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Sobrino-García M, Muñoz-Bellido FJ, Moreno-Rodilla E, Martín-Muñoz R, García-Iglesias A, Dávila I. Delabeling of allergy to beta-lactam antibiotics in hospitalized patients: a prospective study evaluating cost savings. Int J Clin Pharm 2024; 46:1067-1075. [PMID: 38642250 DOI: 10.1007/s11096-024-01737-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/04/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Patients with a penicillin allergy label are at risk of an associated increase in adverse antibiotic events and hospitalization costs. AIM We aimed to study the economic savings derived from the correct diagnosis and delabeling inpatients with suspected beta-lactam allergy, considering the acquisition cost of antimicrobials prescribed during a patient's hospital stay. METHOD We prospectively evaluated patients admitted to the University Hospital of Salamanca who had been labeled as allergic to beta-lactams and performed a delabeling study. Subsequently, cost differences between antibiotics administered before and after the allergy study and those derived from those patients who received alternative antibiotics during admission and those who switched to beta-lactams after the allergy study were calculated. RESULTS One hundred seventy-seven inpatients labeled as allergic to beta-lactams underwent a delabeling study; 34 (19.2%) were confirmed to have allergy to beta-lactams. Of the total number of patients, 136 (76.8%) received antibiotics during their hospitalization, involving a mean (SD) cost of €203.07 (318.42) and a median (IQR) cost of €88.97 (48.86-233.56). After delabeling in 85 (62.5%) patients, the antibiotic treatment was changed to beta-lactams. In this group of patients, the mean cost (SD) decreased from €188.91 (351.09) before the change to 91.31 (136.07) afterward, and the median cost (IQR) decreased from €72.92 (45.82-211.99) to €19.24 (11.66-168). The reduction was significant compared to the median cost of patients whose treatment was not changed to beta-lactams (p<0.001). CONCLUSION Delabeling hospitalized patients represents a cost-saving measure for treating patients labeled as allergic to beta-lactams.
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Affiliation(s)
- Miriam Sobrino-García
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain
| | - Francisco J Muñoz-Bellido
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain.
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain.
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Castilla y León, Spain.
- Red de Enfermedades Inflamatorias - Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain.
- Servicio de Alergología, Hospital Universitario de Salamanca, Paseo de La Transición Española, 37007, Salamanca, Spain.
| | - Esther Moreno-Rodilla
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Castilla y León, Spain
- Red de Enfermedades Inflamatorias - Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain
| | - Rita Martín-Muñoz
- Hospital Pharmacy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
| | - Aránzazu García-Iglesias
- Admission and Clinical Documentation Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
| | - Ignacio Dávila
- Allergy Service, University Hospital of Salamanca, Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Castilla y León, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Castilla y León, Spain
- Red de Enfermedades Inflamatorias - Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain
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Honda R, Ishikawa K, Ozawa H, Matsumoto-Takahashi ELA, Mori N. Retrospective study on penicillin allergy delabeling and evaluation of an antibiotic allergy assessment tool. J Infect Chemother 2024:S1341-321X(24)00267-8. [PMID: 39307419 DOI: 10.1016/j.jiac.2024.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 09/10/2024] [Accepted: 09/19/2024] [Indexed: 10/02/2024]
Abstract
BACKGROUND It has been reported that 95 % of patients labeled as penicillin-allergic may be mislabeled. However, the process of delabeling has not advanced due to a shortage of allergy specialists capable of conducting accurate assessments. To address this issue, The Antibiotics Allergy Assessment Tool (AAAT) has been proposed as a tool to evaluate patients who can be delabeled by non-specialists. OBJECTIVE This study aims to identify patients who can be delabeled and to evaluate patients who are likely to be delabeled using AAAT. METHODS Patients admitted to the hospital between January 1, 2017, and December 31, 2021, with documented penicillin allergy labels were included in the study. Patients who demonstrated tolerance to labeled antibiotics or were labeled without explicit allergy declarations were defined as delabeling. Subsequently, patients who did not meet the criteria for delabeling were evaluated for their potential to be delabeled using the AAAT, retrospectively. RESULTS 530 patients were selected, of which 62 (11.7 %) were delabeled. The AAAT evaluation of the remaining patients indicated that at least an additional 137 (25.8 %) patients could potentially be delabeled. CONCLUSION The use of AAAT demonstrated the potential to delabel approximately third as many patients without the need for specialist evaluation. To promote broader delabeling efforts in the future, prospective studies should investigate the safety and effectiveness of evaluation tools such as the AAAT.
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Affiliation(s)
- Ryoko Honda
- St. Luke's International Hospital, Tokyo, Japan
| | | | - Hiroki Ozawa
- Graduate School of Public Health, St. Luke's International University, Tokyo, Japan
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Huang GX, Merz LE, Mehta GD, Marquis KD, Besz K, Lynch DM, Cutler C, Castells MC. Preadmission Penicillin Allergy Evaluation Before Hematopoietic Stem Cell Transplantation Optimizes Febrile Neutropenia Treatment and Inpatient Resource Utilization. Transplant Cell Ther 2024:S2666-6367(24)00623-7. [PMID: 39241913 DOI: 10.1016/j.jtct.2024.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 08/04/2024] [Accepted: 08/26/2024] [Indexed: 09/09/2024]
Abstract
Febrile neutropenia is a common complication of conditioning chemotherapy for hematopoietic stem cell transplant (HSCT), but a major barrier for optimal treatment of febrile neutropenia is historical penicillin allergies. Our group recently published a development of a clinical pipeline for delabeling penicillin allergies in adult patients planned to undergo hematopoietic stem cell transplant (HSCT). In this retrospective cohort study, we followed patients to evaluate their outcomes during inpatient admission for HSCT. We hypothesized that, among patients planned for HSCT with a self-reported penicillin allergy, completing penicillin allergy testing (amoxicillin ingestion challenge with or without concomitant penicillin skin testing) prior to HSCT admission would be associated with differences in inpatient treatment for febrile neutropenia (including antibiotic selection and timing of antibiotic administration) and improved inpatient resource utilization (including nursing and inpatient physician consults). We identified patients with a self-reported penicillin allergy who answered a penicillin allergy questionnaire and were subsequently admitted to our institution for HSCT. We divided the cohort into 2 groups: patients whose penicillin allergy was evaluated prior to admission (EPTA) and patients whose penicillin allergy was not evaluated prior to admission (NEPTA). We then performed comparison between the 2 groups for general clinical outcomes of HSCT admission (duration of admission, need for ICU transfer, readmission rate, etc.), febrile neutropenia treatment, and inpatient resource utilization. Statistics were calculated using the nonparametric 2-tailed Fisher exact test for categorical outcomes and the nonparametric 2-tailed Mann-Whitney U test for numerical outcomes. Within our cohort, 35 patients completed penicillin allergy testing prior to HSCT admission (EPTA) and 44 patients did not (NEPTA). Demographics were similar between these groups, and there was no significant difference in the rate of febrile neutropenia during HSCT admission (EPTA 64% versus NEPTA 66%, P = 1.00). EPTA patients were significantly more likely to receive standard first-line antibiotics (cefepime or ceftazidime) for febrile neutropenia (EPTA 95% versus NEPTA 65%, P = .015) and time between febrile neutropenia onset and antibiotic administration was shorter (EPTA mean 66 mins versus NEPTA mean 121 mins, P = .0058). No patients in the EPTA group experienced an immediate hypersensitivity reaction (hives, anaphylaxis, etc.) or severe cutaneous adverse reaction (SCAR) during HSCT admission. EPTA patients were also significantly less likely to require 1:1 nursing for antibiotic test doses, challenges, and desensitizations (EPTA 0% versus NEPTA 49%, P < .0001); less likely to require inpatient allergy consult (EPTA 0% versus NEPTA 12%, P = .031); and less likely to require inpatient antimicrobial stewardship consult (EPTA 0% versus NEPTA 13%, P = .013) during their HSCT admission. In summary, patients who completed penicillin allergy testing prior to HSCT admission were more likely to receive first-line antibiotics and received antibiotics more rapidly for treatment of febrile neutropenia. Furthermore, patients who completed penicillin allergy testing prior to HSCT admission were less likely to require 1:1 nursing, inpatient allergy consults, and inpatient antimicrobial stewardship consults during HSCT admission.
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Affiliation(s)
- George X Huang
- Division of Allergy & Clinical Immunology, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Lauren E Merz
- Division of Transplantation and Cellular Therapy, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Geneva D Mehta
- Allergy & Immunology, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Kathleen D Marquis
- Division of Allergy & Clinical Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kylie Besz
- Division of Allergy & Clinical Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Donna-Marie Lynch
- Division of Allergy & Clinical Immunology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Corey Cutler
- Division of Transplantation and Cellular Therapy, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Mariana C Castells
- Division of Allergy & Clinical Immunology, Brigham and Women's Hospital, Boston, Massachusetts
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4
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Foong KS, Fowle L, Doron S, Cumming M, Leaf J, Bolstorff B, Brandeburg C, Chen Y, Wurcel A. Antibiotic allergy prevalence and documentation quality in Massachusetts long-term care facilities: A cross-sectional survey. Ann Allergy Asthma Immunol 2024; 133:335-340.e1. [PMID: 38897407 DOI: 10.1016/j.anai.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/14/2024] [Accepted: 06/14/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Antimicrobial resistance poses a significant global health challenge, particularly affecting older adults who are more susceptible to infections and their complications. Accurate diagnosis and documentation of antibiotic allergies are essential for effective antimicrobial stewardship. Despite the recognized overdiagnosis of antibiotic allergies, comprehensive studies on this subject in long-term care (LTC) settings are limited. OBJECTIVE To determine the point prevalence of antibiotic allergies and documentation quality in Massachusetts LTC facilities. METHODS We conducted a cross-sectional, 1-day point prevalence survey from July 1, 2023, to March 31, 2024, across 20 participating LTC facilities in Massachusetts in partnership with the Massachusetts Department of Public Health. The survey assessed the prevalence and documentation of antibiotic allergies among 2345 residents. Multivariable logistic regression was used to explore associations between documented penicillin allergy and demographic factors, including non-penicillin antibiotic allergies. RESULTS The overall point prevalence of documented antibiotic allergies was 39.1%, with the most frequently reported classes being penicillins at 23.1%, sulfonamides at 15.4%, and cephalosporins at 5.2%. Significant documentation gaps were identified, with up to 92.8% of the allergy records found to be incomplete. Factors associated with documented penicillin allergies included female sex (adjusted odds ratio [aOR], 1.50; 95% CI, 1.16-1.94), White race (aOR, 1.92; 95% CI, 1.25-2.94), having allergies to non-penicillin antibiotics (aOR, 2.89; 95% CI, 2.33-3.59), and receipt of antibiotic (aOR, 2.13; 95% CI, 1.68-2.71). CONCLUSION The high prevalence of documented antibiotic allergies and the notable deficiencies in their documentation underscore the urgent need for enhanced antibiotic evaluation, documentation practices, and penicillin delabeling in LTC facilities.
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Affiliation(s)
- Kap Sum Foong
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts.
| | - Leslie Fowle
- Division of Epidemiology, Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, Massachusetts
| | - Shira Doron
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Melissa Cumming
- Division of Epidemiology, Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, Massachusetts
| | - Jessica Leaf
- Division of Epidemiology, Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, Massachusetts
| | - Barbara Bolstorff
- Division of Epidemiology, Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, Massachusetts
| | - Christina Brandeburg
- Division of Epidemiology, Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, Massachusetts
| | - Ye Chen
- Tufts Clinical and Translational Science Institute, Tufts School of Graduate Biomedical Sciences, Boston, Massachusetts
| | - Alysse Wurcel
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
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Belmont AP, Stone CA, Guyer AC, Edelman EJ, Trubiano JA. A call to address penicillin allergy labels in patients with hematopoietic stem cell transplants: How to avoid rash decisions. Transpl Infect Dis 2024:e14350. [PMID: 39101669 DOI: 10.1111/tid.14350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 08/06/2024]
Abstract
Among patients with hematopoietic stem cell transplants, infections, particularly multidrug-resistant infections, pose a grave threat. In this setting, penicillin allergy labels are both common and harmful. Though the majority of patients who report penicillin allergy can actually tolerate penicillin, penicillin allergy labels are associated with use of alternative antibiotics, which are often more broad spectrum, less effective, and more toxic. In turn, they are associated with more severe infections, multidrug-resistant infections, Clostridium difficile, and increased mortality. Evaluating penicillin allergy labels can immediately expand access to preferred therapeutic options, which are critical to care in patients with recent hematopoietic stem cell transplants. Point-of-care assessment and clinical decision tools now exist to aid the nonallergist in assessment of penicillin allergy. This can aid in expanding use of other beta-lactam antibiotics and assist in risk-stratifying patients to determine a testing strategy. In patients with low-risk reaction histories, direct oral challenges can be employed to efficiently delabel patients across clinical care settings. We advocate for multidisciplinary efforts to evaluate patients with penicillin allergy labels prior to transplantation.
