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Alsulaiman JW, Kheirallah KA, Alrawashdeh A, Saleh T, Obeidat M, Alawneh YJ, Abu Sanad Z, Amayreh W, Alawneh RJ. Risk Stratification of Penicillin Allergy Labeled Children: A Cross-Sectional Study from Jordan. Ther Clin Risk Manag 2024; 20:505-514. [PMID: 39188939 PMCID: PMC11346476 DOI: 10.2147/tcrm.s464511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 08/07/2024] [Indexed: 08/28/2024] Open
Abstract
Background Implementing allergy testing among children with a reported history of penicillin allergy could be challenging, particularly in developing countries with limited resources. This study screened and risk-stratified the likelihood of true penicillin allergy among children labeled with penicillin allergy in Jordan. Methods A web-based survey, completed by parents, assessed history, type, and severity of penicillin allergic reactions, including age at diagnosis, symptoms, time to the reaction, reaction's course and resolution, and received medical evaluation/testing. Low-risk allergic symptoms were defined as vomiting, diarrhea, headache, dizziness, itching, rash, cough, or runny nose without evidence of anaphylaxis or severe cutaneous reactions. Results A total of 530 parents of "penicillin allergy"-labeled children completed the survey. Of these, 86.4% reported allergic reactions to penicillin and 13.6% reported avoidance of penicillin due to family history. Among the former, 52.2% were male, 67.3% were three years old or younger when the reported reaction was established, and 68.3% experienced exclusively low-risk symptoms. Overall, skin rash was the most reported symptom (86.0%). High-risk symptoms were reported in 31.5% of children. About two-thirds (64.0%) of children were reported to have experienced symptoms after the first exposure to penicillin. The most common indication for antibiotic use was a throat infection (63.8%). Asthma comorbidity was significantly higher among high-risk (24.8%) compared low-risk group (11.5%). Conclusion In Jordan, many parent-reported penicillin allergic reactions seem to be clinically insignificant and unlikely to be verifiable, which can adversely affect patients' care and antimicrobial stewardship. An appropriate clinical history/evaluation is a key step in identifying true immunoglobulin E-mediated allergic reactions and risk stratifying patients for either de-labeling those with obviously non-immune-mediated reactions or identifying candidates for direct oral challenge test.
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Affiliation(s)
- Jomana W Alsulaiman
- Department of Pediatrics, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Khalid A Kheirallah
- Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Ahmad Alrawashdeh
- Department of Allied Medical Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Tareq Saleh
- Department of Pharmacology and Public Health, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Maha Obeidat
- Department of Pediatrics, Princess Rahma Teaching Hospital, Irbid, Jordan
| | - Yareen J Alawneh
- Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Ziydoun Abu Sanad
- Department of Pediatrics, Princess Rahma Teaching Hospital, Irbid, Jordan
| | - Wajdi Amayreh
- Department of Pediatrics, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Rama J Alawneh
- Department of Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Shi W, Liu N, Huang JX, Xiao H, Meng J, Li PH. Penicillin Allergy in China: Consequences of Inappropriate Skin Testing Practices and Policies. Clin Exp Allergy 2024. [PMID: 39053914 DOI: 10.1111/cea.14546] [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: 04/23/2024] [Revised: 06/23/2024] [Accepted: 07/09/2024] [Indexed: 07/27/2024]
Abstract
Penicillins are the most frequently prescribed class of medications worldwide and first-line antibiotic of choice for most bacterial infections. They are also commonly labelled as the culprit of drug 'allergy'; leading to obligatory use of second-line antibiotics, suboptimal antibiotic therapy and increased antimicrobial resistance. However, the majority of reported penicillin 'allergy' labels are found to be incorrect after allergy testing, emphasising the importance of proper drug allergy testing and evaluation. Penicillin skin testing (PST) remains an important component of drug allergy diagnosis; however, its practice and policies significantly differ across the world. Inappropriate and non-evidence-based PST practices can lead to consequences associated with allergy mislabelling. Even within different regions of China, with a population exceeding 1.4 billion, there are marked differences in the implementation, execution and interpretation of PST. This review aims to examine the differences in PST between Mainland China, Hong Kong and the rest of the world. We critically analyse the current practice of 'pre-emptive' PST in Mainland China, which has a significant false-positive rate leading to high levels of penicillin allergy mislabelling. Non-evidence-based practices further compound the high false-positive rates of indiscriminatory PST. We postulate that inappropriate PST policies and practices may exacerbate the mislabelling of penicillin allergy, leading to unnecessary overuse of inappropriate second-line antibiotics, increasing antimicrobial resistance and healthcare costs. We advocate for the importance of more collaborative research to improve the contemporary workflow of penicillin allergy diagnosis, reduce mislabelling and promote the dissemination of evidence-based methods for allergy diagnosis.
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Affiliation(s)
- Weihong Shi
- Division of Rheumatology & Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Ning Liu
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Jin-Xian Huang
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Hao Xiao
- Allergy Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Juan Meng
- Allergy Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Philip H Li
- Division of Rheumatology & Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China
- Division of Rheumatology & Clinical Immunology, Department of Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
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3
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Zoller M, Weber A, Mehringer L. [Penicillin allergy-Truth or duty?]. DIE ANAESTHESIOLOGIE 2024; 73:436-443. [PMID: 38904675 DOI: 10.1007/s00101-024-01425-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/28/2024] [Indexed: 06/22/2024]
Abstract
The beta-lactam antibiotics are some of the safest and best-tolerated antibiotic agents; however, many patients have reported allergies against penicillin. All beta-lactam antibiotics are only restrictively prescribed for these patients and alternative antibiotics are increasingly given, which carries the risk of negative clinical results and socioeconomic sequelae; however, over 95% of patients who reported an allergy to penicillin show a negative result in the allergy tests for penicillin and this antibiotic can safely be prescribed. The use of sensitive and specific instruments for identification of false penicillin allergies should be an important topic within the framework of antibiotic stewardship. Anesthesists can play a central role in the reduction of the enormous individual and public health burden associated with the classification of penicillin allergy by taking an appropriate medical history and a risk stratification for the identification of patients with a penicillin allergy. This overview article presents a possible delabelling algorithm within the framework of the clarification of a beta-lactam antibiotic allergy. The focus is on a structured allergy anamnesis using the penicillin allergy, five or fewer years ago, anaphylaxis/angioedema, severe cutaneous adverse reaction (SCAR) and treatment required for allergy episode (PEN-FAST) score.
