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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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2
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Marchiori JGT, Nunes APF. TIME UNTIL THE START OF ANTIBIOTIC PROPHYLAXIS AND THE RISK OF OPEN FRACTURE INFECTION: A SYSTEMATIC REVIEW. ACTA ORTOPEDICA BRASILEIRA 2024; 32:e263176. [PMID: 38933354 PMCID: PMC11197951 DOI: 10.1590/1413-785220243202e263176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/05/2022] [Indexed: 06/28/2024]
Abstract
Open fractures are highly incident injuries closely related to the modern life, in which accidents caused by motor vehicles or other machines impart high energy to bone tissue. Individual morbidity is represented by the functional impairment resultant of infection, nonunion, or vicious healing. In terms of public health, there are huge costs involved with the treatment of these fractures, particularly with their complications. One of the critical issues in managing open fractures is the use of antibiotics (ATB), including decisions about which specific agents to administer, duration of use, and ideal timing of the first prophylactic dose. Although recent guidelines have recommended starting antibiotic prophylaxis as soon as possible, such a recommendation appears to stem from insufficient evidence. In light of this, we conducted a systematic review, including studies that addressed the impact of the time to first antibiotic and the risk of infectious outcomes. Fourteen studies were selected, of which only four found that the early initiation of treatment with antibiotics is able to prevent infection. All studies had important risks of bias. The results indicate that this question remains open, and further prospective and methodologically sound studies are necessary in order to guide practices and health policies related to this matter. Level of Evidence II; Therapeutic Studies Investigating the Results Level of Treatment.
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Affiliation(s)
| | - Ana Paula Ferreira Nunes
- Universidade Federal do Espírito Santo (UFES), Department of Pathology, Postgraduate Program in Infectious Diseases, Health Sciences Center, Vitória, ES, Brazil
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3
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Egerci OF, Yapar A, Dogruoz F, Selcuk H, Kose O. Preventive strategies to reduce the rate of periprosthetic infections in total joint arthroplasty; a comprehensive review. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05301-w. [PMID: 38635048 DOI: 10.1007/s00402-024-05301-w] [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] [Received: 11/12/2023] [Accepted: 03/24/2024] [Indexed: 04/19/2024]
Abstract
The increasing frequency of total hip (THA) and knee arthroplasties (TKA) is marred by the rise in periprosthetic joint infections (PJIs) and surgical site infections (SSIs), with PJIs incurring costs over $1.62 billion as of 2020 and individual case management averaging $90,000. SSIs additionally burden the U.S. healthcare economy with billions in expenses annually. PJI prevalence in primary THA and TKA ranges from 0.5% to 2.4%, spiking to 20% in revisions and representing 25% of TKA revision causes. Projections estimate up to 270,000 annual PJI cases by 2030. Often caused by gram-positive bacteria, particularly methicillin-resistant staphylococci, these infections demand preventive measures. This review dissects PJI prevention across preoperative, intraoperative, and perioperative phases, aligning with evidence-based CDC and WHO guidelines. Preoperative measures include managing diabetes, obesity, tobacco use, Staphylococcus aureus screening and nasal decolonization, nutritional optimization, and management of inflammatory arthropathies. Intraoperatively, antibiotic prophylaxis, skin preparation, operative room environmental controls, surgical technique precision, and irrigation options are scrutinized. Perioperative concerns focus on anticoagulation, blood management, and infection risk mitigation. Integrating these strategies promotes a patient-centric care model, aiming to reduce PJI incidence, improve patient outcomes, and increase care cost-effectiveness in joint arthroplasty.
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Affiliation(s)
- Omer Faruk Egerci
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Aliekber Yapar
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Fırat Dogruoz
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Huseyin Selcuk
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Ozkan Kose
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey.
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4
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Dutra KJ, Lazenby GB, Goje O, Soper DE. Cefazolin as the mainstay for antibiotic prophylaxis in patients with a penicillin allergy in obstetrics and gynecology. Am J Obstet Gynecol 2024:S0002-9378(24)00448-4. [PMID: 38527607 DOI: 10.1016/j.ajog.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/20/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024]
Abstract
Cefazolin is the most common antibiotic used for prophylaxis in obstetrics and gynecology. Among those with a penicillin allergy, alternative antibiotics are often chosen for prophylaxis, given fears of cross-reactivity between penicillin and cefazolin. Alternative antibiotics in this setting are associated with adverse sequelae, including surgical site infection, induction of bacterial resistance, higher costs to the healthcare system, and possible Clostridium difficile infection. Given the difference in R1 side chains between penicillin and cefazolin, cefazolin use is safe and should be recommended for patients with a penicillin allergy, including those who experience Immunoglobulin E-mediated reactions such as anaphylaxis. Cefazolin should only be avoided in those who experience a history of a severe, life-threatening delayed hypersensitivity reaction manifested as severe cutaneous adverse reactions (Steven-Johnson Syndrome), hepatitis, nephritis, serum sickness, and hemolytic anemia in response to penicillin administration. In addition, >90% of those with a documented penicillin allergy do not have true allergies on skin testing. Increased referral for penicillin allergy testing should be incorporated into routine obstetric care and preoperative assessment to reduce suboptimal antibiotic prophylaxis use. More education is needed among providers surrounding penicillin allergy assessment and cross-reactivity among penicillins and cephalosporins to optimize antibiotic prophylaxis in obstetrics and gynecology.
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Affiliation(s)
- Karley J Dutra
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC.
| | - Gweneth B Lazenby
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
| | - Oluwatosin Goje
- Department of Subspecialties, Obstetrics and Gynecology Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - David E Soper
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
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5
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Doña I, Torres MJ, Celik G, Phillips E, Tanno LK, Castells M. Changing patterns in the epidemiology of drug allergy. Allergy 2024; 79:613-628. [PMID: 38084822 DOI: 10.1111/all.15970] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/23/2023] [Accepted: 11/26/2023] [Indexed: 03/01/2024]
Abstract
Drug allergy (DA) remains a complex and unaddressed problem worldwide that often deprives patients of optimal medication choices and places them at risk for life-threatening reactions. Underdiagnosis and overdiagnosis are common and due to the lack of standardized definitions and biomarkers. The true burden of DA is unknown, and recent efforts in data gathering through electronic medical records are starting to provide emerging patterns around the world. Ten percent of the general population engaged in health care claim to have a DA, and the most common label is penicillin allergy. Up to 20% of emergency room visits for anaphylaxis are due to DA and 15%-20% of hospitalized patients report DA. It is estimated that DA will increase based on the availability and use of new and targeted antibiotics, vaccines, chemotherapies, biologicals, and small molecules, which are aimed at improving patient's options and quality of life. Global and regional variations in the prevalence of diseases such as human immunodeficiency virus and mycobacterial diseases, and the drugs used to treat these infections have an impact on DA. The aim of this review is to provide an update on the global impact of DA by presenting emerging data on drug epidemiology in adult and pediatric populations.
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Affiliation(s)
- Immaculada Doña
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Malaga, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga, Malaga, Spain
| | - Maria Jose Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Malaga, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga, Malaga, Spain
- Departamento de Medicina, Universidad de Málaga, Malaga, Spain
| | - Gulfem Celik
- Division of Immunology and Allergy, Department of Chest Diseases, Ankara University School of Medicine, Ankara, Turkey
| | - Elizabeth Phillips
- Department of Medicine, Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Luciana Kase Tanno
- Division of Allergy, Department of Pulmonology, Allergy and Thoracic Oncology, University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA11 University of Montpellier-INSERM, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Mariana Castells
- Division of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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6
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Allen GP, Morrill HL. Safety Aspects and Rational Use of Single Intramuscular Dose Ceftriaxone: Clinical Insights on the Management of Uncomplicated Gonococcal Infections. Drug Healthc Patient Saf 2023; 15:159-170. [PMID: 37941731 PMCID: PMC10629349 DOI: 10.2147/dhps.s350763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023] Open
Abstract
Gonorrhea, a sexually transmitted infection caused by Neisseria gonorrhoeae, is a grave public health concern. Gonorrhea is the second most reported sexually transmitted infection worldwide. The treatment of uncomplicated gonococcal infections has evolved dramatically in response to the emergence of antimicrobial resistance. Multiple resistance mechanisms (for example, beta-lactamase production, antimicrobial efflux, and target site modification) exist, some of which may cause multidrug-resistance. Ceftriaxone was first recommended as an option for uncomplicated gonococcal infections in 1985, and it is now a mainstay of therapy in all clinical practice guidelines. Ceftriaxone has consistently shown high microbiologic cure rates in clinical trials, and it has demonstrated an excellent safety profile. Although its use may be limited in patients with hypersensitivity to penicillins, the risk of using ceftriaxone in such patients is overestimated. The emergence of reduced ceftriaxone susceptibility in N. gonorrhoeae, coupled with a lack of diverse treatment alternatives and the limited pipeline of new antimicrobials, is a significant threat to the treatment of gonorrhea.
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Affiliation(s)
- George P Allen
- School of Pharmacy, Westbrook College of Health Professions, University of New England, Portland, ME, USA
| | - Haley L Morrill
- School of Pharmacy, Westbrook College of Health Professions, University of New England, Portland, ME, USA
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7
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Naureckas Li C, Herman K, Yim R, Nakamura MM, Chu E, Wilder JL, Alfieri M, Ethier B, Esty B. Impact of a Documented Penicillin Allergy on Antibiotic Selection in Pediatric Patients With Osteomyelitis. Pediatr Infect Dis J 2023; 42:e140-e142. [PMID: 36795541 DOI: 10.1097/inf.0000000000003863] [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: 02/17/2023]
Abstract
Penicillin allergy labels are common in hospitalized patients, and there is a frequent misconception that these patients cannot receive cephalosporins. Through retrospective review, we found that patients with reported penicillin allergies were significantly less likely to receive first-line therapy for acute hematogenous osteomyelitis.