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Affiliation(s)
- Ami P Belmont
- Section of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cosby A Stone
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Autumn C Guyer
- Allergy and Immunology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
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6
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Ali SB, Hughes T, Smith A. Penicillin or cephalosporin antibiotic allergy label: Influence on length of stay and hospital readmission. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100272. [PMID: 38817345 PMCID: PMC11137559 DOI: 10.1016/j.jacig.2024.100272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/04/2024] [Accepted: 02/15/2024] [Indexed: 06/01/2024]
Abstract
Background A penicillin or cephalosporin antibiotic (PCA) allergy label (PCAAL) has negative implications for both the patient and health care alike. Objective A retrospective study was undertaken to evaluate the influence of a PCAAL on length of stay (LOS) and hospital readmissions. Methods Over 4 weeks, inpatients with a PCAAL who were referred to the allergy service or opportunistically reviewed were grouped in the categories delabeled (group 1a) or advice not followed (ie, label carriage) (group 1b). Comparator groups without a PCAAL were identified, those either on a PCA (the PCA group [group 2]) or on a non-PCA (the non-PCA group [group 3]). Results The study population comprised 77 patients as follows: group 1a (n = 19), group 1b (n = 6), group 2 (n = 36), and group 3 (n = 16). Those in group 1a were significantly older (median age 78 years) than those in group 1b (median age 53 years [P = .013]) or group 3 (median age 59 years [P = .013]).There was a trend toward lower LOS in group 1a (10 days) than in group 1b (11.5 days [P = not significant]). Group 2 had a significantly lower LOS (6 days) than either both group 1a (10 days [P = .043]) or group 3 (15 days [P = .002]). Group 3 had the highest rate of patients readmitted within 30 days (n = 5 [71.4%]). Conclusion A PCAAL carries influence on both LOS and readmissions, thus identifying the prompt need for allergy review to provide specific recommendations: delabeling and transition to an appropriate antibiotic. The significantly older group of those with a PCAAL who received a PCA after delabeling (ie, a 20-year age difference) may also be a signal that more elderly and comorbid patients benefit from this intervention the most.
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Affiliation(s)
- Syed B. Ali
- Department of Clinical Immunology and Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine, Flinders University, Bedford Park, Australia
| | - Tiffany Hughes
- Department of Clinical Immunology and Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine, Flinders University, Bedford Park, Australia
| | - Anthony Smith
- Department of Clinical Immunology and Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine, Flinders University, Bedford Park, Australia
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Rose MT, Mitri EA, Vogrin S, Holmes NE, Chua KYL, Slavin MA, Trubiano JA. Durability of penicillin allergy delabeling and post-testing penicillin utilization in adults with immune compromise. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1928-1930.e1. [PMID: 38582191 DOI: 10.1016/j.jaip.2024.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/08/2024]
Affiliation(s)
- Morgan T Rose
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia; Department of Infectious Diseases, the University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Parkville, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
| | - Elise A Mitri
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia
| | - Sara Vogrin
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia; Department of Medicine (St Vincent's Health), University of Melbourne, Fitzroy, VIC, Australia
| | - Natasha E Holmes
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia; Department of Infectious Diseases, the University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Parkville, VIC, Australia
| | - Kyra Y L Chua
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia; Department of Infectious Diseases, the University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Parkville, VIC, Australia
| | - Monica A Slavin
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, VIC, Australia; Department of Infectious Diseases, the University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Parkville, VIC, Australia
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So W, Khalak SI, Ho S, Ross JA, Dadwal SS, Puing AG, Nanayakkara DD, Kaur A, Taplitz RA, Dickter JK. Implementation and outcomes of beta-lactam allergy management protocol at a comprehensive cancer center. Infection 2024:10.1007/s15010-024-02274-1. [PMID: 38907094 DOI: 10.1007/s15010-024-02274-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 04/16/2024] [Indexed: 06/23/2024]
Abstract
PURPOSE Beta-lactam allergy (BLA) is associated with increased broad-spectrum antibiotic (Br-ABX) use and worse clinical outcomes. We evaluated our hospital-wide BLA protocol (BLA-P) that used following categories: intolerance, low-risk, and high-risk. METHODS Hospitalized adult patients with listed BLA during 10/2021-12/2022 were eligible. Exclusions were critically ill, surgical, hospice or comfort care, or non-verbal patients. Assessment was counted each time a pharmacist evaluated BLA. Interventions were no further action (high-risk allergy, patient refusal, unstable clinical status), updated allergy label, or delabeled. Delabeling was done either based on antibiotic history (direct-delabeling), or via test-dose challenge for low-risk patients. Br-ABX usage was compared in the unique delabeled patients: the empiric antibiotic use 90 days post-delabeling versus pre-delabeling using McNemar test (SPSS). RESULTS A total of 700 assessments in 631 patients were identified. 441 assessments in 377 patients (median 63 years-old, 41% male, 50% hematological cancer) met inclusion criteria. The assessments revealed 9% intolerance, 55% low-risk, 23% high-risk and 13% unknown reaction. Interventions resulted in no further action 7%, updated label 72%, and delabeling 21%. 65% of the delabeling was via direct-delabeling and 35% test-dose challenge. Among patients who received a test-dose challenge, 36/36(97%) had no documented allergic reactions, and 1/26(3%) developed a mild rash. The use of aztreonam (pre-delabeling 28% vs. post-delabeling 1.2%, p < 0.001) and meropenem (13% vs. 2.4%, p = 0.022) significantly decreased while cefepime (24% vs. 50%, p = 0.001) and piperacillin-tazobactam (3.7% vs. 22%, p < 0.001) increased after delabeling. CONCLUSION BLA-P led to 21% delabeling, which resulted in increased preferred Br-ABX and decrease in aztreonam/meropenem use among delabeled patients.
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Affiliation(s)
- Wonhee So
- College of Pharmacy, Western University of Health Sciences, 309 E. 2nd St, Pomona, CA, 91766, USA.
- Department of Pharmacy, City of Hope, 1500 E Duarte Rd, Duarte, CA, 91010, USA.
| | | | - Stephanie Ho
- Department of Pharmacy, City of Hope, 1500 E Duarte Rd, Duarte, CA, 91010, USA
| | - Justine Abella Ross
- Department of Pharmacy, City of Hope, 1500 E Duarte Rd, Duarte, CA, 91010, USA
| | - Sanjeet S Dadwal
- Department of Medicine, City of Hope, 1500 E Duarte Rd, Duarte, CA, 91010, USA
| | - Alfredo G Puing
- Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
| | - Deepa D Nanayakkara
- Department of Medicine, City of Hope, 1500 E Duarte Rd, Duarte, CA, 91010, USA
| | - Avneet Kaur
- Department of Medicine, City of Hope, 1500 E Duarte Rd, Duarte, CA, 91010, USA
| | - Randy A Taplitz
- Department of Medicine, City of Hope, 1500 E Duarte Rd, Duarte, CA, 91010, USA
| | - Jana K Dickter
- Department of Medicine, City of Hope, 1500 E Duarte Rd, Duarte, CA, 91010, USA
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9
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Stone S, Henao MP, Craig TJ, Al-Shaikhly T. Impact of Sulfonamide Allergy Label on Clinical Outcomes in Patients with Pneumocystis jirovecii Pneumonia. Pulm Ther 2024; 10:225-236. [PMID: 38782820 PMCID: PMC11282000 DOI: 10.1007/s41030-024-00260-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION The presence of antibiotic allergy labels can have harmful impacts on clinical outcomes, particularly among immunosuppressed patients, in whom there have been associations with increased complications, readmission rates, and mortality. We explore the effects of a sulfonamide allergy label (SAL) on clinical outcomes in adult patients with Pneumocystis jirovecii pneumonia (PJP). METHODS In this retrospective matched cohort study, we utilized TriNetX, a multicenter national database, to match 535 adult patients with PJP and SAL to an equal number of controls. We identified cases indexed between 01/01/2010 and 01/01/2023 utilizing ICD-10 codes for PJP and allergy status to sulfonamides and through detection of P. jirovecii antigen with immunofluorescence or PCR. Propensity score matching was performed in a 1:1 fashion for demographics and comorbidities, and our analysis included clinical outcomes that occurred within 30 days after the occurrence of the index event. RESULTS While hospitalization risk tended to be lower among patients with SAL as compared to controls (RR: 0.90; 95% CI 0.81-1.01), there were no major differences in the risk of respiratory failure (RR: 0.94; 95% CI 0.84-1.05), prednisone use (RR: 1; 95% CI 0.91-1.10), intensive level of care requirement (RR: 0.85; 95% CI 0.69-1.06), intubation (RR: 0.85; 95% CI 0.61-1.19), or mortality (RR: 0.98; 95% CI 0.68-1.42). The presence of SAL did however impact antibiotic prescription patterns, with an underutilization of trimethoprim (RR: 0.50; 95% CI 0.43-0.59) and sulfamethoxazole (RR, 0.47; 95% CI 0.40-0.56) and overuse of alternative agents by patients with SAL as compared to controls. Yet, there was no difference in the occurrence of adverse outcomes such as hepatotoxicity (RR: 1.09; 95% CI 0.49-2.45) or acute kidney injury (RR: 0.94; 95% CI 0.78-1.14) between patients with SAL and controls. CONCLUSIONS The presence of SAL alters antibiotic prescription patterns among adults with Pneumocystis infection but has no clinically significant impact on outcomes.
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Affiliation(s)
- Shane Stone
- Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
- Section of Allergy, Asthma & Immunology, Penn State College of Medicine, 500 University Drive, PO Box 850, Hershey, PA, USA
| | - Maria P Henao
- Section of Allergy, Asthma & Immunology, Penn State College of Medicine, 500 University Drive, PO Box 850, Hershey, PA, USA
| | - Timothy J Craig
- Section of Allergy, Asthma & Immunology, Penn State College of Medicine, 500 University Drive, PO Box 850, Hershey, PA, USA.
- Vinmec International Hospital, Times City, Hanoi, Vietnam.
| | - Taha Al-Shaikhly
- Section of Allergy, Asthma & Immunology, Penn State College of Medicine, 500 University Drive, PO Box 850, Hershey, PA, USA
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10
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Singh N, Douglas AP, Slavin MA, Haeusler GM, Thursky KA. Antimicrobial use and appropriateness in neutropenic fever: a study of the Hospital National Antimicrobial Prescribing Survey data. J Antimicrob Chemother 2024; 79:632-640. [PMID: 38305582 DOI: 10.1093/jac/dkae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Neutropenic fever (NF) is a common complication in patients receiving chemotherapy. Judicious antimicrobial use is paramount to minimize morbidity and mortality and to avoid antimicrobial-related harms. OBJECTIVES To use an Australian national dataset of antimicrobial prescriptions for the treatment of NF to describe antimicrobial use, prescription guideline compliance and appropriateness; and to compare these findings across different healthcare settings and patient demographics. We also aimed to identify trends and practice changes over time. METHODS Data were extracted from the Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) database from August 2013 to May 2022. Antimicrobial prescriptions with a NF indication were analysed for antimicrobial use, guideline compliance and appropriateness according to the Hospital NAPS methodology. Demographic factors, hospital classifications and disease characteristics were compared. RESULTS A total of 2887 (n = 2441 adults, n = 441 paediatric) NF prescriptions from 254 health facilities were included. Piperacillin-tazobactam was the most prescribed antimicrobial. Overall, 87.4% of prescriptions were appropriate. Piperacillin-tazobactam and cefepime had the highest appropriateness though incorrect piperacillin-tazobactam dosing was observed. Lower appropriateness was identified for meropenem, vancomycin, and gentamicin prescribing particularly in the private hospital and paediatric cohorts. The most common reasons for inappropriate prescribing were spectrum too broad, incorrect dosing or frequency, and incorrect duration. CONCLUSIONS This study provides insights into antimicrobial prescribing practices for NF in Australia. We have identified three key areas for improvement: piperacillin-tazobactam dosing, paediatric NF prescribing and private hospital NF prescribing. Findings from this study will inform the updated Australian and New Zealand consensus guidelines for the management of neutropenic fever in patients with cancer.
