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Bodega-Azuara J, Belles Medall MD, Edo-Peñarrocha J, Puplá-Bartoll A, Ferrando Piqueres R, Torres-Górriz MC, Germán-Sánchez A, Enrique E. Beta-lactam allergy in patients: an antibiotic stewardship challenge. Eur J Hosp Pharm 2024; 31:307-313. [PMID: 36564160 PMCID: PMC11265552 DOI: 10.1136/ejhpharm-2022-003304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 12/12/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patients are commonly reported as being allergic to beta-lactam (BL) antibiotics. However, many patients with this reported allergy are able to receive BL treatments because they do not have true allergies. In many cases these are simply intolerances due to side effects reported as an allergy. Delabelling these patients leads to better clinical outcomes, optimal antibiotic usage, decreased bacterial resistance and reduced healthcare costs. Therefore, the aims of this study were to identify incorrectly labelled BL allergies in hospitalised patients and to assess antibiotic use in delabelled patients in order to establish a quality indicator to optimise antimicrobial treatments. METHODS A prospective study was conducted in which hospitalised patients treated with antimicrobial drugs and labelled as 'BL-allergic' were identified by clinical pharmacists. An allergist assessed whether patients were suitable candidates for a skin test or oral challenge. The Allergy Service removed 'BL-allergic' labels if negative results were obtained. Delabelled patients were followed up by clinical pharmacists to study the use of BL antibiotics as a result of the delabelling programme. RESULTS A total of 176 suspected allergic patients were identified and 91 (51.7%) were tested either by a skin test or oral challenge based on the patient indicators. Seven (16.4%) patients tested were allergic to BL antibiotics, 76 (83.5%) were totally delabelled and eight (0.1%) were partially delabelled. Thirty-two (38.1%) delabelled patients required antibiotic treatment in another inpatient or outpatient setting, of whom 27 (84.3%) patients with a new infectious episode received BL treatments while five (15.7%) continued to receive antimicrobial treatments without BL. CONCLUSION After the implementation of a protocol to detect incorrect BL allergy labels, 83.5% of the patients in this cohort were completely delabelled. This shows that there is a clear opportunity to optimise the use of antibiotics by delabelling 'BL-allergic' patients.
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Affiliation(s)
- Julia Bodega-Azuara
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | | | - Josep Edo-Peñarrocha
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | - Aarón Puplá-Bartoll
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | - Raul Ferrando Piqueres
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | | | - Adrián Germán-Sánchez
- Allergology, Hospital General Universitari de Castello, Castellon de la Plana, Spain
| | - Ernesto Enrique
- Allergology, Hospital General Universitari de Castello, Castellon de la Plana, Spain
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2
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Epstein-Rigbi N, Ziv S, Bulanenkova M, Bouganim R, Tal-Jasper R, Marchaim D. Beta-lactam antibiotics administration among adult inpatients with a beta-lactam allergy label: incidence, predictors, and outcomes. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e68. [PMID: 38698943 PMCID: PMC11062790 DOI: 10.1017/ash.2024.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/31/2024] [Accepted: 04/04/2024] [Indexed: 05/05/2024]
Abstract
Background A beta-lactam antibiotics (BLA) allergy label is common, resulting in disadvantageous outcomes due to the usage of second-line antimicrobial agents. Noncontrolled case-series analyses report low rates of hypersensitivity reactions, following intentional/non-intentional BLA challenges among labeled inpatients. The study aims were to explore predictors and outcomes associated with hypersensitivity reactions following BLA challenge among BLA-allergic labeled inpatients. Methods Retrospective cohort study (2019-2020) of adult (≥18 years) inpatients (Shamir Medical Center, Israel), labeled as allergic to ≥1 BLA, who received ≥1 dose/s of BLA during their stay. Independent predictors to develop allergic reactions and the independent associations of allergic reactions with clinical outcomes were queried by logistic and Cox regressions. Results Of 9,670 inpatients (14,088 hospitalizations), 3,570 (37%) were labeled as allergic to ≥1 BLA. Of those, 1,171 (33%) patients received ≥1 BLA. The majority were women (67%), and the mean age was 69.3 ± 19.4 years. Only 30 patients (2.6%) developed a reaction, all mild. Independent predictors to develop an allergic reaction were documented reactions in the past, atopic background, antihistamines administration prior to the BLA challenge, and high risk for cross-reactivity, based on the BLA side chains, between the labeled and the challenged agents. Reaction upon the BLA challenge was not independently associated with any worse outcome. Conclusions Despite the commonality of allergy labeling, and the commonality of BLA administration to labeled inpatients, hypersensitivity reactions were mild and rare. Interventional stewardship strategies for active BLA de-labeling among low-risk patients should be promoted, to improve patients' and institutional health and fiscal outcomes.
