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Sanders S, Barratt A, Buchbinder R, Doust J, Kazda L, Jones M, Glasziou P, Bell K. Evidence for overdiagnosis in noncancer conditions was assessed: a metaepidemiological study using the 'Fair Umpire' framework. J Clin Epidemiol 2024; 165:111215. [PMID: 37952702 DOI: 10.1016/j.jclinepi.2023.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES To evaluate the strength of the evidence for, and the extent of, overdiagnosis in noncancer conditions. STUDY DESIGN AND SETTING We systematically searched for studies investigating overdiagnosis in noncancer conditions. Using the 'Fair Umpire' framework to assess the evidence that cases diagnosed by one diagnostic strategy but not by another may be overdiagnosed, two reviewers independently identified whether a Fair Umpire-a disease-specific clinical outcome, a test result or risk factor that can determine whether an additional case does or does not have disease-was present. Disease-specific clinical outcomes provide the strongest evidence for overdiagnosis, follow-up or concurrent tests provide weaker evidence, and risk factors provide only weak evidence. Studies without a Fair Umpire provide the weakest evidence of overdiagnosis. RESULTS Of 132 studies, 47 (36%) did not include a Fair Umpire to adjudicate additional diagnoses. When present, the most common Umpire was a single test or risk factor (32% of studies), with disease-specific clinical outcome Umpires used in only 21% of studies. Estimates of overdiagnosis included 43-45% of screen-detected acute abdominal aneurysms, 54% of cases of acute kidney injury, and 77% of cases of oligohydramnios in pregnancy. CONCLUSION Much of the current evidence for overdiagnosis in noncancer conditions is weak. Application of the framework can guide development of robust studies to detect and estimate overdiagnosis in noncancer conditions, ultimately informing evidence-based policies to reduce it.
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Affiliation(s)
- Sharon Sanders
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia.
| | - Alexandra Barratt
- Sydney School of Public Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3800, Australia
| | - Jenny Doust
- Centre for Longitudinal and Life Course Research, School of Public Health, University of Queensland, Herston, Queensland 4006, Australia
| | - Luise Kazda
- NHMRC Healthy Environments And Lives (HEAL) National Research Network, National Centre for Epidemiology and Population Health, College of Health and Medicine, The Australian National University, Canberra, Australian Capital Territory 2601, Australia
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia
| | - Katy Bell
- Sydney School of Public Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
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Vyas L, Raja K, Morrison S, Beggs D, Attalla MS, Patel M, Philips M. Beta-lactam comprehensive allergy management program in a community medical center. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e189. [PMID: 38028889 PMCID: PMC10654959 DOI: 10.1017/ash.2023.461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 12/01/2023]
Abstract
Objective The Beta-lactam Comprehensive Allergy Management Program (CAMP) was implemented to facilitate complete beta-lactam allergy history documentation in the electronic medical record (EMR) and increase beta-lactam utilization. The study objective was to assess the rate of complete allergy histories and days of antimicrobial therapy (DOT) before versus after CAMP implementation. Design Quasi-experimental study with interrupted time-series analysis. Setting Non-teaching, urban, and community medical center within a multi-hospital health system. Patients Adult inpatients with a beta-lactam allergy receiving antimicrobial therapy. Methods The multidisciplinary CAMP team screened, interviewed, and collected allergy history details of adult inpatients with a beta-lactam allergy receiving antimicrobial therapy starting January 4, 2021. Patients were stratified as high, moderate, or low risk of IgE-mediated allergy and referred to an allergist for skin testing or drug challenge. The EMR was updated with interview details and drug challenge or skin test results. The primary endpoint was rate of complete allergy history documentation before (12/1/18-4/1/19) compared to after (1/4/21-5/1/21) program implementation. The secondary endpoint was days of inpatient beta-lactam therapy. Implementation logistics, de-labeling rate, and antimicrobial therapy changes were evaluated. Results The program evaluated 392 individuals, with 184 and 208 patients comprising the pre- and post-intervention groups, respectively. The post-intervention period was associated with an increase of 19.8% in complete allergy histories (0.359 PPc; R 2 0.26; p = 0.002) and 9.34 beta-lactam DOT per 1,000-days-present (1.106 PPc; R 2 0.194; p = 0.009). Conclusion Implementation of a comprehensive beta-lactam allergy management program was associated with higher rates of complete beta-lactam allergy history and beta-lactam use.