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Affiliation(s)
- Michael Zoller
- Klinik für Anästhesiologie, LMU Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland.
| | | | - Laurenz Mehringer
- Klinik für Anästhesiologie, LMU Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland
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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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Wong JCY, Kan AKC, Chik TSH, Chu MY, Li TCM, Mak HWF, Chiang V, Li PH. Prospective, Multicenter, Head-to-Head Comparison Between Allergists Versus Nonallergists in Low-Risk Penicillin Allergy Delabeling: Effectiveness, Safety, and Quality of Life (HK-DADI2). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1801-1808.e2. [PMID: 38631522 DOI: 10.1016/j.jaip.2024.04.010] [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: 02/06/2024] [Revised: 04/03/2024] [Accepted: 04/06/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Penicillin "allergy" labels are prevalent but frequently misdiagnosed. Mislabelled allergies are associated with adverse outcomes and increased antimicrobial resistance. With an urgent need to delabel the overwhelming number of mislabeled allergies, nonallergist evaluations have been advocated for low-risk individuals. Despite growing interest in non-allergist-led initiatives, evidence on their effectiveness, safety, and impact by direct comparisons is lacking. OBJECTIVE To assess the comparative outcomes of penicillin allergy evaluations conducted by allergists versus nonallergists. METHODS A prospective, multicenter, pragmatic study was conducted at 4 tertiary hospitals (1 allergist- vs 3 non-allergist-led) for low-risk penicillin allergy patients in Hong Kong-the Hong Kong Drug Allergy Delabelling Initiative 2 (HK-DADI2). RESULTS Among 228 low-risk patients who underwent testing (32.9% by allergists, 67.1% by nonallergists), only 14 (6.1%) had positive penicillin allergy testing results. Delabeling rates (94.1% vs 93.3%; P = .777), positive skin test results (2.6% vs 2.7%; P > .99), and drug provocation test results (3.3% vs 2.7%; P = 1.000) were similar between allergists and nonallergists. There were no systemic reactions in either cohort. All patients had significant improvements in health-related quality of life (Drug Hypersensitivity Quality of Life Questionnaire scores -5.00 vs -8.33; P = .072). Nonallergist evaluations had shorter waiting times (0.57 vs 15.7 months; P < .001), whereas allergists required fewer consultations with higher rate of completing evaluations within a single visit (odds ratio, 0.04; P < .001). CONCLUSIONS With training and support, nonallergists can independently evaluate low-risk penicillin allergies. Compared with allergists, evaluation of low-risk penicillin allergy by nonallergists can be comparably effective, safe, and impactful on quality of life. More multidisciplinary partnerships to empower nonallergists to conduct allergy evaluations should be encouraged.
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Affiliation(s)
- Jane C Y Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Andy K C Kan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Thomas S H Chik
- Division of Infectious Diseases, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | - M Y Chu
- Division of Infectious Diseases, Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Timothy C M Li
- Division of Infectious Diseases, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong
| | - Hugo W F Mak
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
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Rose MT, Holmes NE, Eastwood GM, Vogrin S, James F, De Luca JF, Bellomo R, Warrillow SJ, Phung M, Barnes SL, Murfin B, Rogers B, Lambros B, Collis B, Peel TN, Slavin MA, Trubiano JA. Oral challenge vs routine care to assess low-risk penicillin allergy in critically ill hospital patients (ORACLE): a pilot safety and feasibility randomised controlled trial. Intensive Care Med 2024; 50:913-921. [PMID: 38739277 PMCID: PMC11164790 DOI: 10.1007/s00134-024-07448-x] [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: 01/25/2024] [Accepted: 04/14/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE Critically ill patients are vulnerable to penicillin allergy labels that may be incorrect. The validity of skin testing in intensive care units (ICUs) is uncertain. Many penicillin allergy labels are low risk, and validated tools exist to identify those amenable to direct oral challenge. This pilot randomised controlled trial explored the feasibility, safety, and validity of direct enteral challenge for low-risk penicillin allergy labels in critical illness. METHODS Consenting patients with a low-risk penicillin allergy label (PAL) (PEN-FAST risk assessment score < 3) in four ICUs (Melbourne, Australia) were randomised 1:1 to penicillin (250 mg amoxicillin or implicated penicillin) direct enteral challenge versus routine care (2-h post-randomisation observation for each arm). Repeat challenge was performed post -ICU in the intervention arm. Patients were reviewed at 24 h and 5 days after each challenge/observation. RESULTS We screened 533 patients. 130 (24.4%) were eligible and 80/130 (61.5%) enrolled (age median 64.5 years (interquartile range, IQR 53.5, 74), PEN-FAST median 1 (IQR 0,1)), with 40 (50%) randomised to direct enteral challenge. A positive challenge rate of 2.5% was identified. No antibiotic-associated serious adverse events were identified. 32/40 (80%) received a repeat challenge (zero positive). Post-randomisation, 13 (32%) of the intervention arm and 4 (10%) of the control arm received penicillin (odds ratio, OR 4.33 [1.27, 14.78] p = 0.019). CONCLUSION These findings support the safety, validity, and feasibility of direct enteral challenge for critically ill patients with PEN-FAST assessed low-risk penicillin allergy. The absence of false negative results was confirmed by subsequent negative repeat challenges. A relatively low recruitment to screened ratio suggests that more inclusive eligibility criteria and integration of allergy assessment into routine ICU processes are needed to optimise allergy delabelling in critical illness.
