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The impact of antibiotic allergy labels on antibiotic exposure, clinical outcomes, and healthcare costs: A systematic review. Infect Control Hosp Epidemiol 2020; 42:530-548. [PMID: 33059777 DOI: 10.1017/ice.2020.1229] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE A growing body of evidence suggests that antibiotic allergy labels as documented in medical records are a risk factor for poor clinical outcomes. In this systematic review, we aimed to determine how antibiotic allergy labels influence 3 domains: antibiotic use and exposure, clinical outcomes, and healthcare-related costs. DESIGN We performed a systematic review to identify studies reporting outcomes in patients with antibiotic allergy labels compared to nonallergic counterparts. The search included PubMed, EMBASE, Cochrane CENTRAL, EBSCO, Cochrane Database of Abstracts of Reviews of Effects and Web of Science. Two reviewers independently screened studies for inclusion and abstracted data. Studies were graded using the Newcastle-Ottawa quality assessment scale. Study outcomes included antibiotic use, clinical outcomes, and economic outcomes. RESULTS In total, 41 studies met our criteria for inclusion. These studies varied in medical specialty, patient population, healthcare delivery system, and design, but most were conducted among adults age >18 years (85%) in the inpatient setting (82.5%). Among 34 studies examining antibiotic exposure, 32 (94%) found that patients with antibiotic allergy labels received more broad-spectrum antibiotics. Moreover, 31 studies examined clinical outcomes such as length of hospitalization, ICU admission, hospital readmission, multidrug-resistant or opportunistic infection, or mortality, and 27 (87%) found that allergy-labeled patients had at least 1 negative outcome. Of 9 studies examining healthcare costs, 7 (78%) found that allergy-labeled patients incurred significantly higher drug or hospital-related costs. CONCLUSIONS Antibiotic allergy labels have negative effects on antibiotic use, clinical outcomes, and economic outcomes in a variety of clinical settings and populations.
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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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Trubiano JA, Grayson ML, Thursky KA, Phillips EJ, Slavin MA. How antibiotic allergy labels may be harming our most vulnerable patients. Med J Aust 2019; 208:469-470. [PMID: 29902399 DOI: 10.5694/mja17.00487] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/15/2017] [Indexed: 01/17/2023]
Affiliation(s)
| | | | - Karin A Thursky
- Peter MacCallum Cancer Centre and National Centre for Infections in Cancer, Melbourne, VIC
| | | | - Monica A Slavin
- Peter MacCallum Cancer Centre and National Centre for Infections in Cancer, Melbourne, VIC
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Wolfson AR, Huebner EM, Blumenthal KG. Acute care beta-lactam allergy pathways: approaches and outcomes. Ann Allergy Asthma Immunol 2019; 123:16-34. [PMID: 31009700 DOI: 10.1016/j.anai.2019.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Anna R Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Emily M Huebner
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Medical Practice Evaluation Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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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: 320] [Impact Index Per Article: 64.0] [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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Moran R, Devchand M, Smibert O, Trubiano JA. Antibiotic allergy labels in hospitalized and critically ill adults: A review of current impacts of inaccurate labelling. Br J Clin Pharmacol 2019; 85:492-500. [PMID: 30521088 DOI: 10.1111/bcp.13830] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 11/04/2018] [Accepted: 11/19/2018] [Indexed: 11/29/2022] Open
Abstract
Antibiotic allergy labels (AALs) are reported by approximately 20% of hospitalized patients, yet over 85% will be negative on formal allergy testing. Hospitalized patients with an AAL have inferior patient outcomes, increased colonization with multidrug-resistant organisms and frequently receive inappropriate antimicrobials. Hospitalized populations have been well studied but, to date, the impact of AALs on patients with critical illness remains less well defined. We review the prevalence and impact of AALs on hospitalized patients, including those in in critical care.