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Affiliation(s)
- Naama Epstein-Rigbi
- The Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (Assaf Harofeh) Medical Center, Beer Yaacov, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Sharon Ziv
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Marina Bulanenkova
- Department of Geriatrics, Shmuel Harofeh Medical Center, Beer Yaacov, Israel
| | - Ruth Bouganim
- Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Beer Yaacov, Israel
| | - Ruthy Tal-Jasper
- Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Beer Yaacov, Israel
| | - Dror Marchaim
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Beer Yaacov, Israel
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3
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Olans RN, Olans RD. Linking the Who, What, When, and Where of Inpatient Direct Oral Penicillin Challenge With the How of Durable Penicillin Allergy Delabeling. Clin Infect Dis 2024; 78:227. [PMID: 37585654 DOI: 10.1093/cid/ciad478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/11/2023] [Indexed: 08/18/2023] Open
Affiliation(s)
- Richard N Olans
- Tufts Medicine, Melrose-Wakefield Hospital, Melrose, Massachusetts, USA
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4
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Fransson S, Boel JB, Holm A, Kahlhofen N, Hjortlund J, Mosbech HF, Poulsen LK, Reventlow S, Garvey LH. Inconsistencies in penicillin allergy labels in hospital and primary care after allergy investigation. Clin Exp Allergy 2023; 53:969-973. [PMID: 37246612 DOI: 10.1111/cea.14347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Sara Fransson
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Jonas Bredtoft Boel
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Anne Holm
- Department of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Natasha Kahlhofen
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Janni Hjortlund
- Laegerne Hansen, Møller, Pelvig and Hjortlund, Valby, Denmark
| | - Holger F Mosbech
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Lars K Poulsen
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Susanne Reventlow
- Department of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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5
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Pinto T, Li J, Boyle T, Zaragoza R, Fernando SL. Follow-up of penicillin allergy labels 1 year after successful penicillin delabeling. Ann Allergy Asthma Immunol 2023; 130:80-83.e3. [PMID: 36116749 DOI: 10.1016/j.anai.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Penicillin allergy delabeling confers many benefits, including reduced patient morbidity and mortality and improved health economics. Reports suggest that both patients and clinicians often remain hesitant to take and prescribe penicillins, respectively, after penicillin delabeling. However, follow-up of an individual's penicillin allergy label and incorporation of this into relevant health care records after delabeling have not been well studied in the Australian population. OBJECTIVE To evaluate the status of penicillin allergy labels in the community 1 year after penicillin delabeling at a tertiary hospital in Australia. METHODS A cross-sectional study was performed using follow-up interviews with patients and community primary care providers after 1 year from the date of patients' penicillin delabeling at a tertiary hospital in New South Wales, Australia. The main outcome measures that were evaluated included patient willingness to accept penicillin for future infections, patient self-reported receipt of penicillin-based antibiotics after delabeling, accuracy of penicillin allergy labels in the records of the primary care provider, and prescription of penicillin-based antibiotics by the general practitioner. RESULTS A total of 86 patients were included in this study. The percentage of patients with a correct penicillin allergy status at 1-year follow-up was 94% in the hospital electronic medical record but only 37% in primary care records. At 1-year follow-up, 14% of delabeled patients continued to reject penicillin prescriptions. CONCLUSION Better strategies are required to increase patient confidence in receiving penicillins after penicillin delabeling and to ensure that penicillin allergy labels are translated into the medical records at the primary care level.
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Affiliation(s)
- Trisha Pinto
- Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, Australia; Sydney Medical School-Northern, The University of Sydney, Sydney, Australia
| | - Jamma Li
- Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, Australia; Sydney Medical School-Northern, The University of Sydney, Sydney, Australia; Immunology Laboratory, NSW Health Pathology-North, Royal North Shore Hospital, Sydney, Australia
| | - Therese Boyle
- Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, Australia; Sydney Medical School-Northern, The University of Sydney, Sydney, Australia; Immunology Laboratory, NSW Health Pathology-North, Royal North Shore Hospital, Sydney, Australia.
| | - Reina Zaragoza
- Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, Australia
| | - Suran L Fernando
- Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, Australia; Sydney Medical School-Northern, The University of Sydney, Sydney, Australia; Immunology Laboratory, NSW Health Pathology-North, Royal North Shore Hospital, Sydney, Australia
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6
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Atakul G, Köse SŞ, Atay O, Boyacıoglu OK, Al S, Asilsoy S, Uzuner N, Karaman O. Oral Challenge without Penicillin Skin Tests in Children with Suspected Beta-Lactam Hypersensitivity. JOURNAL OF CHILD SCIENCE 2022. [DOI: 10.1055/s-0042-1757151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Abstract
Objective A misdiagnosed “penicillin allergy” is a common problem in childhood. Recently, skipping skin tests (STs) and performing a direct oral challenge test (OCT) have become an increasingly common approach in children with suspected β-lactam (BL) allergy. In our study, we aimed to evaluate the safety and efficacy of OCT without using ST in children who had a history of hypersensitivity reactions with BL antibiotics.
Materials and Methods We retrospectively evaluated direct OCT outcomes in children with both nonimmediate and immediate-type reaction history with BL antibiotics. STs were not performed before the challenge test. The patients were monitored for 4 hours after the challenge and continued using the drug in two divided doses for 3 days at home.