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Affiliation(s)
- Nikhil Singh
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Pharmacy Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Abby P Douglas
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Department of Infectious Diseases, Austin Health, Melbourne, Australia
| | - Monica A Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia
| | - Gabrielle M Haeusler
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Karin A Thursky
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- RMH Guidance Group, Royal Melbourne Hospital, Melbourne, Australia
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11
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Al-Obaydi S, Ssentongo P, Cherneskie JJ, Craig TJ, Al-Shaikhly T. Outcomes of acute pyelonephritis in patients with a penicillin allergy label in the United States. Ann Allergy Asthma Immunol 2024; 132:97-99. [PMID: 37778455 PMCID: PMC10842634 DOI: 10.1016/j.anai.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/10/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Sarah Al-Obaydi
- Division of Hospitalist Medicine, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Paddy Ssentongo
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania; Division of Infectious Diseases, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - John J Cherneskie
- Section of Allergy, Asthma & Immunology, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Timothy J Craig
- Section of Allergy, Asthma & Immunology, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Taha Al-Shaikhly
- Section of Allergy, Asthma & Immunology, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania.
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12
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Hand J, Imlay H. Antimicrobial Stewardship in Immunocompromised Patients: Current State and Future Opportunities. Infect Dis Clin North Am 2023; 37:823-851. [PMID: 37741735 DOI: 10.1016/j.idc.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
Abstract
Immunocompromised (IC) patients are high risk for complications due to a high rate of antibiotic exposure. Antimicrobial stewardship interventions targeted to IC patients can be challenging due to limited data in this population and a high risk of severe infection-related outcomes. Here, the authors review immunocompromised antimicrobial stewardship barriers, metrics, and opportunities for antimicrobial use and testing optimization. Last, the authors highlight future steps in the field.
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Affiliation(s)
- Jonathan Hand
- Ochsner Health, New Orleans, LA, USA; University of Queensland School of Medicine, Ochsner Clinical School
| | - Hannah Imlay
- University of Utah Department of Internal Medicine, Salt Lake City, UT, USA.
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13
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Rodríguez-Alarcón A, Sanz de Mena M, Alanti SS, Echeverría-Esnal D, Sorli L, Sendra E, Benítez-Cano A, Membrilla E, Cots F, Güerri-Fernández R, Adalia R, Horcajada JP, Escolano F, Grau S, Gómez-Zorrilla S. A retrospective case-control study to evaluate the use of beta-lactam desensitization in the management of penicillin-allergic patients: a potential strategy for Antimicrobial Stewardship Programs. Front Pharmacol 2023; 14:1260632. [PMID: 38034998 PMCID: PMC10684946 DOI: 10.3389/fphar.2023.1260632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction: Penicillin allergy labels (PAL) are common in the hospital setting and are associated with worse clinical outcomes. Desensitization can be a useful strategy for allergic patients when alternative options are suboptimal or not available. The aim was to compare clinical outcomes of patients with PAL managed with antibiotic desensitization vs. those who received alternative non-beta-lactam antibiotic treatments. Methods: A retrospective 3:1 case-control study was performed between 2015-2022. Cases were adult PAL patients with infection who required antibiotic desensitization; controls were PAL patients with infection managed with an alternative antibiotic treatment. Cases and controls were adjusted for age, sex, infection source, and critical or non-critical medical services. Results: Fifty-six patients were included: 14 in the desensitization group, 42 in the control group. Compared to the control group, desensitized PAL patients had more comorbidities, with a higher Charlson index (7.4 vs. 5; p = 0.00) and more infections caused by multidrug-resistant (MDR) pathogens (57.1% vs. 28.6%; p = 0.05). Thirty-day mortality was 14.3% in the desensitized group, 28.6% in the control group (p = 0.24). Clinical cure occurred in 71.4% cases and 54.8% controls (p = 0.22). Four control patients selected for MDR strains after alternative treatment; selection of MDR strains did not occur in desensitized patients. Five controls had antibiotic-related adverse events, including Clostridioides difficile or nephrotoxicity. No antibiotic-related adverse events were found in the study group. In multivariate analysis, no differences between groups were observed for main variables. Conclusion: Desensitization was not associated with worse clinical outcomes, despite more severe patients in this group. Our study suggests that antibiotic desensitization may be a useful Antimicrobial Stewardship tool for the management of selected PAL patients.
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Affiliation(s)
- Alicia Rodríguez-Alarcón
- Pharmacy Service, Hospital del Mar, Infectious Pathology and Antimicrobial Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Manuela Sanz de Mena
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Soukaina Sara Alanti
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Daniel Echeverría-Esnal
- Pharmacy Service, Hospital del Mar, Infectious Pathology and Antimicrobial Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Luisa Sorli
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Sendra
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Adela Benítez-Cano
- Department of Anesthesiology and Surgical Intensive Care, Hospital del Mar, Parc de Salut Mar. Hospital del Mar Research Institute, Barcelona, Spain
| | - Estela Membrilla
- Surgery Service, Parc de Salut Mar. IHospital del Mar Research Institute, Barcelona, Spain
| | - Francesc Cots
- Management Control Department, Hospital del Mar-Parc de Salut Mar, Barcelona, Spain
| | - Robert Güerri-Fernández
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Ramón Adalia
- Department of Anesthesiology and Surgical Intensive Care, Hospital del Mar, Parc de Salut Mar. Hospital del Mar Research Institute, Barcelona, Spain
| | - Juan Pablo Horcajada
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Fernando Escolano
- Department of Anesthesiology and Surgical Intensive Care, Hospital del Mar, Parc de Salut Mar. Hospital del Mar Research Institute, Barcelona, Spain
| | - Santiago Grau
- Pharmacy Service, Hospital del Mar, Infectious Pathology and Antimicrobial Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Silvia Gómez-Zorrilla
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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14
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Sáenz de Santa María R, Bogas G, Labella M, Ariza A, Salas M, Doña I, Torres MJ. Approach for delabeling beta-lactam allergy in children. FRONTIERS IN ALLERGY 2023; 4:1298335. [PMID: 38033918 PMCID: PMC10684789 DOI: 10.3389/falgy.2023.1298335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023] Open
Abstract
A considerable number of pediatric patients treated with beta-lactam (BL) antibiotics develop delayed onset of skin rashes during the course of treatment. Although the most frequent cause of these symptoms is infectious, many cases are labeled as allergic reactions to these drugs. BL allergy labels could have a negative impact, as they imply avoidance of this group of drugs and the use of second-line antibiotics, leading to a potential increase in adverse effects and the utilization of less effective therapies. This constitutes a major public health concern and economic burden, as the use of broad-spectrum antibiotics can result in multidrug-resistant organisms and prolonged hospital stays. Therefore, it is crucial to delabel patients during childhood to avoid false labeling in adult life. Although the label of BL allergy is among the most frequent causes of allergy referral, its management remains controversial, and new diagnostic perspectives are changing the paradigm of managing BL allergies in children. Traditionally, drug provocation testing (DPT) was exclusively performed in patients who had previously obtained negative results from skin tests (STs). However, the sensitivity of STs is low, and the role of in vitro testing in the pediatric population is not well defined. Recent studies have demonstrated the safety of direct DPT without prior ST or serum tests for pediatric patients who report a low-risk reaction to BLs, which is cost-effective. However, there is still a debate on the optimal allergic workup to be performed in children with a benign immediate reaction and the management of children with severe cutaneous adverse drug reactions. In this review, we will discuss the impact of the label of BL allergy and the role of the different tools currently available to efficiently address BL allergy delabeling in children.
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Affiliation(s)
- R. Sáenz de Santa María
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - G. Bogas
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. Labella
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - A. Ariza
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. Salas
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - I. Doña
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
| | - M. J. Torres
- Allergy Unit, Hospital Regional Universitario de Málaga, Hospital Civil, Málaga, Spain
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Civil, Málaga, Spain
- Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
- Departamento de Medicina, Universidad de Málaga, Facultad de Medicina, Málaga, Spain
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15
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Johnson M, Snyder M, Miller DR. A new clinical opportunity: Rechallenging penicillin allergy in an outpatient pharmacy. J Am Pharm Assoc (2003) 2023; 63:1681-1684. [PMID: 37579992 DOI: 10.1016/j.japh.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/16/2023]
Abstract
In the United States, approximately 27 million people have a documented penicillin allergy, but 90% of the allergies are falsely labeled. By rechallenging suspected allergies, a pharmacist can optimize patient care, fulfill antimicrobial stewardship objectives, and educate patients on true allergies. We suggest a protocol that allows pharmacists to investigate the presence of an allergy and conduct a challenge when indicated. The protocol consists of a patient interview, a risk assessment, an oral rechallenge, and the potential for a skin test. The testing and delabeling of penicillin allergies will enhance the practice of antimicrobial stewardship in the outpatient setting. In the changing landscape of pharmacy, community pharmacists can increase their services and improve patient care. Owing to limited documented experience in the outpatient pharmacy, an opportunity to set the standard and be a leader in the field is present.
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16
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Chadha S, Troost JP, Shivers PL. Does thePenicillin Allergy Label Affect Outcomes of Complicated Odontogenic Infections? J Oral Maxillofac Surg 2023; 81:1301-1310. [PMID: 37507104 DOI: 10.1016/j.joms.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/31/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023]
Abstract
PURPOSE Penicillins are a potent antibiotic in managing odontogenic infections, but 10% of the population is labelled as allergic to these drugs. This has limited their use and resulted in increased utilization of health care resources as well as complications associated with alternative antibiotics. The purpose of the study was to measure the association between patients labeled as penicillin allergic and treatment outcomes in a sample of patients treated for complicated odontogenic infections. Additionally, we sought to investigate antibiotic resistance patterns in these patients. MATERIALS AND METHODS A retrospective cohort study was performed at the Michigan Medicine health care system to include patients who were treated for complicated odontogenic infections by oral and maxillofacial surgery between 2016 and 2020. Complicated odontogenic infection was defined as any odontogenic infection requiring admission and surgical management in the operating room. The primary predictor variable was the penicillin allergy label, which was determined by chart review and not confirmed with formal testing. Outcomes were measures of disease severity. The primary outcome variable was hospital length of stay. Secondary outcome variables were ICU admission (yes/no), repeat computed tomography scan(s), repeat surgery (yes/no), and re-admission (yes/no). Co-variates included were age, sex (male/female), tobacco use status, diabetes, immunocompromised state, number of spaces involved, white blood cell count upon admission and insurance status. For our secondary aim, the primary predictor variable was again penicillin allergy and outcome variable was antibiotic resistance as determined by wound culture results following surgical intervention. Negative binomial regression and logistic regression analyses were performed. P < .05 was considered significant. RESULTS A total of 150 patients met the inclusion criteria and of those 17.3% reported as penicillin allergic. Patients labelled as penicillin allergic did not differ significantly from patients without penicillin allergy label in terms of treatment outcomes. Age, diabetes, and immunosuppression were associated with an increased length of stay. Patients labelled as penicillin allergic were at significantly higher risk for antibiotic resistance (relative risk = 2.34; 95% confidence interval, 1.66 to 3.32; P < .001), specifically clindamycin resistance (relative risk = 3.17; 95% confidence interval, 1.93 to 5.18; P < .001). CONCLUSIONS Penicillin allergy was significantly associated with clindamycin resistance. There were similar outcomes amongst patients with and without a penicillin allergy label despite antibiotic differences. Delabeling efforts for patients with a reported penicillin allergy must be considered and local nomograms for antibiotic selection should be used by providers when seeking alternative antibiotics.
