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Wanat M, Santillo M, Galal U, Davoudianfar M, Bongard E, Savic S, Savic L, Porter C, Fielding J, Butler CC, Pavitt S, Sandoe J, Tonkin-Crine S. Mixed-methods evaluation of a behavioural intervention package to identify and amend incorrect penicillin allergy records in UK general practice. BMJ Open 2022; 12:e057471. [PMID: 36691248 PMCID: PMC9171226 DOI: 10.1136/bmjopen-2021-057471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 05/11/2022] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES About 6% of the UK general practice population has a record of a penicillin allergy but fewer than 10% of these are likely to be truly allergic. In the ALABAMA (Allergy Antibiotics and Microbial resistance) feasibility trial, primary care patients with penicillin allergy were randomised to penicillin allergy assessment pathway or usual care to assess the effect on health outcomes. A behavioural intervention package was developed to aid delabelling. This study aimed to investigate patients' and clinicians' views of penicillin allergy testing (PAT). DESIGN We conducted a mixed-methods process evaluation embedded within the ALABAMA trial, which included a clinician survey, a patient survey (at baseline and follow-up) and semistructured interviews with patients and clinicians. SETTINGS The study was conducted in primary care, as part of the feasibility stage of the ALABAMA trial. PARTICIPANTS Patients and primary care clinicians. RESULTS Clinicians (N=53; 52.2%) were positive about PAT and its potential value but did not have previous experience of referring patients for a PAT and were unsure whether patients would take penicillin after a negative allergy test. Patients (N=36; 46%) were unsure whether they were severely allergic to penicillin and did not fear a severe allergic reaction to penicillin. Clinician interviews showed that they were already aware of the benefit of PAT. Interviews with patients suggested the importance of safety as patients valued having numerous opportunities to address their concerns about safety of the test. CONCLUSIONS This study highlights the positive effects of the ALABAMA behavioural intervention for both patients and clinicians. TRIAL REGISTRATION NUMBER NCT04108637; ISRCTN20579216; Pre-results.
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Affiliation(s)
- Marta Wanat
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Ushma Galal
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sinisa Savic
- University of Leeds and Leeds Teaching Hospitals NHS Trust, Faculty of Medicine and Health, Leeds, UK
| | - Louise Savic
- University of Leeds and Leeds Teaching Hospitals NHS Trust, Faculty of Medicine and Health, Leeds, UK
| | - Catherine Porter
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joanne Fielding
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sue Pavitt
- Dental Translational and Clinical Research Unit, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Jonathan Sandoe
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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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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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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Stone CA, Trubiano J, Coleman DT, Rukasin CRF, Phillips EJ. The challenge of de-labeling penicillin allergy. Allergy 2020; 75:273-288. [PMID: 31049971 DOI: 10.1111/all.13848] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 03/28/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Even though 8%-25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de-labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. METHODS We performed an evidence-based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de-labeling. Over the period 1928-2018 in Pubmed and Medline, search terms used included "penicillin allergy" or "penicillin hypersensitivity" alone or in combination with "adverse events," "testing," "evaluation," "effects," "label," "de-labeling," "prick or epicutaneous," and "intradermal" skin testing, "oral challenge or provocation," "cross-reactivity," and "antimicrobial stewardship". RESULTS Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. CONCLUSIONS Operationalizing penicillin allergy de-labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de-labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.