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Affiliation(s)
- Caitlin Naureckas Li
- From the Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Katherine Herman
- Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics
| | | | - Mari M Nakamura
- From the Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Antimicrobial Stewardship Program
| | | | - Jayme L Wilder
- Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics
- Division of General Pediatrics
| | | | | | - Brittany Esty
- Harvard Medical School, Boston, Massachusetts
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
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8
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Villarreal-González RV, Canel-Paredes A, Arias-Cruz A, Fraga-Olvera A, Delgado-Bañuelos A, Rico-Solís GA, Ochoa-García IV, Jiménez-Sandoval JO, Ramírez-Heredia J, Flores-González JV, Cortés-Grimaldo RM, Zecua-Nájera Y, Ortega-Cisneros M. [Drug allergy: Fundamental aspects in diagnosis and treatment.]. REVISTA ALERGIA MÉXICO 2023; 69:195-213. [PMID: 37218047 DOI: 10.29262/ram.v69i4.1181] [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: 10/26/2022] [Accepted: 02/14/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Any substance used as a treatment for any disease can produce harmful or unpleasant events called adverse drug reactions (ADRs). They are due to inherent biological effects of the drug and are caused by immunological and non-immunological mechanisms. OBJECTIVES To describe the immunological mechanisms of hypersensitivity reactions (HSR) to drugs, their epidemiology, risk factors, classification, clinical manifestations, diagnosis, treatment, and prognosis. METHODS A review of the most current literature in English and Spanish was carried out, in the main databases, related to the HSR of various drug groups. RESULTS This study describes the terms used to define ADRs and HSRs, their classification and clinical manifestations, current diagnostic tools, treatment algorithms and prognosis of the most frequently used medications and with the highest prevalence of reported adverse events. CONCLUSION ADRs are a challenging entity, with a complex pathophysiology that has not been fully understood. Its approach requires a careful consideration since not all drugs have validated tests for their diagnosis nor a specific treatment. When indicating the use of any drug, the severity of the disease, the availability of other treatments and the potential risks of developing future adverse events should always be taken into consideration.
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Affiliation(s)
- Rosalaura Virginia Villarreal-González
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Servicio de Alergia e Inmunología Clínica, Hospital Universitario Dr. José Eleuterio González, Nuevo León, México
| | - Alejandra Canel-Paredes
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Servicio de Alergia e Inmunología Clínica, Hospital Universitario Dr. José Eleuterio González, Nuevo León, México
| | - Alfredo Arias-Cruz
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Servicio de Alergia e Inmunología Clínica, Hospital Universitario Dr. José Eleuterio González, Nuevo León, México
| | - Alira Fraga-Olvera
- Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Ciudad de México; Hospital Amerimed, Quintana Roo, México
| | - Angélica Delgado-Bañuelos
- Servicio de Alergia e Inmunología Clínica, Hospital General Regional 58, Instituto Mexicano del Seguro Social, Guanajuato, México
| | | | - Itzel Vianey Ochoa-García
- Departamento de Inmunología clínica y Alergia, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Jalisco, México
| | - Jaime Omar Jiménez-Sandoval
- Departamento de Alergia e Inmunología Clínica, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México; Hospital Regional Río Blanco, SESVER, Veracruz, México
| | - Jennifer Ramírez-Heredia
- Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México; Hospital MAC, Irapuato, Guanajuato, México
| | | | - Rosa María Cortés-Grimaldo
- Departamento de Alergia e Inmunología Clínica, Unidad Médica de Alta Especialidad, Hospital de Pediatría del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Jalisco, México
| | - Yahvéh Zecua-Nájera
- Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Ciudad de México; Centro Médico San Carlos, Tlaxcala, México
| | - Margarita Ortega-Cisneros
- Departamento de Inmunología Clínica y Alergia, Unidad Médica de Alta Especialidad, Hospital de especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social.
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Tarabichi S, Parvizi J. Prevention of surgical site infection: a ten-step approach. ARTHROPLASTY 2023; 5:21. [PMID: 37029444 PMCID: PMC10082525 DOI: 10.1186/s42836-023-00174-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/20/2023] [Indexed: 04/09/2023] Open
Abstract
Surgical site infection (SSI) is a common cause of morbidity and mortality in patients undergoing surgery. Similarly, periprosthetic joint infection (PJI), is a major cause of failure after total joint arthroplasty (TJA). As the annual volume of TJA procedures is projected to rise, so will the rate of subsequent SSI and PJI. Currently, prevention has been identified as the single most important strategy for combating SSI/PJI. Hence, the present article will serve as a summary of an evidence-based ten-step approach for SSI/PJI prevention that may help orthopedic surgeons with their infection prevention strategies.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA.
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
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10
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Tarabichi S, Chen AF, Higuera CA, Parvizi J, Polkowski GG. 2022 American Association of Hip and Knee Surgeons Symposium: Periprosthetic Joint Infection. J Arthroplasty 2023:S0883-5403(23)00065-7. [PMID: 36738863 DOI: 10.1016/j.arth.2023.01.045] [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] [Received: 12/01/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/06/2023] Open
Abstract
Periprosthetic joint infection (PJI) is the leading cause of failure in patients undergoing total joint arthroplasty. This article is a brief summary of a symposium on PJI that was presented at the annual AAHKS meeting. It will provide an overview of current technqiues in the prevention, diagnosis, and management of PJI. It will also highlight emerging technologies in this setting.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gregory G Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J, Khan DA, Golden DBK, Shaker M, Stukus DR, Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333-1393. [PMID: 36122788 DOI: 10.1016/j.jaci.2022.08.028] [Citation(s) in RCA: 167] [Impact Index Per Article: 83.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Aleena Banerji
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Roland Solensky
- Corvallis Clinic, Oregon State University/Oregon Health Science University College of Pharmacy, Corvallis, Ore
| | - Andrew A White
- Department of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St Joe's Hamilton, Hamilton, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew J Greenhawt
- Food Challenge and Research Unit Section of Allergy and Immunology, Children's Hospital Colorado University of Colorado School of Medicine, Aurora, Colo
| | - Caroline C Horner
- Department of Pediatrics, Division of Allergy Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla; James A. Haley Veterans Affairs Hospital, Tampa, Fla
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | - John Oppenheimer
- Division of Allergy, Rutgers New Jersey Medical School, Rutgers, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Collins K, Rueter K, Lucas M, Sommerfield D, Sommerfield A, Khan N, von Ungern‐Sternberg BS. Penicillin allergy SHACK: Survey of hospital and community knowledge. J Paediatr Child Health 2022; 58:1414-1419. [PMID: 35502826 PMCID: PMC9546145 DOI: 10.1111/jpc.16007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022]
Abstract
AIM Penicillin allergy accounts for the majority of all reported adverse drug reactions in adults and children. Foregoing first-line antibiotic therapy due to penicillin allergy label is associated with an increased prevalence of infections by resistant organisms and longer hospitalisation. Clinician awareness of allergy assessment, referral indications, management of allergy and anaphylaxis is therefore vital but globally lacking. We aim to assess the knowledge of penicillin allergy, assessment and management in Western Australian health professionals. METHODS An anonymous survey was distributed to pharmacists, nurses and physicians within Western Australian paediatric and adult Hospitals, Community and General Practice. RESULTS In total, 487/611 were completed and included in the statistical analysis. Only 62% (301/487) of respondents routinely assessed for patient medication allergies. Of those who assessed allergy, 9% (28/301) of respondents met the Australian standards for allergy assessment. Only 22% (106/487) of participants correctly cited all indications for management with adrenaline in anaphylaxis to antibiotics and 67% (197/292) of physicians rarely or never referred to an allergy service. Paediatric clinicians had an increased understanding of allergy assessment and anaphylaxis management. Recent penicillin allergy education within a 5-year period led to significant improvements in allergy knowledge. CONCLUSION Overall, knowledge, assessment and management of penicillin allergies among practitioners in Western Australia are currently inadequate in adults and paediatric clinicians to provide safe and effective clinical care. The implementation of a targeted education program for WA health professionals is urgently required and is expected to improve clinician knowledge and aid standardised penicillin assessment (de-labelling) practices.