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Affiliation(s)
- Sagar Chadha
- Resident, Department of Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, MI
| | - Jonathan P Troost
- Lead Statistician, Michigan Institute for Clinical Health and Research, Ann Arbor, MI
| | - Paul L Shivers
- Clinical Instructor, Department of Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, MI.
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Arnold A, Coventry LL, Foster MJ, Koplin JJ, Lucas M. The Burden of Self-Reported Antibiotic Allergies in Health Care and How to Address It: A Systematic Review of the Evidence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3133-3145.e3. [PMID: 37352931 DOI: 10.1016/j.jaip.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/28/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Antibiotics are the first-line treatment for bacterial infections; however, overuse and inappropriate prescribing have made antibiotics less effective with increased antimicrobial resistance. Unconfirmed reported antibiotic allergy labels create a significant barrier to optimal antimicrobial stewardship in health care, with clinical and economic implications. OBJECTIVE A systematic review was conducted to summarize the impact of patient-reported antibiotic allergy on clinical outcomes and various strategies that have been employed to effectively assess and remove these allergy labels, improving patient care. METHODS The review was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A critical appraisal was conducted on all studies and a narrative synthesis was performed to identify themes. RESULTS Four themes emerged: the prevalence of antibiotic allergy, impact of antibiotic allergy on antimicrobial prescribing, impact of antibiotic allergy on clinical outcomes, and delabeling strategies to improve clinical outcomes. Of the 32 studies, including 1,089,675 participants, the prevalence of reported antibiotic allergy was between 5% and 35%. Patients with a reported antibiotic allergy had poorer concordance with prescribing guidelines in 30% to 60% of cases, with a higher use of alternatives such as quinolone, tetracycline, macrolide, lincosamide, and carbapenem and lower use of beta-lactam antibiotics. Antibiotic allergy delabeling was identified as an intervention and recommendation to advance the state of the science. CONCLUSIONS There is substantial evidence within the literature that antibiotic allergy labels significantly impact patient clinical outcomes and a consensus that systematic assessment of reported antibiotic allergies, commonly referred to as delabeling, improves the clinical management of patients.
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Affiliation(s)
- Annabelle Arnold
- Immunology Department, Perth Children's Hospital, Perth, Australia; School of Nursing and Midwifery, Edith Cowan University, Perth, Australia
| | - Linda L Coventry
- School of Nursing and Midwifery, Edith Cowan University, Perth, Australia; Centre for Nursing Research, Sir Charles Gairdner Hospital, Perth, Australia
| | - Mandie J Foster
- School of Nursing and Midwifery, Edith Cowan University, Perth, Australia; Auckland University of Technology, School of Clinical Sciences, Auckland, New Zealand
| | - Jennifer J Koplin
- University of Queensland, Child Health Research Centre, Brisbane, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Michaela Lucas
- Immunology Department, Perth Children's Hospital, Perth, Australia; Medical School, University of Western Australia, Perth, Australia; Immunology Department, PathWest Laboratory Medicine WA, Perth, Australia; Immunology Department, Sir Charles Gairdner Hospital, Perth, Australia.
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18
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Contejean A, Maillard A, Canouï E, Kernéis S, Fantin B, Bouscary D, Parize P, Garcia-Vidal C, Charlier C. Advances in antibacterial treatment of adults with high-risk febrile neutropenia. J Antimicrob Chemother 2023; 78:2109-2120. [PMID: 37259598 DOI: 10.1093/jac/dkad166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND High-risk febrile neutropenia (HR-FN) is a life-threatening complication in patients with haematological malignancies or receiving myelosuppressive chemotherapy. Since the last international guidelines were published over 10 years ago, there have been major advances in the understanding and management of HR-FN, including on antibiotic pharmacokinetics and discontinuation/de-escalation strategies. OBJECTIVES Summarizing major advances in the field of antibacterial therapy in patients with HR-FN: empirical therapy, pharmacokinetics of antibiotics and antibiotic stewardship. SOURCES Narrative review based on literature review from PubMed. We focused on studies published between 2010 and 2023 about the pharmacokinetics of antimicrobials, management of antimicrobial administration, and discontinuation/de-escalation strategies. We did not address antimicrobial prophylaxis, viral or fungal infections. CONTENT Several high-quality publications have highlighted important modifications of antibiotic pharmacokinetics in HR-FN, with standard dosages exposing patients to underdosing. These recent clinical and population pharmacokinetics studies help improve management protocols with optimized initial dosing and infusion rules for β-lactams, vancomycin, daptomycin and amikacin; they highlight the potential benefits of therapeutic drug monitoring. A growing body of evidence also shows that antibiotic discontinuation/de-escalation strategies are beneficial for bacterial ecology and patients' outcome. We further discuss methods and limitations for implementation of such protocols in haematology. IMPLICATIONS We highlight recent information about the management of antibacterial therapy in HR-FN that might be considered in updated guidelines for HR-FN management.
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Affiliation(s)
- Adrien Contejean
- Service d'Hématologie, Centre Hospitalier Annecy Genevois, 1 Avenue de l'hôpital, F-74370 Epagny Metz-Tessy, France
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
| | - Alexis Maillard
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Etienne Canouï
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Solen Kernéis
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Équipe de Prévention du Risque Infectieux, AP-HP, Hôpital Bichat, F-75018 Paris, France
- Université Paris Cité, INSERM, IAME, F-75018 Paris, France
| | - Bruno Fantin
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Département de Médecine Interne, AP-HP, Hôpital Beaujon, F-92110, Clichy, France
| | - Didier Bouscary
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Service d'Hématologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Perrine Parize
- Service de Maladies Infectieuses, AP-HP, APHP.CUP, Hôpital Necker-Enfants Malades, F-75015 Paris, France
| | - Carolina Garcia-Vidal
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
- CIBERINF, Madrid, Spain
| | - Caroline Charlier
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- National Reference Center Listeriosis WHO Collaborating Center, Institut Pasteur, F-75015 Paris, France
- Biology of Infection Unit, Inserm U1117 Institut Pasteur, F-75015 Paris, France
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19
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Jones NK, Morris B, Santos R, Nasser S, Gouliouris T. Characterizing Antibiotic Allergy Labels in a Large UK Hospital Population to Inform Antimicrobial Stewardship and Delabeling Assessment Strategy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2180-2189.e4. [PMID: 37088372 DOI: 10.1016/j.jaip.2023.03.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Antibiotic allergy labels are important barriers to treatment and antimicrobial stewardship, but their prevalence in UK hospitals is poorly described. OBJECTIVE To ascertain the prevalence and characteristics of antibiotic allergy labels in a large UK hospital setting and estimate the proportion of penicillin allergy labels for which point-of-care (POC) delabeling assessment would be appropriate. METHODS Electronic health records data were analyzed from all patients treated at Cambridge University Hospitals NHS Foundation Trust in 2019. Validated POC delabeling risk stratification criteria were retrospectively applied to penicillin allergy labels. RESULTS Recorded reactions to antibiotics were present in 11.8% of all patients (32,148 of 273,216), 16.3% of inpatients (13,874 of 85,230), and 9.7% of outpatients (18,274 of 187,986). Penicillins were the commonest reaction precipitant described (9.0% of patients; 24,646 of 273,216), followed by sulfonamides/trimethoprim (1.4%; 3869 of 273,216) and macrolides/lincosamides (1.3%; 3644 of 273,216). A total of 3.9% of inpatients had recorded reactions to >1 antibiotic class (3348 of 85,230). Cutaneous manifestations were the most commonly described reaction features (40.7% of labels; 15,821 of 38,902). Of 15,949 labels describing probable or possible penicillin "allergy" with sufficient detail to allow for the retrospective assessment of POC delabeling suitability, 1702 were deemed suitable for removal or downgrading of the label to "intolerance" without further investigation (10.7%), 11,887 were appropriate for POC assessment using an oral penicillin challenge (OPC) or OPC with prior bedside skin testing (74.5%), and 2360 were identified as unsuitable for any form of POC assessment (14.8%). CONCLUSIONS Antibiotic allergy labels are highly prevalent in a UK hospital setting. A large proportion of penicillin allergy labels may be suitable for POC delabeling assessment.
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Affiliation(s)
- Nick K Jones
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
| | - Bethan Morris
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Reem Santos
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Theodore Gouliouris
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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20
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Patel VM, Chu B, Hamilton KW, Bellamy C, Harker C, Bryer JS, Shields B, Hirsh RL, Fadugba OO, Micheletti RG. Penicillin allergy evaluation in hospitalized patients with hematologic malignancy. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e92. [PMID: 37228506 PMCID: PMC10204135 DOI: 10.1017/ash.2023.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 05/27/2023]
Abstract
A penicillin allergy testing service (PATS) assessed penicillin allergy in patients with hematologic malignancies; 17 patients who met criteria had negative skin testing. Patients who underwent penicillin challenge passed and were delabeled. Of delabeled patients, 87% received and tolerated β-lactams during follow-up. Providers found the PATS valuable.
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Affiliation(s)
- Vima M. Patel
- Section of Allergy and Immunology, Division of Pulmonary Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian Chu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keith W. Hamilton
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cassandra Bellamy
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christina Harker
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua S. Bryer
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bridget Shields
- Department of Dermatology, University of Wisconsin, Madison, Wisconsin
| | - Rebecca L. Hirsh
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Olajumoke O. Fadugba
- Section of Allergy and Immunology, Division of Pulmonary Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert G. Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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21
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Samarakoon U, Accarino J, Wurcel AG, Jaggers J, Judd A, Blumenthal KG. Penicillin allergy delabeling: Opportunities for implementation and dissemination. Ann Allergy Asthma Immunol 2023; 130:554-564. [PMID: 36563744 DOI: 10.1016/j.anai.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/01/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Although existing as a safety measure to prevent iatrogenic harm, unconfirmed penicillin allergy labels have a negative impact on personal and public health. One downstream effect of unconfirmed penicillin allergy is the continued emergence and transmission of resistant bacteria and their associated health care costs. Recognizing the consequences of inaccurate penicillin allergy labels, professional and public health organizations have started promoting the adoption of proactive penicillin allergy evaluations, with the ultimate goal of removing the penicillin allergy label when the allergy is disproved, also known as penicillin allergy "delabeling." A penicillin allergy evaluation includes a comprehensive allergy history often followed by drug challenge, sometimes with preceding skin testing. Currently, penicillin allergy delabeling is largely carried out by allergy specialists in outpatient settings. Penicillin allergy delabeling is performed on inpatients, albeit rarely, often at the time of need, as a point-of-care procedure. Access to penicillin allergy evaluation services is limited. Recent studies demonstrate the feasibility of expanding penicillin allergy evaluations and delabeling to internists, pediatricians, emergency medicine physicians, infectious diseases specialists, and clinical pharmacists. However, reducing the impact of mislabeled penicillin allergy will require comprehensive efforts and new investments. In this review, we summarize the current practices of penicillin allergy delabeling and discuss expansion opportunities for penicillin allergy delabeling as quality improvement.