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Affiliation(s)
- Morgan T Rose
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia.
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia.
| | - Natasha E Holmes
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, Austin Health/University of Melbourne, Melbourne, VIC, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Sara Vogrin
- Department of Medicine (St Vincent's Hospital), University of Melbourne, Melbourne, VIC, Australia
| | - Fiona James
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Joseph F De Luca
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Parkville, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Stephen J Warrillow
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, The University of Melbourne, Parkville, VIC, Australia
| | - Michelle Phung
- Pharmacy Department, Monash Health, Clayton, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, VIC, Australia
| | - Sara L Barnes
- Monash Lung Sleep Allergy and Immunology, Monash Health, Clayton, VIC, Australia
| | - Brendan Murfin
- Intensive Care Unit, Monash Health, Clayton, VIC, Australia
| | - Ben Rogers
- Monash Infectious Diseases, Monash Health, Clayton, VIC, Australia
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Belinda Lambros
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Brennan Collis
- Department of Infectious Diseases, Alfred Health, Melbourne, VIC, Australia
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Health, Melbourne, VIC, Australia
- Department of Infectious Diseases, Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Monica A Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Immunocompromised Host Infection Service, Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
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Anton-Vazquez V, Ferretti F, Kaya D, Mishra S, Kerneis S, Eden C, Doan H, Leung HF, Baltazar J, Starkey S, Uwagwu J, Dall'Antonia M, Cepeda J. Impact of penicillin allergy records on antimicrobial prescribing in hospitalised patients. Clin Med (Lond) 2024; 24:100024. [PMID: 38382835 DOI: 10.1016/j.clinme.2024.100024] [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] [Indexed: 02/23/2024]
Abstract
BACKGROUND The overdiagnosis of penicillin allergy and misclassification of non-truly allergic reactions is a growing public health problem, associated with the overuse of broad-spectrum and restricted antimicrobials. We aimed to evaluate the impact of penicillin allergy status on antimicrobial prescribing. METHODS A retrospective study of inpatients with a documented penicillin allergy receiving antimicrobials was conducted from 1 April to 1 July 2021. Antimicrobial prescribing and clinical characteristics were compared between patients with an active penicillin allergy label and those whose label was removed following antimicrobial stewardship team review. Antimicrobials were classified in two categories: i) 'Access' (recommended), ii) 'Watch and Reserve' (restricted) according to WHO AWaRe classification, a tool to guide appropriate antibiotic use. RESULTS 437 patients with a documented penicillin allergy receiving antimicrobials were included. 353 patients with an active penicillin allergy label, more frequently received antimicrobials from the 'Watch and Reserve list' (283;80% vs 30;37%; p<0.001). In contrast, 84 patients who were de-labelled received more often antimicrobials from the 'Access list' (53;63% vs 64;18%; p<0.001). CONCLUSIONS Penicillin allergy reviews and de-labelling strategies may reduce the use of restricted antimicrobials under the 'Watch and Reserve list'. This practice should be encouraged and reinforced in all hospitals.
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Affiliation(s)
| | | | - Deniz Kaya
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Shashwat Mishra
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Sven Kerneis
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Charlotte Eden
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Hong Doan
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Hiu Fung Leung
- Antimicrobial pharmacy, Lewisham & Greenwich NHS Trust, London, UK
| | | | - Sarah Starkey
- Medical Microbiology, Lewisham & Greenwich NHS Trust, London, UK
| | - Juliet Uwagwu
- Medical Microbiology, Lewisham & Greenwich NHS Trust, London, UK
| | | | - Jorge Cepeda
- Medical Microbiology, Lewisham & Greenwich NHS Trust, London, UK
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Cox F, Mitri E, Trubiano JA. The Death of Desensitization-Delabeling the Destroyer. Open Forum Infect Dis 2024; 11:ofae109. [PMID: 38524225 PMCID: PMC10960593 DOI: 10.1093/ofid/ofae109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 02/24/2024] [Indexed: 03/26/2024] Open
Affiliation(s)
- Fionnuala Cox
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia
| | - Elise Mitri
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
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9
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Bennett MR, Mathioudakis AG, Wu J, Chu MMH, Tontini C, Thomas I, Simpson A. Performance Characteristics of Basophil Activation Tests for Diagnosing Penicillin Allergy: A Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:714-723.e5. [PMID: 37940090 DOI: 10.1016/j.jaip.2023.11.004] [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: 04/16/2023] [Revised: 09/22/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Approximately 10% of the global population identify themselves as penicillin allergic, yet 90% are not truly allergic and could safely tolerate penicillin. There is no simple way to identify these people. Current in vitro diagnostics include specific immunoglobulin E (with a sensitivity of 19% and specificity of 97%) and a basophil activation test (BAT) with undefined sensitivity and specificity. OBJECTIVE To define the sensitivity and specificity of BAT in the diagnosis of penicillin allergy METHODS: We searched PubMed and EMBASE from inception to April 2, 2023, for original studies evaluating the performance characteristics of BAT for penicillin allergy in adults. Study selection, data extraction, risk of bias, assessment with QUADAS-2 tool, certainty assessment with Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology were performed independently, in duplicate. Meta-analysis was performed using Reitsma methodology. RESULTS Twenty-two studies fulfilled the inclusion criteria. Twelve used the same positive threshold giving a summary point sensitivity 51% (95% confidence interval [95% CI]46%-56%) and specificity 89% (95% CI 85%-93%). Significant risk of bias was identified owing to patient selection. GRADE certainty of evidence rated sensitivity very low due to imprecision and specificity as low. There was great heterogeneity in methods used. Use of 1,000 basophils per test did not improve performance above 500 basophils. CONCLUSIONS BAT sensitivity is highly variable across studies and remains too low to be considered as a routine element of clinical practice. BAT specificity is not as good as specific immunoglobulin E in penicillin allergy diagnosis. Significant further work is required in this field before clinical application of BAT in routine practice.