Results In this study, 72 patients were included, with median age of 7 years (interquartile range: 4; min: 1 year to max: 16 years), and of these, 56% were male. Forty-five subjects (63%) reported immediate-type adverse reactions. The most common clinical manifestation was urticaria/angioedema (51%, n: 37) and maculopapular exanthema in 46% (n: 33) of patients, respectively. The most commonly suspected drug was 71% amoxicillin-clavulanate. A 3-day OCT without preceding ST was performed in all patients. Only three patients (4.2%) showed a positive response to the oral drug challenge test. None of these reactions observed was more severe than index reactions.
Conclusion Performing OCT without STs is a safe and convenient method to exclude BL hypersensitivity in the pediatric age group.
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Affiliation(s)
- Gizem Atakul
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Seda Şirin Köse
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Ozge Atay
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Ozge Kangallı Boyacıoglu
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Serdar Al
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Suna Asilsoy
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Nevin Uzuner
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Ozkan Karaman
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
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7
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Antibiotic Allergy De-Labeling: A Pathway against Antibiotic Resistance. Antibiotics (Basel) 2022; 11:antibiotics11081055. [PMID: 36009924 PMCID: PMC9404790 DOI: 10.3390/antibiotics11081055] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 12/10/2022] Open
Abstract
Antibiotics are one of the most frequently prescribed drugs. Unfortunately, they also are the most common cause for self-reported drug allergy, limiting the use of effective therapies. However, evidence shows that more than 90% of patients labeled as allergic to antibiotics are not allergic. Importantly, the label of antibiotic allergy, whether real or not, constitutes a major public health problem as it directly impacts antimicrobial stewardship: it has been associated with broad-spectrum antibiotic use, often resulting in the emergence of bacterial resistance. Therefore, an accurate diagnosis is crucial for de-labeling patients who claim to be allergic but are not really allergic. This review presents allergy methods for achieving successful antibiotic allergy de-labeling. Patient clinical history is often inaccurately reported, thus not being able to de-label most patients. In vitro testing offers a complementary approach but it shows limitations. Immunoassay for quantifying specific IgE is the most used one, although it gives low sensitivity and is limited to few betalactams. Basophil activation test is not validated and not available in all centers. Therefore, true de-labeling still relies on in vivo tests including drug provocation and/or skin tests, which are not risk-exempt and require specialized healthcare professionals for results interpretation and patient management. Moreover, differences on the pattern of antibiotic consumption cause differences in the diagnostic approach among different countries. A multidisciplinary approach is recommended to reduce the risks associated with the reported penicillin allergy label.
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8
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De-labeling Beta-lactam in Adult Population. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00316-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Bassir F, Varghese S, Wang L, Chin YP, Zhou L. The Use of Electronic Health Records to Study Drug-Induced Hypersensitivity Reactions from 2000 to 2021: A Systematic Review. Immunol Allergy Clin North Am 2022; 42:453-497. [PMID: 35469629 PMCID: PMC9267416 DOI: 10.1016/j.iac.2022.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Electronic health records (EHRs) have revolutionized the field of drug hypersensitivity reaction (DHR) research. In this systematic review, we assessed 140 articles from 2000-2021, classifying them under six themes: observational studies (n=61), clinical documentation (n=27), case management (n=22), clinical decision support (CDS) (n=18), case identification (n=9), and genetic studies (n=3). EHRs provide convenient access to millions of medical records, facilitating epidemiological studies of DHRs. Though the goal of CDS is to promote safe drug prescribing, allergy alerts must be designed and used in a way that supports this effort. Ultimately, accurate allergy documentation is essential for DHR prevention.
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Affiliation(s)
- Fatima Bassir
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, 399 Revolution Drive, Suite 1315, Somerville, MA 02145, USA; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 399 Revolution Drive, Suite 1315, Somerville, MA 02145, USA.
| | - Sheril Varghese
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, 399 Revolution Drive, Suite 1315, Somerville, MA 02145, USA
| | - Liqin Wang
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 399 Revolution Drive, Suite 1315, Somerville, MA 02145, USA
| | - Yen Po Chin
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 399 Revolution Drive, Suite 1315, Somerville, MA 02145, USA
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 399 Revolution Drive, Suite 1315, Somerville, MA 02145, USA
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10
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Anstey KM, Tsao L, Otani IM. Drug Allergy Delabeling Programs: Recent Strategies and Targeted Populations. Clin Rev Allergy Immunol 2022; 62:484-504. [PMID: 35031956 DOI: 10.1007/s12016-021-08913-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 12/12/2022]
Abstract
Drug allergy delabeling programs have become an essential element of antibiotic stewardship. Development of delabeling programs involves careful selection of target patient population, thoughtful design of delabeling approach, stakeholder engagement, assembly of key team members, implementation, and evaluation of clinical and safety outcomes. Recent programs have targeted patients thought to be most likely to benefit from removal of inaccurate antibiotic allergy labels, those with β-lactam antibiotic allergies and high-risk populations likely to need β-lactam antibiotics as first-line treatment. This review provides an overview of current risk stratification methods and β-lactam cross-reactivity data and summarizes how different inpatient and outpatient delabeling programs have used these concepts in delabeling algorithms. β-Lactam delabeling programs for inpatients, pediatric patients, and programs utilizing telehealth have been implemented with good outcomes. This review also focuses on delabeling programs for high-risk populations likely to benefit from first-line β-lactam antibiotics. These populations include perioperative, prenatal, and immunocompromised patients. Delabeling programs have been successful in the inpatient and outpatient settings at enabling appropriate antibiotic use. This article reviews delabeling strategies utilized by these programs with a focus on highlighting elements key to their success and future areas for innovation.