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Affiliation(s)
- Rebekah Moran
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Misha Devchand
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of Pharmacy, Austin Health, Heidelberg, VIC, Australia
| | - Olivia Smibert
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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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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Blumenthal KG, Shenoy ES, Wolfson AR, Berkowitz DN, Carballo VA, Balekian DS, Marquis KA, Elshaboury R, Gandhi RG, Meka P, Kubiak DW, Catella J, Lambl BB, Hsu JT, Freeley MM, Gruszecki A, Wickner PG. Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:616-625.e7. [PMID: 28483315 DOI: 10.1016/j.jaip.2017.02.019] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/17/2017] [Accepted: 02/22/2017] [Indexed: 12/19/2022]
Abstract
Addressing inaccurate penicillin allergies is encouraged as part of antibiotic stewardship in the inpatient setting. However, implementing interventions targeted at the 10% to 15% of inpatients reporting a previous penicillin allergy can pose substantial logistic challenges. We implemented a computerized guideline for patients with reported beta-lactam allergy at 5 hospitals within a single health care system in the Boston area. In this article, we describe our implementation roadmap, including both successes achieved and challenges faced. We explain key implementation steps, including assembling a team, stakeholder engagement, developing or selecting an approach, spreading the change, establishing measures, and measuring impact. The objective was to detail the lessons learned while empowering others to be part of this important, multidisciplinary work to improve the care of patients with reported beta-lactam allergies.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and the Massachusetts General Professional Organization, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Erica S Shenoy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Infection Control Unit, Massachusetts General Hospital, Boston, Mass; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | | | | | - Diana S Balekian
- Allergy Unit, Department of Medicine, North Shore Medical Center, Salem, Mass; Asthma and Allergy Affiliates, Salem, Mass
| | - Kathleen A Marquis
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Ramy Elshaboury
- Department of Pharmacy, Massachusetts General Hospital, Boston, Mass
| | - Ronak G Gandhi
- Department of Pharmacy, Massachusetts General Hospital, Boston, Mass
| | - Praveen Meka
- Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Faulkner Hospital, Boston, Mass
| | - David W Kubiak
- Harvard Medical School, Boston, Mass; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Department of Pharmacy, Brigham and Women's Hospital, Boston, Mass
| | | | - Barbara B Lambl
- Division of Infectious Diseases, Department of Medicine, North Shore Medical Center, Salem, Mass
| | - Joyce T Hsu
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | | | - Alana Gruszecki
- Pharmacy Department, Brigham and Women's Faulkner Hospital, Boston, Mass
| | - Paige G Wickner
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
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Trubiano JA, Stone CA, Grayson ML, Urbancic K, Slavin MA, Thursky KA, Phillips EJ. The 3 Cs of Antibiotic Allergy-Classification, Cross-Reactivity, and Collaboration. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:1532-1542. [PMID: 28843343 PMCID: PMC5681410 DOI: 10.1016/j.jaip.2017.06.017] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/08/2017] [Accepted: 06/16/2017] [Indexed: 12/22/2022]
Abstract
Antibiotic allergy labeling is highly prevalent and negatively impacts patient outcomes and antibiotic appropriateness. Reducing the prevalence and burden of antibiotic allergies requires the engagement of key stakeholders such as allergists, immunologists, pharmacists, and infectious diseases physicians. To help address this burden of antibiotic allergy overlabeling, we review 3 key antibiotic allergy domains: (1) antibiotic allergy classification, (2) antibiotic cross-reactivity, and (3) multidisciplinary collaboration. We review the available evidence and research gaps of currently used adverse drug reaction classification systems, antibiotic allergy cross-reactivity, and current and future models of antibiotic allergy care.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Karen Urbancic
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia; Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia; National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Elizabeth J Phillips
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Pathology, Microbiology, Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University Medical School, Nashville, Tenn
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10
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Trubiano JA, Thursky KA, Stewardson AJ, Urbancic K, Worth LJ, Jackson C, Stevenson W, Sutherland M, Slavin MA, Grayson ML, Phillips EJ. Impact of an Integrated Antibiotic Allergy Testing Program on Antimicrobial Stewardship: A Multicenter Evaluation. Clin Infect Dis 2017; 65:166-174. [PMID: 28520865 PMCID: PMC5849110 DOI: 10.1093/cid/cix244] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 05/12/2017] [Indexed: 01/03/2023] Open
Abstract