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Affiliation(s)
- Upeka Samarakoon
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John Accarino
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Alysse G Wurcel
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts; Tufts University School of Medicine, Boston, Massachusetts
| | - Jordon Jaggers
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Allen Judd
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, 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; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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22
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[Efficiency of the allergological study in the diagnosis of allergic reactions to beta-lactams]. Semergen 2023; 49:101866. [PMID: 36434940 DOI: 10.1016/j.semerg.2022.101866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/14/2022] [Accepted: 10/08/2022] [Indexed: 11/24/2022]
Abstract
AIMS Assessing the rate of β-lactams-allergic patients who are still labelled as such in their medical records after being performed an allergic test; as well as the rate of no allergic patients who were prescribed one of these antibiotics; and pondering whether the allergic test is hence cost-effective. METHODS This is a retrospective study developed from 2019 to 2021 focusing on patients suspected of β-lactams allergy (n=688). By means of an allergy test, it was cleared out if they were actually allergic. Later, we checked if the patient was still labelled as allergic in their medical record. Tracking through the digital health services card, we followed up if the antibiotic was ever prescribed again, and if the drug was then dispensed to the patient. RESULTS 11.3% of the patients showed hypersensitivity to β-lactams. Nonetheless, 33.1% of the patients were still considered allergic to these antibiotics in their medical record even though not being such. 32% of the patients - who had their allergy confirmed - had been labelled without the general practitioner's acknowledgment, and 32.8% had even been prescribed a β-lactam again. CONCLUSIONS Discarding any allergy to β-lactams is as important as registering the allergy on medical records after testing the patient. A remarkable quantity of non-allergic patients is still addressed as actual allergic, in spite not being such. Labelling patients as β-lactams allergic may have consequences, short-term and long-term, for the patient but also for the health service budget.
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23
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Niu T, Zhang Y, Li Z, Bian Y, Zhang J, Wang Y. The association between penicillin allergy and surgical site infection after orthopedic surgeries: a retrospective cohort study. Front Cell Infect Microbiol 2023; 13:1182778. [PMID: 37153141 PMCID: PMC10160653 DOI: 10.3389/fcimb.2023.1182778] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/03/2023] [Indexed: 05/09/2023] Open
Abstract
Background Cephalosporins are used as first-line antimicrobial prophylaxis for orthopedics surgeries. However, alternative antibiotics are usually used in the presence of penicillin allergy (PA), which might increase the risk of surgical site infection (SSI). This study aimed to analyze the relationship between SSI after orthopedic surgeries and PA among surgical candidates and related alternative antibiotic use. Methods In this single-center retrospective cohort study, we compared inpatients with and without PA from January 2015 to December 2021. The primary outcome was SSI, and the secondary outcomes were SSI sites and perioperative antibiotic use. Moreover, pathogen characteristics of all SSIs were also compared between the two cohorts. Results Among the 20,022 inpatient records, 1704 (8.51%) were identified with PA, and a total of 111 (0.55%) SSI incidents were reported. Compared to patients without PA, patients with PA had higher postoperative SSI risk (1.06%, 18/1704 vs. 0.51%, 93/18318), shown both in multivariable regression analysis (odds ratio [OR] 2.11; 95% confidence interval [CI], 1.26-3.50; p= 0.004) and propensity score matching (OR 1.84; 95% CI, 1.05-3.23; p= 0.034). PA was related to elevated deep SSI risk (OR 2.79; 95% CI, 1.47-5.30; p= 0.002) and had no significant impact on superficial SSI (OR 1.39; 95% CI, 0.59-3.29; p= 0.449). The PA group used significantly more alternative antibiotics. Complete mediation effect of alternative antibiotics on SSI among these patients was found in mediation analysis. Pathogen analysis revealed gram-positive cocci as the most common pathogen for SSI in our study cohort, while patients with PA had higher infection rate from gram-positive rods and gram-negative rods than non-PA group. Conclusion Compared to patients without PA, patients with PA developed more SSI after orthopedic surgeries, especially deep SSI. The elevated infection rate could be secondary to the use of alternative prophylactic antibiotics.
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Affiliation(s)
- Tong Niu
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuelun Zhang
- Medical Research Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ziquan Li
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yanyan Bian
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yipeng Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Yipeng Wang,
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24
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Kaminsky LW, Ghahramani A, Hussein R, Al-Shaikhly T. Penicillin Allergy Label Is Associated With Worse Clinical Outcomes in Bacterial Pneumonia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3262-3269. [PMID: 36182647 PMCID: PMC10129071 DOI: 10.1016/j.jaip.2022.08.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/19/2022] [Accepted: 08/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Penicillins (PCNs) are a first-line treatment option for bacterial pneumonia. PCN allergy label can delay antimicrobial treatment and result in the use of alternative antibiotic regimens risking an inadequate response to treatment and potentially increased adverse drug reactions. OBJECTIVE To investigate the impact of PCN allergy label on clinical outcomes of bacterial pneumonia. METHODS This retrospective cohort study used TriNetX, a web-based tool for population cohort research, to identify adult patients with and without PCN allergy label diagnosed with bacterial pneumonia. Cohorts were matched for baseline demographics and chronic medical conditions. The 30-day risks of hospitalization, acute respiratory failure, intubation, need for intensive level of care, and mortality were compared. Antibiotics used and their possible adverse reactions were explored. RESULTS After matching, there were 68,748 patients in each cohort. Patients with bacterial pneumonia with PCN allergy label had higher risks of hospitalization (risk ratio [RR], 1.23; 95% confidence interval [CI], 1.22-1.24), acute respiratory failure (RR, 1.14; 95% CI, 1.12-1.15), intubation (RR, 1.18; 95% CI, 1.13-1.22), intensive level of care (RR, 1.11; 95% CI, 1.08-1.14), and mortality (RR, 1.08; 95% CI, 1.04-1.13) compared with patients without PCN allergy label. Patients with PCN allergy label had decreased use of PCNs and cephalosporins and increased utilization of other antibiotic classes compared with patients without PCN allergy label. PCN allergy label was also associated with increased risk of adverse drug reactions. CONCLUSION PCN allergy label is associated with worse clinical outcomes in bacterial pneumonia, and risk mitigation strategies should be considered.
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Affiliation(s)
- Lauren W Kaminsky
- Section of Allergy, Asthma, and Immunology, Department of Medicine, Penn State College of Medicine, Hershey, Pa.
| | | | - Rezhan Hussein
- Division of Infectious Diseases, Department of Medicine, Penn State College of Medicine, Hershey, Pa
| | - Taha Al-Shaikhly
- Section of Allergy, Asthma, and Immunology, Department of Medicine, Penn State College of Medicine, Hershey, Pa
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25
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Waldron JL, Trubiano JA. Antibiotic allergy labels in immunocompromised populations. Transpl Infect Dis 2022; 24:e13955. [DOI: 10.1111/tid.13955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/11/2022] [Accepted: 07/25/2022] [Indexed: 01/15/2023]
Affiliation(s)
- Jamie L. Waldron
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases Austin Health Heidelberg Victoria Australia
| | - Jason A. Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases Austin Health Heidelberg Victoria Australia
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26
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Motzer AR, Holaday E, Axelrod P, Mishkin A. Effects of reported beta‐lactam allergies on pneumonia outcomes in lung transplant recipients. Transpl Infect Dis 2022; 24:e13906. [DOI: 10.1111/tid.13906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/03/2022] [Accepted: 06/08/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Andrew R. Motzer
- Lewis Katz School of Medicine at Temple University Philadelphia Pennsylvania USA
| | - Eric Holaday
- Virtua Medical Group Mount Laurel New Jersey USA
| | - Peter Axelrod
- Lewis Katz School of Medicine at Temple University Philadelphia Pennsylvania USA
| | - Aaron Mishkin
- Lewis Katz School of Medicine at Temple University Philadelphia Pennsylvania USA
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27
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Copaescu AM, James F, Vogrin S, Rose M, Chua K, Holmes NE, Turner NA, Stone C, Phillips E, Trubiano J. Use of a penicillin allergy clinical decision rule to enable direct oral penicillin provocation: an international multicentre randomised control trial in an adult population (PALACE): study protocol. BMJ Open 2022; 12:e063784. [PMID: 35940831 PMCID: PMC9364402 DOI: 10.1136/bmjopen-2022-063784] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Penicillin allergies are highly prevalent in the healthcare setting and associated with the prescription of second-line inferior antibiotics. More than 85% of all penicillin allergy labels can be removed by skin testing and 96%-99% of low-risk penicillin allergy labels can be removed by direct oral challenge. An internally and externally validated clinical assessment tool for penicillin allergy, PEN-FAST, can identify a low-risk penicillin allergy without the need for skin testing; a score of less than 3 has a negative predictive value of 96.3% (95% CI, 94.1 to 97.8) for the presence of a penicillin allergy. It is hypothesised that PEN-FAST is a safe and effective tool for assessing penicillin allergy in an outpatient clinic setting. METHODS AND ANALYSIS This is an international, multicentre randomised control trial using the PEN-FAST tool to risk-stratify penicillin allergy labels in adult outpatients. The study's primary objective is to evaluate the non-inferiority of using PEN-FAST score-guided management with direct oral challenge compared with standard care (defined as prick and intradermal skin testing followed by oral penicillin challenge). Participants will be randomised 1:1 to the intervention arm (direct oral penicillin challenge) or standard of care arm (skin testing followed by oral penicillin challenge, if skin testing is negative). The sample size of 380 randomised patients (190 per treatment arm) is required to demonstrate non-inferiority. ETHICS AND DISSEMINATION The study will be performed according to the guidelines of the Helsinki Declaration and is approved by the Austin Health Human Research Ethics Committee (HREC/62425/Austin-2020) in Melbourne Australia, Vanderbilt University Institutional Review Board (IRB #202174) in Tennessee, USA, Duke University Institutional Review Board (IRB #Pro00108461) in North Carolina, USA and McGill University Health Centre Research Ethics Board in Canada (PALACE/2022-7605). The results of this study will be published and presented in various scientific forums. TRIAL REGISTRATION NUMBER NCT04454229.
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Affiliation(s)
- Ana-Maria Copaescu
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Division of Allergy and Clinical Immunology, McGill University Health Centre (MUHC), Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Fiona James
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Victoria, Australia
| | - Morgan Rose
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Kyra Chua
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Natasha E Holmes
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Nicholas A Turner
- Department of Infectious Diseases, Duke University Medical Center, Durham, Carolina, USA
| | - Cosby Stone
- Department of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth Phillips
- Department of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Jason Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Zhang HL, Anesi JA, Hamilton KW, Cressman L, Bilker WB, Lautenbach E. The Impact of Reported β-Lactam Allergy on Clinical Outcomes and Antibiotic Use Among Solid Organ Transplant Recipients. Open Forum Infect Dis 2022; 9:ofac384. [PMID: 35983261 PMCID: PMC9379814 DOI: 10.1093/ofid/ofac384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background Reported β-lactam allergies (BLAs) are common and frequently inaccurate, but there are limited data on the clinical implications of BLA among solid organ transplant (SOT) recipients. We examined the impact of BLA on clinical outcomes and antibiotic use among SOT recipients. Methods This retrospective cohort study included adult patients undergoing single-organ heart, kidney, liver, lung, or pancreas transplant at a United States academic medical center from 1 April 2017 to 31 December 2020. Demographic and clinical data were collected from the electronic health record. Multivariate median regression was performed to evaluate the association between BLA and days alive and out of the hospital in the first 180 days posttransplant (DAOH180). Multivariate logistic regression was performed to evaluate the association between BLA and antibiotic use. Results Among 1700 SOT recipients, 285 (16.8%) had a BLA at the time of transplant. BLA was not associated with DAOH180 (adjusted median difference, -0.8 days [95% confidence interval {CI}, -2.7 to 1.2]; P = .43). Patients with BLA were more likely to receive intravenous vancomycin (adjusted odds ratio [aOR], 1.8 [95% CI, 1.3-2.6]; P < .001), clindamycin (aOR, 9.9 [95% CI, 5.1-18.9]; P < .001), aztreonam (aOR, 19.6 [95% CI, 5.9-64.4]; P < .001), fluoroquinolones (aOR, 3.8 [95% CI, 2.8-5.0]; P < .001), or aminoglycosides (aOR, 3.9 [95% CI, 2.5-6.2]; P < .001). Conclusions BLA was associated with use of β-lactam alternative antibiotics but not DAOH180 among SOT recipients.