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Affiliation(s)
- Karen M Anstey
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code UHN67, Portland, OR, 97239, USA.
| | - Lulu Tsao
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
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11
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McDanel D, Hosch L, Pham KD, Schwery A, Seiler K, Dowden AM. Relabeling of penicillin drug allergy after evaluation in a drug allergy clinic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:346-348. [PMID: 34537400 DOI: 10.1016/j.jaip.2021.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 09/02/2021] [Accepted: 09/03/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Deanna McDanel
- Department of Pharmacy, University of Iowa Hospitals and Clinics, Iowa City, Iowa; Department of Pharmacy Practice and Science, Division of Applied Clinical Science, University of Iowa College of Pharmacy, Iowa City, Iowa.
| | - Lyvia Hosch
- University of Iowa College of Pharmacy, Iowa City, Iowa
| | - Kassi D Pham
- University of Iowa College of Pharmacy, Iowa City, Iowa
| | - Abbey Schwery
- University of Iowa College of Pharmacy, Iowa City, Iowa
| | - Karlie Seiler
- University of Iowa College of Pharmacy, Iowa City, Iowa
| | - Amy M Dowden
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; Department of Internal Medicine, Division of Immunology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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12
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Anstey KM, Choi L, Dawson D, Kleinhenz ME, Otani IM. Enabling antibiotic allergy evaluations and reintroduction of first-line antibiotics for patients with cystic fibrosis. Ann Allergy Asthma Immunol 2021; 127:456-461. [PMID: 34048884 DOI: 10.1016/j.anai.2021.05.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/29/2021] [Accepted: 05/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with cystic fibrosis (CF) often have a history of antibiotic adverse drug reactions (ADRs) that pose a barrier to receiving recommended first-line treatment. Targeted antibiotic allergy evaluations are increasingly recognized as an important strategy for optimization of antimicrobial stewardship. OBJECTIVE To improve first-line antibiotic use in patients with CF with antibiotic ADRs by streamlining access to antibiotic allergy evaluations and standardizing documentation of plans for antibiotic reintroduction. METHODS We incorporated allergy evaluations into a multidisciplinary CF clinic and used telemedicine when allergy evaluations could not be performed during CF clinic. Standard documentation of antibiotic allergy plans was used to enable safe reintroduction of first-line antibiotics by CF providers. RESULTS Strategies used in this study allowed 81.3% (26 of 32) of patients with CF to receive allergy evaluations and antibiotic allergy plans for prioritized antibiotics (penicillin, cephalosporin, sulfonamide), with removal of 41.0% (16 of 39) of prioritized antibiotic ADRs. Only 5.1% (2 of 39) of prioritized antibiotic ADRs evaluated required strict avoidance after evaluation. There were 9 patients who received at least 1 prioritized antibiotic, with 66.6% (6 of 9) of these patients given the antibiotic after only 1 allergy evaluation visit. Furthermore, these strategies allowed allergy evaluations of 23 nonprioritized antibiotics to occur, with removal of the ADR in 39.1% (9 of 23) and use of 77.8% (7 of 9) of nonprioritized antibiotics after removal. CONCLUSION Incorporating allergy evaluations into a multidisciplinary CF clinic can liberalize first-line antibiotic use in patients with CF. Standard documentation of antibiotic allergy plans allowed antibiotic reintroduction to occur even before complete removal of documented antibiotic ADRs.
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Affiliation(s)
- Karen M Anstey
- Section of Allergy and Clinical Immunology, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, School of Medicine, Portland, Oregon; Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California.
| | - Lei Choi
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Diana Dawson
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Mary Ellen Kleinhenz
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California
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13
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Wangberg H, Namazy J. Predicting Who Will Stop Medications During Pregnancy: A Complex Issue. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1253-1254. [PMID: 33685608 DOI: 10.1016/j.jaip.2020.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Hannah Wangberg
- Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, Calif.