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Affiliation(s)
- Lakhini Vyas
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
| | - Karan Raja
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
- Ernest Mario School of Pharmacy, Rutgers University, New Brunswick, NJ, USA
| | - Susan Morrison
- Department of Medicine, Clara Maass Medical Center, Belleville, NJ, USA
| | - Donald Beggs
- Department of Medicine, Clara Maass Medical Center, Belleville, NJ, USA
| | - Mark S. Attalla
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
| | - Mitesh Patel
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
| | - Mona Philips
- Pharmacy Department, Clara Maass Medical Center, Belleville, NJ, USA
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Gaudin C, Ryan D, Demoly P, Tanno LK. Drug allergy in primary care: systematic review to support quality improvement initiative of management and optimization of healthcare pathways. Curr Opin Allergy Clin Immunol 2023; 23:263-270. [PMID: 37357792 DOI: 10.1097/aci.0000000000000924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the practice of general practitioners (GPs) in regard to the diagnosis and management of drug hypersensitivity reactions (DHRs) to identify major challenges and to facilitate the development of decision support tools to GPs confronted with DHRs patients. RECENT FINDINGS DHRs are still a challenge in the GPs clinical practice, which implies difficulties in clinical decisions and referral to allergy specialists. SUMMARY DHRs can range from mild to severe and even life-threatening. Drugs are the main cause of anaphylaxis deaths in most countries. Most DHRs are firstly seen by GPs, paediatricians or emergency doctors. However, our systematic review demonstrated difficulties in differentiating DHRs from other drug side effects. Most DHRs epidemiological data are from hospital and emergency departments, which may not reflect the real-life experience in primary care. GPs should be aware of the alert signs of DHRs: the involvement of other systems beyond the skin and/or atypical skin/ mucosal involvement, which mandated immediate referral to an emergency department. Data still stress difficulties in the recognition of DHRs clinical manifestations and highlight the need for decision aids to support their management by GPs. Structured clinical history and clinical examination are key diagnostic tools. Reasons for referring to allergy specialists based on the literature are to investigate cause, to undergo specific procedure, such as desensitization and to identify well tolerated, alternative drugs.
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Affiliation(s)
- Clara Gaudin
- University Hospital of Montpellier, Montpellier, France
| | - Dermot Ryan
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, UK
| | - Pascal Demoly
- University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA-11, University of Montpellier - INSERM
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Luciana Kase Tanno
- University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA-11, University of Montpellier - INSERM
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
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Sijbom M, Braun KK, Büchner FL, van Bodegom-Vos L, Hendriks BJC, de Boer MGJ, Numans ME, Lambregts MMC. Cues to improve antibiotic-allergy registration: A mixed-method study. PLoS One 2022; 17:e0266473. [PMID: 35390063 PMCID: PMC8989191 DOI: 10.1371/journal.pone.0266473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/21/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Approximately 2% of patients in primary care practice and up to 25% of hospital patients are registered as being allergic to an antibiotic. However, up to 90% of these registrations are incorrect, leading to unnecessary prescription of 2nd choice antibiotics with the attendant loss of efficacy, increased toxicity and antibiotic resistance. To improve registration, a better understanding is needed of how incorrect labels are attributed. OBJECTIVE To investigate the quality of antibiotic allergy registration in primary care and identify determinants to improve registration of antibiotic allergies. DESIGN Registration of antibiotic allergies in primary care practices were analysed for 1) completeness and 2) correctness. To identify determinants for improvement, semi-structured interviews with healthcare providers from four healthcare domains were conducted. PARTICIPANTS A total of 300 antibiotic allergy registrations were analysed for completeness and correctness. Thirty-four healthcare providers were interviewed. MAIN MEASURES A registration was defined as complete when it included a description of all symptoms, time to onset of symptoms and the duration of symptoms. It was defined as correct when the conclusion was concordant with the Salden criteria. Determinants of correct antibiotic allergy registrations were divided into facilitators or obstructers. KEY RESULTS Rates of completeness and correctness of registrations were 0% and 29.3%, respectively. The main perceived barriers for correct antibiotic allergy registration were insufficient knowledge, lack of priority, limitations of registration features in electronic medical records (EMR), fear of medical liability and patients interpreting side-effects as allergies. CONCLUSIONS The quality of antibiotic allergy registrations can be improved. Potential interventions include raising awareness of the consequences of incomplete and the importance of correct registrations, by continued education, and above all simplifying registration in an EMR by adequate ICT support.
