am J Obstet Gynecol MFM 2022; 4:100674. [PMID: 35691578 DOI: 10.1016/j.ajogmf.2022.100674] [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: 03/22/2022] [Revised: 06/03/2022] [Accepted: 06/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Beta-lactam antibiotics are often clinically indicated in the peripartum period, posing a challenge for pregnant women who report a penicillin allergy. Allergy verification testing is rarely performed during pregnancy even though most women do not have a true allergy. OBJECTIVE To evaluate a hospital-wide multidisciplinary program introduced in August 2020 to identify, refer, evaluate, and test pregnant women with unverified penicillin allergies, and assess its association with maternal and neonatal outcomes. STUDY DESIGN We conducted a retrospective cohort study at a large academic hospital of all pregnant women with a penicillin allergy documented in the electronic medical record who delivered from September 2020 to October 2021. Data were abstracted by chart review. Women referred for penicillin allergy evaluation were compared to those who were not. Maternal outcomes were alternative antibiotic (clindamycin or vancomycin) use, postpartum infection, and maternal length of postpartum hospital stay. Neonatal outcomes were intensive care unit admission, postnatal blood draw, antibiotic treatment, and birth hospitalization length of hospital stay. Bivariate and multivariable analyses were performed. RESULTS Of 689 women with a documented penicillin allergy, 232 (33.7%) were referred for allergy evaluation during the study period. Of those referred, 175 (75.4%) underwent allergy consultation and 167 (95.4%) of them were considered appropriate for allergy verification testing. 117 (70.1%) underwent skin testing with or without graded oral amoxicillin drug challenge, and all but one (99.1%) were found to be penicillin tolerant. Five additional women were de-labeled of their penicillin allergy based on history and pharmacy confirmation of penicillin tolerance subsequent to index reaction. Referred women had a 62% lower likelihood of receiving an alternative antibiotic than those who were not referred, and this significance persisted even after adjusting for potential confounders (aOR 0.49, 95% CI 0.27-0.89). Other maternal and neonatal adverse outcomes were less frequent in those referred, but these associations did not reach statistical significance. CONCLUSION This study documents the feasibility, safety, and clinical benefit of an outpatient penicillin allergy referral program for pregnant women. Referred patients were significantly less likely to receive alternative antibiotics, however, more patients are needed to assess whether there are additional clinical benefits.
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Affiliation(s)
- Jason H Kwah
- Section of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Martina S Burn
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Jane Liao
- Section of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jennifer Cate
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
| | - Moeun Son
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
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Olans RD, Olans RN, Marfatia R, Angoff GH. Inaccurate Penicillin Allergy Labeling, The Electronic Health Record, and Adverse Outcomes of Care. Jt Comm J Qual Patient Saf 2022; 48:552-558. [DOI: 10.1016/j.jcjq.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022]
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Miceli LM, Chang OH, Zhang S, Yao M, Propst K. Antimicrobial Stewardship in Patients with Penicillin Allergy Undergoing Hysterectomy for Benign Indications. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2021.0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lia M. Miceli
- Department of Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Olivia H. Chang
- Department of Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Salina Zhang
- Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Katie Propst
- Department of Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Zembles TN, Vyles DE, Mitchell ML. Management of Children with Reported Penicillin Allergies. Infect Dis Clin North Am 2022; 36:219-229. [DOI: 10.1016/j.idc.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Boesch TS, Eischen E, M AR, Quinn A, Dave A, Beezhold DW. Promoting β-lactam utilization through suppression of electronic medical record cross-allergy alerts. Am J Health Syst Pharm 2022; 79:S43-S52. [PMID: 35136927 DOI: 10.1093/ajhp/zxac040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Current literature surrounding management of patients with reported β-lactam allergies focuses on allergy delabeling. Standard clinical decision support tools have not been optimized to be compatible with the currently accepted cross-reaction rate of 1% to 2%. This potentially promotes use of non-β-lactam antibiotics, which are often not first-line therapy and may carry increased risks. The impact of electronic medical record (EMR) clinical decision support tool optimization on utilization of β-lactam antibiotics in β-lactam-allergic patients was evaluated. METHODS A retrospective pre-post β-lactam cross-allergy EMR alert suppression quality improvement intervention cohort study of β-lactam-allergic adult inpatients prescribed antibiotics was conducted. Preintervention baseline data were collected for an initial cohort admitted during September 2018. The intervention, in which clinical decision support rules were updated to display β-lactam cross-sensitivity allergy alerts only for β-lactam-allergic patients with documentation of organization-defined high-severity reactions of anaphylaxis, hives, and shortness of breath, was implemented August 20, 2019. The postintervention cohort included patients admitted during September 2019. RESULTS A 91% increase in the percentage of β-lactam-allergic patients who received a β-lactam agent at any time during their admission was noted after the intervention (26.6% vs 51%, P < 0.001). Statistically significant decreases in prescribing of alternative antibiotic classes were seen for fluoroquinolones (decrease from 45.3% to 26%, P < 0.001), aminoglycosides (decrease from 9.4% to 2.9%, P = 0.002), and aztreonam (decrease from 30% to 16.7%, P < 0.001). CONCLUSION EMR β-lactam cross-allergy alert optimization consistent with current literature significantly improved the utilization of alternative β-lactam subclasses, mostly through β-lactam prescribing as initial therapy in β-lactam-allergic patients.