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Affiliation(s)
- Cosby A. Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
| | - Jason Trubiano
- Department of Infectious Diseases Austin Health Heidelberg Victoria Australia
- Department of Infectious Diseases Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Medicine (Austin Health) University of Melbourne Parkville Victoria Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Parkville Victoria Australia
| | - David T. Coleman
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
| | - Christine R. F. Rukasin
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
| | - Elizabeth J. Phillips
- Division of Infectious Diseases, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
- Department of Pharmacology Vanderbilt University School of Medicine Nashville Tennessee
- Department of Pathology, Microbiology and Immunology Vanderbilt University Medical Center Nashville Tennessee
- Institute for Immunology & Infectious Diseases Murdoch University Murdoch Western Australia Australia
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Foolad F, Berlin S, White C, Dishner E, Jiang Y, Taremi M. The Impact of Penicillin Skin Testing on Aztreonam Stewardship and Cost Savings in Immunocompromised Cancer Patients. Open Forum Infect Dis 2019; 6:ofz371. [PMID: 31660339 PMCID: PMC6767966 DOI: 10.1093/ofid/ofz371] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/20/2019] [Indexed: 02/07/2023] Open
Abstract
Objective Reported penicillin allergies result in alternative antimicrobial use and are associated with worse outcomes and increased costs. Penicillin skin testing (PST) has recently been shown to be safe and effective in immunocompromised cancer patients, yet its impact on antimicrobial costs and aztreonam utilization has not been evaluated in this population. Method From September 2017 to January 2018, we screened all admitted patients receiving aztreonam. Those with a self-reported history of possible immunoglobulin E (IgE)-mediated reaction to penicillin were eligible for PST with oral challenge. Results A total of 129 patients were screened, and 49 patients were included and underwent testing. Sixteen patients (33%) had hematologic malignancies and 33 patients (67%) had solid tumors. After PST with oral challenge, 46 patients (94%) tested negative, 1 patient tested positive on oral challenge, and 2 patients had indeterminate results. The median time from admission to testing was 2 days (interquartile range, 1–4). After testing negative, 33 patients (72%) were switched to beta-lactam therapy, which resulted in a total of 390 days of beta-lactam therapy. For identical therapy durations, the direct total antibiotic cost was $15 138.89 for beta-lactams versus $78 331.50 for aztreonam, resulting in $63 192.61 in projected savings. A significant reduction in median days of aztreonam therapy per 1000 patient days (10.0 vs 8.0; P = .005) was found during the intervention period. Conclusions Use of PST in immunocompromised cancer patients receiving aztreonam resulted in improved aztreonam stewardship and significant cost savings. Our study demonstrates that PST with oral challenge should be considered in all cancer patients with reported penicillin allergies.
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Affiliation(s)
- Farnaz Foolad
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston
| | - Sheila Berlin
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Candice White
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Emma Dishner
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Ying Jiang
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
| | - Mahnaz Taremi
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston
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Chen JR, Tarver SA, Alvarez KS, Wei W, Khan DA. Improving Aztreonam Stewardship and Cost Through a Penicillin Allergy Testing Clinical Guideline. Open Forum Infect Dis 2018; 5:ofy106. [PMID: 29977963 PMCID: PMC6016425 DOI: 10.1093/ofid/ofy106] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/03/2018] [Indexed: 11/12/2022] Open
Abstract
Background Patients reporting penicillin allergy often receive unnecessary and costly broad-spectrum alternatives such as aztreonam with negative consequences. Penicillin allergy testing improves antimicrobial therapy but is not broadly used in hospitals due to insufficient testing resources and short-term expenses. We describe a clinical decision support (CDS) tool promoting pharmacist-administered penicillin allergy testing in patients receiving aztreonam and its benefits toward antimicrobial stewardship and costs. Methods A CDS tool was incorporated into the electronic medical record, directing providers to order penicillin allergy testing for patients receiving aztreonam. An allergy-trained pharmacist reviewed orders placed through this new guideline and performed skin testing and oral challenges to determine whether these patients could safely take penicillin. Data on tests performed, antibiotic utilization, and cost-savings were compared with patients tested outside the new guideline as part of our institution's standard stewardship program. Results The guideline significantly increased penicillin allergy testing among patients receiving aztreonam from 24% to 85% (P < .001) while reducing the median delay between admission and testing completion from 3.31 to 1.05 days (P = 0.008). Patients tested under the guideline saw a 58% increase in penicillin exposure (P = .046). Institutional aztreonam administration declined from 2.54 to 1.47 administrations per 1000 patient-days (P = .016). Average antibiotic costs per patient tested before and after CDS decreased from $1265.81 to $592.08 USD, a 53% savings. Conclusions Targeting penicillin allergy testing to patients on aztreonam yields therapeutic and economic benefits during a single admission. This provides a cost-effective model for inpatient testing.