Background Despite the high prevalence of patient-reported antibiotic allergy (so-called antibiotic allergy labels [AALs]) and their impact on antibiotic prescribing, incorporation of antibiotic allergy testing (AAT) into antimicrobial stewardship (AMS) programs (AAT-AMS) is not widespread. We aimed to evaluate the impact of an AAT-AMS program on AAL prevalence, antibiotic usage, and appropriateness of prescribing. Methods AAT-AMS was implemented at two large Australian hospitals during a 14-month period beginning May 2015. Baseline demographics, AAL history, age-adjusted Charlson comorbidity index, infection history, and antibiotic usage for 12 months prior to testing (pre-AAT-AMS) and 3 months following testing (post-AAT-AMS) were recorded for each participant. Study outcomes included the proportion of patients who were "de-labeled" of their AAL, spectrum of antibiotic courses pre- and post-AAT-AMS, and antibiotic appropriateness (using standard definitions). Results From the 118 antibiotic allergy-tested patients, 226 AALs were reported (mean, 1.91/patient), with 53.6% involving 1 or more penicillin class drug. AAT-AMS allowed AAL de-labeling in 98 (83%) patients-56% (55/98) with all AALs removed. Post-AAT, prescribing of narrow-spectrum penicillins was more likely (adjusted odds ratio [aOR], 2.81, 95% confidence interval [CI], 1.45-5.42), as was narrow-spectrum β-lactams (aOR, 3.54; 95% CI, 1.98-6.33), and appropriate antibiotics (aOR, 12.27; 95% CI, 5.00-30.09); and less likely for restricted antibiotics (aOR, 0.16; 95% CI, .09-.29), after adjusting for indication, Charlson comorbidity index, and care setting. Conclusions An integrated AAT-AMS program was effective in both de-labeling of AALs and promotion of improved antibiotic usage and appropriateness, supporting the routine incorporation of AAT into AMS programs.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- Department of Medicine, University of Melbourne, Parkville
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
| | | | - Karen Urbancic
- Department of Infectious Diseases, Austin Health, Heidelberg
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
- Department of Pharmacy, Austin Health, Heidelberg
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
| | - Cheryl Jackson
- Department of Pharmacy, Peter MacCallum Cancer Centre, VCCC, Parkville, and
| | - Wendy Stevenson
- Department of Infectious Diseases, Austin Health, Heidelberg
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, and
| | - Michael Sutherland
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, and
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg
- Department of Medicine, University of Melbourne, Parkville
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia; and
- Departments of Medicine and Pharmacology, Vanderbilt University Medical Centre, Nashville, Tennessee
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Blumenthal KG, Wickner PG, Hurwitz S, Pricco N, Nee AE, Laskowski K, Shenoy ES, Walensky RP. Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship. J Allergy Clin Immunol 2017; 140:154-161.e6. [PMID: 28254470 DOI: 10.1016/j.jaci.2017.02.005] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/13/2017] [Accepted: 02/07/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Reported penicillin allergy rarely reflects penicillin intolerance. Failure to address inpatient penicillin allergies results in more broad-spectrum antibiotic use, treatment failures, and adverse drug events. OBJECTIVE We aimed to determine the optimal approach to penicillin allergies among medical inpatients. METHODS We evaluated internal medicine inpatients reporting penicillin allergy in 3 periods: (1) standard of care (SOC), (2) penicillin skin testing (ST), and (3) computerized guideline application with decision support (APP). The primary outcome was use of a penicillin or cephalosporin, comparing interventions to SOC using multivariable logistic regression. RESULTS There were 625 patients: SOC, 148; ST, 278; and APP, 199. Of 278 ST patients, 179 (64%) were skin test eligible; 43 (24%) received testing and none were allergic. In the APP period, there were 292 unique Web site views; 112 users (38%) completed clinical decision support. Although ST period patients did not have increased odds of penicillin or cephalosporin use overall (adjusted odds ratio [aOR] 1.3; 95% CI, 0.8-2.0), we observed significant increased odds of penicillin or cephalosporin use overall in the APP period (aOR, 1.8; 95% CI, 1.1-2.9) and in a per-protocol analysis of the skin tested subset (aOR, 5.7; 95% CI, 2.6-12.5). CONCLUSIONS Both APP and ST-when completed-increased the use of penicillin and cephalosporin antibiotics among inpatients reporting penicillin allergy. While the skin tested subset showed an almost 6-fold impact, the computerized guideline significantly increased penicillin or cephalosporin use overall nearly 2-fold and was readily implemented.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and the Massachusetts General Professional Organization, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Paige G Wickner
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Shelley Hurwitz
- Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | | | | | - Karl Laskowski
- Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Erica S Shenoy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Infection Control Unit, Massachusetts General Hospital, Boston, Mass
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Mass