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Affiliation(s)
- Helen L Zhang
- Correspondence: Helen L. Zhang, MD, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 Silverstein Ste. E, Philadelphia, PA 19104, USA ()
| | - Judith A Anesi
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Keith W Hamilton
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Leigh Cressman
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Warren B Bilker
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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29
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Olans RD, Olans RN, Marfatia R, Angoff GH. Inaccurate Penicillin Allergy Labeling, The Electronic Health Record, and Adverse Outcomes of Care. Jt Comm J Qual Patient Saf 2022; 48:552-558. [DOI: 10.1016/j.jcjq.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022]
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Lanoue D, van Walraven C. Association of antibiotic allergy labels with hospital length of stay. Ann Allergy Asthma Immunol 2022; 128:705-712. [PMID: 35292364 DOI: 10.1016/j.anai.2022.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Many antibiotic allergy labels (AAL) are invalid. Excluding true allergy in people with AAL ("delabeling") could improve health outcomes and decrease costs. Several studies with limited covariate adjustment have associated AAL with a prolonged hospital length of stay (LOS). OBJECTIVE This study determined whether AAL's association with LOS persisted after extensive adjustment for potential confounders and covariates. METHODS All nonpsychiatric admissions to a tertiary care teaching hospital from 2012 to 2015 were included. Generalized estimating equation methods were used to model the daily discharge likelihood as a function of AAL and other important factors (death risk score, daily discharge score, daily severity of illness score, antibiotic use, hospital day and location, weekend-holiday status, and service). RESULTS A total of 111,611 admissions (76,460 patients) were studied, in which 16,489 (14.8%) had recorded AAL. Patients with an AAL had a notably greater disease burden: they were older and had more comorbidities, greater health system utilization, and higher death risk. In the univariate analysis, AAL was associated with a significantly decreased daily discharge likelihood (odds ratio [OR], 0.93; [95% confidence interval, 0.90-0.95]). After adjustment for potential confounders and covariates, AAL was not associated with daily discharge likelihood (adjusted OR [aOR] without antibiotics: 1.00 [0.98-1.03]; aOR with antibiotics: 1.02 [0.99-1.04]). Similar results were also seen with penicillin AAL (aOR without antibiotics: 0.99 [0.95-1.02]; aOR with antibiotics: 1.00 [0.96-1.03]). CONCLUSION Antibiotic allergy label was strongly associated with a greater disease burden. After adjusting for important covariates, our analysis found no significant association between AAL and hospital LOS.
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Affiliation(s)
- Derek Lanoue
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Carl van Walraven
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada; Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada; International Credential Evaluation Service (ICES), British Columbia, Canada.
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31
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Bediako H, Dutcher L, Rao A, Sigafus K, Harker C, Hamilton KW, Fadugba O. Impact of an inpatient nurse-initiated penicillin allergy delabeling questionnaire. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e86. [PMID: 36483390 PMCID: PMC9726580 DOI: 10.1017/ash.2022.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/06/2022] [Indexed: 06/17/2023]
Abstract
Penicillin allergy delabeling is an important component of antimicrobial stewardship and improves patient outcomes. We demonstrated the successful use of a nurse-initiated questionnaire to remove inappropriate penicillin allergy labels in inpatients. Nurses can play a key role in improving antibiotic allergy assessment and more broadly in interprofessional antimicrobial stewardship.
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Affiliation(s)
- Hilary Bediako
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lauren Dutcher
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Aditi Rao
- Department of Nursing, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Kristen Sigafus
- Department of Nursing, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christina Harker
- Department of Nursing, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keith W. Hamilton
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Olajumoke Fadugba
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Infection prevention requirements for the medical care of immunosuppressed patients: recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute. GMS HYGIENE AND INFECTION CONTROL 2022; 17:Doc07. [PMID: 35707229 PMCID: PMC9174886 DOI: 10.3205/dgkh000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In Germany, guidelines for hygiene in hospitals are given in form of recommendations by the Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, "KRINKO"). The KRINKO and its voluntary work are legitimized by the mandate according to § 23 of the Infection Protection Act (Infektionsschutzgesetz, "IfSG"). The original German version of this document was published in February 2021 and has now been made available to the international professional public in English. The guideline provides recommendations on infection prevention and control for immunocompromised individuals in health care facilities. This recommendation addresses not only measures related to direct medical care of immunocompromised patients, but also management aspects such as surveillance, screening, antibiotic stewardship, and technical/structural aspects such as patient rooms, air quality, and special measures during renovations.
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Boesch TS, Eischen E, M AR, Quinn A, Dave A, Beezhold DW. Promoting β-lactam utilization through suppression of electronic medical record cross-allergy alerts. Am J Health Syst Pharm 2022; 79:S43-S52. [PMID: 35136927 DOI: 10.1093/ajhp/zxac040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Current literature surrounding management of patients with reported β-lactam allergies focuses on allergy delabeling. Standard clinical decision support tools have not been optimized to be compatible with the currently accepted cross-reaction rate of 1% to 2%. This potentially promotes use of non-β-lactam antibiotics, which are often not first-line therapy and may carry increased risks. The impact of electronic medical record (EMR) clinical decision support tool optimization on utilization of β-lactam antibiotics in β-lactam-allergic patients was evaluated. METHODS A retrospective pre-post β-lactam cross-allergy EMR alert suppression quality improvement intervention cohort study of β-lactam-allergic adult inpatients prescribed antibiotics was conducted. Preintervention baseline data were collected for an initial cohort admitted during September 2018. The intervention, in which clinical decision support rules were updated to display β-lactam cross-sensitivity allergy alerts only for β-lactam-allergic patients with documentation of organization-defined high-severity reactions of anaphylaxis, hives, and shortness of breath, was implemented August 20, 2019. The postintervention cohort included patients admitted during September 2019. RESULTS A 91% increase in the percentage of β-lactam-allergic patients who received a β-lactam agent at any time during their admission was noted after the intervention (26.6% vs 51%, P < 0.001). Statistically significant decreases in prescribing of alternative antibiotic classes were seen for fluoroquinolones (decrease from 45.3% to 26%, P < 0.001), aminoglycosides (decrease from 9.4% to 2.9%, P = 0.002), and aztreonam (decrease from 30% to 16.7%, P < 0.001). CONCLUSION EMR β-lactam cross-allergy alert optimization consistent with current literature significantly improved the utilization of alternative β-lactam subclasses, mostly through β-lactam prescribing as initial therapy in β-lactam-allergic patients.
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Affiliation(s)
- Teryl S Boesch
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Edward Eischen
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Amanda Ries M
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Andrea Quinn
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Ankur Dave
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
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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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Covington EW, Durham SH, Bland CM, Bookstaver PB, Chahine EB, Cho JC, Diggs F, Jones BM, Kyle JA, Stover KR, Wagner JL, Hughes PJ. A Continuing Education Activity Durably Addressed Knowledge Gaps Related to Penicillin Allergies Among Pharmacists and Pharmacy Technicians. J Pharm Technol 2021; 38:18-25. [DOI: 10.1177/87551225211051015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Penicillin allergy is one of the most frequent self-reported allergies; however, only about 10% of reported allergies are accurate. Objectives: Through the creation of a continuing pharmacy education (CPE) activity, we sought to assess knowledge gaps and comfort levels in the management of penicillin allergies. Methods: A 1-hour enduring-content CPE activity was offered as an interactive course from September 20, 2019, to September 20, 2020. Participants completed 3 surveys (pre-survey, post-survey, and follow-up survey). Participants were pharmacists and pharmacy technicians who completed, at a minimum, the activity and both pre- and post-surveys. The primary outcome was the percentage of participants scoring >80% on knowledge-based questions on the post-survey compared with the pre-survey. Secondary outcomes included pre-post comparisons on knowledge-based questions, participants’ self-report of an allergy, and comfort levels dispensing cephalosporins in a patient with a self-reported penicillin allergy. Results: A total of 389 participants completed the CPE activity, with 176 included for analysis. Significantly more participants scored >80% on knowledge-based questions on the post-survey compared with the pre-survey (71.6% vs 22.7%, P < .001). There was no significant difference between the percentage of participants scoring >80% on the post-survey and the follow-up survey (71.6% vs 65%, P = .119). The majority of participants (74%) felt comfortable dispensing a cephalosporin in a patient with a penicillin allergy on the pre-survey, with similar percentages on the post- and follow-up surveys (77% and 90%, respectively). Conclusion: A targeted continuing education program improved overall knowledge, which was sustained for up to 2 months.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce M. Jones
- St. Joseph’s/Candler Health System, Inc, Savannah, GA, USA
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Minaldi E, Phillips EJ, Norton A. Immediate and Delayed Hypersensitivity Reactions to Beta-Lactam Antibiotics. Clin Rev Allergy Immunol 2021; 62:449-462. [PMID: 34767158 DOI: 10.1007/s12016-021-08903-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 12/16/2022]
Abstract
Beta-lactam antibiotics are the most commonly reported drug allergy in adults and children. More than 95% of those with reported allergy labels to beta lactams are not confirmed when subjected to allergy testing. Beta lactam antibiotics are associated with a wide spectrum of immediate and delayed drug hypersensitivity reactions. The latency period to symptoms and clinical presentation aids in the causality assessment. Risk stratification based on diagnosis and timing then allows for appropriate management and evaluation. Skin prick testing, intradermal testing and oral challenge are well established for evaluation of immediate reactions. Delayed intradermal testing, patch testing and oral challenge can also be considered for evaluation of mild to moderate delayed reactions. Cross-reactivity between beta-lactams appears to be driven most commonly by a shared R1 side-chain. Standardized algorithms, protocols and pathways are needed for widespread implementation of a pragmatic and effective approach to patients reporting beta lactam allergy.
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Affiliation(s)
- Ellen Minaldi
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Allison Norton
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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Nelson J, Carrillo-Martin I, Bosch W, Brumble L, Oring JM, Park MA, Gonzalez-Estrada A. Outcomes in hospitalized kidney transplant patients with a penicillin allergy label in the United States, 2005-2014. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:867-869.e2. [PMID: 34673288 DOI: 10.1016/j.jaip.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 09/29/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Jared Nelson
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Fla
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Fla
| | - Lisa Brumble
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Fla
| | - Justin M Oring
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Fla
| | - Miguel A Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla.
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Burden of antibiotic allergy labels in Australian aged care residents: Findings from a national point-prevalence survey. Infect Control Hosp Epidemiol 2021; 41:641-644. [PMID: 32188526 DOI: 10.1017/ice.2020.53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the prevalence of antibiotic allergy labels (AALs) in Australian aged care residents and to describe the impact of labels on antibiotic prescribing practices. DESIGN Point-prevalence survey. SETTING Australian residential aged care facilities. PARTICIPANTS We surveyed 1,489 residents in 407 aged care facilities. METHODS Standardized data were collected on a single day between June 1 and August 31, 2018, for residents prescribed an antibiotic. An AAL was reported if it was documented in the resident's health record. Resident-level data were used to calculate overall prevalence, and antibiotic-level data were used to report relative frequency of AALs for individual antibiotics and classes. RESULTS Among 1,489 residents, 356 (24%) had 1 or more documented AALs. The AALs for penicillin (28.3%), amoxicillin or amoxicillin/clavulanic acid (10.5%), cefalexin (7.2%), and trimethoprim (7.0%) were most commonly reported. The presence of an AAL was associated with significantly less prescribing of penicillins (OR, 0.43; 95% CI, 0.31-0.62; P < .001) and significantly more prescribing of lincosamides (OR, 4.81; P < .001), macrolides (OR, 2.03; P = .007), and tetracyclines (OR, 1.54; P = .033). Of residents with AALs, 7 residents (1.9%) were prescribed an antibiotic that was listed on the allergy section of their health record. CONCLUSIONS A high prevalence of AALs was observed among residents of Australian aged care facilities, comparable to the prevalence of AALs in high-risk hospitalized patients. Significant increases in prescribing of lincosamide, macrolide, and tetracycline agents poses a potential risk to aged populations, and future studies must evaluate the benefits of AAL delabelling programs tailored for aged care settings.