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Affiliation(s)
- Teryl S Boesch
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Edward Eischen
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Amanda Ries M
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Andrea Quinn
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Ankur Dave
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
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Liu HH, Mutneja H, Buckley M, Cushinotto L. Trends in Antimicrobial Allergies in Patients Seen in Infectious Disease Consultation During Selected Periods 2007–2016. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Collins CD, Bookal RS, Malani AN, Leo HL, Shankar T, Scheidel C, West N. Antibiotic Use in Patients With β-Lactam Allergies and Pneumonia: Impact of an Antibiotic Side Chain-Based Cross-Reactivity Chart Combined With Enhanced Allergy Assessment. Open Forum Infect Dis 2022; 9:ofab544. [PMID: 34988249 PMCID: PMC8715852 DOI: 10.1093/ofid/ofab544] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/29/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND β-lactam antibiotics with dissimilar R-group side chains are associated with low cross-reactivity. Despite this, patients with β-lactam allergies are often treated with non-β-lactam alternative antibiotics. An institutional β-lactam side chain-based cross-reactivity chart was developed and implemented to guide in antibiotic selection for patients with β-lactam allergies. METHODS This single-center, retrospective cohort study analyzed the impact of the implementation of the cross-reactivity chart for patients with pneumonia. Study time periods were defined as January 2013 to October 2014 prior to implementation of the chart (historical cohort) and January 2017 to October 2018 (intervention cohort) following implementation. The primary outcome was the incidence of β-lactam utilization between time periods. Propensity-weighted scoring and interrupted time-series analyses compared outcomes. RESULTS A total of 341 and 623 patient encounters were included in the historical and intervention cohorts, respectively. There was a significantly greater use of β-lactams in the intervention cohort (70.4% vs 89.3%; P < .001) and decreased use of alternative therapy (58.1% vs 36%; P < .001). There was no difference in overall allergic reactions between cohorts (2.4% vs 1.6%; P = .738) or in reactions caused by β-lactams (1.3% vs 0.9%; P = .703). Inpatient mortality increased (0% vs 6.4%; P < .001); however, no deaths were due to allergic reactions. Healthcare facility-onset Clostridioides difficile infections decreased between cohorts (1.2% vs 0.2%; P = .032). CONCLUSIONS Implementation of a β-lactam side chain-based cross-reactivity chart and enhanced allergy assessment was associated with increased use of β-lactams in patients with pneumonia without increasing allergic reactions.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Renee S Bookal
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Department of Internal Medicine, Division of Infectious Diseases, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Harvey L Leo
- Allergy and Immunology Associates of Ann Arbor, PC, Ann Arbor, Michigan, USA
| | - Tara Shankar
- Allergy and Immunology Associates of Ann Arbor, PC, Ann Arbor, Michigan, USA
| | - Caleb Scheidel
- Methods Consultants of Ann Arbor, Ypsilanti, Michigan, USA
| | - Nina West
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
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Rischin KJ, Mostaghim M, Rao A, Smith B, O'Brien TA, Trubiano JA, Frith K, McMullan B. ESCAPE-Allergy: Evaluating screening for children and adolescents with penicillin allergy. J Paediatr Child Health 2022; 58:83-89. [PMID: 34323321 DOI: 10.1111/jpc.15657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/31/2022]
Abstract
AIM Penicillin allergy labels are frequently encountered in children and are associated with significant harms. Most children are falsely labelled and can safely tolerate a penicillin but delabelling strategies are underutilised and paediatric-specific resources are lacking. The aim of this study was to evaluate an allergy assessment tool for children in hospital. METHODS We evaluated a paediatric-adapted penicillin allergy assessment tool, using an online survey of clinicians in a tertiary paediatric hospital, with 10 hypothetical potential penicillin allergy or adverse reaction cases (including non-allergy reactions). For each case, respondents were asked to use the tool to assign a reaction phenotype and recommend management. We determined the tool's sensitivity, specificity and acceptability to end users. RESULTS We evaluated 30 complete survey responses from