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Affiliation(s)
- Miriam R Bennett
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK.
| | - Alexander G Mathioudakis
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK; Manchester University NHS Foundation Trust, Respiratory and Allergy, Manchester, UK
| | - Jiakai Wu
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Michael M H Chu
- Manchester University NHS Foundation Trust, Otolaryngology, Manchester, UK
| | - Chiara Tontini
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Iason Thomas
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK; Manchester University NHS Foundation Trust, Respiratory and Allergy, Manchester, UK
| | - Angela Simpson
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK; Manchester University NHS Foundation Trust, Respiratory and Allergy, Manchester, UK
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10
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Mitri E, Reynolds G, Hornung CJ, Trubiano JA. Low-risk penicillin allergy delabeling: a scoping review of direct oral challenge practice, implementation, and multi-disciplinary approaches. Expert Rev Anti Infect Ther 2024; 22:59-69. [PMID: 38098185 DOI: 10.1080/14787210.2023.2296068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/13/2023] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Penicillin allergy is common, and there is increased clinician interest in direct oral challenge (DOC) as a testing strategy for low-risk penicillin allergy. To aid wider implementation of DOC, consensus definitions of low-risk penicillin allergy phenotypes, and standardized approaches to assessment, DOC procedures, and evaluation, are required. AREAS COVERED This review systematically reviews studies that have utilized penicillin DOC in healthcare settings to identify heterogeneity in implementation approaches and synthesize low-risk definitions, procedures, and evaluation. EXPERT OPINION Opportunity exists to standardize penicillin DOC procedures in patients with a low-risk penicillin allergy to optimize antimicrobial prescribing and reduce the burden of penicillin allergy. Standardizing the definitions of 'low-risk' and 'positive challenge,' and improving the evaluation of patient safety, alongside the development of a unified approach to the structure of undertaking an oral challenge, is likely to increase uptake and confidence among non-allergist clinicians.
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Affiliation(s)
- Elise Mitri
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- National Allergy Centre of Excellence (NACE), Parkville, Victoria, Australia
| | - Gemma Reynolds
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Catherine J Hornung
- National Allergy Centre of Excellence (NACE), Parkville, Victoria, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- National Allergy Centre of Excellence (NACE), Parkville, Victoria, Australia
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
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11
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Wrenn RH, Trubiano JA. Penicillin Allergy Impact and Management. Infect Dis Clin North Am 2023; 37:793-822. [PMID: 37537003 DOI: 10.1016/j.idc.2023.06.005] [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: 08/05/2023]
Abstract
There is international evidence that penicillin allergies are associated with inferior prescribing and patient outcomes. A host of tools now exist from assessment (risk assessment tools, clinical decision rules) to delabeling (the removal of a beta-lactam allergy via testing or medical reconciliation) to reduce the impact of these "labels" in the hospital and community setting, as a primary antimicrobial stewardship intervention.
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Affiliation(s)
- Rebekah H Wrenn
- Duke University Medical Center, Durham, NC, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA.
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Melbourne, Australia; Department of Infectious Diseases, University of Melbourne, at The Peter Doherty Institute for Infection and Immunity, Victoria 3000, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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12
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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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13
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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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14
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Copaescu AM, Vogrin S, James F, Chua KYL, Rose MT, De Luca J, Waldron J, Awad A, Godsell J, Mitri E, Lambros B, Douglas A, Youcef Khoudja R, Isabwe GAC, Genest G, Fein M, Radojicic C, Collier A, Lugar P, Stone C, Ben-Shoshan M, Turner NA, Holmes NE, Phillips EJ, Trubiano JA. Efficacy of a Clinical Decision Rule to Enable Direct Oral Challenge in Patients With Low-Risk Penicillin Allergy: The PALACE Randomized Clinical Trial. JAMA Intern Med 2023; 183:944-952. [PMID: 37459086 PMCID: PMC10352926 DOI: 10.1001/jamainternmed.2023.2986] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/17/2023] [Indexed: 07/20/2023]
Abstract
Importance Fewer than 5% of patients labeled with a penicillin allergy are truly allergic. The standard of care to remove the penicillin allergy label in adults is specialized testing involving prick and intradermal skin testing followed by an oral challenge with penicillin. Skin testing is resource intensive, limits practice to specialist-trained physicians, and restricts the global population who could undergo penicillin allergy delabeling. Objective To determine whether a direct oral penicillin challenge is noninferior to the standard of care of penicillin skin testing followed by an oral challenge in patients with a low-risk penicillin allergy. Design, Setting, and Participants This parallel, 2-arm, noninferiority, open-label, multicenter, international randomized clinical trial occurred in 6 specialized centers, 3 in North America (US and Canada) and 3 in Australia, from June 18, 2021, to December 2, 2022. Eligible adults had a PEN-FAST score lower than 3. PEN-FAST is a prospectively derived and internationally validated clinical decision rule that enables point-of-care risk assessment for adults reporting penicillin allergies. Interventions Patients were randomly assigned to either direct oral challenge with penicillin (intervention arm) or a standard-of-care arm of penicillin skin testing followed by oral challenge with penicillin (control arm). Main Outcome and Measure The primary outcome was a physician-verified positive immune-mediated oral penicillin challenge within 1 hour postintervention in the intention-to-treat population. Noninferiority was achieved if a 1-sided 95% CI of the risk difference (RD) did not exceed 5 percentage points (pp). Results A total of 382 adults were randomized, with 377 patients (median [IQR] age, 51 [35-65] years; 247 [65.5%] female) included in the analysis: 187 in the intervention group and 190 in the control group. Most patients had a PEN-FAST score of 0 or 1. The primary outcome occurred in 1 patient (0.5%) in the intervention group and 1 patient (0.5%) in the control group, with an RD of 0.0084 pp (90% CI, -1.22 to 1.24 pp). The 1-sided 95% CI was below the noninferiority margin of 5 pp. In the 5 days following the oral penicillin challenge, 9 immune-mediated adverse events were recorded in the intervention group and 10 in the control group (RD, -0.45 pp; 95% CI, -4.87 to 3.96 pp). No serious adverse events occurred. Conclusions and Relevance In this randomized clinical trial, direct oral penicillin challenge in patients with a low-risk penicillin allergy was noninferior compared with standard-of-care skin testing followed by oral challenge. In patients with a low-risk history, direct oral penicillin challenge is a safe procedure to facilitate the removal of a penicillin allergy label. Trial Registration ClinicalTrials.gov Identifier: 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
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Department of Medicine, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent’s Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Fiona James
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Kyra Y. L. Chua