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Affiliation(s)
- Justin R Chen
- Department of Internal Medicine, Division of Allergy and Immunology, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Scott A Tarver
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas
| | - Kristin S Alvarez
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas
| | - Wenjing Wei
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas
| | - David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, The University of Texas Southwestern Medical Center, Dallas, Texas
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Derrick MI, Williams KB, Shade LMP, Phillips EJ. A survey of drug allergy training opportunities in the United States. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:302-304. [PMID: 28958742 DOI: 10.1016/j.jaip.2017.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/31/2017] [Accepted: 08/02/2017] [Indexed: 11/25/2022]
Affiliation(s)
| | | | | | - Elizabeth Jane Phillips
- Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia.
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Macy E, Romano A, Khan D. Practical Management of Antibiotic Hypersensitivity in 2017. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:577-586. [DOI: 10.1016/j.jaip.2017.02.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 02/17/2017] [Accepted: 02/22/2017] [Indexed: 12/19/2022]
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Blumenthal KG, Wickner PG, Hurwitz S, Pricco N, Nee AE, Laskowski K, Shenoy ES, Walensky RP. Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship. J Allergy Clin Immunol 2017; 140:154-161.e6. [PMID: 28254470 DOI: 10.1016/j.jaci.2017.02.005] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/13/2017] [Accepted: 02/07/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Reported penicillin allergy rarely reflects penicillin intolerance. Failure to address inpatient penicillin allergies results in more broad-spectrum antibiotic use, treatment failures, and adverse drug events. OBJECTIVE We aimed to determine the optimal approach to penicillin allergies among medical inpatients. METHODS We evaluated internal medicine inpatients reporting penicillin allergy in 3 periods: (1) standard of care (SOC), (2) penicillin skin testing (ST), and (3) computerized guideline application with decision support (APP). The primary outcome was use of a penicillin or cephalosporin, comparing interventions to SOC using multivariable logistic regression. RESULTS There were 625 patients: SOC, 148; ST, 278; and APP, 199. Of 278 ST patients, 179 (64%) were skin test eligible; 43 (24%) received testing and none were allergic. In the APP period, there were 292 unique Web site views; 112 users (38%) completed clinical decision support. Although ST period patients did not have increased odds of penicillin or cephalosporin use overall (adjusted odds ratio [aOR] 1.3; 95% CI, 0.8-2.0), we observed significant increased odds of penicillin or cephalosporin use overall in the APP period (aOR, 1.8; 95% CI, 1.1-2.9) and in a per-protocol analysis of the skin tested subset (aOR, 5.7; 95% CI, 2.6-12.5). CONCLUSIONS Both APP and ST-when completed-increased the use of penicillin and cephalosporin antibiotics among inpatients reporting penicillin allergy. While the skin tested subset showed an almost 6-fold impact, the computerized guideline significantly increased penicillin or cephalosporin use overall nearly 2-fold and was readily implemented.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and the Massachusetts General Professional Organization, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Paige G Wickner
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Shelley Hurwitz
- Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | | | | | - Karl Laskowski
- Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Erica S Shenoy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Infection Control Unit, Massachusetts General Hospital, Boston, Mass
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Mass
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Trubiano JA, Beekmann SE, Worth LJ, Polgreen PM, Thursky KA, Slavin MA, Grayson ML, Phillips EJ. Improving Antimicrobial Stewardship by Antibiotic Allergy Delabeling: Evaluation of Knowledge, Attitude, and Practices Throughout the Emerging Infections Network. Open Forum Infect Dis 2016; 3:ofw153. [PMID: 27800527 PMCID: PMC5084721 DOI: 10.1093/ofid/ofw153] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 07/12/2016] [Indexed: 12/02/2022] Open
Abstract
Antibiotic allergy testing (AAT) practices of Emerging Infections Network infectious disease physicians were surveyed. Although AAT was perceived to be necessary for removal of inappropriate or unnecessary allergy labels, there was limited access to any form of testing. In this study, we discuss current antibiotic allergy knowledge gaps and the development of AAT practices within antimicrobial stewardship programs, which will potentially improve antimicrobial prescribing.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Susan E Beekmann
- Department of Internal Medicine, Carver College of Medicine , University of Iowa , Iowa City
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Philip M Polgreen
- Department of Internal Medicine, Carver College of Medicine , University of Iowa , Iowa City
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia; Department of Medicine, Vanderbilt Medical Centre, Nashville, Tennessee
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