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Trubiano JA, Worth LJ, Urbancic K, Brown TM, Paterson DL, Lucas M, Phillips E. Return to sender: the need to re-address patient antibiotic allergy labels in Australia and New Zealand. Intern Med J 2016; 46:1311-1317. [PMID: 27527526 PMCID: PMC5096978 DOI: 10.1111/imj.13221] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/04/2016] [Accepted: 08/08/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND/AIM Antibiotic allergies are frequently reported and have significant impacts upon appropriate prescribing and clinical outcomes. We surveyed infectious diseases physicians, allergists, clinical immunologists and hospital pharmacists to evaluate antibiotic allergy knowledge and service delivery in Australia and New Zealand. METHODS An online multi-choice questionnaire was developed and endorsed by representatives of the Australasian Society of Clinical Immunology and Allergy (ASCIA) and the Australasian Society of Infectious Diseases (ASID). The 37-item survey was distributed in April 2015 to members of ASCIA, ASID, the Society of Hospital Pharmacists of Australia and the Royal Australasian College of Physicians. RESULTS Of 277 respondents, 94% currently use or would utilise antibiotic allergy testing (AAT) and reported seeing up to 10 patients/week labelled as antibiotic-allergic. Forty-two per cent were not aware of or did not have AAT available. Most felt that AAT would aid antibiotic selection, antibiotic appropriateness and antimicrobial stewardship (79, 69 and 61% respectively). Patients with the histories of immediate hypersensitivity were more likely to be referred than those with delayed hypersensitivities (76 vs 41%, P = 0.0001). Lack of specialist physicians (20%) and personal experience (17%) were barriers to service delivery. A multidisciplinary approach was a preferred AAT model (53%). Knowledge gaps were identified, with the majority overestimating rates of penicillin/cephalosporin (78%), penicillin/carbapenem (57%) and penicillin/monobactam (39%) cross-reactivity. CONCLUSIONS A high burden of antibiotic allergy labelling and demand for AAT is complicated by a relative lack availability or awareness of AAT services in Australia and New Zealand. Antibiotic allergy education and deployment of AAT, accessible to community and hospital-based clinicians, may improve clinical decisions and reduce antibiotic allergy impacts. A collaborative approach involving infectious diseases physicians, pharmacists and allergists/immunologists is required.
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Affiliation(s)
- J A Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.
| | - L J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - K Urbancic
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
- Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia
| | - T M Brown
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - D L Paterson
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - M Lucas
- Department of Clinical Immunology, Pathwest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - E Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
- Department of Medicine, Vanderbilt Medical Center, Nashville, Tennessee, USA
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Trubiano JA, Pai Mangalore R, Baey YW, Le D, Graudins LV, Charles PGP, Johnson DF, Aung AK. Old but not forgotten: Antibiotic allergies in General Medicine (the AGM Study). Med J Aust 2016; 204:273. [PMID: 27078602 DOI: 10.5694/mja15.01329] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 01/19/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the nature, prevalence and description accuracy of recorded antibiotic allergy labels (AALs) in a cohort of general medical inpatients, and to assess the feasibility of an oral antibiotic re-challenge study. DESIGN Multicentre cross-sectional study. SETTING AND PARTICIPANTS All patients admitted to the general medical units of Austin Health and Alfred Health, 18 May - 5 June 2015. MAIN OUTCOME MEASURES Baseline demographics, medical and allergy history, infection diagnoses and antibiotic prescribing data for general medical inpatients were collected. A questionnaire was administered to clarify AAL history, followed by correlation of responses with electronic and admissions record descriptions. A hypothetical oral re-challenge in a supervised setting was offered to patients with low risk allergy phenotypes (non-immediate reaction, non-severe cutaneous adverse reaction, or unknown reaction more than 10 years ago). RESULTS Of the 453 inpatients, 107 (24%) had an AAL (median age, 82 years; interquartile range, 74-87 years); 160 individual AALs were recorded, and there was a mismatch in AAL description between recording platforms in 25% of cases. Most patients with an AAL were women (64%; P < 0.001), and more presented with concurrent immunosuppression than those without an AAL (23% v 8%; P < 0.001). β-Lactam penicillins were employed less frequently in patients with an AAL (16% v 35%; P = 0.02), while ceftriaxone (32% v 20%; P = 0.02) and fluoroquinolones (6% v 2%; P = 0.04) were used more often. Fifty-four per cent of patients with AALs were willing to undergo oral re-challenge, of whom 48% had a low risk allergy phenotype. CONCLUSIONS AAL prevalence in general medical inpatients was 24%, and was associated with excessive use of broad spectrum antibiotics. Allergies in a large proportion of patients with AALs were incorrectly documented, and were non-immune-mediated and potentially amenable to oral re-challenge. A direct oral re-challenge study in carefully selected patients with low risk allergy phenotypes appears feasible.