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Morgan T. Rose
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Joseph De Luca
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jamie Waldron
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew Awad
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Jack Godsell
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Clinical Immunology and Allergy, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Elise Mitri
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Belinda Lambros
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Abby Douglas
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Rabea Youcef Khoudja
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Ghislaine A. C. Isabwe
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Genevieve Genest
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Michael Fein
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Cristine Radojicic
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ann Collier
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Patricia Lugar
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Cosby Stone
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Moshe Ben-Shoshan
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Division of Allergy, Immunology and Dermatology, Montreal Children’s Hospital, McGill University Health Centre McGill University, Montreal, Quebec, Canada
| | - Nicholas A. Turner
- Department of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Natasha E. Holmes
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth J. Phillips
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Jason A. Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, 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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15
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Rose M, Holmes N, Eastwood G, Vogrin S, James F, Phung M, Barnes S, Murfin B, Rogers B, Lambros B, Peel T, Gibney G, Slavin M, Trubiano J. Oral challenge vs routine care to assess low-risk penicillin allergy in critically ill hospital patients (ORACLE): a pilot randomised controlled trial. Pilot Feasibility Stud 2023; 9:126. [PMID: 37475038 DOI: 10.1186/s40814-023-01337-8] [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: 01/13/2023] [Accepted: 06/07/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Self-reported penicillin allergies are highly prevalent in hospitalised patients and are associated with poor health and health service outcomes. Critically ill patients have historically been underrepresented in prospective delabelling studies in part due to concerns around clinical stability and reliability of penicillin skin testing. Allergy assessment tools exist to identify low-risk penicillin allergy phenotypes and facilitate direct oral challenge delabelling. PEN-FAST is a clinical decision rule that has been validated to predict true penicillin allergy in a cohort of non-critically ill patients. There is however limited evidence regarding the feasibility, safety and efficacy of direct oral challenges and the use of delabelling clinical decisions rules in the intensive care setting. METHODS Critically ill patients in the intensive care unit (ICU) with low-risk penicillin allergy phenotypes (PEN-FAST score < 3) will be randomised 1:1 to direct oral penicillin challenge (single dose 250 mg oral amoxicillin or implicated penicillin) or routine care, followed by a 2-h observation period. Patients will receive a second oral challenge/observation prior to hospital discharge (with subsequent observation for 2 h). An assessment for antibiotic-associated adverse events will also be undertaken at 24 h and 5 days post each challenge/observation and again at 90 days post-randomisation. The primary outcome measures are feasibility (proportion of eligible patients recruited and protocol compliance) and safety (proportion of patients who experience an antibiotic-associated immune-mediated adverse event or serious adverse event). DISCUSSION We will report the feasibility and safety of point-of-care penicillin direct oral challenge in this first randomised controlled trial of low-risk penicillin allergy in critically ill hospitalised patients. Upon completion of the project, important findings will inform the design of planned large prospective multi-centre clinical trials in Australian and international ICUs, further examining safety and efficacy and exploring antimicrobial prescribing-related outcomes following penicillin oral challenge. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry Registration Number: ACTRN12621000051842 Date registered: 20/01/2021 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379735&isReview=true.
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Affiliation(s)
- Morgan Rose
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia.
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
| | - Natasha Holmes
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- Department of Infectious Diseases, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, Austin Health/University of Melbourne, Heidelberg, VIC, Australia
- Department of Critical Care, The University of Melbourne, Parkville, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Sara Vogrin
- Department of Medicine (St Vincent's Hospital), University of Melbourne, Melbourne, VIC, Australia
| | - Fiona James
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Michelle Phung
- Pharmacy Department, Monash Health, Clayton, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Sara Barnes
- Monash Lung Sleep Allergy and Immunology, Monash Health, Clayton, VIC, Australia
| | - Brendan Murfin
- Intensive Care Unit, Monash Health, Clayton, VIC, Australia
| | - Ben Rogers
- Monash Infectious Diseases, Monash Health, Clayton, VIC, Australia
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Belinda Lambros
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Trisha Peel
- Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Department of Infectious Diseases, Alfred Health, Melbourne, VIC, Australia
| | - Grace Gibney
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Monica Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Immunocompromised Host Infection Service, Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jason Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
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16
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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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17
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Fransson S, Damving CM, Boel JB, Arpi M, Skinhøj IG, Jarløv JO, Mosbech HF, Poulsen LK, Garvey LH. Delabeling of Penicillin Allergy: Room for Improvement. Int Arch Allergy Immunol 2023; 184:870-874. [PMID: 37321191 DOI: 10.1159/000530770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/11/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Penicillin allergy labels have been shown to be associated with suboptimal treatment, negative health outcomes, and increased antibiotic resistance. Many inpatients claim to have penicillin allergy, but studies show that allergy can be disproved and the label removed in up to 90% of cases. OBJECTIVES The purpose of the study was to investigate the proportion of patients with a penicillin allergy label in a Danish hospital and to classify patients according to the risk of having penicillin allergy in "no risk," low, and high risk. METHODS For 22 days, inpatients with penicillin allergy labels were interviewed, had their dispensed penicillin prescriptions examined, and were subsequently categorized into risk groups based on the risk evaluation criteria in national guidelines. RESULTS In total, 260 patients had a penicillin allergy label (10% of the inpatients). Out of 151 included patients, 25 were "no risk" patients (17%), who could potentially have their penicillin allergy label removed without testing. 42 were low-risk patients (28%). 10 "no risk" patients and 20 low-risk patients had been prescribed and dispensed one or more penicillins despite an allergy label. CONCLUSION Ten percent of inpatients have a penicillin allergy label in a Danish hospital. 17% of these could potentially have their penicillin allergy label removed without allergy testing.