| | - Jennifer Namazy
- Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, Calif
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14
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Sousa-Pinto B, Blumenthal KG, Macy E, Pereira AM, Azevedo LF, Delgado L, Fonseca JA. Penicillin Allergy Testing Is Cost-Saving: An Economic Evaluation Study. Clin Infect Dis 2021; 72:924-938. [PMID: 32107530 DOI: 10.1093/cid/ciaa194] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Having a penicillin allergy label is associated with the use of less appropriate and more expensive antibiotics and increased healthcare utilization. Penicillin allergy testing results in delabeling most allergy claimants and may be cost-saving. This study aimed to project whether penicillin allergy testing in patients reporting a penicillin allergy is cost-saving. METHODS In this economic evaluation study, we built decision models to project the economic impact of 2 strategies for a patient with a penicillin allergy label: (1) perform diagnostic testing (drug challenges, with or without skin tests); and (2) do not perform diagnostic testing. The health service perspective was adopted, considering costs with penicillin allergy tests, and with hospital bed-days/outpatient visits, antibiotic use, and diagnostic testing. Twenty-four base case decision models were built, accounting for differences in the diagnostic workup, setting (inpatient vs outpatient) and geographic region. Uncertainty was explored via probabilistic sensitivity analyses. RESULTS Penicillin allergy testing was cost-saving in all decision models built. For models assessing the performance of both skin tests and drug challenges, allergy testing resulted in average savings (in United States [US] dollars) of $657 for inpatients (US: $1444; Europe: $489) and $2746 for outpatients (US: $256; Europe: $6045). 75% of simulations obtained through probabilistic sensitivity analysis identified testing as the less costly option. CONCLUSIONS Penicillin allergy testing was projected to be cost-saving across different scenarios. These results are devised to inform guidelines, supporting the adoption of policies promoting widespread testing of patients with a penicillin allergy label.
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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, Porto, Portugal.,Basic and Clinical Immunology Unit, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, California, USA
| | - Ana Margarida Pereira
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
| | - Luís Filipe Azevedo
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
| | - Luís Delgado
- Center for Health Technology and Services Research, Porto, Portugal.,Basic and Clinical Immunology Unit, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Almeida Fonseca
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
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15
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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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16
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Ben Fadhel N, Aroua F, Chadli Z, Ben Romdhane H, Chaabane A, Sahtout M, Boughattas NA, Ben Fredj N, Aouam K. Betalactam hypersensitivity: The importance of delabelling in primary care. Br J Clin Pharmacol 2021; 87:4619-4624. [PMID: 33899257 DOI: 10.1111/bcp.14879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/05/2021] [Accepted: 04/14/2021] [Indexed: 12/23/2022] Open
Abstract
PATIENTS AND METHODS An allergy work-up was performed on adult patients with a history of a penicillin allergy seen by primary medical care in Monastir (Tunisia) between July 2016 and February 2018. Patients with negative skin tests were challenged with amoxicillin. Patients who were delabelled were contacted by phone after 6 months to determine outcomes after any therapeutic penicillin-class antibiotic intake. RESULTS A total of 39 patients were evaluated and 33 (84.6%) were delabelled. Five patients were penicillin skin-test positive and one was oral challenge positive. We succeeded in contacting 33 delabelled patients at 6 months. Twenty-two patients tolerated a subsequent therapeutic course of amoxicillin, eight patients did not retake penicillin due to a lack of therapeutic indication, and three patients refused an indicated penicillin use fearful of another reaction. CONCLUSION This study highlights the importance of allergy work-up in the diagnosis of beta-lactam hypersensitivity. Most patients were excessively labelled as beta-lactam allergic and this mislabelling could increase healthcare costs and lead to the development of drug resistance by the use of wide-spectrum antibiotics.
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Affiliation(s)
- Najah Ben Fadhel
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Fares Aroua
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Zohra Chadli
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Haifa Ben Romdhane
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Amel Chaabane
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | | | - Naceur A Boughattas
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Nadia Ben Fredj
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Karim Aouam
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
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17
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Drug Allergy Labels Lost in Translation: From Patient to Charts and Backwards. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3015-3020. [PMID: 33607342 DOI: 10.1016/j.jaip.2021.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 12/12/2022]
Abstract
The current method of defining, reporting, assessment, labeling, delabeling, and reconciliation of adverse drug reactions (ADRs), and specifically immunologically mediated drug hypersensitivity reactions (HSRs), in electronic health records (EHRs) is inadequate and compromises care quality and safety. It is critical to accurately and succinctly report the signs and symptoms associated with ADRs and suspected HSRs to enable clinicians to determine the plausible reaction type and help guide appropriate future management plans. Despite the current limitations of the EHR allergy module, we must encourage improved clinical documentation and demand technological improvements. Telehealth methods have been shown to be valuable in the assessment of ADRs and HSRs, particularly in the case of penicillin allergy evaluation and delabeling. The implementation, assessment, and refinement of advanced technologies, including clinical informatics and artificial intelligence, along with continued education of health care providers have potential to improve EHR documentation and communication, thereby advancing patient safety efforts.