senior and junior medical staff, nurses and pharmacists. The tool's overall sensitivity was 80.7% (95% confidence interval (CI) 74.2-87.1%) for assigning the correct reaction phenotype and 85.3% (95% CI 79.4-91.3%) for appropriate management. The tool had high sensitivity for identifying immediate hypersensitivity reactions at 95.6% (95% CI 90.2-100%). Most respondents agreed or strongly agreed that they would use the tool in their practice (22/30, 73.3%). CONCLUSION This survey evaluated a paediatric-adapted penicillin allergy assessment tool in a tertiary paediatric hospital among multidisciplinary clinician groups. The tool performed well overall and had high safety in identifying immediate hypersensitivity reactions. Further research to support implementation of allergy assessment and delabelling programmes among children is required.
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Affiliation(s)
- Kobi J Rischin
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia
| | - Mona Mostaghim
- Pharmacy Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Arjun Rao
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Bridget Smith
- Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Tracey A O'Brien
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Katie Frith
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia.,Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Brendan McMullan
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia.,Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia
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Covington EW, Durham SH, Bland CM, Bookstaver PB, Chahine EB, Cho JC, Diggs F, Jones BM, Kyle JA, Stover KR, Wagner JL, Hughes PJ. A Continuing Education Activity Durably Addressed Knowledge Gaps Related to Penicillin Allergies Among Pharmacists and Pharmacy Technicians. J Pharm Technol 2021; 38:18-25. [DOI: 10.1177/87551225211051015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Penicillin allergy is one of the most frequent self-reported allergies; however, only about 10% of reported allergies are accurate. Objectives: Through the creation of a continuing pharmacy education (CPE) activity, we sought to assess knowledge gaps and comfort levels in the management of penicillin allergies. Methods: A 1-hour enduring-content CPE activity was offered as an interactive course from September 20, 2019, to September 20, 2020. Participants completed 3 surveys (pre-survey, post-survey, and follow-up survey). Participants were pharmacists and pharmacy technicians who completed, at a minimum, the activity and both pre- and post-surveys. The primary outcome was the percentage of participants scoring >80% on knowledge-based questions on the post-survey compared with the pre-survey. Secondary outcomes included pre-post comparisons on knowledge-based questions, participants’ self-report of an allergy, and comfort levels dispensing cephalosporins in a patient with a self-reported penicillin allergy. Results: A total of 389 participants completed the CPE activity, with 176 included for analysis. Significantly more participants scored >80% on knowledge-based questions on the post-survey compared with the pre-survey (71.6% vs 22.7%, P < .001). There was no significant difference between the percentage of participants scoring >80% on the post-survey and the follow-up survey (71.6% vs 65%, P = .119). The majority of participants (74%) felt comfortable dispensing a cephalosporin in a patient with a penicillin allergy on the pre-survey, with similar percentages on the post- and follow-up surveys (77% and 90%, respectively). Conclusion: A targeted continuing education program improved overall knowledge, which was sustained for up to 2 months.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce M. Jones
- St. Joseph’s/Candler Health System, Inc, Savannah, GA, USA
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40
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Rider NL. Standardizing Accurate Penicillin Drug Allergy Diagnosis via a Smartphone App. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:4419-4420. [PMID: 34893194 DOI: 10.1016/j.jaip.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Nicholas L Rider
- Section of Immunology, Allergy and Retrovirology and the William T. Shearer Center for Human Immunobiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