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Affiliation(s)
- Katherine Collins
- Department of Anaesthesia and Pain ManagementPerth Children's HospitalPerthWestern AustraliaAustralia
| | - Kristina Rueter
- Department of Emergency MedicinePerth Children's HospitalPerthWestern AustraliaAustralia,Department of ImmunologyPerth Children's HospitalPerthWestern AustraliaAustralia,School of MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Michaela Lucas
- Department of ImmunologyPerth Children's HospitalPerthWestern AustraliaAustralia,School of MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia,Department of ImmunologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia,Institute for Immunology and Infectious DiseasesMurdoch UniversityMurdochWestern AustraliaAustralia,PathWest Laboratory MedicinePerthWestern AustraliaAustralia
| | - David Sommerfield
- Department of Anaesthesia and Pain ManagementPerth Children's HospitalPerthWestern AustraliaAustralia,School of MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia,Perioperative MedicineTelethon Kids InstitutePerthWestern AustraliaAustralia
| | - Aine Sommerfield
- Department of Anaesthesia and Pain ManagementPerth Children's HospitalPerthWestern AustraliaAustralia,Perioperative MedicineTelethon Kids InstitutePerthWestern AustraliaAustralia
| | - Nazim Khan
- Department of Mathematics and StatisticsUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - Britta S von Ungern‐Sternberg
- Department of Anaesthesia and Pain ManagementPerth Children's HospitalPerthWestern AustraliaAustralia,School of MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia,Perioperative MedicineTelethon Kids InstitutePerthWestern AustraliaAustralia
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13
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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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14
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Gill MM, Gasner S, Banken A, Park M, Weaver A, Sharpe E, Theiler R. Improving routine prenatal penicillin allergy testing for reported penicillin allergy. BMJ Open Qual 2022; 11:e001859. [PMID: 35906008 PMCID: PMC9345039 DOI: 10.1136/bmjoq-2022-001859] [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] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/28/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Patients with self-reported antibiotic allergies have a higher cost of care, more frequent infections with resistant bacteria and worse health outcomes than patients without antibiotic allergies. Ultimately, less than 5% of patients who report a penicillin allergy have a clinically significant immune-mediated hypersensitivity reaction when tested. As 10%-30% of the population of pregnant patients are colonised for group B Streptococcus (GBS) and guidelines recommend penicillin as the treatment of choice for GBS, current recommendations support penicillin allergy testing in pregnant patients who report an allergy. METHODS AND INTERVENTION In this quality improvement project, nursing staff used an algorithm outlining inclusion and exclusion criteria to determine which patients were eligible to have penicillin allergy testing completed. Penicillin allergy testing consisted of a skin test using benzylpenicilloyl polylysine (Pre-Pen), penicillin G potassium, amoxicillin and alkaline hydrolysis mix (penicilloate) as a prick skin test, followed by intradermal skin test and finally an oral challenge with either amoxicillin or penicillin. Patient outcomes were analysed to evaluate the impact of the intervention. RESULTS Of the 1266 patients receiving prenatal care during the intervention, 236 (19%) reported a history of penicillin allergy, and 212 if these were eligible for testing. 150 of the eligible patients were offered penicillin allergy testing. 101 patients (67%) completed testing and 49 (33%) declined testing. Seven patients (7%) had positive penicillin allergy testing, while 94 patients (93%) had negative penicillin allergy testing and were immediately de-labelled as penicillin allergic. Seventeen of the de-labelled patients subsequently tested positive for GBS colonisation, and all received intrapartum penicillin without adverse events. CONCLUSIONS Pursuing penicillin allergy testing for pregnant patients with reported penicillin allergy is a safe and feasible approach, allowing for allergy de-labelling and safe, guideline-driven antimicrobial therapy during subsequent labour and delivery hospitalisations. Cost-effectiveness of the allergy testing and impact on later episodes of care should be further investigated.
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Affiliation(s)
| | - Sara Gasner
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Alisha Banken
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy Weaver
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Emily Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Regan Theiler
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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15
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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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16
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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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17
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Goh GS, Shohat N, Austin MS. A Simple Algorithmic Approach Allows the Safe Use of Cephalosporin in "Penicillin-Allergic" Patients without the Need for Allergy Testing. J Bone Joint Surg Am 2021; 103:2261-2269. [PMID: 34644269 DOI: 10.2106/jbjs.21.00027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients who report a penicillin allergy are often given second-line antibiotic prophylaxis during total joint arthroplasty (TJA), with only a minority of patients undergoing additional consultations and allergy testing. In an effort to increase the use of cephalosporin prophylaxis in TJA, the present study aimed to assess the effectiveness of a simple, protocol-driven penicillin allergy screening program without the need for additional work-up. METHODS Following implementation of a questionnaire-based screening protocol in May 2019, all patients scheduled for primary TJA were risk-stratified into low or high-risk categories. The low-risk cohort received cefazolin, and the high-risk cohort received non-cefazolin antibiotics. Patients were monitored prospectively, and data on antibiotic usage and adverse outcomes were documented. The protocol group (n = 2,078) was propensity score matched 1:1 with a control group that included patients who underwent TJA in the same institution prior to implementation of the protocol. The primary end point was the efficacy of the protocol in reducing unnecessary use of non-cephalosporin antibiotics for prophylaxis. Secondary outcomes included the rate of surgical site infections and allergic reactions to the administered antibiotic. RESULTS A total of 357 patients (17.2%) reported a penicillin allergy in the protocol group compared with 310 patients (14.9%) with a recorded allergy in the control group (p = 0.052). The number of patients who received non-cephalosporin antibiotics was significantly lower in the protocol group (5.7% compared with 15.2% in the control group; p < 0.001), whereas there was no difference in the rate of total allergic reactions (0.8% compared with 0.7%, respectively; p = 0.857). Of the 239 low-risk patients (66.9%) in the protocol group, only 3 (1.3%) experienced a mild cutaneous reaction following cefazolin administration. There were no differences in the rates of superficial wound, deep periprosthetic, or Clostridioides difficile infections between the protocol and control groups. CONCLUSIONS A simple screening protocol allowed two-thirds of patients with a self-reported allergy to receive cefazolin without the need for additional consultations or testing. We believe this protocol can be safely implemented to increase the rate of cefazolin usage without a corresponding increase in the number of allergic reactions. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Noam Shohat
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Matthew S Austin
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
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18
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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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19
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Chen X, Wang J. Degradation of antibiotic Cephalosporin C in different water matrices by ionizing radiation: Degradation kinetics, pathways, and toxicity. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 791:148253. [PMID: 34118661 DOI: 10.1016/j.scitotenv.2021.148253] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/31/2021] [Accepted: 05/31/2021] [Indexed: 06/12/2023]
Abstract
Cephalosporin antibiotics are ubiquitous emerging pollutants in various aquatic environments due to their extensive production and application. Herein, the radiolytic degradation of antibiotic Cephalosporin C (CEP-C) in different water matrices was comprehensively investigated using gamma radiation at various experimental conditions. The results revealed that CEP-C oxidation obeyed pseudo first-order kinetics, and 100%, 94.9%, 67.0%, 44.6% and 34.5% removal of CEP-C with 10-200 mg/L was achieved at 0.4 kGy, respectively. The degradation was faster at higher absorbed dose and acidic conditions (pH = 3.5). The inorganic anions, including SO42-, NO3-, and HCO3-, had negative influence on the degradation of CEP-C, the corresponding rate constant decreased from 4.603 to 3.667, 1.677 and 2.509 kGy-1 respectively in the presence of SO42-, NO3-, and HCO3-. The analysis of intermediate products indicated that CEP-C was oxidized to generate about 10 intermediate products. Besides, it was inferred that the thioether sulfur oxidation, β-lactam ring opening, acetyl dissociation from dihydrothiazine ring and D-α-aminohexylamide group abscission were the major reaction mechanisms of CEP-C degradation by gamma radiation. Importantly, the antibacterial activity of CEP-C could be completely vanished by gamma radiation alone, while more toxic intermediate products might be formed. Addition of hydrogen peroxide and peroxymonosulfate could significantly improve the CEP-C degradation, and reduce the toxicity of intermediates of CEP-C degradation. Similar degradation behavior was observed in the groundwater and wastewater, implying that ionizing radiation can be used for degradation of Cephalosporin in water and wastewater.
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Affiliation(s)
- Xiaoying Chen
- Laboratory of Environmental Technology, INET, Tsinghua University, Beijing 100084, PR China
| | - Jianlong Wang
- Laboratory of Environmental Technology, INET, Tsinghua University, Beijing 100084, PR China; Beijing Key Laboratory of Radioactive Waste Treatment, Tsinghua University, Beijing 100084, PR China.
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20
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Fernandez J, Jimenez-Rodriguez TW, Blanca-Lopez N. Classifying cephalosporins: from generation to cross-reactivity. Curr Opin Allergy Clin Immunol 2021; 21:346-354. [PMID: 34074874 DOI: 10.1097/aci.0000000000000755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW To review the most recent literature studying the classifications, immunochemistry, and crossreactivity of allergy reactions to cephalosporins. RECENT FINDINGS Over the last five years, research interest has focused on three areas related to cephalosporin allergy: cross-reactivity among cephalosporins and with other beta-lactams; the incidence of adverse reactions in penicillin allergy patients or in reported penicillin allergy labels; and new cephalosporins structures involved in the immunological recognition. SUMMARY Meta-analysis of a substantial number of studies shows that cephalosporins are safer than previously thought. Evidence supports two main conclusions in that regard. First, there is a relatively low percentage of cross-reactivity between cephalosporins and other beta-lactams with penicillins in penicillin allergy patients. Second, there is a very low incidence of allergy reactions in nonselected as well as in selected penicillin allergy patients when cephalosporins are used prior to surgical intervention.On the other hand, few structures have been discovered related to the immune mechanism of cephalosporin allergy reactions, and these are far from being ready to use in clinical practice.
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Affiliation(s)
- Javier Fernandez
- Allergy Section, Alicante General University Hospital, ISABIAL-UMH, Alicante
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21
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Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1-187. [PMID: 34292926 PMCID: PMC8344968 DOI: 10.15585/mmwr.rr7004a1] [Citation(s) in RCA: 793] [Impact Index Per Article: 264.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
These guidelines for the treatment of persons who have or are at risk for
sexually transmitted infections (STIs) were updated by CDC after consultation
with professionals knowledgeable in the field of STIs who met in Atlanta,
Georgia, June 11–14, 2019. The information in this report updates the
2015 guidelines. These guidelines discuss 1) updated recommendations for
treatment of Neisseria gonorrhoeae, Chlamydia trachomatis,
and Trichomonas vaginalis; 2) addition of
metronidazole to the recommended treatment regimen for pelvic inflammatory
disease; 3) alternative treatment options for bacterial vaginosis; 4) management
of Mycoplasma genitalium; 5) human papillomavirus vaccine
recommendations and counseling messages; 6) expanded risk factors for syphilis
testing among pregnant women; 7) one-time testing for hepatitis C infection; 8)
evaluation of men who have sex with men after sexual assault; and 9) two-step
testing for serologic diagnosis of genital herpes simplex virus. Physicians and
other health care providers can use these guidelines to assist in prevention and
treatment of STIs.