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18
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Lutfeali S, DiLoreto FF, Alvarez KS, Patel SV, Joshi SR, Tarver SA, Khan DA. Maintaining penicillin allergy delabeling: A quality improvement initiative. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2104-2106.e2. [PMID: 33482418 DOI: 10.1016/j.jaip.2021.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/30/2022]
Affiliation(s)
- Shazia Lutfeali
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Felicia F DiLoreto
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas
| | - Kristin S Alvarez
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas; Division of Hospital Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Shyam R Joshi
- Division of Allergy and Immunology, Department of Internal Medicine, Oregon Health and Science University, Portland, Ore
| | - Scott A Tarver
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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19
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Hills T, Arroll N, Duffy E, Capstick J, Jordan A, Fitzharris P. Penicillin Allergy De-labeling Results in Significant Changes in Outpatient Antibiotic Prescribing Patterns. FRONTIERS IN ALLERGY 2020; 1:586301. [PMID: 35386932 PMCID: PMC8974713 DOI: 10.3389/falgy.2020.586301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/14/2020] [Indexed: 11/13/2022] Open
Abstract
Unverified penicillin allergies are common but most patients with a penicillin allergy label can safely use penicillin antibiotics. Penicillin allergy labels are associated with poor clinical outcomes and overuse of second-line antibiotics. There is increasing focus on penicillin allergy "de-labeling" as a tool to improve antibiotic prescribing and antimicrobial stewardship. The effect of outpatient penicillin allergy de-labeling on long-term antibiotic use is uncertain. We performed a retrospective pre- and post- study of antibiotic dispensing patterns, from an electronic dispensing data repository, in patients undergoing penicillin allergy assessment at Auckland City Hospital, New Zealand. Over a mean follow-up of 4.55 years, 215/304 (70.7%) of de-labeled patients were dispensed a penicillin antibiotic. Rates of penicillin antibiotic dispensing were 0.24 (0.18-0.30) penicillin courses per year before de-labeling and 0.80 (0.67-0.93) following de-labeling with a reduction in total antibiotic use from 2.30 (2.06-2.54) to 1.79 (1.59-1.99) antibiotic courses per year. In de-labeled patients, the proportion of antibiotic courses that were penicillin antibiotics increased from 12.81 to 39.62%. Rates of macrolide, cephalosporin, trimethoprim/co-trimoxazole, fluoroquinolone, "other" non-penicillin antibiotic use, and broad-spectrum antibiotic use were all lower following de-labeling. Further, antibiotic costs were lower following de-labeling. In this study, penicillin allergy de-labeling was associated with significant changes in antibiotic dispensing patterns.
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Affiliation(s)
- Thomas Hills
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Nicola Arroll
- Health Information and Technology Service, Auckland District Health Board, Auckland, New Zealand
| | - Eamon Duffy
- Depatment of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand
| | - Janice Capstick
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
| | - Anthony Jordan
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
| | - Penny Fitzharris
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
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20
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Kuder MM, Lennox MG, Li M, Lang DM, Pien L. Skin testing and oral amoxicillin challenge in the outpatient allergy and clinical immunology clinic in pregnant women with penicillin allergy. Ann Allergy Asthma Immunol 2020; 125:646-651. [PMID: 32798617 DOI: 10.1016/j.anai.2020.08.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/30/2020] [Accepted: 08/07/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Penicillin allergy is frequently reported. In pregnant women, reported penicillin allergy is associated with negative health outcomes and suboptimal group B streptococcal prophylaxis. For individuals having penicillin allergy, skin testing followed by an observed oral challenge is recommended. Previous data indicate a low risk of adverse reaction with skin testing in pregnant women, but the subsequent oral challenge was not routinely pursued. OBJECTIVE To determine whether skin testing followed by the outpatient oral challenge is tolerated by pregnant women. METHODS We conducted a retrospective review of all pregnant women who underwent penicillin allergy evaluation at an outpatient allergy and clinical immunology clinic. The patients underwent oral amoxicillin challenges based on the discretion of the allergy provider. We evaluated the index reaction history, skin test results, oral challenge results, and subsequent antibiotic exposure. RESULTS A total of 46 pregnant women underwent skin testing without adverse reactions, of whom 44 patients (95.6%) received negative results. A total of 18 women (39%) completed an oral challenge without adverse reactions. Patients challenged vs not challenged did not differ in patient age, gestational age, latency since index reaction, or reaction history risk level. Notably, 28 women received intrapartum antibiotics. There was no difference in intrapartum antibiotic administration between those who did or who did not complete an in-office oral challenge (P = .90). CONCLUSION Penicillin skin testing and oral challenge in pregnant women can safely be performed in the outpatient setting. There was no difference in the intrapartum antibiotic use between women who were and those who were not challenged. Further research is needed to determine the utility of oral challenge in pregnant patients.
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Affiliation(s)
- Margaret M Kuder
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Maria G Lennox
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Manshi Li
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lily Pien
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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21
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Norris MR, Bielory L. Impact of merging electronic medical records on penicillin allergy relabeling. Ann Allergy Asthma Immunol 2020; 125:713-714. [PMID: 32781241 DOI: 10.1016/j.anai.2020.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/27/2020] [Accepted: 08/03/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Matthew R Norris
- Department of Medicine, Overlook Medical Center, Summit, New Jersey.