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Mitchell AB, Ness RA, Bennett JG, Bowden JE, Elliott WV, Gillion AR, Pattanaik DN. Implementation and Impact of a β-Lactam Allergy Assessment Protocol in a Veteran Population. Fed Pract 2021; 38:420-425. [PMID: 34737539 DOI: 10.12788/fp.0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Approximately 10% of the US population reports having a β-lactam allergy, although nearly 90% do not have a true immunoglobulin E (IgE)-mediated reaction. This misconception results in using nonpreferred antibiotics, leading to antimicrobial resistance and treatment failure. To evaluate, clarify, and clear β-lactam allergies, we implemented a pharmacist-driven β-lactam allergy assessment (BLAA) protocol and penicillin allergy clinic (PAC). The purpose of this study was to illustrate the BLAA process, including the pharmacist-run PAC, and assess the impact on allergy clearance. Methods Clinical pharmacy specialists (CPS) evaluated hospitalized veterans with β-lactam allergies, using the BLAA protocol. Eligible patients could later be seen in PAC. This was a retrospective observational review of the BLAA protocol to assess recommendations for β-lactam antibiotic use and PAC outcomes. Results Between November 2017 and February 2020, 278 patients were evaluated, and 32 were seen in the clinic. The most common allergen was penicillin, and the most reported reaction was a rash (27%) or pruritus and urticaria (18%). Through PAC and the BLAA protocol, 86 patients (31%) were cleared for allergy removal, and 188 (68%) were cleared for alternative β-lactams. The evaluation revealed that 274 patients (99%) were eligible to receive a β-lactam antibiotic, and only 4 patients (1%) were recommended for avoidance of all β-lactams. Conclusions These findings highlight the utility of the pharmacist-driven BLAA protocol. We illustrated that most patients with documented β-lactam allergies were eligible for alternative β-lactams. The implementation of the BLAA protocol and pharmacist-run PAC facilitated allergy clearance and has the potential to promote alternative β-lactam use.
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Affiliation(s)
- Anna B Mitchell
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
| | - Rachel A Ness
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
| | - Jessica G Bennett
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
| | - Jarred E Bowden
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
| | - Whitney V Elliott
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
| | - Amanda R Gillion
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
| | - Debendra N Pattanaik
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
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Macy E, Crawford WW, Nguyen MT, Adams JL, McGlynn EA, McCormick TA. Population-Based Incidence of New Ampicillin, Cephalexin, Cefaclor, and Sulfonamide Antibiotic "Allergies" in Exposed Individuals with and without Preexisting Ampicillin, Cephalexin, or Cefaclor "Allergies". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:550-555. [PMID: 34757066 DOI: 10.1016/j.jaip.2021.10.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/01/2021] [Accepted: 10/15/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is a theoretical concern, unconfirmed by population-based challenge data, that clinically significant, immunologically mediated hypersensitivity occurs among β-lactams sharing side chains. OBJECTIVE To determine the population-based allergy incidence associated with the use of β-lactams sharing exact R1 side chains (ampicillin, cephalexin, and cefaclor [ACC]), with or without a current ACC allergy or a sulfonamide antibiotic allergy for comparison. METHODS All courses of ACC and trimethoprim-sulfamethoxazole used by any Kaiser Permanente California members in 2017 and 2018, with follow-up through January 2019, were identified along with their preexisting antibiotic allergy status and all new antibiotic-specific allergies reported within 30 days of course initiation. RESULTS A total of 1,167,713 courses of ACC were administered to individuals. No sulfonamide antibiotic or ACC allergy and 4771 new ACC allergies (0.41%) were reported. Moreover, 130,032 courses of ACC were administered to individuals with a sulfonamide antibiotic allergy; no ACC allergy and 904 new ACC allergies (0.70%) were reported. There were 5,958 courses of ACC administered to individuals with an ACC allergy; 2,341 who also had sulfonamide antibiotic allergy, as well as 52 new ACC allergies (0.87%) were reported. CONCLUSIONS The incidence of new ACC allergy reports is minimally and no-specifically increased when a preexisting ACC or sulfonamide antibiotic allergy exists greater than the baseline incidence in the population. This argues against clinically significant, immunologically mediated cross-reactivity among β-lactams sharing exact side chains in individuals with preexisting but unconfirmed β-lactam allergy. Any previously reported, even unrelated antibiotic allergy appears to be a risk factor for reporting a new antibiotic allergy.