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Affiliation(s)
| | | | | | - Duy Le
- Austin Health, Melbourne, VIC
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Blumenthal KG, Shenoy ES, Huang M, Kuhlen JL, Ware WA, Parker RA, Walensky RP. The Impact of Reporting a Prior Penicillin Allergy on the Treatment of Methicillin-Sensitive Staphylococcus aureus Bacteremia. PLoS One 2016; 11:e0159406. [PMID: 27438379 PMCID: PMC4954694 DOI: 10.1371/journal.pone.0159406] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 07/02/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia is a morbid infection with mortality benefit from receipt of parenteral β-lactam therapy. A substantial portion of MSSA bacteremia patients report penicillin allergy, but infrequently have true allergy. OBJECTIVE To determine the frequency and predictors of optimal and adequate therapy in patients with MSSA bacteremia. DESIGN Retrospective cohort. PARTICIPANTS Adult inpatients with MSSA bacteremia, January 2009 through October 2013. MAIN MEASURES The primary measure was a trial of optimal therapy (OT), defined as ≥3 inpatient days or discharge on any first-line agents (nafcillin, oxacillin, cefazolin, or penicillin G, if susceptible). The secondary measure was completion of adequate therapy (AT), defined as ≥10 inpatient days or discharge on an agent appropriate for MSSA bacteremia. Data were electronically gathered with key variables manually validated through chart review. Log-binomial regression models were used to determine the frequency and predictors of outcomes. KEY RESULTS Of 456 patients, 346 (76%) received a trial of OT. Patients reporting penicillin allergy (13%) were less likely to receive OT trial than those without penicillin allergy (47% vs. 80%, p <0.001). Adjusting for other factors, penicillin allergy was the largest negative predictor of OT trial (RR 0.64 [0.49, 0.83]). Infectious Disease (ID) consultation was the largest positive predictor of OT trial across all patients (RR 1.34 [1.14, 1.57]). Allergy/Immunology consultation was the single most important predictor of OT trial among patients reporting penicillin allergy (RR 2.33 [1.44, 3.77]). Of 440 patients, 391 (89%) completed AT, with ID consultation the largest positive predictor of the outcome (RR 1.28 [1.15, 1.43]). CONCLUSIONS Nearly 25% of patients with MSSA bacteremia did not receive OT trial and about 10% did not receive AT completion. Reported penicillin allergy reduced, and ID consult increased, the likelihood of OT. Allergy evaluation, coupled with ID consultation, may improve outcomes in MSSA bacteremic patients.
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Affiliation(s)
- Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Erica S. Shenoy
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Mingshu Huang
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - James L. Kuhlen
- Acadia Allergy and Immunology, Department of Medicine, University of South Carolina School of Medicine, Greenville, South Carolina, United States of America
| | - Winston A. Ware
- Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Robert A. Parker
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Blumenthal KG, Shenoy ES. Editorial Commentary: Fortune Favors the Bold: Give a Beta-Lactam! Clin Infect Dis 2016; 63:911-3. [DOI: 10.1093/cid/ciw467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/03/2016] [Indexed: 11/13/2022] Open
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