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Affiliation(s)
- Martijn Sijbom
- Department of Public Health and Primary Care Campus-Den Haag, Leiden University Medical Center, Leiden, The Netherlands
| | - Karolina K. Braun
- Department of Public Health and Primary Care Campus-Den Haag, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederike L. Büchner
- Department of Public Health and Primary Care Campus-Den Haag, Leiden University Medical Center, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart J. C. Hendriks
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G. J. de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Mattijs E. Numans
- Department of Public Health and Primary Care Campus-Den Haag, Leiden University Medical Center, Leiden, The Netherlands
| | - Merel M. C. Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
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Bassir F, Varghese S, Wang L, Chin YP, Zhou L. The Use of Electronic Health Records to Study Drug-Induced Hypersensitivity Reactions from 2000 to 2021. Immunol Allergy Clin North Am 2022; 42:453-497. [PMID: 35469629 PMCID: PMC9267416 DOI: 10.1016/j.iac.2022.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Electronic health records (EHRs) have revolutionized the field of drug hypersensitivity reaction (DHR) research. In this systematic review, we assessed 140 articles from 2000-2021, classifying them under six themes: observational studies (n=61), clinical documentation (n=27), case management (n=22), clinical decision support (CDS) (n=18), case identification (n=9), and genetic studies (n=3). EHRs provide convenient access to millions of medical records, facilitating epidemiological studies of DHRs. Though the goal of CDS is to promote safe drug prescribing, allergy alerts must be designed and used in a way that supports this effort. Ultimately, accurate allergy documentation is essential for DHR prevention.
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Affiliation(s)
- Fatima Bassir
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, 399 Revolution Drive, Suite 1315, Somerville, MA 02145, USA; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 399 Revolution Drive, Suite 1315, Somerville, MA 02145, USA.
| | - Sheril Varghese
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, 399 Revolution Drive, Suite 1315, Somerville, MA 02145, USA
| | - Liqin Wang
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 399 Revolution Drive, Suite 1315, Somerville, MA 02145, USA
| | - Yen Po Chin
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 399 Revolution Drive, Suite 1315, Somerville, MA 02145, USA
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 399 Revolution Drive, Suite 1315, Somerville, MA 02145, USA
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Liu HH, Mutneja H, Buckley M, Cushinotto L. Trends in Antimicrobial Allergies in Patients Seen in Infectious Disease Consultation During Selected Periods 2007–2016. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ben Fadhel N, Aroua F, Chadli Z, Ben Romdhane H, Chaabane A, Sahtout M, Boughattas NA, Ben Fredj N, Aouam K. Betalactam hypersensitivity: The importance of delabelling in primary care. Br J Clin Pharmacol 2021; 87:4619-4624. [PMID: 33899257 DOI: 10.1111/bcp.14879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/05/2021] [Accepted: 04/14/2021] [Indexed: 12/23/2022] Open
Abstract
PATIENTS AND METHODS An allergy work-up was performed on adult patients with a history of a penicillin allergy seen by primary medical care in Monastir (Tunisia) between July 2016 and February 2018. Patients with negative skin tests were challenged with amoxicillin. Patients who were delabelled were contacted by phone after 6 months to determine outcomes after any therapeutic penicillin-class antibiotic intake. RESULTS A total of 39 patients were evaluated and 33 (84.6%) were delabelled. Five patients were penicillin skin-test positive and one was oral challenge positive. We succeeded in contacting 33 delabelled patients at 6 months. Twenty-two patients tolerated a subsequent therapeutic course of amoxicillin, eight patients did not retake penicillin due to a lack of therapeutic indication, and three patients refused an indicated penicillin use fearful of another reaction. CONCLUSION This study highlights the importance of allergy work-up in the diagnosis of beta-lactam hypersensitivity. Most patients were excessively labelled as beta-lactam allergic and this mislabelling could increase healthcare costs and lead to the development of drug resistance by the use of wide-spectrum antibiotics.