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Affiliation(s)
- Eric Macy
- Department of Allergy and Clinical Immunology, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, Calif.
| | - William W Crawford
- Department of Allergy and Clinical Immunology, Southern California Permanente Medical Group, South Bay Medical Center, Los Angeles, Calif
| | - Myngoc T Nguyen
- Department of Allergy and Clinical Immunology, Permanente Medical Group, Oakland Medical Center, Oakland, Calif
| | - John L Adams
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif; Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif
| | - Elizabeth A McGlynn
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif; Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif; Kaiser Permanente Research, Pasadena, Calif
| | - Thomas A McCormick
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif
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Arikoglu T, Kont AO, Demirhan A, Yuksek BC, Tokmeci N, Kuyucu S. Risk stratification in beta-lactam allergy. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00295-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Macy E. Why Was There Ever a Warning Not to Use Cephalosporins in the Setting of a Penicillin "Allergy"? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3929-3933. [PMID: 34303019 DOI: 10.1016/j.jaip.2021.06.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/23/2021] [Accepted: 06/30/2021] [Indexed: 12/20/2022]
Abstract
It is now well-established that avoiding β-lactam antibiotics, when they are the drugs of choice, results in significantly worse long-term global outcomes for patients. Much of this avoidable morbidity has been caused by widespread warnings in electronic health care record systems not to use cephalosporins in the setting of penicillin allergy. High rates, up to 1000-fold higher than now seen, of immunologically mediated reactions were associated with early impure penicillin preparations. This instilled a rational fear of β-lactam-associated anaphylaxis in generations of physicians. In the late 1970s, several editorial comments regarding a potential increased risk to patients given cephalosporins who had a history of a penicillin allergy resulted in the warning that became imbedded in the culture of medicine. Over the past 40 years, compelling data have been developed that refute this warning and showed that the risks of avoiding cephalosporins outweighed the benefits. In late 2017, Kaiser Permanente Southern California completely removed all warnings not to use cephalosporins in the setting of a penicillin allergy. The results have recently been published in JAMA Network Open. This Rostrum article provides some of the backstory on the establishment and removal of this warning for physicians who trained over the past 30 years.
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Affiliation(s)
- Eric Macy
- Allergy Department, Kaiser San Diego Medical Center, Permanente Southern California, San Diego, Calif.
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Piotin A, Godet J, Trubiano JA, Grandbastien M, Guénard-Bilbault L, de Blay F, Metz-Favre C. Predictive factors of amoxicillin immediate hypersensitivity and validation of PEN-FAST clinical decision rule. Ann Allergy Asthma Immunol 2021; 128:27-32. [PMID: 34271183 DOI: 10.1016/j.anai.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/12/2021] [Accepted: 07/06/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The challenge of delabeling amoxicillin allergy is an important issue for patients and clinicians, especially when anaphylaxis is reported. A recent study has proposed a clinical decision rule, PEN-FAST, to identify low-risk penicillin allergies. OBJECTIVE To validate the PEN-FAST clinical decision rule in a population with high risk of suspected immediate amoxicillin allergy and to identify clinical predictive factors of amoxicillin immediate hypersensitivity. METHODS We retrospectively analyzed medical records of patients with a suspected immediate amoxicillin allergy who carried out an allergologic evaluation by a specialist in the Allergy Unit of Strasbourg University Hospital from 2015 to 2020. RESULTS A total of 142 adult patients (88 women [62.0%]; median age, 52 [interquartile range, 40.3-62.0] years) were analyzed. Most of them reported anaphylaxis (68.8%). Internal validation of PEN-FAST score revealed a good discrimination with area under the curve of 0.86 (95% confidence interval, 0.79-0.92). A cutoff of less than 3 points for PEN-FAST was used to classify 29 from 142 patients at low risk of allergy, of whom only 2 (6.9%) received positive results of allergy testing. The negative predictive value for successful delabeling was 0.93 (95% confidence interval, 0.77-0.99). Predictive clinical features for immediate amoxicillin hypersensitivity were time since reaction (P < .001), time elapsed between drug intake and first symptom (P < .001), severity grade reaction (P < .001), and treatment or hospitalization required (P < .001). CONCLUSION PEN-FAST has been validated to identify low-risk penicillin allergies in our European cohort of patients mainly reporting anaphylaxis. This is the first reported external validation of a penicillin allergy clinical decision rule internationally.