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Affiliation(s)
- Sara Fransson
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Christina Monnerup Damving
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Jonas Bredtoft Boel
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Magnus Arpi
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Ida Gjørup Skinhøj
- Department of Infectious Disease, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Jens Otto Jarløv
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Holger F Mosbech
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Lars K Poulsen
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Lene H Garvey
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Dunham TB, Gardner RM, Lippner EA, Fasani DE, Moir E, Halpern-Felsher B, Sundaram V, Liu AY. Digital Antibiotic Allergy Decision Support Tool Improves Management of β-Lactam Allergies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1243-1252.e6. [PMID: 36736957 PMCID: PMC10085826 DOI: 10.1016/j.jaip.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/20/2022] [Accepted: 01/02/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Frontline providers frequently make time-sensitive antibiotic choices, but many feel poorly equipped to handle antibiotic allergies. OBJECTIVE We hypothesized that a digital decision support tool could improve antibiotic selection and confidence when managing β-lactam allergies. METHODS A digital decision support tool was designed to guide non-allergist providers in managing patients with β-lactam allergy labels. Non-allergists were asked to make decisions in clinical test cases without the tool, and then with it. These decisions were compared using paired t tests. Users also completed surveys assessing their confidence in managing antibiotic allergies. RESULTS The tool's algorithm was validated by confirming its recommendations aligned with that of five allergists. Non-allergist providers (n = 102) made antibiotic management decisions in test cases, both with and without the tool. Use of the tool increased the proportion of correct decisions from 0.41 to 0.67, a difference of 0.26 (95% CI, 0.22-0.30; P < .001). Users were more likely to give full-dose antibiotics in low-risk situations, give challenge doses in medium-risk situations, and avoid the antibiotic and/or consult allergy departments in high-risk situations. A total of 98 users (96%) said the tool would increase their confidence when choosing antibiotics for patients with allergies. CONCLUSIONS A point-of-care clinical decision tool provides allergist-designed guidance for non-allergists and is a scalable system for addressing antibiotic allergies, irrespective of allergist availability. This tool encouraged appropriate antibiotic use in low- and medium-risk situations and increased caution in high-risk situations. A digital support tool should be considered in quality improvement and antibiotic stewardship efforts.
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Affiliation(s)
- Theresa B Dunham
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, Calif.
| | - Rebecca M Gardner
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Elizabeth A Lippner
- Division of Allergy and Immunology, Department of Pediatrics, Anne and Robert H. Lurie Children's Hospital and Northwestern Feinberg School of Medicine, Chicago, Ill
| | | | - Elwyn Moir
- Clinical Observation and Medical Transcription Program, Stanford, Calif
| | - Bonnie Halpern-Felsher
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, Calif
| | - Vandana Sundaram
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Anne Y Liu
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, Calif; Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
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De Luca JF, James F, Vogrin S, Chua K, Fletcher L, Nazareth J, Guha R, Hardidge A, Douglas N, Carruthers J, Stewardson A, Cheng AC, Johnson D, Douglass J, Peel T, Trubiano J. Study protocol for PREPARE: a phase II feasibility/safety randomised controlled trial on PeRiopErative Penicillin AlleRgy TEsting. BMJ Open 2023; 13:e067653. [PMID: 36828661 PMCID: PMC9972415 DOI: 10.1136/bmjopen-2022-067653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/23/2023] [Indexed: 02/26/2023] Open
Abstract
INTRODUCTION Patient-reported antibiotic allergy labels (AALs) are common. These labels have been demonstrated to have a negative impact on use of appropriate antibiotics and patient-related health outcomes. These patients are more likely to receive suboptimal antibiotics, have increased rates of surgical site infections and are more likely to be colonised with multidrug-resistant organisms. Increasing recognition that antibiotic allergy forms a key part of good antimicrobial stewardship has led to calls for greater access to antibiotic allergy assessment.PREPARE is a pilot randomised controlled trial of beta-lactam allergy assessment and point of care delabelling in perioperative patients utilising a validated antibiotic allergy assessment tool that has been repurposed into a smartphone application. The aim of the study is to assess the feasibility and safety of this approach in the perioperative outpatient setting. METHODS AND ANALYSIS Adult participants requiring elective surgery and are likely to require prophylactic intravenous antibiotics will be recruited. During the intervention phase, participants will be randomised to the intervention or control arm, with control patients receiving usual standard of care. Those randomised to intervention undertake a risk assessment via the smartphone application, with those deemed low risk proceeding to direct oral provocation with either a penicillin or cephalosporin. Study outcomes will be evaluated in the postintervention phase, 30 and 90 days after surgery.Feasibility of intervention delivery and recruitment will be reported as proportions with respective 95% CIs. Participants who experience an antibiotic adverse event will be reported by group with respective 95% CIs and compared using modified Poisson regression model with robust SE estimation. ETHICS AND DISSEMINATION This protocol has received approval from the Austin Health human research and ethics committee, Heidelberg, Victoria, Australia (HREC/17/Austin/575). Results will be disseminated via publication in peer-reviewed journals as well as presentation at international conferences. TRIAL REGISTRATION NUMBER ACTRN12620001295932.