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Hanssen P, Nieuwhof C, van Mens S, van de Plas A, Horstman K. Implementing a new antibiotic allergy protocol in clinical practice: well-trusted but not used. JAC Antimicrob Resist 2021; 3:dlab077. [PMID: 34223136 PMCID: PMC8210085 DOI: 10.1093/jacamr/dlab077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/30/2021] [Indexed: 11/19/2022] Open
Abstract
Background Suboptimal antibiotic prescriptions in patients with an antibiotic allergy label lead to increased incidence of adverse events and antimicrobial resistance (AMR). An antibiotic allergy protocol was developed in a Dutch academic hospital guiding optimal and safe antibiotic use in potentially penicillin-allergic patients. Informed by previous studies of implementation processes in clinical care, we studied the implementation of this protocol. Methods Medical professionals in the Departments of Surgery, Internal Medicine, and Pulmonary Care were interviewed. Additionally, focus groups were conducted in Internal Medicine and Pulmonary Care to validate the outcomes of the interviews. Results Dissemination of the protocol via the regular online hospital-wide guidance system did not have a significant impact on the knowledge about or use of the protocol. If healthcare professionals found the protocol, they thought it was valuable and expressed trust in the expertise embodied in it. However, its use in practice was rather minimal. Interviewees doubted the accuracy of the patient’s histories about their previous adverse drug reactions, and/or the information in their medical records and concluded that adherence to the expert guideline was needlessly risky. They felt the acute allergic reaction risk for a patient outweighed the risk of suboptimal therapy or future AMR. Conclusions For successful implementation and dissemination of the protocol, the accessibility of the protocol, the information about the actual risks of following the protocol and the registration of allergic history should be improved. However, whether this actually results in improvement also depends on changes in the hospital culture and organization.
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Affiliation(s)
- P Hanssen
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - C Nieuwhof
- Department of Allergology and Clinical Immunology, Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S van Mens
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A van de Plas
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - K Horstman
- Department of Health, Ethics, and Society, Care and Public Health Research Institute CAPHRI, Maastricht University, Maastricht, The Netherlands
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Collins CD, Scheidel C, Anam K, Polega S, Malani AN, Hayward A, Leo HL, Shankar T, Morrin C, Brockhaus K. Impact of an Antibiotic Side-Chain-Based Cross-reactivity Chart Combined With Enhanced Allergy Assessment Processes for Surgical Prophylaxis Antimicrobials in Patients With β-Lactam Allergies. Clin Infect Dis 2021; 72:1404-1412. [PMID: 32155264 DOI: 10.1093/cid/ciaa232] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND β-Lactam antibiotics are first-line therapy for perioperative prophylaxis; however, patient-reported allergies often lead to increased prescribing of alternative antibiotics that may increase the incidence of surgical site infections. The R-group side chain of the β-lactam ring is responsible for allergic cross-reactivity and experts recommend the use of β-lactams that are structurally dissimilar. METHODS An internally developed, antibiotic side-chain-based cross-reactivity chart was developed and implemented alongside enhanced allergy assessment processes. This single-center, quasi-experimental study analyzed antibiotic prescribing in all adult patients with a documented β-lactam allergy undergoing an inpatient surgical procedure between quartile (Q) 1 (2012)-Q3 (2014) (historical group) and Q3 (2016)-Q3 (2018) (intervention group). Propensity-weighted scoring analyses compared categorical and continuous outcomes. Interrupted time-series analysis further analyzed key outcomes. RESULTS A total of 1119 and 1089 patients were included in the historical and intervention cohorts, respectively. There was a significant difference in patients receiving a β-lactam alternative antibiotic between cohorts (84.9% vs 15.1%; P < .001). There was a decrease in 30-day readmissions in the intervention cohort (7.9% vs 6.3%; P = .035); however, there was no difference in the incidence of SSIs in patients readmitted (14.8% vs 13%; P = .765). No significant differences were observed in allergic reactions (0.5% vs 0.3%; P = .323), surgical site infections, in-hospital and 30-day mortality, healthcare facility-onset Clostridiodes difficile infection, acute kidney injury, or hospital costs. CONCLUSIONS Implementation of an antibiotic cross-reactivity chart combined with enhanced allergy assessment processes significantly improved the prescribing of β-lactam antibiotics for surgical prophylaxis.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Caleb Scheidel
- Methods Consultants of Ann Arbor, Ypsilanti, Michigan, USA
| | - Kishore Anam
- Michigan Data Analytics, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Shikha Polega
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Division of Infectious Diseases, Department of Internal Medicine, St Joseph Mercy Health System, Ann Arbor, Michigan, USA.,Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Alexandra Hayward
- Department of Infection Prevention and Control, 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
| | - Cheryl Morrin
- Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Kara Brockhaus
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
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Felix MMR, Aun MV, Menezes UPD, Queiroz GRESD, Rodrigues AT, D'Onofrio-Silva AC, Perelló MI, Camelo-Nunes IC, Malaman MF. Allergy to penicillin and betalactam antibiotics. EINSTEIN-SAO PAULO 2021; 19:eMD5703. [PMID: 33909756 PMCID: PMC8054529 DOI: 10.31744/einstein_journal/2021md5703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
Betalactams are the most frequent cause of hypersensitivity reactions to drugs mediated by a specific immune mechanism. Immediate reactions occur within 1 to 6 hours after betalactam administration, and are generally IgE-mediated. They clinically translate into urticaria, angioedema and anaphylaxis. Non-immediate or delayed reactions occur after 1 hour of administration. These are the most common reactions and are usually mediated by T cells. The most frequent type is the maculopapular or morbilliform exanthematous eruption. Most individuals who report allergies to penicillin and betalactams can tolerate this group of antibiotics. To make diagnosis, a detailed medical history is essential to verify whether it was an immediate or non-immediate reaction. Thereafter, in vivo and/or in vitro tests for investigation may be performed. The challenging test is considered the gold standard method for diagnosis of betalactam hypersensitivity. The first approach when suspecting a reaction to betalactam is to discontinue exposure to the drug, and the only specific treatment is desensitization, which has very precise indications. The misdiagnosis of penicillin allergy affects the health system, since the "penicillin allergy" label is associated with increased bacterial resistance, higher rate of therapeutic failure, prolonged hospitalizations, readmissions, and increased costs. Thus, it is essential to develop strategies to assist the prescription of antibiotics in patients identified with a label of "betalactam allergy" at hospitals, and to enhance education of patients and their caregivers, as well as of non-specialist physicians.
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Affiliation(s)
- Mara Morelo Rocha Felix
- Escola de Medicina e Cirurgia, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Marcelo Vivolo Aun
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Ullissis Pádua de Menezes
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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Sousa-Pinto B, Blumenthal KG, Courtney L, Mancini CM, Jeffres MN. Assessment of the Frequency of Dual Allergy to Penicillins and Cefazolin: A Systematic Review and Meta-analysis. JAMA Surg 2021; 156:e210021. [PMID: 33729459 PMCID: PMC7970387 DOI: 10.1001/jamasurg.2021.0021] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/17/2020] [Indexed: 12/15/2022]
Abstract
Importance Cefazolin is the preoperative antibiotic of choice because it is safer and more efficacious than second-line alternatives. Surgical patients labeled as having penicillin allergy are less likely to prophylactically receive cefazolin and more likely to receive clindamycin or vancomycin, which results in higher rates of surgical site infections. Objective To examine the incidence of dual allergy to cefazolin and natural penicillins. Data Sources MEDLINE/PubMed, Web of Science, and Embase were searched without language restrictions for relevant articles published from database inception until July 31, 2020. Study Selection In this systematic review and meta-analysis, a search of MEDLINE/PubMed, Web of Science, and Embase was performed for articles published from database inception to July 31, 2020, for studies that included patients who had index allergies to a natural penicillin and were tested for tolerability to cefazolin or that included patients who had index allergies to cefazolin and were tested for tolerability to a natural penicillin. A total of 3228 studies were identified and 2911 were screened for inclusion. Data Extraction and Synthesis Data were independently extracted by 2 authors. Bayesian meta-analysis was used to estimate the frequency of allergic reactions. Main Outcomes and Measures Dual allergy to cefazolin and a natural penicillin. Results Seventy-seven unique studies met the eligibility criteria, yielding 6147 patients. Cefazolin allergy was identified in 44 participants with a history of penicillin allergy, resulting in a dual allergy meta-analytical frequency of 0.7% (95% credible interval [CrI], 0.1%-1.7%; I2 = 74.9%). Such frequency was lower for participants with unconfirmed (0.6%; 95% CrI, 0.1%-1.3%; I2 = 54.3%) than for those with confirmed penicillin allergy (3.0%; 95% CrI, 0.01%-17.0%; I2 = 88.2%). Thirteen studies exclusively assessed surgical patients (n = 3884), among whom 0.7% (95% CrI, 0%-3.3%; I2 = 85.5%) had confirmed allergy to cefazolin. Low heterogeneity was observed for studies of patients with unconfirmed penicillin allergy who had been exposed to perioperative cefazolin (0.1%; 95% CrI, 0.1%-0.3%; I2 = 13.1%). Penicillin allergy was confirmed in 16 participants with a history of cefazolin allergy, resulting in a meta-analytical frequency of 3.7% (95% CrI, 0.03%-13.3%; I2 = 64.4%). The frequency of penicillin allergy was 4.4% (95% CrI, 0%-23.0%; I2 = 75%) for the 8 studies that exclusively assessed surgical patients allergic to cefazolin. Conclusions and Relevance These findings suggest that most patients with a penicillin allergy history may safely receive cefazolin. The exception is patients with confirmed penicillin allergy in whom additional care is warranted.