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Leone M, Zunino C, Pauly V, Mathieu C, Antonini F, Orlean V, Cassir N, Pradel V, Bourenne J, Boussen S, Hraiech S, Lagier D, Vitte J, Wiramus S, Zieleskiewicz L, Papazian L, Boyer L. Beta-lactam allergy labeling in intensive care units: An observational, retrospective study. Medicine (Baltimore) 2021; 100:e26494. [PMID: 34232182 PMCID: PMC8270612 DOI: 10.1097/md.0000000000026494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/22/2021] [Accepted: 06/08/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT This retrospective study aimed to describe the association between the "β-lactam allergy" labeling (BLAL) and the outcomes of a cohort of intensive care unit (ICU) patients.Retrospective cohort study.Seven ICU of the Aix Marseille University Hospitals from Marseille in France.We collected the uses of the label "β-lactam allergy" in the electronic medical files of patients aged 18 years or more who required more than 48 hours in the ICU with mechanical ventilation and/or vasopressors admitted to 7 ICUs of a single institution.We retrospectively compared the patients with this labeling (BLAL group) with those without this labeling (control group).The primary outcome was the duration of ICU stay. Among the 7146 patients included in the analysis, 440 and 6706 patients were classified in the BLAL group and the control group, respectively. The prevalence of BLAL was 6.2%. In univariate and multivariate analyses, BLAL was weakly or not associated with the duration of ICU and hospital stays (respectively, 6 [3-14] vs 6 [3-14] days, standardized beta -0.09, P = .046; and 18 [10-29] vs 15 [8-28] days, standardized beta -0.09, P = .344). In multivariate analysis, the ICU and 28-day mortality rates were both lower in the BLAL group than in the control group (aOR 0.79 95% CI [0.64-0.98] P = .032 and 0.79 [0.63-0.99] P = .042). Antibiotic use differed between the 2 groups, but the outcomes were similar in the subgroups of septic patients in the BLAL group and the control group.In our cohort, the labeling of a β-lactam allergy was not associated with prolonged ICU and hospital stays. An association was found between the labeling of a β-lactam allergy and lower ICU and 28-day mortality rates.Trial registration: Retrospectively registered.
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Affiliation(s)
- Marc Leone
- Aix Marseille Université, Hôpitaux Universitaires de Marseille, Service d’Anesthésie et de Réanimation, Hôpital Nord
- Aix Marseille Université, IRD, AP-HM, MEPHI
| | - Claire Zunino
- Aix Marseille Université, Hôpitaux Universitaires de Marseille, Service d’Anesthésie et de Réanimation, Hôpital Nord
| | - Vanessa Pauly
- Aix Marseille Université, School of Medicine – La Timone Medical Campus, EA 3279, CEReSS – Health Service Research and Quality of Life Center
| | - Calypso Mathieu
- Aix Marseille Université, Hôpitaux Universitaires de Marseille, Service d’Anesthésie et de Réanimation, Hôpital Nord
| | - François Antonini
- Aix Marseille Université, Hôpitaux Universitaires de Marseille, Service d’Anesthésie et de Réanimation, Hôpital Nord
| | - Veronica Orlean
- Aix Marseille Université, School of Medicine – La Timone Medical Campus, EA 3279, CEReSS – Health Service Research and Quality of Life Center
| | | | - Vincent Pradel
- Aix Marseille Université, School of Medicine – La Timone Medical Campus, EA 3279, CEReSS – Health Service Research and Quality of Life Center
| | - Jérémy Bourenne
- Aix Marseille Université, Hôpitaux Universitaires de Marseille, Service de Réanimation Médicale, Timone University Hospital, 13005 Marseille
| | - Salah Boussen
- LBA, UMRT 24, Aix Marseille Université-IFSTTAR, Boulevard Pierre Dramard 13916 Marseille Cedex 20
- Department of Anesthesiology and Intensive Care, Timone University Hospital, 264 Rue Saint-Pierre
| | - Sami Hraiech
- Aix Marseille Université, Hôpitaux Universitaires de Marseille, Service de Réanimation des Détresses Respiratoires, Hôpital Nord
| | - David Lagier
- Aix Marseille Université, Hôpitaux Universitaires de Marseille, Service d’Anesthésie et de Réanimation 2 Adultes, Timone University Hospital
| | | | - Sandrine Wiramus
- Aix Marseille Université, Hôpitaux Universitaires de Marseille, Service d’Anesthésie et de Réanimation, Hôpital de la Conception, 13005 Marseille, France
| | - Laurent Zieleskiewicz
- Aix Marseille Université, Hôpitaux Universitaires de Marseille, Service d’Anesthésie et de Réanimation, Hôpital Nord
| | - Laurent Papazian
- Aix Marseille Université, Hôpitaux Universitaires de Marseille, Service de Réanimation des Détresses Respiratoires, Hôpital Nord
| | - Laurent Boyer
- Aix Marseille Université, School of Medicine – La Timone Medical Campus, EA 3279, CEReSS – Health Service Research and Quality of Life Center
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Yuson C, Shakib S, Smith W. Prevalence of drug allergy in South Australia. Intern Med J 2021; 52:1957-1961. [PMID: 34160122 DOI: 10.1111/imj.15440] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Drug allergy is commonly reported in patient notes and electronic health records. The prevalence of self-reported drug allergy in the general Australian population has not previously been studied. METHODS We surveyed a representative sample of the South Australian adult population regarding their own perception of drug allergy, including drug type and severity as well as the use of medical alert devices. Data were weighted to correspond to age and sex of the South Australian population. RESULTS 22.2% of adults in South Australia consider themselves allergic to one or more drugs, 9.3% declared themselves to be allergic to penicillin, 5% to an antibiotic other than penicillin, and 13% to one or more antibiotics. Drug allergy and penicillin allergy was significantly more prevalent in females, and increased with age. Thirteen percent of those with an antibiotic allergy reported a severe reaction, of whom 27% wore a medical notification device. Of those allergic to penicillin, 75% had their index reaction more than 10 years ago and did not report severe features. DISCUSSION Self-reported drug allergy is common in the general population, as it is in medical clinic and hospital populations. The majority of those reporting penicillin allergy would be considered low-risk and suitable for delabelling procedures. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Carlo Yuson
- Immunology and Allergy Department, Royal Adelaide Hospital, Adelaide, Australia
| | - Sepehr Shakib
- Clinical Pharmacology Department, Royal Adelaide Hospital, Adelaide, Australia
| | - William Smith
- Immunology and Allergy Department, Royal Adelaide Hospital, Adelaide, Australia
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Naureckas Li C, Fu X, Mancini CM, Zhang Y, Blumenthal KG. Association of beta-lactam allergy documentation and antibiotic use in patients with febrile neutropenia. Ann Allergy Asthma Immunol 2021; 127:275-277. [PMID: 34010699 DOI: 10.1016/j.anai.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/29/2021] [Accepted: 05/09/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Caitlin Naureckas Li
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts; Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Christian M Mancini
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Yuqing Zhang
- Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Kimberly G Blumenthal
- Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts.
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Jaffa RK, Hammer J, Medaris LA, Anderson WE, Heffner AC, Pillinger KE. Empiric aztreonam is associated with increased mortality compared to beta-lactams in septic shock. Am J Emerg Med 2021; 48:255-260. [PMID: 34004470 DOI: 10.1016/j.ajem.2021.04.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/10/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To determine if aztreonam as initial empiric treatment of adult septic shock is associated with increased mortality compared to the use of anti-pseudomonal beta-lactam agents. METHODS This was a multicenter, retrospective cohort study of 582 adult emergency department patients admitted to 12 acute care facilities within a single health system from January 2014 to December 2017 with septic shock receiving either aztreonam or an anti-pseudomonal beta-lactam for empiric treatment and discharged with an infection-related ICD-9 or ICD-10 code. The primary endpoint was in-hospital mortality. RESULTS Initial exposure to aztreonam was associated with increased hospital mortality compared to treatment with an anti-pseudomonal beta-lactam agent (22.7% vs. 12.9%, OR = 1.98, 95% CI: 1.27-3.11). When adjusted for APACHE II score, the treatment group effect on mortality remained statistically significant (OR = 1.74, 95% CI: 1.08-2.80). Aztreonam use was also associated with increased utilization of aminoglycosides (28.9% vs. 12.4%, p < 0.0001) and fluoroquinolones (50.5% vs. 25.8%, p < 0.01). There was no difference in hospital or intensive care unit length of stay in surviving patients between the two groups. CONCLUSIONS Compared to anti-pseudomonal beta-lactams, empiric treatment with aztreonam is associated with increased mortality and greater antibiotic exposure among patients with acute septic shock. These findings suggest that treatment with anti-pseudomonal beta-lactams should be prioritized over allergy avoidance whenever feasible.
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Affiliation(s)
- Rupal K Jaffa
- Division of Pharmacy, Atrium Health's Carolinas Medical Center, United States of America.
| | - John Hammer
- Division of Pharmacy, Atrium Health's Carolinas Medical Center, United States of America.
| | - Leigh Ann Medaris
- Department of Infectious Diseases, Atrium Health's Carolinas Medical Center, United States of America.
| | - William E Anderson
- Center for Outcomes Research and Evaluation, Atrium Health's Carolinas Medical Center, United States of America
| | - Alan C Heffner
- Department of Internal Medicine, Division of Critical Care, Atrium Health's Carolinas Medical Center, United States of America; Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, United States of America.
| | - Kelly E Pillinger
- University of Rochester Medical Center - Strong Memorial Hospital, United States of America.
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Turner NA, Wrenn R, Sarubbi C, Kleris R, Lugar PL, Radojicic C, Moehring RW, Anderson DJ. Evaluation of a Pharmacist-Led Penicillin Allergy Assessment Program and Allergy Delabeling in a Tertiary Care Hospital. JAMA Netw Open 2021; 4:e219820. [PMID: 33983399 PMCID: PMC8120333 DOI: 10.1001/jamanetworkopen.2021.9820] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Penicillin allergies are frequently mislabeled, which may contribute to use of less-preferred alternative antibiotics. OBJECTIVE To evaluate a pharmacist-led allergy assessment program's association with antimicrobial use and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS A pharmacist-led allergy assessment program was launched in 2 phases (June 1, 2015, and November 2, 2016) at a single-center tertiary referral hospital. The longitudinal cross-sectional study included all study period adult admissions; hospitalwide outcomes were assessed by segmented regression. Individual outcomes were assessed within an embedded propensity score-matched case-control study of inpatients undergoing comprehensive allergy assessment following self-report of penicillin allergy. Analysis occurred from March 1, 2020, to February 29, 2020. EXPOSURES The longitudinal study analyzed hospital-level outcomes over 3 periods: preintervention (15 months), phase 1 (structured allergy history alone, 16 months), and phase 2 (comprehensive assessment including penicillin skin testing, 52 months). The case-control study defined cases as individuals undergoing comprehensive allergy assessment. MAIN OUTCOMES AND MEASURES Hospital-level outcomes included antibiotic days of therapy per 1000 patient-days and hospital-acquired Clostridioides difficile infection (CDI) incidence per 10 000 patient-days. Individual outcomes included antibiotic selection, overall survival, and CDI-free survival. RESULTS Longitudinal analysis spanned 2014-2020 (median admissions, 46 416 per year; interquartile range [IQR], 46 001-50 091 per year). Hospitalwide, allergy histories were temporally associated with decreased use of nonpenicillin alternative antibiotics (rate ratio, 0.87; 95% CI, 0.79-0.97) and high-CDI-risk antibiotics (rate ratio, 0.91; 95% CI, 0.85-0.98). Penicillin skin testing was temporally associated with lower hospital-acquired CDI rates (rate ratio, 0.61; 95% CI, 0.43-0.86). The embedded case-control study included 272 cases and 819 controls. Median age was 63 years (interquartile range, 51-73 years), 553 (50.7%) patients were women, and 229 (21.0%) patients were Black. Allergy-assessed patients were less likely to receive high-CDI-risk antibiotics at discharge (odds ratio, 0.66; 95% CI, 0.44-0.98). Estimated reductions in mortality (hazard ratio, 0.77; 95% CI, 0.55-1.07) and hospital-acquired CDI risk (hazard ratio, 0.53; 95% CI, 0.18-1.55) were not statistically significant. CONCLUSIONS AND RELEVANCE Pharmacist-led allergy assessments may be associated with reduced high-CDI-risk antibiotic use at both hospitalwide and individual levels. Although individual reductions in mortality and CDI risk did not achieve significance, divergence of survival curves suggest longer-term benefits of allergy delabeling warrant future study.