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Affiliation(s)
- Najah Ben Fadhel
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Fares Aroua
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Zohra Chadli
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Haifa Ben Romdhane
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Amel Chaabane
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | | | - Naceur A Boughattas
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Nadia Ben Fredj
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
| | - Karim Aouam
- Department of Pharmacology, University Hospital of Fattouma Bourguiba Monastir, Tunisia
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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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Stirbiene N, Rudzeviciene O, Kapitancuke M, Nazarenkaite N, Valiulis A. Knowledge gaps of drug allergy in children: a survey of primary care doctors. Postepy Dermatol Alergol 2021; 38:63-68. [PMID: 34408568 PMCID: PMC8362765 DOI: 10.5114/ada.2021.104280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/13/2019] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION There is still lack of knowledge of drug allergy in children. Proper knowledge and management of drug hypersensitivity reactions is important to physicians. AIM To evaluate the approach of primary care doctors regarding drug allergy in children. MATERIAL AND METHODS A total of 195 primary care doctors were questioned in various parts of Lithuania from 2015 to 2016. An original questionnaire was used. The incidence of a suspected drug allergy, culprit drugs, the clinical pattern and management of the suspected drug hypersensitivity were analysed. RESULTS The majority of primary care doctors (74.4%) reported a suspected drug allergy. The main suspected drugs were antibiotics (95.2%) and nonsteroidal anti-inflammatory drugs (32.4%). Skin symptoms (skin rash (100%) and itching (82.1%)) were the main symptoms of the suspected drug allergy. The vast majority of doctors (93.8%) withdrew the use of a suspected drug and 68.3% of respondents prescribed an alternative drug. The fact that skin tests, blood tests and provocation tests could be used in a drug allergy workup were indicated by 43.6% of doctors. Most doctors (69.2%) knew about the opportunity to test children for drug allergy in Lithuania and 41.4% of doctors referred patients for the further drug allergy workup. CONCLUSIONS The majority of primary care doctors reported a suspected drug allergy in children. The most common suspected drugs were antibiotics and skin symptoms were the main symptoms. Most doctors knew about the possibility to test for the drug allergy but only less than half of them referred patients for the drug allergy workup.
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Affiliation(s)
- Neringa Stirbiene
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Odilija Rudzeviciene
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Monika Kapitancuke
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Neringa Nazarenkaite
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Arunas Valiulis
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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De Clercq K, Cals JWL, de Bont EGPM. Inappropriate Antibiotic Allergy Documentation in Health Records: A Qualitative Study on Family Physicians' and Pharmacists' Experiences. Ann Fam Med 2020; 18:326-333. [PMID: 32661033 PMCID: PMC7358028 DOI: 10.1370/afm.2537] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/13/2019] [Accepted: 11/27/2019] [Indexed: 12/13/2022] Open
Abstract
PURPOSE It is hypothesized that 90% of antibiotic allergies documented in patients' health records are not actual, potentially life threatening, type I allergies mediated by IgE. This distinction is important because such documentation increases antibiotic resistance, as more second-choice and broad-spectrum antibiotics are then used. Evidence is lacking regarding causes of this inappropriate documentation. To develop interventions aimed at improving documentation, we explored experiences of family physicians and pharmacists in this area. METHODS We conducted a qualitative study among family physicians and pharmacists using focus group discussions, based on purposeful sampling and a naturalistic approach. Discussions were audio-recorded, transcribed verbatim, and analyzed in duplicate by means of constant comparative technique. RESULTS We conducted 4 focus group discussions among 34 family physicians and 10 pharmacists, from which 3 main themes emerged: (1) magnitude and awareness of the problem of inappropriate antibiotic allergy documentation, (2) origin of the problem, and (3) approaches for addressing the problem. Participants noted that the magnitude of contamination of medical files with inappropriate documentation leads to skepticism about current documentation. Major hindering factors are electronic health record systems and electronic communication. In addition, family physicians and pharmacists believed they had insufficient knowledge about antibiotic allergies and called for tools to rectify inappropriate allergy documentation and facilitate proper documentation going forward. CONCLUSIONS Family physicians and pharmacists perceive that few documented antibiotic allergies are in fact correct. Electronic health record barriers and communication barriers, as well as a lack of knowledge and facilitating tools, are main causes for numerous inappropriately documented antibiotic allergies and therefore targets for improving documentation in the future.