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Affiliation(s)
- Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Center for Health Technology and Services Research, University of Porto, Porto, Portugal
- Basic and Clinical Immunology Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- The Mongan Institute, Massachusetts General Hospital, Boston
| | - Lindsay Courtney
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
| | - Christian M. Mancini
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| | - Meghan N. Jeffres
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
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Zuelzer DA, Hayes CB, Hautala GS, Akbar A, Mayer RR, Jacobs CA, Wright RD, Moghadamian ES, Matuszewski PE. Early Antibiotic Administration Is Associated with a Reduced Infection Risk When Combined with Primary Wound Closure in Patients with Open Tibia Fractures. Clin Orthop Relat Res 2021; 479:613-619. [PMID: 33009232 PMCID: PMC7899592 DOI: 10.1097/corr.0000000000001507] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 08/27/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Early administration of antibiotics and wound coverage have been shown to decrease the deep infection risk in all patients with Type 3 open tibia fractures. However, it is unknown whether early antibiotic administration decreases infection risk in patients with Types 1, 2, and 3A open tibia fractures treated with primary wound closure. QUESTIONS/PURPOSES (1) Does decreased time to administration of the first dose of antibiotics decrease the deep infection risk in all open tibia fractures with primary wound closure? (2) What patient demographic factors are associated with an increased deep infection risk in Types 1, 2, and 3A open tibia fractures with primary wound closure? METHODS We identified 361 open tibia fractures over a 5-year period at a Level I regional trauma center that receives direct admissions and transfers from other hospitals which produces large variation in the timing of antibiotic administration. Patients were excluded if they were younger than 18 years, had associated plafond or plateau fractures, associated with compartment syndrome, had a delay of more than 24 hours from injury to the operating room, underwent repeat débridement procedures, had incomplete data, and were treated with negative-pressure dressings or other adjunct wound management strategies that would preclude primary closure. Primary closure was at the descretion of the treating surgeon. We included patients with a minimum follow-up of 6 weeks with assessment at 6 months and 12 months. One hundred forty-three patients with were included in the analysis. Our primary endpoint was deep infection as defined by the CDC criteria. We obtained chronological data, including the time to the first dose of antibiotics and time to surgical débridement from ambulance run sheets, transferring hospital records, and the electronic medical record to answer our first question. We considered demographics, American Society of Anesthesiologists classification, mechanism of injury, smoking status, presence of diabetes, and Injury Severity Score in our analysis of other factors. These were compared using one-way ANOVA, chi-square, or Fisher's exact tests. Binary regression was used to to ascertain whether any factors were associated with postoperative infection. Receiver operator characteristic curves were used to identify threshold values. RESULTS Increased time to first administration of antibiotics was associated with an increased infection risk in patients who were treated with primary wound closure; the greatest inflection point on that analysis occurred at 150 minutes, when the increased infection risk was greatest (20% [8 of 41] versus 4% [3 of 86]; odds ratio 5.6 [95% CI 1.4 to 22.2]; p = 0.01). After controlling for potential confounding variables like age, diabetes and smoking status, none of the variables we evaluated were associated with an increased risk of deep infection in Type 1, 2, and 3A open tibia fractures in patients treated with primary wound closure. CONCLUSION Our findings suggest that in open tibia fractures, which receive timely antibiotic administration, primary wound closure is associated with a decreased infection risk. We recognize that more definitive studies need to be performed to confirm these findings and confirm feasibility of early antibiotic administration, especially in the pre-hospital context. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- David A Zuelzer
- D. A. Zuelzer, G. S. Hautala, R. R. Mayer, C. A. Jacobs, R. D. Wright, E. S. Moghadamian, P. E. Matuszewski, Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
- C. B. Hayes, Department of Orthopaedic Surgery, University of California-Davis, CA, USA
- A. Akbar, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Christopher B Hayes
- D. A. Zuelzer, G. S. Hautala, R. R. Mayer, C. A. Jacobs, R. D. Wright, E. S. Moghadamian, P. E. Matuszewski, Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
- C. B. Hayes, Department of Orthopaedic Surgery, University of California-Davis, CA, USA
- A. Akbar, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Gavin S Hautala
- D. A. Zuelzer, G. S. Hautala, R. R. Mayer, C. A. Jacobs, R. D. Wright, E. S. Moghadamian, P. E. Matuszewski, Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
- C. B. Hayes, Department of Orthopaedic Surgery, University of California-Davis, CA, USA
- A. Akbar, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Adam Akbar
- D. A. Zuelzer, G. S. Hautala, R. R. Mayer, C. A. Jacobs, R. D. Wright, E. S. Moghadamian, P. E. Matuszewski, Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
- C. B. Hayes, Department of Orthopaedic Surgery, University of California-Davis, CA, USA
- A. Akbar, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Ryan R Mayer
- D. A. Zuelzer, G. S. Hautala, R. R. Mayer, C. A. Jacobs, R. D. Wright, E. S. Moghadamian, P. E. Matuszewski, Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
- C. B. Hayes, Department of Orthopaedic Surgery, University of California-Davis, CA, USA
- A. Akbar, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Cale A Jacobs
- D. A. Zuelzer, G. S. Hautala, R. R. Mayer, C. A. Jacobs, R. D. Wright, E. S. Moghadamian, P. E. Matuszewski, Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
- C. B. Hayes, Department of Orthopaedic Surgery, University of California-Davis, CA, USA
- A. Akbar, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Raymond D Wright
- D. A. Zuelzer, G. S. Hautala, R. R. Mayer, C. A. Jacobs, R. D. Wright, E. S. Moghadamian, P. E. Matuszewski, Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
- C. B. Hayes, Department of Orthopaedic Surgery, University of California-Davis, CA, USA
- A. Akbar, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Eric S Moghadamian
- D. A. Zuelzer, G. S. Hautala, R. R. Mayer, C. A. Jacobs, R. D. Wright, E. S. Moghadamian, P. E. Matuszewski, Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
- C. B. Hayes, Department of Orthopaedic Surgery, University of California-Davis, CA, USA
- A. Akbar, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Paul E Matuszewski
- D. A. Zuelzer, G. S. Hautala, R. R. Mayer, C. A. Jacobs, R. D. Wright, E. S. Moghadamian, P. E. Matuszewski, Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
- C. B. Hayes, Department of Orthopaedic Surgery, University of California-Davis, CA, USA
- A. Akbar, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
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Caruso C, Valluzzi RL, Colantuono S, Gaeta F, Romano A. β-Lactam Allergy and Cross-Reactivity: A Clinician's Guide to Selecting an Alternative Antibiotic. J Asthma Allergy 2021; 14:31-46. [PMID: 33500632 PMCID: PMC7822086 DOI: 10.2147/jaa.s242061] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/07/2021] [Indexed: 12/15/2022] Open
Abstract
β-Lactams which include penicillins, cephalosporins, carbapenems, and monobactams are the most common antibiotic classes reported to cause allergic reactions to drugs. This review is mainly about published studies assessing the cross-reactivity among β-lactams in penicillin- or cephalosporin-allergic subjects by carrying out diagnostic tests with alternative β-lactams and, if appropriate, graded challenges. Several studies demonstrated that cross-reactivity connected with the β-lactam ring, causing positive responses to allergy tests with all β-lactams, is infrequent in subjects with an IgE-mediated allergy and anecdotal in those with a T-cell-mediated allergy. Identities or similarities of β-lactam side-chain structures are mainly responsible for cross-reactivity among these antibiotics. For example, in aminopenicillin-allergic subjects, cross-reactivity with aminocephalosporins could possibly be over 30%. On the other hand, in a few prospective studies of penicillin-allergic individuals, less than 1% of cases show a cross-reactivity between penicillins and both aztreonam and carbapenems. Particular patterns of allergy-test positivity observed in some studies that assessed cross-reactivity among β-lactams seem to indicate that prior exposures may be responsible for coexisting sensitivities. Therefore, pre-treatment skin tests with the related β-lactams are suggested before administering them via graded challenges to β-lactam-allergic patients who need alternative β-lactams.