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Affiliation(s)
- Joseph F De Luca
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Fiona James
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Sara Vogrin
- St Vincent's Department of Medicine, The University of Melbourne, Fitzroy, Victoria, Australia
| | - Kyra Chua
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Luke Fletcher
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Justin Nazareth
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Ranjan Guha
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew Hardidge
- Department of Orthopaedic Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Ned Douglas
- Department of Anaesthesia, Melbourne Health, Parkville, Victoria, Australia
| | - John Carruthers
- Department of Anaesthesia, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew Stewardson
- Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
- Infectious Diseases, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine Clinical Trials Centre, Monash University, Melbourne, Victoria, Australia
| | - Douglas Johnson
- Department of General Medicine, Melbourne Health, Parkville, Victoria, Australia
- Department of Medicine RMH, The University of Melbourne, Parkville, Victoria, Australia
| | - Jo Douglass
- Department of Medicine RMH, The University of Melbourne, Parkville, Victoria, Australia
| | - Trisha Peel
- Infectious Diseases, Monash University, Melbourne, Victoria, Australia
- Infectious Diseases, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
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20
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Heremans K, Toscano A, Elst J, Van Gasse AL, Mertens C, Beyens M, van der Poorten MLM, Hagendorens MM, Ebo DG, Sabato V. Basophil Activation Test Shows Poor Sensitivity in Immediate Amoxicillin Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:500-505. [PMID: 36402397 DOI: 10.1016/j.jaip.2022.10.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/13/2022] [Accepted: 10/30/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND In light of the pandemic of spurious penicillin allergy, correct diagnosis of amoxicillin (AX) allergy is of great importance. The diagnosis of immediate hypersensitivity reactions relies on skin tests and specific IgE, and although reliable, these are not absolutely predictive. Therefore, drug challenges are needed in some cases, which contain the risk of severe reactions. Safe in vitro diagnostics as an alternative for the drug challenge in the diagnostic workup of AX allergy would be more than welcome to fill this gap. In this respect, the basophil activation test (BAT) has shown potential, but its clinical reliability is doubtful. OBJECTIVE To investigate the reliability of the BAT to AX and determining its exact place in the diagnostic algorithm of AX allergy. METHODS BAT for AX was performed in 70 exposed control individuals and 66 patients diagnosed according to the European Academy of Allergy and Clinical Immunology guidelines for AX allergy. Upregulation of both CD63 and CD203c was flow-cytometrically assessed. RESULTS Analyses revealed that 1370 μmol/L and 685 μmol/L were the most discriminative stimulation concentrations for CD63 and CD203c upregulation, respectively, and a diagnostic threshold of 9% for positivity for both markers was identified. At these concentrations, sensitivity and specificity for CD63 upregulation were 13% and 100%, respectively, and for CD203c upregulation, 23% and 98%. CONCLUSIONS BAT with dual analysis of CD63 and CD203c is of poor performance to document AX allergy. The sensitivity is too low to let it occupy a prominent role in the diagnostic algorithm.
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Affiliation(s)
- Kevin Heremans
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Alessandro Toscano
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Jessy Elst
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; The Infla-Med Centre of Excellence, Antwerp University, Antwerpen, Belgium
| | - Athina L Van Gasse
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Christel Mertens
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; The Infla-Med Centre of Excellence, Antwerp University, Antwerpen, Belgium
| | - Michiel Beyens
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Marie-Line M van der Poorten
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Margo M Hagendorens
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; The Infla-Med Centre of Excellence, Antwerp University, Antwerpen, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Didier G Ebo
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; The Infla-Med Centre of Excellence, Antwerp University, Antwerpen, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium.
| | - Vito Sabato
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; The Infla-Med Centre of Excellence, Antwerp University, Antwerpen, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium
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21
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Maduemem K, Clark H, Sohal I, Dawson T, Makwana N. Barriers to paediatric penicillin allergy de-labelling in UK secondary care: a regional survey. Arch Dis Child 2022; 108:363-366. [PMID: 36535750 DOI: 10.1136/archdischild-2022-324564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Incorrect penicillin allergy labels result in the use of inappropriately broad-spectrum antibiotics. De-labelling inaccurate penicillin allergy promotes antimicrobial stewardship and optimises prescribing practices. The objectives were to evaluate paediatric clinicians' knowledge and understanding of penicillin allergy and to identify barriers in tackling incorrect penicillin allergy labels. METHODS Paediatric clinicians from across the West Midlands of the UK were surveyed using an online, anonymised questionnaire between 1 August and 30 September 2021. Domains explored were (1) approach to penicillin allergy clinical vignettes, (2) knowledge of the impact of penicillin allergy labels, (3) frequency of allergy-focused history questions and (4) barriers in tackling incorrect penicillin allergy. RESULTS Responses were received from 307 paediatric clinicians across 12 hospitals. Sixty-one per cent would not prescribe a penicillin-based antibiotic if a family history of penicillin allergy was reported. There was an overall deficit in taking an allergy-focused history with only 36.5% inquiring about diagnostic confirmation. Absence, or lack of awareness of a referral pathway for antibiotic allergy evaluation (58.6%) and unfamiliarity of the indications for oral provocation testing (55%) were the most common reported barriers to penicillin allergy de-labelling. Fifty-one per cent would rather 'play it safe' than explore penicillin allergy confirmation as it is felt that alternative treatments were readily available. CONCLUSIONS The deficiency in antibiotic allergy-focused history among paediatric clinicians highlights the need for better allergy education across all clinical grades. Pragmatic algorithms and clear referral pathways could address barriers faced by non-allergists in de-labelling incorrect penicillin allergy.