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Affiliation(s)
- Kitty De Clercq
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Centre, The Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Centre, The Netherlands
| | - Eefje G P M de Bont
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Centre, The Netherlands
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Nisticò D, Passanisi S, Oppedisano EM, Caminiti L, Marino A, Ruggeri P, Crisafulli G, Pajno GB. Direct drug provocation test for the diagnosis of self-reported, mild and immediate drug hypersensitivity reaction in children and adolescents: our real-life experience. Minerva Pediatr (Torino) 2020; 73:209-214. [PMID: 32418402 DOI: 10.23736/s2724-5276.20.05710-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Approximately 10% of the parents report suspected drug hypersensitivity reactions to at least one drug in their children, but most of these reactions are not confirmed after an adequate diagnostic work-up. The diagnosis of drugs hypersensitivity is frequently laborious and based on anamnesis, skin tests, serum specific IgE research and drug provocation test. Nevertheless, drug provocation test is necessary to confirm or definitively exclude the diagnosis of allergy. Aims of our study were to evaluate the real incidence of drug hypersensitivity in a large pediatric population and the validity of a short diagnostic algorithm. METHODS One hundred nine patients with a history of self-reported, immediate and mild drug hypersensitivity reactions to β-lactam antibiotics, macrolides and non-steroidal anti-inflammatory drugs underwent drug provocation test without prior skin or blood tests. After one-year, a telephone questionnaire was conducted in order to evaluate patient's use of the tested drug and any reactions. RESULTS Only 7 of the 109 patients (6.4%) resulted positive to drug provocation test. No severe reactions were reported. After the challenge, 64 patients took the culprit drug again within one year and only two reported a drug reaction. CONCLUSIONS Drug hypersensitivity is highly overestimated. Our results prompt the opportunity to directly perform the challenge for those children with self-reported, mild and immediate drug hypersensitivity reaction.
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Affiliation(s)
- Daniela Nisticò
- Department of Pediatric, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, University of Trieste, Trieste, Italy
| | - Stefano Passanisi
- Gaetano Barresi Department of Human Pathology in Adult and Developmental Age, University of Messina, Messina, Italy -
| | - Erminia M Oppedisano
- Gaetano Barresi Department of Human Pathology in Adult and Developmental Age, University of Messina, Messina, Italy
| | - Lucia Caminiti
- Gaetano Barresi Department of Human Pathology in Adult and Developmental Age, University of Messina, Messina, Italy
| | - Alessandra Marino
- Gaetano Barresi Department of Human Pathology in Adult and Developmental Age, University of Messina, Messina, Italy
| | - Paolo Ruggeri
- Unit of Pneumology, Department of Biomedical, Dental and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Giuseppe Crisafulli
- Gaetano Barresi Department of Human Pathology in Adult and Developmental Age, University of Messina, Messina, Italy
| | - Giovanni B Pajno
- Gaetano Barresi Department of Human Pathology in Adult and Developmental Age, University of Messina, Messina, Italy
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Presumed β-Lactam Allergy and Cross-reactivity in the Operating Theater: A Practical Approach. Anesthesiology 2019; 129:335-342. [PMID: 29762180 DOI: 10.1097/aln.0000000000002252] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A β-lactam allergy is the most common suspected in-hospital drug allergy. This article aims to provide a practical approach to a patient with presumed β-lactam allergy in the perioperative setting.
Supplemental Digital Content is available in the text.
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Doña I, Caubet JC, Brockow K, Doyle M, Moreno E, Terreehorst I, Torres MJ. An EAACI task force report: recognising the potential of the primary care physician in the diagnosis and management of drug hypersensitivity. Clin Transl Allergy 2018; 8:16. [PMID: 29760877 PMCID: PMC5944153 DOI: 10.1186/s13601-018-0202-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 04/04/2018] [Indexed: 01/20/2023] Open
Abstract
Adverse drug reactions include drug hypersensitivity reactions (DHRs), which can be immunologically mediated (allergy) or non-immunologically mediated. The high number of DHRs that are unconfirmed and often self-reported is a frequent problem in daily clinical practice, with considerable impact on future prescription choices and patient health. It is important to distinguish between hypersensitivity and non-hypersensitivity reactions by adopting a structured diagnostic approach to confirm or discard the suspected drug, not only to avoid life-threatening reactions, but also to reduce the frequent over-diagnosis of DHRs. Primary care physicians are often the first point of contact for the sufferer of a reaction, as such they have a key role in deciding whether to discard the diagnosis or send the patient for further investigation. In this review, we highlight the importance of diagnosing DHRs, analysing in detail the role of primary care physicians. We describe the common patterns of DHRs and signs of its progression, as well as the indications and contraindications for referring the patient to an allergist. The diagnostic process is described and the possible tests are discussed, which often depend on the drug involved and the type of DHR suspected. We also describe recommendations regarding the avoidance of medication suspected to have caused the reaction and the use of alternatives.