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Affiliation(s)
- Cristiano Caruso
- Allergy Unit, Columbus Hospital, Fondazione Policlinico A. Gemelli, IRCCS, Rome, Italy
| | - Rocco Luigi Valluzzi
- Department of Pediatrics, Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Vatican City, Italy
| | - Stefania Colantuono
- Allergy Unit, Columbus Hospital, Fondazione Policlinico A. Gemelli, IRCCS, Rome, Italy
| | - Francesco Gaeta
- Allergy Unit, Columbus Hospital, Fondazione Policlinico A. Gemelli, IRCCS, Rome, Italy
| | - Antonino Romano
- Oasi Research Institute-IRCCS, Troina, Italy
- Fondazione Mediterranea G.B. Morgagni, Catania, Italy
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Delayed Sepsis Management Due to Ambiguous Allergy. AORN J 2020; 112:726-728. [DOI: 10.1002/aorn.13253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 11/06/2022]
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Yu RJ, Krantz MS, Phillips EJ, Stone CA. Emerging Causes of Drug-Induced Anaphylaxis: A Review of Anaphylaxis-Associated Reports in the FDA Adverse Event Reporting System (FAERS). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:819-829.e2. [PMID: 32992044 DOI: 10.1016/j.jaip.2020.09.021] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/09/2020] [Accepted: 09/13/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Drug-induced anaphylaxis is a well-known adverse drug reaction for some drug classes, but emerging drug causes of anaphylaxis and novel mechanisms may contribute in unrecognized ways. OBJECTIVE We sought to determine the top drugs reported in association with anaphylaxis and anaphylaxis followed by death in the Food and Drug Administration Adverse Event Reporting System (FAERS). METHODS We reviewed the publicly available FAERS database from 1999 to 2019. Using search terms "anaphylactic shock" or "anaphylactic reaction" and sorting cases by generic drug names, we counted and trended reports to FAERS in which a drug was associated with anaphylaxis or anaphylaxis followed by death. RESULTS From 1999 to 2019, there were 17,506,002 adverse drug events reported in FAERS, of which 47,496 (0.27%) were reported as anaphylaxis. Excluding patients without age, sex, or country data, respectively, the median age of patients in reports of anaphylaxis was 52 (interquartile range: 28), 62.71% were female, and 13,899 of 34,381 (40.43%) reports were from the United States. There were 2984 of 47,496 (6.28%) reports of anaphylaxis followed by death. Top drug classes associated with anaphylaxis in FAERS were antibiotics, monoclonal antibodies (mAbs), nonsteroidal anti-inflammatory drugs, and acetaminophen. Top drug classes associated with anaphylaxis deaths were antibiotics, radiocontrast agents, and intraoperative agents. Linear regression demonstrated reports of anaphylaxis to mAbs increasing at an average rate of 0.77% of total anaphylaxis reports per year (95% confidence interval: 0.65, 0.88) from 2.00% in 1999 to 17.37% in 2019, faster than any other drug class. CONCLUSION Antibiotics were highly reported for anaphylaxis overall and anaphylaxis followed by death. Increasing reports were noted for anaphylaxis to mAb therapies.
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Affiliation(s)
- Roger J Yu
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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Savic L, Stannard N, Farooque S. Allergy and anaesthesia: managing the risk. BJA Educ 2020; 20:298-304. [DOI: 10.1016/j.bjae.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2020] [Indexed: 10/23/2022] Open
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Stone CA, Trubiano JA, Phillips EJ. Testing Strategies and Predictors for Evaluating Immediate and Delayed Reactions to Cephalosporins. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:435-444.e13. [PMID: 32822918 DOI: 10.1016/j.jaip.2020.07.056] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 07/24/2020] [Accepted: 07/31/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although 1% to 2% of the general population carries a cephalosporin allergy label (CAL), we lack validated testing strategies and predictors of true allergy. OBJECTIVE To identify cross-reactivity patterns and predictors of skin test positive (STP) in geographically disparate patients with a CAL. METHODS A total of 780 adult patients labeled with a CAL or penicillin allergy label (PAL) with unknown tolerance of cephalosporins identified from the Austin Hospital (Melbourne, Australia) (n = 410) and Vanderbilt University Medical Center (Nashville, TN) (n = 370) between 2014 and 2018 underwent a standardized skin testing. RESULTS Of 328 patients with a CAL, 29 (8.8%) tested STP to ≥1 cephalosporin(s). There were no cefazolin or ceftriaxone STP, 0 of 452 (0%), in patients with a PAL only. Of 328 patients with a CAL, 16 (4.8%) were ampicillin STP. Eleven of 16 of these patients had an initial allergy label to cephalexin. Twenty of 29 cephalosporin STP patients demonstrated tolerance to a cephalosporin with a different R1 side chain, and 8 of 14 ampicillin STP patients demonstrated tolerance to ≥1 non-amino R1 group cephalosporin. Eleven of 13 patients STP to cefazolin were skin and ingestion challenge negative to all other penicillins and cephalosporins predicted by its distinct R1/R2 groups. Seven of 15 ceftriaxone STP patients demonstrated cross-reactivity with R1-similar cephalosporins. Time since the original reaction predicted STP testing to both penicillins, adjusted odds ratio (aOR) per year 0.93 (95% confidence interval [CI]: 0.90, 0.97), and cephalosporins, aOR per year 0.71 (95% CI: 0.56, 0.90). CONCLUSIONS Cephalosporin cross-reactivity is based on shared R1 groupings. Increasing time since the original reaction and the presence of a PAL with unknown cephalosporin tolerance predict a lower likelihood of cephalosporin STP.
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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, Tenn.
| | - Jason A Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia; National Centre for Infections in Cancer and Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn; Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, WA, Australia
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Abstract
Although clinical guidelines for antibiotic prophylaxis across a wide array of surgical procedures have been proposed by multidisciplinary groups of physicians and pharmacists, clinicians often deviate from recommendations. This is particularly true when recommendations are based on weak data or expert opinion. The goal of this review is to highlight certain common but controversial topics in perioperative prophylaxis and to focus on the data that does exist for the recommendations being made.
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Cephalosporin allergens: Is the cephalosporoyl and R1 side-chain focus too narrow? J Allergy Clin Immunol 2020; 146:459-460. [PMID: 32362533 DOI: 10.1016/j.jaci.2020.02.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 02/07/2020] [Indexed: 11/20/2022]
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Yuson C, Kumar K, Le A, Ahmadie A, Banovic T, Heddle R, Kette F, Smith W, Hissaria P. Immediate cephalosporin allergy. Intern Med J 2020; 49:985-993. [PMID: 30667130 DOI: 10.1111/imj.14229] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 12/18/2018] [Accepted: 01/09/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients who suffer from acute IgE-mediated allergy to a cephalosporin antibiotic are frequently assumed to be at high risk of allergy to other cephalosporins and penicillins. AIM To define cross-reactivity patterns in patients with confirmed allergy to a cephalosporin. METHODS Subjects presenting with a history of immediate allergy to a cephalosporin-family antibiotic between March 2009 and July 2017 were investigated with specific IgE testing to penicillin, amoxycillin and cefaclor, followed by skin prick testing, intradermal testing and drug provocation testing with a panel of penicillins and cephalosporins. RESULTS Out of 564 subjects with a reported beta-lactam allergy, 90 identified a cephalosporin as their index drug. Fifty-five (61.1%) of the 90 subjects tested had a history consistent with an IgE-mediated reaction, of whom 24 (43.6%) were proven to be allergic to their index cephalosporin. Twenty (83.3%) of the 24 were allergic only to their index cephalosporin. Of the four remaining subjects, two were co-sensitised to another beta-lactam with a similar side chain, while the other two had no specific cross-reactivity pattern. Major and minor penicillin determinants were negative for all cephalosporin-allergic individuals. CONCLUSION In our cohort, cephalosporin allergy does not appear to be a class effect, with most cases found allergic only to their index cephalosporin. Co-sensitisation to other cephalosporins or penicillins was uncommon, and when it occurred, was usually consistent with side chain cross-reactivity.
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Affiliation(s)
- Carlo Yuson
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Kimti Kumar
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adriana Le
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Aida Ahmadie
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tatjana Banovic
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Robert Heddle
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Frank Kette
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - William Smith
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Pravin Hissaria
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Adverse Reactions Associated with Penicillins, Carbapenems, Monobactams, and Clindamycin: A Retrospective Population-based Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1302-1313.e2. [DOI: 10.1016/j.jaip.2019.11.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 12/16/2022]
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A Streamlined Approach to Optimize Perioperative Antibiotic Prophylaxis in the Setting of Penicillin Allergy Labels. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1316-1322. [DOI: 10.1016/j.jaip.2019.12.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 12/30/2022]
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Abstract
PURPOSE OF REVIEW To review phenotyping and risk classification of penicillin allergy and provide an update on penicillin allergy delabeling strategies for primary care. RECENT FINDINGS Beta-lactams are considered the treatment of choice for a wide range of bacterial pathogens; however, many patients receive second-line agents due to being labeled as having an allergy to penicillin. This approach can lead to antibiotic resistance and inferior health outcomes. While 10% of the population is labeled as penicillin allergic, penicillin anaphylaxis occurs in less than 1% of patients. For patients with delayed benign skin rashes (e.g., urticaria or maculopapular exanthem >1 h after administration) attributable to beta-lactam administration occurring more than 12 months ago, direct oral challenge (rechallenge with antibiotic in the clinical setting) can be a safe and effective strategy, with immediate reactions occurring in less than 5% of such low-risk patients and delayed reactions appearing infrequently. In patients with penicillin-associated immediate urticaria, other IgE-mediated features, or anaphylaxis, further allergy evaluation and penicillin skin testing is warranted. Any severe idiosyncratic cutaneous adverse reaction is rare, but can be dangerous so prompt removal of the inciting agent is required. SUMMARY Penicillin allergy delabeling is a high-value service that can be effectively delivered through a multidisciplinary collaborative approach.