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Affiliation(s)
- Anays Piotin
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France.
| | - Julien Godet
- Public Health Department, Strasbourg University Hospital, Strasbourg, France
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Australia; Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Manon Grandbastien
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France
| | | | - Frédéric de Blay
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France; EA 3070 Federation of Translational Medicine, FHU Homicare, University of Strasbourg, Strasbourg, France
| | - Carine Metz-Favre
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France
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Penicillin Allergy Delabeling: A Multidisciplinary Opportunity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2858-2868.e16. [PMID: 33039010 DOI: 10.1016/j.jaip.2020.04.059] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022]
Abstract
The penicillin allergy label has been consistently linked with deleterious effects that span the health care spectrum, including suboptimal clinical outcomes, the emergence of bacterial resistance, and increased health care expenditures. These risks have recently motivated professional organizations and public health institutes to advocate for the implementation of penicillin allergy delabeling initiatives; however, the burden of delabeling millions of patients is too expansive for any one discipline to bear alone. This review presents the unique perspectives and roles of various stakeholder groups involved in penicillin allergy diagnosis, assessment, and delabeling; we emphasize opportunities, barriers, and promising areas of innovation. We summarize penicillin allergy methods and tools that have proven successful in delabeling efforts. A multidisciplinary approach to delabeling patients with reported penicillin allergy, bolstered by evidence-based clinical practices, is recommended to reduce the risks that associate with the penicillin allergy label.
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Macy E, McCormick TA, Adams JL, Crawford WW, Nguyen MT, Hoang L, Eng V, Davis AC, McGlynn EA. Association Between Removal of a Warning Against Cephalosporin Use in Patients With Penicillin Allergy and Antibiotic Prescribing. JAMA Netw Open 2021; 4:e218367. [PMID: 33914051 PMCID: PMC8085727 DOI: 10.1001/jamanetworkopen.2021.8367] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Electronic health records (EHRs) often include default alerts that can influence physician selection of antibiotics, which in turn may be associated with a suboptimal choice of agents and increased antibiotic resistance. OBJECTIVE To examine whether removal of a default alert in the EHR to avoid cephalosporin use in patients with penicillin allergies is associated with changes in cephalosporin dispensing or administration in these patients. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of a natural experiment included data on patients who had received antibiotic treatment in the hospital or outpatient setting in 2 regions of a large, integrated health system in California from January 1, 2017, to December 31, 2018. Of 4 398 792 patients, 4 206 480 met the eligibility criteria: enrollment in the health system during antibiotic use, availability of complete demographic data, and use of antibiotics outside of the washout period. INTERVENTIONS OR EXPOSURES Oral or parenteral antibiotics dispensed or administered after removal of an EHR alert to avoid cephalosporin use in patients with a recorded penicillin allergy. MAIN OUTCOMES AND MEASURES Probability that an antibiotic course was a cephalosporin. A multinomial logistic regression model was used to examine the change in rates of cephalosporin use before and after an EHR penicillin allergy alert was removed in 1 of the study regions. Temporal changes in use rates were controlled for by comparing changes in cephalosporin use among patients with or without a penicillin allergy at the site that removed the warning and among patients at a comparison site that retained the warning. Regression models were used to examine adverse events. RESULTS Of the 4 206 480 patients who met all inclusion criteria, 2 465 849 (58.6%) were women; the mean (SD) age was 40.5 (23.2) years. A total of 10 652 014 antibiotic courses were administered or dispensed, divided approximately evenly between the period before and after removal of the warning. Before removal of an alert in the electronic health record system to avoid prescribing of cephalosporins to patients with a penicillin allergy at 1 of the 2 sites, 58 228 courses of cephalosporins (accounting for 17.9% of all antibiotic use at the site) were used among patients with a penicillin allergy; after removal of the alert, administration or dispensing of cephalosporins increased by 47% compared with cephalosporin administration or dispensing among patients without a penicillin allergy at the same site and patients at the comparison site that retained the warning (ratio of ratios of odds ratios [RROR], 1.47; 95% CI, 1.38-1.56) . No significant differences in anaphylaxis (9 total cases), new allergies (RROR, 1.02; 95% CI, 0.93-1.12), or treatment failures (RROR, 1.02; 95% CI, 0.99-1.05) were found at the course level. No significant differences were found in all-cause mortality (ratio of ratios of rate ratios [RRRR], 1.03; 95% CI, 0.94-1.13), hospital days (RRRR, 1.04; 95% CI, 0.99-1.10), and new infections (Clostridioides difficile: RRRR, 1.02; 95% CI, 0.84-1.22; methicillin-resistant Staphylococcus aureus: RRRR, 0.87; 95% CI, 0.75-1.00; and vancomycin-resistant Enterococcus: RRRR, 0.82; 95% CI, 0.55-1.22) at the patient level. CONCLUSIONS AND RELEVANCE In this cohort study, removal of a warning in the electronic health record to avoid cephalosporin use in patients with penicillin allergies was associated with increased administration and dispensing of cephalosporin. This simple and rapidly implementable system-level intervention may be useful for improvement in antibiotic stewardship.