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Affiliation(s)
- I. Doña
- Allergy Unit (Pavilion C), Regional University Hospital of Malaga, UMA, IBIMA, National Network ARADyAL, Plaza del Hospital Civil, 29009 Malaga, Spain
| | - J. C. Caubet
- Department of Child and Adolescent, Medical School of the University of Geneva, University Hospitals of Geneva, Geneva, Switzerland
| | - K. Brockow
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| | - M. Doyle
- Indigo Medical, Saint Helier, Jersey
| | - E. Moreno
- Allergy Service, University Hospital of Salamanca, National Network ARADyAL, Salamanca, Spain
- Biosanitary Institute of Salamanca, Salamanca, Spain
- Department of Biomedical and Diagnostics Sciences, Salamanca Medical School, Salamanca, Spain
| | - I. Terreehorst
- Department of ENT, Academisch Medisch Centrum, Amsterdam, The Netherlands
| | - M. J. Torres
- Allergy Unit (Pavilion C), Regional University Hospital of Malaga, UMA, IBIMA, National Network ARADyAL, Plaza del Hospital Civil, 29009 Malaga, Spain
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Moussa Y, Shuster J, Matte G, Sullivan A, Goldstein RH, Cunningham D, Ben-Shoshan M, Baldini G, Carli F, Tsoukas C. De-labeling of β-lactam allergy reduces intraoperative time and optimizes choice in antibiotic prophylaxis. Surgery 2018; 164:S0039-6060(18)30127-2. [PMID: 29751965 DOI: 10.1016/j.surg.2018.03.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/26/2018] [Accepted: 03/19/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Suspected penicillin allergic individuals receive suboptimal non-β-lactams for intraoperative prophylaxis which may prolong operations and have negative clinical outcomes. We therefore studied if β-lactam de-labeling optimized choice of prophylactic antibiotics and improved intraoperative time efficiency. METHODS A multistep approach was used. It included a risk assessment tool by an allergist, β-lactam skin testing and oral provocation. To determine the value of de-labeling, we appraised intraoperative antibiotic choices and correlated them with time to first incision. RESULTS A total of 194 patients were evaluated preoperatively. Four patients were diagnosed β-lactam allergic on skin testing. Of the remaining 190 skin test negative patients, 146 were β-lactam challenged. Only 5% reacted and were considered β-lactam allergic. Cefazolin became the perioperative antibiotic of choice for 77% of patients requiring antibiotic prophylaxis. Only 5 confirmed β-lactam allergic patients received intraoperative vancomycin. Patients avoiding use of vancomycin saved an average of 22 minutes in operative time. Of the 44 patients not having a β-lactam challenge, 36 received antibiotics and 18 (50%) of these were prescribed intraoperative cefazolin. CONCLUSION Using this three step process, almost all of those claiming penicillin allergy were de-labeled. In most patients that were drug challenged, β-lactam antibiotics became the perioperative drug of choice. In cases where oral challenge was not used in the assessment only 50% were given a β-lactam. The reduced use of vancomycin minimized delays in initiation of incision time, thus improving operative efficiency. Ultimately, randomized controlled studies are required to objectively determine the effectiveness of this approach.
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Affiliation(s)
- Yara Moussa
- Department of Medicine, Division of Allergy and Clinical Immunology, McGill University, Montreal, Quebec, Canada; Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Joseph Shuster
- Department of Medicine, Division of Allergy and Clinical Immunology, McGill University, Montreal, Quebec, Canada; Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Gilbert Matte
- Department of Pharmacy, McGill University Health Center, Montreal, Quebec, Canada
| | - Andrew Sullivan
- Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Robert H Goldstein
- Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Dayle Cunningham
- Department of Medicine, Division of Allergy and Clinical Immunology, McGill University, Montreal, Quebec, Canada
| | - Moshe Ben-Shoshan
- Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada; Department of Pediatrics, Divisions of Allergy, Immunology and Dermatology, McGill University, Montreal, Quebec, Canada
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada
| | - Christos Tsoukas
- Department of Medicine, Division of Allergy and Clinical Immunology, McGill University, Montreal, Quebec, Canada; Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada.