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Romano A, Valluzzi RL, Caruso C, Zaffiro A, Quaratino D, Gaeta F. Tolerability of Cefazolin and Ceftibuten in Patients with IgE-Mediated Aminopenicillin Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1989-1993.e2. [PMID: 32145403 DOI: 10.1016/j.jaip.2020.02.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Side-chain similarities or identities constitute the predominant factor for cross-reactivity between penicillins and cephalosporins, whereas differences in the side-chain structure seem to account for the absence of such cross-reactivity. OBJECTIVE We sought to assess the cross-reactivity between penicillins and 2 cephalosporins (ie, cefazolin and ceftibuten) that have side chains different from those of penicillins, as well as to evaluate the possibility of using these cephalosporins in penicillin-allergic subjects. METHODS We conducted a prospective study of 131 consecutive subjects who had suffered 170 immediate reactions (mostly anaphylaxis) to penicillins and had positive skin test results to at least 1 penicillin reagent. All patients underwent skin tests with cefazolin and ceftibuten. Patients with negative results were challenged with them. RESULTS One participant had positive skin test results to cefazolin and ceftibuten, as well as to all other reagents tested, including aztreonam and carbapenems. All 129 subjects who underwent challenges with cefazolin and ceftibuten tolerated them. One subject refused cephalosporin challenges. CONCLUSIONS Subjects with an IgE-mediated hypersensitivity to penicillins could be treated with cephalosporins such as cefazolin and ceftibuten, which are among the cephalosporins that have side-chain determinants different from those of penicillins. Nevertheless, in patients with such hypersensitivity who need these alternative β-lactams, pretreatment skin tests are advisable because of the possibility of coexisting sensitivities or, much less frequently, of a sensitivity to an antigenic determinant of the common β-lactam ring.
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Affiliation(s)
- Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy & Fondazione Mediterranea G.B. Morgagni, Catania, Italy.
| | - Rocco Luigi Valluzzi
- Department of Pediatrics, Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Vatican City, Italy
| | - Cristiano Caruso
- Allergy Unit, Columbus Hospital, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | | | - Francesco Gaeta
- Allergy Unit, Columbus Hospital, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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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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Macy E. Addressing the epidemic of antibiotic "allergy" over-diagnosis. Ann Allergy Asthma Immunol 2019; 124:550-557. [PMID: 31881269 DOI: 10.1016/j.anai.2019.12.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/04/2019] [Accepted: 12/16/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE An epidemic of antibiotic allergy is occurring. DATA SOURCES Articles published since 2008. STUDY SELECTIONS Articles on antibiotic allergy and stewardship. RESULTS A number of overlapping factors contribute. The most important factor is antibiotic overuse. Antibiotics are commonly used in situations in which no antibiotics are indicated. Thirty percent to 50% of ambulatory antibiotic use may be inappropriate. The duration of indicated antibiotic use is often excessive, which leads to more side effects. All antibiotic use can result in adverse reactions, and a fraction of these will be dutifully recorded as an allergy in the electronic health record (EHR). Most EHRs are not well structured to accurately convey information on expected side effects that have occurred, metabolic or other contraindications, dose-related or situational toxicities, personal preferences, clinically significant immunologically mediated hypersensitivity, and other reasons a particular patient may not want or should not be given a specific drug or type of drug in the future. As populations age, their accumulated baggage of reported antibiotic allergies increase. Suspected antibiotic allergy is rarely confirmed with appropriate testing or rechallenge. Patients then receive suboptimal antibiotic therapy and experience more side effects, treatment failures, and serious antibiotic-resistant infections. Reporting an antibiotic allergy in the EHR is nominally done to improve patient safety, but unfortunately, this is often not the actual result. CONCLUSION Audit and feedback, to help ensure adherence to Choosing Wisely recommendations and good antibiotic stewardship practices, can help reduce inappropriate antibiotic use. Restructuring EHRs to facilitate correct drug intolerance reporting, along with active antibiotic allergy delabeling programs, can help stem this epidemic.
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Affiliation(s)
- Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, California.
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Perioperative Management of the Penicillin-Allergic Patient. J Perianesth Nurs 2019; 34:1284-1288. [PMID: 31611035 DOI: 10.1016/j.jopan.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 08/09/2019] [Indexed: 11/24/2022]
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Chaudhry SB, Veve MP, Wagner JL. Cephalosporins: A Focus on Side Chains and β-Lactam Cross-Reactivity. PHARMACY 2019; 7:E103. [PMID: 31362351 PMCID: PMC6789778 DOI: 10.3390/pharmacy7030103] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/24/2019] [Accepted: 07/26/2019] [Indexed: 12/13/2022] Open
Abstract
Cephalosporins are among the most commonly prescribed antibiotic classes due to their wide clinical utility and general tolerability, with approximately 1-3% of the population reporting a cephalosporin allergy. However, clinicians may avoid the use of cephalosporins in patients with reported penicillin allergies despite the low potential for cross-reactivity. The misdiagnosis of β-lactam allergies and misunderstanding of cross-reactivity among β-lactams, including within the cephalosporin class, often leads to use of broader spectrum antibiotics with poor safety and efficacy profiles and represents a serious obstacle for antimicrobial stewardship. Risk factors for cephalosporin allergies are broad and include female sex, advanced age, and a history of another antibiotic or penicillin allergy; however, cephalosporins are readily tolerated even among individuals with true immediate-type allergies to penicillins. Cephalosporin cross-reactivity potential is related to the structural R1 side chain, and clinicians should be cognizant of R1 side chain similarities when prescribing alternate β-lactams in allergic individuals or when new cephalosporins are brought to market. Clinicians should consider the low likelihood of true cephalosporin allergy when clinically indicated. The purpose of this review is to provide an overview of the role of cephalosporins in clinical practice, and to highlight the incidence of, risk factors for, and cross-reactivity of cephalosporins with other antibiotics.
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Affiliation(s)
- Saira B Chaudhry
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ 08854, USA
- Department of Infectious Diseases, Jersey Shore University Medical Center, Neptune, NJ 07753, USA
| | - Michael P Veve
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Knoxville, TN 37920, USA.
| | - Jamie L Wagner
- Department of Pharmacy Practice, School of Pharmacy, University of Mississippi, Jackson, MS 39216, USA
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Blanca-Lopez N, Jimenez-Rodriguez TW, Somoza ML, Gomez E, Al-Ahmad M, Perez-Sala D, Blanca M. Allergic reactions to penicillins and cephalosporins: diagnosis, assessment of cross-reactivity and management. Expert Rev Clin Immunol 2019; 15:707-721. [DOI: 10.1080/1744666x.2019.1619548] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - Maria L. Somoza
- Allergy Service, Infanta Leonor University Hospital, Madrid, Spain
| | - Enrique Gomez
- Roche Innovation Center Basel, F Hoffmann-La Roche AG, Basel, Switzerland
| | - Mona Al-Ahmad
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Dolores Perez-Sala
- Department of Structural and Chemical Biology, Centro de Investigaciones Biológicas, C.S.I.C, Madrid, Spain
| | - Miguel Blanca
- Allergy Service, Infanta Leonor University Hospital, Madrid, Spain
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Vyles D, Macy E. Self-reported beta-lactam intolerance: not a class effect, dangerous to patients, and rarely allergy. Expert Rev Anti Infect Ther 2019; 17:429-435. [PMID: 31067139 DOI: 10.1080/14787210.2019.1617132] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: About 8% of the United States population carries an unconfirmed penicillin 'allergy' in their medical record. Many physicians needlessly avoid other beta-lactam use in individuals with unconfirmed penicillin allergies. There is a significantly increased risk of developing serious antibiotic-resistant infections, and increased morbidity and mortality in those who report penicillin allergy. Areas covered: Within this study, we reviewed the relevant literature on self-reported beta-lactam allergy. We discuss how the myth of serious allergy to penicillin developed and then discuss and in detail clinically significant immunologically mediated hypersensitivity reactions. Following this discussion, we delineate the risks of not using a beta-lactam when it is the drug of choice and then discuss the epidemiology of beta-lactam-associated anaphylaxis, serious cutaneous adverse reactions, and serious systemic immunologically mediated reactions. Following these topics, we further discuss the consensus current best practices to de-label patients with reported penicillin allergy. Expert opinion: An unconfirmed allergy to penicillin offers considerable harm to patients. Many patients have low-risk allergy symptoms to penicillin who could likely tolerate the medication without having an allergic reaction. The current best practices to de-label reported penicillin allergy is the utilization of a single dose oral challenge, with 1 h of observation, in low-risk patients.
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Affiliation(s)
- David Vyles
- a Pediatric Emergency Medicine , Medical College of Wisconsin , Milwaukee , WI , USA
| | - Eric Macy
- b Department of Allergy , Southern California Permanente Medical Group, San Diego Medical Center , San Diego , CA , USA
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Outcomes from an inpatient beta-lactam allergy guideline across a large US health system. Infect Control Hosp Epidemiol 2019; 40:528-535. [PMID: 30915929 PMCID: PMC6536839 DOI: 10.1017/ice.2019.50] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: To assess the safety of, and subsequent allergy documentation associated with, an antimicrobial stewardship intervention consisting of test-dose challenge procedures prompted by an electronic guideline for hospitalized patients with reported β-lactam allergies. Design: Retrospective cohort study. Setting: Large healthcare system consisting of 2 academic and 3 community acute-care hospitals between April 2016 and December 2017. Methods: We evaluated β-lactam antibiotic test-dose outcomes, including adverse drug reactions (ADRs), hypersensitivity reactions (HSRs), and electronic health record (EHR) allergy record updates. HSR predictors were examined using a multivariable logistic regression model. Modification of the EHR allergy record after test doses considered relevant allergy entries added, deleted, and/or specified. Results: We identified 1,046 test-doses: 809 (77%) to cephalosporins, 148 (14%) to penicillins, and 89 (9%) to carbapenems. Overall, 78 patients (7.5%; 95% confidence interval [CI], 5.9%–9.2%) had signs or symptoms of an ADR, and 40 (3.8%; 95% CI, 2.8%–5.2%) had confirmed HSRs. Most HSRs occurred at the second (ie, full-dose) step (68%) and required no treatment beyond drug discontinuation (58%); 3 HSR patients were treated with intramuscular epinephrine. Reported cephalosporin allergy history was associated with an increased odds of HSR (odds ratio [OR], 2.96; 95% CI, 1.34–6.58). Allergies were updated for 474 patients (45%), with records specified (82%), deleted (16%), and added (8%). Conclusion: This antimicrobial stewardship intervention using β-lactam test-dose procedures was safe. Overall, 3.8% of patients with β-lactam allergy histories had an HSR; cephalosporin allergy histories conferred a 3-fold increased risk. Encouraging EHR documentation might improve this safe, effective, and practical acute-care antibiotic stewardship tool.