| | - Leonard Bielory
- Department of Medicine and Ophthalmology, Hackensack Meridian School of Medicine, Seton Hall University, Nutley, New Jersey; Center for Environmental Prediction, Department of Environmental Sciences, School of Environmental and Biological Sciences, Rutgers University, New Brunswick, New Jersey; Department of Medicine, Sidney Kimmel Medical College Thomas Jefferson University, Philadelphia, Pennsylvania
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22
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Patient perspectives on antibiotic allergy delabeling: Enablers and barriers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3637-3639.e5. [PMID: 32712200 DOI: 10.1016/j.jaip.2020.07.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/25/2020] [Accepted: 07/10/2020] [Indexed: 11/22/2022]
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23
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Romano A, Atanaskovic‐Markovic M, Barbaud A, Bircher AJ, Brockow K, Caubet J, Celik G, Cernadas J, Chiriac A, Demoly P, Garvey LH, Mayorga C, Nakonechna A, Whitaker P, Torres MJ. Towards a more precise diagnosis of hypersensitivity to beta-lactams - an EAACI position paper. Allergy 2020; 75:1300-1315. [PMID: 31749148 DOI: 10.1111/all.14122] [Citation(s) in RCA: 177] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/08/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023]
Abstract
A recent survey of the European Academy of Allergy and Clinical Immunology (EAACI) Drug Allergy Interest Group (DAIG) on how European allergy specialists deal with beta-lactam (BL) hypersensitivity demonstrated a significant heterogeneity in current practice, suggesting the need to review and update existing EAACI guidelines in order to make the diagnostic procedures as safe and accurate, but also as cost-effective, as possible. For this purpose, a bibliographic search on large studies regarding BL hypersensitivity diagnosis was performed by an EAACI task force, which reviewed and evaluated the literature data using the GRADE system for quality of evidence and strength of recommendation. The updated guidelines provide a risk stratification in BL hypersensitivity according to index reaction(s), as well as an algorithmic approach, based on cross-reactivity studies, in patients with a suspicion of BL hypersensitivity and an immediate need for antibiotic therapy, when referral to an allergist is not feasible. Furthermore, the update addresses availability and concentrations of skin test (ST) reagents, ST and drug provocation test (DPT) protocols, and diagnostic algorithms and administration of alternative BL in allergic subjects. Specifically, distinct diagnostic algorithms are suggested depending on risk stratification of the patient into high and low risk based on the morphology and chronology of the reaction, immediate (ie, occurring within 1-6 hours after the last administered dose) or nonimmediate (ie, occurring more than 1 hour after the initial drug administration), and the reaction severity. Regarding the allergy workup, the main novelty of this document is the fact that in some low-risk nonimmediate reactions ST are not mandatory, especially in children. For DPT, further studies are necessary to provide data supporting the standardization of protocols, especially of those regarding nonimmediate reactions, for which there is currently no consensus.
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Affiliation(s)
- Antonino Romano
- Casa di Cura Quisisana Rome & Fondazione Mediterranea G.B. Catania Italy
| | | | - Annick Barbaud
- Departement of Dermatology and Allergology Institut Pierre Louis d'Epidemiologie et de Sante Publique INSERM Tenon Hospital Sorbonne Université Paris France
| | | | - Knut Brockow
- Department of Dermatology and Allergy Biederstein Technische Universität München Munich Germany
| | | | - Gulfem Celik
- Department of Immunology and Allergy Ankara University School of Medicine Ankara Turkey
| | - Josefina Cernadas
- Department of Allergy and Immunology Centro Hospitalar Universitário de S João Porto Portugal
| | - Anca‐Mirela Chiriac
- Division of Allergy Department of Pulmonology Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- UMRS 1136 Equipe ‐ EPAR ‐ IPLESP UPMC Univ Sorbonne Universités Paris France
| | - Pascal Demoly
- Division of Allergy Department of Pulmonology Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- UMRS 1136 Equipe ‐ EPAR ‐ IPLESP UPMC Univ Sorbonne Universités Paris France
| | - Lene H. Garvey
- Allergy Clinic Department of Dermatology and Allergy Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga-IBIMA Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga-UMA-ARADyAL Malaga Spain
| | - Alla Nakonechna
- Clinical Immunology and Allergy Unit Sheffield Teaching Hospital Sheffield UK
- University of Liverpool Liverpool UK
| | - Paul Whitaker
- Regional Adult Cystic Fibrosis Unit St James's Hospital Leeds UK
| | - María José Torres
- Allergy Unit Hospital Regional Universitario de Málaga-UMA-ARADyAL Malaga Spain
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24
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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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Schatz M, Sicherer SH, Khan DA, Zeiger RS. The Journal of Allergy and Clinical Immunology: In Practice 2019 Highlights. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:912-936. [PMID: 31980411 DOI: 10.1016/j.jaip.2020.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
This article provides highlights of the clinically impactful original studies and reviews published in The Journal of Allergy and Clinical Immunology: In Practice in 2019 on the subjects of anaphylaxis, asthma, dermatitis, drug allergy, food allergy, immunodeficiency, immunotherapy, rhinitis/sinusitis, and urticaria/angioedema/mast cell disorders. Within each topic, practical aspects of diagnosis and management are emphasized. Treatments discussed include lifestyle modifications, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We designed this review to help readers consolidate and use this extensive and practical knowledge for the benefit of their patients.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif.