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Affiliation(s)
- Eric Macy
- Department of Allergy and Clinical Immunology, Southern California Permanente Medical Group, San Diego Medical Center, San Diego
| | - Thomas A. McCormick
- Kaiser Permanente Center for Effectiveness & Safety Research, Pasadena, California
| | - John L. Adams
- Kaiser Permanente Center for Effectiveness & Safety Research, Pasadena, California
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - William W. Crawford
- Department of Allergy and Clinical Immunology, Southern California Permanente Medical Group, South Bay Medical Center, Los Angeles
| | - Myngoc T. Nguyen
- Department of Allergy and Clinical Immunology, The Permanente Medical Group, Oakland Medical Center, Oakland, California
| | - Liem Hoang
- Department of Pharmacy, Arrowhead Regional Medical Center, Colton, California
| | - Victoria Eng
- Department of Allergy and Immunology, Sansum Clinic, Santa Barbara, California
| | - Anna C. Davis
- Kaiser Permanente Center for Effectiveness & Safety Research, Pasadena, California
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Elizabeth A. McGlynn
- Kaiser Permanente Center for Effectiveness & Safety Research, Pasadena, California
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
- Kaiser Permanente Research, Pasadena, California
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Manning J, Pammett RT, Hamour AO, Enemark A, Barr B. Assessing Use of a Standardized Allergy History Questionnaire for Patients with Reported Allergy to Penicillin. Can J Hosp Pharm 2021; 74:104-109. [PMID: 33896948 PMCID: PMC8042189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Inappropriate allergy labelling is associated with significant clinical and pharmacoeconomic implications. Detailed antimicrobial allergy assessments represent a key component of antimicrobial stewardship and aid in identifying true type I (immediate hypersensitivity) reactions. The allergy history form currently used at the University Hospital of Northern British Columbia (UHNBC), in Prince George, relies on the assessor's ability to ask appropriate prompting questions to obtain a thorough history, but it may not be sufficient to accurately identify true allergies. OBJECTIVE To compare a standardized allergy history questionnaire and the current allergy history form in terms of the quality and quantity of documentation gathered. METHODS This prospective observational study involved patients who were admitted to medical and surgical services at UHNBC from November 2018 to January 2019 with a penicillin-class allergy reported on their electronic medical record (EMR). A list of patients with EMR-reported allergies was generated by the hospital's health information software system, and these patients were interviewed using the standardized allergy history questionnaire. RESULTS A total of 48 patients were assessed during the study period. Nineteen (40%) of the patients had an inappropriate allergy label on their EMR. Only 36 (75%) had an allergic reaction described on their EMR. Furthermore, only 36 (75%) of the 48 patients had the same allergy recorded on the EMR and on the allergy history form contained in their paper chart, of whom 22 had a documented reaction. The mean time to complete the standardized allergy history questionnaire was 2 minutes. CONCLUSIONS At the study institution, documentation of allergy histories was often incomplete. Detailed allergy assessments are the first step in identifying true immunoglobulin E-mediated hypersensitivity reactions. Utilization of a standardized allergy history questionnaire is feasible and may serve to improve documentation and overall antimicrobial stewardship.