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Su T, Broekhuizen BDL, Verheij TJM, Rockmann H. The impact of penicillin allergy labels on antibiotic and health care use in primary care: a retrospective cohort study. Clin Transl Allergy 2017; 7:18. [PMID: 28593040 PMCID: PMC5461748 DOI: 10.1186/s13601-017-0154-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Suspected penicillin allergy (Pen-A) is often not verified by diagnostic testing. In third line penicillin allergy labels were associated with prescription of broad spectrum antibiotics, hospital stay duration and readmission. OBJECTIVE Assess the impact of Pen-A labels on antibiotic and health care use in primary care. METHODS A retrospective cohort study was conducted in primary care in the Utrecht area, the Netherlands. All patients registered with a penicillin allergy on 31 December 2013 were selected from the General Practitioner Network database. Each patient with a Pen-A label was matched for age, gender, follow-up period with three patients without Pen-A label. Risk (OR) of receiving a reserve and second choice antibiotic, number and type of antibiotics prescribed during follow-up and number of GP contacts were compared between the two cohorts. RESULTS Of 196,440 patients, 1254 patients (0.6%) with a Pen-A label were identified and matched with 3756 patients without Pen-A label. Pen-A labels resulted in higher risk of receiving ≥1 antibiotic prescription per year (OR 2.56, 95% CI 2.05-3.20), ≥1 s choice antibiotic prescription per year (OR 2.21 95% CI 1.11-4.40), and ≥4 GP contacts per year (OR 1.71 95% CI 1.46-2.00). The chance of receiving tetracyclins (OR 2.24, 95% CI 1.29-3.89), macrolides/lincosamides/streptogamins (OR 8.69, 95% CI 4.26-17.73) and quinolones (OR 2.59, 95% CI 1.22-5.48) was higher in Pen-A patients. CONCLUSIONS In primary health care Pen-A labels are associated with increased antibiotic use, including second choice antibiotics, and more health care use.
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Affiliation(s)
- Tanly Su
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Berna D L Broekhuizen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heike Rockmann
- Department of Dermatology and Allergology, University Medical Center Utrecht, G02.129, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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Macy E, Romano A, Khan D. Practical Management of Antibiotic Hypersensitivity in 2017. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:577-586. [DOI: 10.1016/j.jaip.2017.02.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 02/17/2017] [Accepted: 02/22/2017] [Indexed: 12/19/2022]
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van Dijk SM, Gardarsdottir H, Wassenberg MWM, Oosterheert JJ, de Groot MCH, Rockmann H. The High Impact of Penicillin Allergy Registration in Hospitalized Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:926-31. [PMID: 27131826 DOI: 10.1016/j.jaip.2016.03.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/07/2016] [Accepted: 03/23/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Suspected penicillin allergy (Pen-A) is often not verified or excluded by diagnostic testing. OBJECTIVE To assess the prevalence and impact of Pen-A registration in a Dutch University Medical Center. METHODS In a prospective matched cohort study, all admitted patients (July 2013-July 2014) who underwent a pharmacotherapeutic interview were selected. Patients with a registered Pen-A were matched on age, sex, and department of admission with up to 3 patients without a registered Pen-A. Relative risks (RRs) of receiving a reserve antibiotic, death during hospitalization, and rehospitalization were compared in the 2 cohorts. The number and type of antibiotics prescribed during admission and duration of hospitalization were compared. RESULTS Of 17,959 patients, 1010 (5.6%) patients (66.7% women; median age, 55 years) had a Pen-A registration. These patients had a higher risk of receiving reserve antibiotics (RR, 1.38; 95% CI, 1.22-1.56) and of being rehospitalized within 12 weeks (RR, 1.28; 95% CI, 1.10-1.49). A significantly larger proportion of Pen-A registered patients received reserve antibiotics such as tetracyclines (1.8% vs 0.8%), macrolides/lincosamides/streptogramins (12.5% vs 4.9%), and quinolones (7.9% vs 4.3%) or received 2 or more types of antibiotics during hospitalization (21.7% vs 16.9%). CONCLUSIONS Prevalence of Pen-A registration in hospitalized patients is high, has high impact on antibiotic prescribing, and is associated with a higher risk of readmission. Verification of the Pen-A in hospitalized patients might restrict the use of reserve antibiotics and improve patient outcome.
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Affiliation(s)
- Savannah M van Dijk
- Department of Dermatology and Allergology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Helga Gardarsdottir
- Division of Laboratory and Pharmacy, Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Marjan W M Wassenberg
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mark C H de Groot
- Division of Laboratory and Pharmacy, Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heike Rockmann
- Department of Dermatology and Allergology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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