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Affiliation(s)
- Nicholas A. Turner
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Rebekah Wrenn
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | | | - Renee Kleris
- Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Patricia L. Lugar
- Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Christine Radojicic
- Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Rebekah W. Moehring
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Deverick J. Anderson
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
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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: 52] [Impact Index Per Article: 17.3] [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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45
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Shenoy ES, Ramsey A. Carved in Stone with Consequences: Antibiotic Allergy Labels in Transplant Patients. Clin Infect Dis 2021; 71:1595-1597. [PMID: 31621837 DOI: 10.1093/cid/ciz1028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/11/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Erica S Shenoy
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.,Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Allison Ramsey
- Allergy and Immunology, Rochester Regional Health, Rochester, New York, USA.,University of Rochester, Rochester, New York, USA
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46
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Brown M, Uzoma J, Vansice R, Mahan K, Conn KM, Ramsey A, Staicu ML. Examining the impact of a penicillin allergy skin testing brochure on inpatient perceptions: A pre-post intervention study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:1736-1737.e3. [PMID: 33181343 DOI: 10.1016/j.jaip.2020.10.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 09/25/2020] [Accepted: 10/22/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Mikaela Brown
- Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY
| | - Joy Uzoma
- Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY; Rochester General Hospital, Rochester, NY
| | - Ryan Vansice
- Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY; Rochester General Hospital, Rochester, NY
| | | | - Kelly M Conn
- Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY
| | - Allison Ramsey
- Rochester General Hospital, Rochester, NY; University of Rochester School of Medicine and Dentistry, Rochester, NY
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47
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Gateman DP, Rumble JE, Protudjer JLP, Kim H. Amoxicillin oral provocation challenge in a primary care clinic: a descriptive analysis. CMAJ Open 2021; 9:E394-E399. [PMID: 33863797 PMCID: PMC8084548 DOI: 10.9778/cmajo.20200077] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Penicillin is the most frequently reported drug allergen; however, most of these allergies are not true allergies and do not justify the prescription of alternative, less effective and more expensive antibiotic drugs. We aimed to show that patients at low risk of amoxicillin allergy can safely and efficiently undergo oral provocation challenge (OPC) by their primary care physician. METHODS In this descriptive analysis, we conducted a retrospective chart review of all primary care patients who had undergone OPC from November 2017 to October 2019 in the Amoxicillin Allergy Clinic at the North Perth Family Health Team, Listowel, Ontario. Eligibility for OPC among patients 18 months and older was determined through review of a self-reported patient intake form asking about symptoms, onset, duration, history and family history of allergic reactions, as well as the patient's electronic medical record. Patients were considered to be at low risk of true penicillin allergy if there was no history of anaphylaxis or severe cutaneous reactions. Those with low-risk allergic reactions returned for testing with an OPC to amoxicillin. We collected data on clinical characteristics, antibiotic exposure, parental drug allergy, response to OPC and wait time from referral. We used t tests to describe and compare these variables. Our primary outcome was reaction to OPC by severity as categorized by the World Allergy Organization grading system. Our secondary outcome was the time from referral to completed testing. RESULTS In total, we included 99 patients (mean age 28.3, standard deviation [SD] 21.2 yr); 72 (73%) were female. Of those tested, 97% (n = 96) completed the OPC with no reaction, 3% (n = 3) had mild immediate reactions, and no serious immediate reactions developed. Mean wait time to testing was 59.0 (SD 69.8) days, with a median (interquartile range) of 39.5 (13.5-70.0) days. INTERPRETATION Oral provocation challenge presents a safe and accessible opportunity for primary care providers to address erroneous allergy labels to penicillin and related drugs within the primary care office setting. There could be positive public health implications if OPC to penicillin drugs is implemented in primary care.
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Affiliation(s)
- Derek Paul Gateman
- Department of Family Medicine (Gateman), McMaster University, Kitchener, Ont.; Department of Family Medicine (Gateman), Western University, Kitchener, Ont.; North Perth Family Health Team (Rumble), Listowel, Ont.; Departments of Pediatrics and Child Health, and Food and Human Nutritional Sciences (Protudjer), University of Manitoba; George & Fay Yee Centre for Healthcare Innovation (Protudjer); The Children's Hospital Research Institute of Manitoba (Protudjer), Winnipeg, Man.; Department of Medicine (Kim), Western University; Department of Medicine (Kim), McMaster University, Kitchener, Ont.
| | - Jessie Erin Rumble
- Department of Family Medicine (Gateman), McMaster University, Kitchener, Ont.; Department of Family Medicine (Gateman), Western University, Kitchener, Ont.; North Perth Family Health Team (Rumble), Listowel, Ont.; Departments of Pediatrics and Child Health, and Food and Human Nutritional Sciences (Protudjer), University of Manitoba; George & Fay Yee Centre for Healthcare Innovation (Protudjer); The Children's Hospital Research Institute of Manitoba (Protudjer), Winnipeg, Man.; Department of Medicine (Kim), Western University; Department of Medicine (Kim), McMaster University, Kitchener, Ont
| | - Jennifer L P Protudjer
- Department of Family Medicine (Gateman), McMaster University, Kitchener, Ont.; Department of Family Medicine (Gateman), Western University, Kitchener, Ont.; North Perth Family Health Team (Rumble), Listowel, Ont.; Departments of Pediatrics and Child Health, and Food and Human Nutritional Sciences (Protudjer), University of Manitoba; George & Fay Yee Centre for Healthcare Innovation (Protudjer); The Children's Hospital Research Institute of Manitoba (Protudjer), Winnipeg, Man.; Department of Medicine (Kim), Western University; Department of Medicine (Kim), McMaster University, Kitchener, Ont
| | - Harold Kim
- Department of Family Medicine (Gateman), McMaster University, Kitchener, Ont.; Department of Family Medicine (Gateman), Western University, Kitchener, Ont.; North Perth Family Health Team (Rumble), Listowel, Ont.; Departments of Pediatrics and Child Health, and Food and Human Nutritional Sciences (Protudjer), University of Manitoba; George & Fay Yee Centre for Healthcare Innovation (Protudjer); The Children's Hospital Research Institute of Manitoba (Protudjer), Winnipeg, Man.; Department of Medicine (Kim), Western University; Department of Medicine (Kim), McMaster University, Kitchener, Ont
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48
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Gilissen L, Spriet I, Gilis K, Peetermans WE, Schrijvers R. Prevalence of Antibiotic Allergy Labels in a Tertiary Referral Center in Belgium. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2415-2425.e8. [PMID: 33607341 DOI: 10.1016/j.jaip.2021.01.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/08/2021] [Accepted: 01/31/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antibiotic (AB) allergies are among the most frequently occurring adverse drug reactions. In US literature, AB allergy labels (AAL) are reported in 10% to 15% of patients' charts; however, large-scale European analyses are scarce. OBJECTIVES To retrospectively assess the prevalence of AAL in a tertiary referral hospital in Belgium between 2010 and 2018. METHODS Patients who consulted and/or were hospitalized during the study period, who had been labeled with an AB allergy, were selected for further analysis. RESULTS Of 1,009,598 unique patients (outpatients, n = 736,469; inpatients, n = 273,129), 28,147 patients (3%) were registered with 1 or more AAL, being 1% of outpatients (n = 9562) and 7% of inpatients (n = 18,585). Women were more likely to carry an AAL (68%) compared with men (32%, P < .001). In patients with an AAL, 9% had multiple labels and 5% had labels for multiple AB classes. Most frequently, beta-lactams were involved (84% of AAL), followed by quinolones (7%) and sulfonamides and macrolides (both 3%). Moreover, 88% of the reactions were self-reported, mostly being an unspecified rash (53%), whereas only 3% were considered confirmed AAL. CONCLUSION With an overall prevalence of 3%, the burden of AAL is less in our Western European center compared with US reports. However, this prevalence most likely still represents an overestimation of genuine AB allergic patients because most labels lack confirmation and/or specifications. Our work indicates that knowledge of the local epidemiology of AAL is necessary to estimate the impact of better allergy labeling and delabeling strategies.
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Affiliation(s)
- Liesbeth Gilissen
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium; Department of Dermatology, Contact Allergy Unit, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium; Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Karin Gilis
- Information Technology Department, University Hospitals Leuven, Leuven, Belgium
| | - Willy E Peetermans
- Department of Microbiology, Immunology and Transplantation, Laboratory for Clinical Infectious and Inflammatory Disorders, KU Leuven, Leuven, Belgium; Department of General Internal Medicine, Infectiology Unit, University Hospitals Leuven, Leuven, Belgium
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium; Department of General Internal Medicine, Division of Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium.
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49
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Blumenthal KG, Oreskovic NM, Fu X, Shebl FM, Mancini CM, Maniates JM, Walensky RP. High-cost, high-need patients: the impact of reported penicillin allergy. AMERICAN JOURNAL OF MANAGED CARE 2021; 26:154-161. [PMID: 32270982 DOI: 10.37765/ajmc.2020.42832] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES More than 90% of patients who report a penicillin allergy have the allergy disproved when tested. Unnecessary use of alternative (non-beta-lactam) antibiotics can result in more treatment failures and adverse reactions. We described the prevalence and impact of a reported penicillin allergy in high-cost, high-need (HCHN) patients. STUDY DESIGN Retrospective cohort. METHODS We identified HCHN patients in a care management program of an urban academic medical center (January 1, 2014, to December 31, 2016). We used multivariable logistic regression models to determine the association between a reported penicillin allergy and antibiotic use. We used multivariable Poisson regression models to determine the association between a reported penicillin allergy, with or without multiple drug intolerance syndrome (MDIS; ≥3 reported drug allergies), and healthcare resource utilization (HRU). RESULTS Of 1870 HCHN patients, 383 (20%) reported penicillin allergy, 835 (45%) had MDIS, and 290 (16%) had both. HCHN patients reporting penicillin allergy had an increased odds of beta-lactam alternative antibiotic use (adjusted odds ratio, 3.84; 95% CI, 2.17-6.80). HRU was significantly higher for patients reporting a penicillin allergy alone (adjusted relative risk [aRR], 1.13; 95% CI, 1.03-1.25) and with concurrent MDIS (aRR, 1.20; 95% CI, 1.08-1.34). CONCLUSIONS HCHN patients had a high burden of reported drug allergy. A reported penicillin allergy conferred a 4-fold increased odds of beta-lactam alternative antibiotic use. Reporting penicillin allergy, with and without MDIS, was associated with significantly more HRU. HCHN care management programs should consider systematic drug allergy evaluations to optimize antibiotic use in these fragile patients.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, The Medical Practice Evaluation Center, The Mongan Institute, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114.
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50
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Fathi A, Hennigs A, Addo MM. [Less is more… in infectious diseases]. Internist (Berl) 2021; 62:373-378. [PMID: 33580310 DOI: 10.1007/s00108-021-00967-5] [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] [Accepted: 01/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The increasing development of antimicrobial resistance has been identified as one of the greatest threats to public health and is caused to a relevant extent by falsely indicated antibiotic treatment. OBJECTIVE The main aim of this article is to identify areas in infectious disease diagnostics and treatment where overuse occurs and to provide recommendations on how to avoid it. MATERIAL AND METHODS The authors identified current and relevant studies on the topic of medical overuse in infectious diseases via a literature search. In particular, contributions from international "less is more" initiatives were included. The focus was on areas in which a reduction of diagnostic and therapeutic measures leads to an optimization of patient outcomes. RESULTS In many cases overuse in the context of diagnostics and treatment of infectious diseases not only leads to an unnecessary financial burden on the healthcare system and is not beneficial but can also increase the risk of development of antimicrobial resistance and have adverse consequences for patients. CONCLUSION Correct indications as well as focused selection and adequate application of antimicrobial agents is crucial to provide the best possible medical care. Diagnostic and antibiotic stewardship measures, which should be implemented in collaboration with infectious disease specialists, can help to identify and reduce areas of overuse and misuse.
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Affiliation(s)
- A Fathi
- Medizinische Klinik und Poliklinik, Sektion Infektiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - A Hennigs
- Medizinische Klinik und Poliklinik, Sektion Infektiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - M M Addo
- Medizinische Klinik und Poliklinik, Sektion Infektiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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