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Savic LC, Khan DA, Kopac P, Clarke RC, Cooke PJ, Dewachter P, Ebo DG, Garcez T, Garvey LH, Guttormsen AB, Hopkins PM, Hepner DL, Kolawole H, Krøigaard M, Laguna JJ, Marshall SD, Mertes PM, Platt PR, Rose MA, Sabato V, Sadleir PHM, Savic S, Takazawa T, Voltolini S, Volcheck GW. Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations. Br J Anaesth 2019; 123:e82-e94. [PMID: 30916014 DOI: 10.1016/j.bja.2019.01.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/21/2018] [Accepted: 01/09/2019] [Indexed: 11/30/2022] Open
Abstract
Unsubstantiated penicillin-allergy labels are common in surgical patients, and can lead to significant harm through avoidance of best first-line prophylaxis of surgical site infections and increased infection with resistant bacterial strains. Up to 98% of penicillin-allergy labels are incorrect when tested. Because of the scarcity of trained allergists in all healthcare systems, only a minority of surgical patients have the opportunity to undergo testing and de-labelling before surgery. Testing pathways can be modified and shortened in selected patients. A variety of healthcare professionals can, with appropriate training and in collaboration with allergists, provide testing for selected patients. We review how patients might be assessed, the appropriate testing strategies that can be used, and the minimum standards of safe testing.
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Affiliation(s)
- L C Savic
- Anaesthetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - D A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - P Kopac
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - R C Clarke
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Nedlands, Western Australia, Australia
| | - P J Cooke
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - P Dewachter
- Service d'Anesthésie-Réanimation, Groupe Hospitalier de Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris 13, Sorbonne-Paris-Cité, Paris, France
| | - D G Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - T Garcez
- Department of Immunology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - L H Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - A B Guttormsen
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - P M Hopkins
- Anaesthetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - D L Hepner
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA, USA
| | - H Kolawole
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia; Department of Anaesthesia, Peninsula Health, Melbourne, Australia
| | - M Krøigaard
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital, Gentofte, Denmark
| | - J J Laguna
- Allergy Unit, Allergo-Anaesthesia Unit, Hospital Central de la Cruz Roja, Faculty of Medicine, Alfonso X El Sabio University, ARADyAL, Madrid, Spain
| | - S D Marshall
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia; Department of Anaesthesia, Peninsula Health, Melbourne, Australia
| | - P M Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France
| | - P R Platt
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Nedlands, Western Australia, Australia
| | - M A Rose
- Department of Anaesthesia, Royal North Shore Hospital, and University of Sydney, Sydney, NSW, Australia
| | - V Sabato
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - P H M Sadleir
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Nedlands, Western Australia, Australia; Department of Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - S Savic
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - T Takazawa
- Intensive Care Unit, Gunma University Hospital, Maebashi, Gunma, Japan
| | - S Voltolini
- Allergy Unit, Policlinic Hospital San Martino, Genoa, Italy
| | - G W Volcheck
- Division of Allergic Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
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Calamelli E, Caffarelli C, Franceschini F, Saretta F, Cardinale F, Bernardini R, Liotti L, Mori F, Crisafulli G, Caimmi S, Bottau P. A practical management of children with antibiotic allergy. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:11-19. [PMID: 30830057 PMCID: PMC6502179 DOI: 10.23750/abm.v90i3-s.8157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/01/2019] [Indexed: 12/12/2022]
Abstract
About 10% of the parents reported that their children are allergic to one drug and the betalactam antibiotics are the most frequently suspected. Even if most of the adverse events following antibiotic prescriptions to children are considered allergic, after a full allergy work-up only a few of the suspected reactions are confirmed. For this reason, many children are incorrectly labelled as "allergic" and this represents an important challenge for the choice of the antibiotic therapy in these "labelled" children, who are frequently improperly deprived of narrow-spectrum antibiotics because considered as allergic. When an allergic reaction is suspected a precise diagnosis and a choice of a safe and effective alternative is essential for the future antibiotic option. In the light of this, the main aim of this paper is to try to provide a practical approach to managing the individuals who have reported adverse reactions to antibiotics.
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Abstract
IMPORTANCE β-Lactam antibiotics are among the safest and most effective antibiotics. Many patients report allergies to these drugs that limit their use, resulting in the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance and adverse events. OBSERVATIONS Approximately 10% of the US population has reported allergies to the β-lactam agent penicillin, with higher rates reported by older and hospitalized patients. Although many patients report that they are allergic to penicillin, clinically significant IgE-mediated or T lymphocyte-mediated penicillin hypersensitivity is uncommon (<5%). Currently, the rate of IgE-mediated penicillin allergies is decreasing, potentially due to a decreased use of parenteral penicillins, and because severe anaphylactic reactions to oral amoxicillin are rare. IgE-mediated penicillin allergy wanes over time, with 80% of patients becoming tolerant after a decade. Cross-reactivity between penicillin and cephalosporin drugs occurs in about 2% of cases, less than the 8% reported previously. Some patients have a medical history that suggests they are at a low risk for developing an allergic reaction to penicillin. Low-risk histories include patients having isolated nonallergic symptoms, such as gastrointestinal symptoms, or patients solely with a family history of a penicillin allergy, symptoms of pruritus without rash, or remote (>10 years) unknown reactions without features suggestive of an IgE-mediated reaction. A moderate-risk history includes urticaria or other pruritic rashes and reactions with features of IgE-mediated reactions. A high-risk history includes patients who have had anaphylaxis, positive penicillin skin testing, recurrent penicillin reactions, or hypersensitivities to multiple β-lactam antibiotics. The goals of antimicrobial stewardship are undermined when reported allergy to penicillin leads to the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance, including increased risk of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Broad-spectrum antimicrobial agents also increase the risk of developing Clostridium difficile (also known as Clostridioides difficile) infection. Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories. Moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95% and approaches 100% when combined with amoxicillin challenge. Clinicians performing penicillin allergy evaluation need to identify what methods are supported by their available resources. CONCLUSIONS AND RELEVANCE Many patients report they are allergic to penicillin but few have clinically significant reactions. Evaluation of penicillin allergy before deciding not to use penicillin or other β-lactam antibiotics is an important tool for antimicrobial stewardship.
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Affiliation(s)
- Erica S Shenoy
- Harvard Medical School, Boston, Massachusetts
- Infection Control Unit, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
| | - Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center
| | - Theresa Rowe
- General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kimberly G Blumenthal
- Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston
- Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston
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Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Antibiotic allergy. Lancet 2019; 393:183-198. [PMID: 30558872 PMCID: PMC6563335 DOI: 10.1016/s0140-6736(18)32218-9] [Citation(s) in RCA: 324] [Impact Index Per Article: 64.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/25/2018] [Accepted: 09/04/2018] [Indexed: 02/07/2023]
Abstract
Antibiotics are the commonest cause of life-threatening immune-mediated drug reactions that are considered off-target, including anaphylaxis, and organ-specific and severe cutaneous adverse reactions. However, many antibiotic reactions documented as allergies were unknown or not remembered by the patient, cutaneous reactions unrelated to drug hypersensitivity, drug-infection interactions, or drug intolerances. Although such reactions pose negligible risk to patients, they currently represent a global threat to public health. Antibiotic allergy labels result in displacement of first-line therapies for antibiotic prophylaxis and treatment. A penicillin allergy label, in particular, is associated with increased use of broad-spectrum and non-β-lactam antibiotics, which results in increased adverse events and antibiotic resistance. Most patients labelled as allergic to penicillins are not allergic when appropriately stratified for risk, tested, and re-challenged. Given the public health importance of penicillin allergy, this Review provides a global update on antibiotic allergy epidemiology, classification, mechanisms, and management.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jonny G Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; The National Centre for Infections in Cancer, Peter McCallum Cancer Centre, Melbourne, VIC, Australia
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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50
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Controversies in Drug Allergy: Drug Allergy Pathways. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:46-60.e4. [PMID: 30573422 DOI: 10.1016/j.jaip.2018.07.037] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 12/16/2022]
Abstract
Drug allergy pathways are standardized approaches for patients reporting prior drug allergies with the aim of quality improvement and promotion of antibiotic stewardship. At the International Drug Allergy Symposium during the 2018 American Academy of Allergy, Asthma, and Immunology/World Allergy Organization Joint Congress in Orlando, Florida, drug allergy pathways were discussed from international perspectives with a focus on beta-lactam allergy pathways and pragmatic approaches for acute care hospitals. In this expert consensus document, we review current pathways, and detail important considerations in devising, implementing, and evaluating beta-lactam allergy pathways for hospitalized patients. We describe the key patient and institutional factors that must be considered in risk stratification, the central feature of pathway design. We detail shared obstacles to widespread beta-lactam allergy pathway implementation and identify potential solutions to address these challenges.
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