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Affiliation(s)
- Jessica Manning
- , BSc(Pharm), ACPR, is with the University Hospital of Northern British Columbia, Northern Health, Prince George, British Columbia
| | - Robert T Pammett
- , BSc, BSP, MSc, BCGP, is with Northern Health, Prince George, British Columbia, and the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Abu Obeida Hamour
- , MBBS, MSc, MRCP(UK), DTM&H, CCST(UK), FRCP(Edin), FRCPC, is with the University Hospital of Northern British Columbia, Northern Health, Prince George, British Columbia, and the Department of Medicine, The University of British Columbia, Vancouver, British Columbia
| | - Aleisha Enemark
- , BSc, BSc(Pharm), ACPR, is with the University Hospital of Northern British Columbia, Northern Health, Prince George, British Columbia
| | - Barret Barr
- , BSc, PharmD, ACPR, is with the University Hospital of Northern British Columbia, Northern Health, Prince George, British Columbia
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Skin Testing for Penicillin Allergy: a Review of the Literature. Curr Allergy Asthma Rep 2021; 21:21. [PMID: 33738621 DOI: 10.1007/s11882-021-00997-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Self-reported penicillin allergies are frequently reported, though more than 95% of those are not truly allergic when challenged. These patients are more likely to receive alternative antibiotic regimens resulting in the use of broad-spectrum antibiotics that may be less effective, more toxic, and/or more expensive than preferred agents. Given the significant burden on patient outcomes and the healthcare system, the ability to reconcile an allergy and broaden future antibiotic options is essential. RECENT FINDINGS This is a narrative review describing risk stratification for penicillin skin testing, practical advice for implementation, and future directions. A summary of studies within the last 5 years is provided. The trend over the past several years has been to offer oral drug challenges to low-risk patients and skin testing to high-risk patients with a reported penicillin allergy. This review provides support for risk stratification assessment of reported penicillin allergy to optimize antibiotic use and prevent emergence of antimicrobial resistance.
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50
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Gaudreau S, Bourque G, Côté K, Nutu C, Beauchesne MF, Longpré AA, Beloin-Jubinville B, Legeleux L, Blaquière M, Martin P, Gilbert M. Resources Assessment for Penicillin Allergy Testing Performed by Pharmacists at the Patient's Bedside. Ann Pharmacother 2021; 55:1355-1362. [PMID: 33703922 PMCID: PMC8908455 DOI: 10.1177/10600280211002412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: False penicillin allergies lead to increased antimicrobial resistance, adverse effects, and health care costs by promoting the use of broad-spectrum antibiotics. The Infectious Diseases Society of America recommends the implementation of allergy testing. Objectives: The primary objective of this research was to estimate the number of pharmacist full-time equivalents (FTEs) required for an intervention aimed at determining penicillin allergy in hospitalized patients. Acceptance of pharmacists’ suggestions on antibiotic therapy are described. Methods: A quasi-experimental study was conducted in a 712-bed university hospital involving hospitalized patients with a suspected penicillin allergy and an infection treatable with penicillin. The time required for the intervention, which included a questionnaire, penicillin allergy testing (skin-prick test, intradermal injection, and oral provocation test), and recommendations on antibiotic therapy were measured to calculate the number of pharmacist FTEs. Results: A total of 55 patients were included. Scarification allergy testing was performed on 37, intradermal allergy test on 33, and oral provocation test on 26 patients. The intervention ruled out penicillin allergy in 26 patients, with no serious adverse effects. The intervention was associated with a median weekly pharmacist FTE of 0.15 (interquartile range = 0.12-0.25). The acceptance of pharmacists’ suggestions was high and led to 9 patients being switched to an antibiotic with a narrower spectrum of activity. Conclusions and Relevance: This study describes penicillin allergy testing and the number of median weekly hospital pharmacist FTEs required, which was approximately 0.15. These data may aid in the implementation of this safe intervention that promotes narrower-spectrum antibiotherapy.
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Affiliation(s)
- Sophie Gaudreau
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | - Geneviève Bourque
- Centre intégré de santé et de services sociaux de la Montérégie-Centre, Saint-Jean-sur-Richelieu, QC, Canada
| | - Kevin Côté
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | | | - Marie-France Beauchesne
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada.,Centre de recherche du CHUS, Sherbrooke, QC, Canada
| | - Audrey-Anne Longpré
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | - Bianca Beloin-Jubinville
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | - Lorraine Legeleux
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | - Martin Blaquière
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Philippe Martin
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Mélanie Gilbert
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
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