| | - Scott H Sicherer
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
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26
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Kufel WD, Justo JA, Bookstaver PB, Avery LM. Penicillin Allergy Assessment and Skin Testing in the Outpatient Setting. PHARMACY 2019; 7:pharmacy7030136. [PMID: 31546887 PMCID: PMC6789533 DOI: 10.3390/pharmacy7030136] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/05/2019] [Accepted: 09/12/2019] [Indexed: 01/09/2023] Open
Abstract
Penicillin allergies are among of the most commonly reported allergies, yet only 10% of these patients are truly allergic. This leads to potential inadvertent negative consequences for patients and makes treatment decisions challenging for clinicians. Thus, allergy assessment and penicillin skin testing (PST) are important management strategies to reconcile and clarify labeled penicillin allergies. While PST is more common in the inpatient setting where the results will immediately impact antibiotic management, this process is becoming of increasing importance in the outpatient setting. PST in the outpatient setting allows clinicians to proactively de-label and educate patients accordingly so beta-lactam antibiotics may be appropriately prescribed when necessary for future infections. While allergists have primarily been responsible for PST in the outpatient setting, there is an increasing role for pharmacist involvement in the process. This review highlights the importance of penicillin allergy assessments, considerations for PST in the outpatient setting, education and advocacy for patients and clinicians, and the pharmacist’s role in outpatient PST.
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Affiliation(s)
- Wesley D Kufel
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY 13902, USA.
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY 13210, USA.
- Department of Pharmacy, State University of New York Upstate University Hospital, Syracuse, NY 13210, USA.
| | - Julie Ann Justo
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia, SC 29208, USA.
- Department of Pharmacy, Prisma Health Richland Hospital, Columbia, SC 29203, USA.
| | - P Brandon Bookstaver
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia, SC 29208, USA.
- Department of Pharmacy, Prisma Health Richland Hospital, Columbia, SC 29203, USA.
| | - Lisa M Avery
- Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY 14618, USA.
- Department of Pharmacy, St. Josephs Health, Syracuse, NY 13203, USA.
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28
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Stover KR, Barber KE, Wagner JL. Allergic Reactions and Cross-Reactivity Potential with Beta-Lactamase Inhibitors. PHARMACY 2019; 7:E77. [PMID: 31261671 PMCID: PMC6789713 DOI: 10.3390/pharmacy7030077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 12/15/2022] Open
Abstract
Although beta-lactam allergies are an emerging focus of stewardship programs and interventions, less is publicly released regarding allergies to beta-lactamase inhibitors. This review presents and evaluates the data regarding allergic reactions with beta-lactamase inhibitors. Clavulanate, sulbactam, and tazobactam are beta-lactam-based beta-lactamase inhibitors that are combined with several penicillins or cephalosporins in order to preserve antimicrobial activity in the presence of beta-lactamases. Avibactam, relebactam, and vaborbactam are non-beta-lactam beta-lactamase inhibitors that are combined with cephalosporins or carbapenems in order to expand the antimicrobial activity against broader-spectrum beta-lactamases. Case reports document hypersensitivity reactions to clavulanate, sulbactam, and tazobactam, but not to avibactam, relebactam, or vaborbactam. Based on these reports and considering the chemical structures, cross-allergenicity with beta-lactams is likely with sulbactam and tazobactam. Considering the slightly altered beta-lactam structure, cross-allergenicity is less likely with clavulanate, but still possible. It appears that cross-allergenicity between beta-lactam antimicrobials and the newer, non-beta-lactam beta-lactamase inhibitors is unlikely. It is important for clinicians to perform allergy testing to both the beta-lactam and the beta-lactamase inhibitor in order to confirm the specific allergy and reaction type.
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Affiliation(s)
- Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS 39216, USA.
| | - Katie E Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS 39216, USA
| | - Jamie L Wagner
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS 39216, USA
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29
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Affiliation(s)
- Erica S Shenoy
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts
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30
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Abstract
PURPOSE OF REVIEW An unconfirmed penicillin allergy is known to confer significant risk to patients. Only a small minority of patients labeled with penicillin allergy will be confirmed to be hypersensitive with the current reference standard test, an oral amoxicillin therapeutic dose challenge. Skin testing has been recommended prior to oral challenges to reduce the risk of severe acute challenge reactions. The rate of severe acute anaphylactic reactions with oral amoxicillin is currently extremely low. Unfortunately, penicillin skin testing, as commonly performed, has a high rate of false positive results. RECENT FINDINGS Encouraging skin testing in all individuals with an unconfirmed penicillin allergy, prior to a confirmatory oral challenge, would be technically difficult, make testing all individuals with an unconfirmed penicillin allergy very unlikely, and ultimately increase the risk to patients because of suboptimal antibiotic use. Most patients, who are appropriate candidates for a direct oral amoxicillin challenge, to confirm current penicillin tolerance, can be safely identified by their clinical histories. Higher risk individuals, those with a history of anaphylaxis or other acute onset potentially IgE-mediated reaction such as hives within 6 h of the first dose of the last course of a penicillin, may benefit from properly performed puncture and intradermal skin testing, using commercially available penicilloyl-polylysine, prior to an oral challenge, if skin test negative. Direct oral amoxicillin challenges in low-risk individuals are well accepted by patients and a safe and effective part of penicillin allergy delabeling.
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