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Affiliation(s)
- Kene Maduemem
- Emergency department, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Hannah Clark
- Paediatrics, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Iseult Sohal
- Paediatrics, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Tom Dawson
- Paediatrics, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Niten Makwana
- Department of Paediatrics, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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22
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Mak HW, Yeung MH, Wong JC, Chiang V, Li PH. Differences in beta-lactam and penicillin allergy: Beyond the West and focusing on Asia-Pacific. FRONTIERS IN ALLERGY 2022; 3:1059321. [PMID: 36483185 PMCID: PMC9723361 DOI: 10.3389/falgy.2022.1059321] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/07/2022] [Indexed: 04/29/2024] Open
Abstract
Beta-lactam (BL) antibiotic "allergy" labels are common, but often overdiagnosed. Although much research has been focused on the BL allergy and the delabelling process in the West, studies from other parts of the world remain sparse. This review outlines the contrasting global epidemiology, shifting clinical practices and disparities of BL allergy in the Asia-Pacific region compared with the West. Innovative strategies to overcome barriers in BL allergy workup are discussed and potential directions for future research and service development are also proposed.
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Affiliation(s)
- Hugo W.F. Mak
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Maegan H.Y. Yeung
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Jane C.Y. Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong, China
| | - Philip H. Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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23
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Mabilat C, Gros MF, Van Belkum A, Trubiano JA, Blumenthal KG, Romano A, Timbrook TT. Improving antimicrobial stewardship with penicillin allergy testing: a review of current practices and unmet needs. JAC Antimicrob Resist 2022; 4:dlac116. [PMID: 36415507 PMCID: PMC9675589 DOI: 10.1093/jacamr/dlac116] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Penicillin allergy, the most frequently reported drug allergy, has been associated with suboptimal antibiotic therapy, increased antimicrobial resistance, increased rates of Clostridioides difficile colonization and infection, as well as extended hospital length of stay and increased cost. Although up to 10% of all patients may report penicillin allergy, most penicillin allergies are not confirmed. As such, most patients with a penicillin allergy can still safely use penicillin and related drugs following a more precise assessment. Herein, we review the current practices and unmet needs in penicillin allergy testing. The diagnostic algorithm is mostly based on a clinical history assessment followed by in vivo testing, i.e. skin test and/or drug challenge. As these tests are labour and resource intensive, there is increased interest in point-of-care penicillin allergy de-labelling solutions incorporated into Antimicrobial Stewardship Programmes including digital assessment tools. These can be locally parameterized on the basis of characteristics of target populations, incidence of specific allergies and local antibiotic usage to perform clinical risk stratification. Safely ruling out any residual risk remains essential and in vivo drug challenge and/or skin testing should be systematically encouraged. Gradual understanding and convergence of the risk stratification of the clinical presentation of penicillin allergy is enabling a wider implementation of this essential aspect of antimicrobial stewardship through digitalized decision tools and in vivo testing. More research is needed to deliver point of care in vitro diagnostic tools to democratize this de-labelling practice, which would be highly beneficial to patient care. This progress, together with better education of patients and clinicians about the availability, efficacy and safety of penicillin allergy testing, will increase the dissemination of penicillin allergy assessment as an important component of Antimicrobial Stewardship Programmes.
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Affiliation(s)
| | - Marie-Françoise Gros
- bioMérieux, Medical Affairs, 100 Rue Louis Pasteur, F-69280 Marcy l'Etoile, France
| | - Alex Van Belkum
- Current address:BaseClear, Sylviusweg 74, 2333 BE Leiden, The Netherlands
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, 145 Studley Road, Heidelberg, Victoria, 3084Australia
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | | | - Tristan T Timbrook
- bioMérieux, BioFire Diagnostics, Global Medical Affairs, 515 Colorow Drive, Salt Lake City, UT 84108, USA
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24
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Gorsline CA, Afghan AK, Stone CA, Phillips EJ, Satyanarayana G. Safety and value of pretransplant antibiotic allergy delabeling in a quaternary transplant center. Transpl Infect Dis 2022; 24:e13885. [PMID: 35765165 PMCID: PMC9588656 DOI: 10.1111/tid.13885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/23/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Self-reported antibiotic allergies, also known as antibiotic allergy labels, are common and may lead to worse patient outcomes. Within immunocompromized patients, antibiotic allergy labels can lead to inappropriate use of antimicrobials and may limit options for prophylactic and therapeutic options in the posttransplant period. While antibiotic allergy delabeling is considered an important aspect of antibiotic stewardship protocols, evidence and awareness of its application in transplant recipients is limited. METHODS We describe our experience with an antibiotic allergy delabeling intervention in the pretransplant evaluation period and its impact on posttransplant antimicrobial utilization. This was a retrospective analysis of patients with an antibiotic allergy label who underwent evaluation for solid organ or stem cell transplantation between 2015 and 2020. Patients included in this analysis were those who completed pretransplant antibiotic allergy delabeling through our Drug Allergy Clinic and were retained in care for 6 months after transplant. RESULTS Twenty-six of 27 patients underwent pretransplant antibiotic allergy delabeling and safely received the delabeled antibiotic posttransplant. There were no reported side effects to the delabeled antibiotic within 6 months posttransplant. Specific examination of sulfonamide (sulfa)-antibiotic delabeling showed cost savings of $254 to $2910 per patient in the posttransplant period compared to the use of alternative antibiotics for prophylaxis protocol. CONCLUSION Antibiotic allergy delabeling prior to transplant is safe, is of high value, and should be considered in the pretransplant evaluation period. More resources are needed for the development of delabeling guidelines and support for broad implementation of pretransplant antibiotic allergy delabeling programs.
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Affiliation(s)
- Chelsea A Gorsline
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Abaseen K Afghan
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gowri Satyanarayana
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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25
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Mowrer C, Lyden E, Matthews S, Abbas A, Bergman S, Alexander BT, Van Schooneveld TC, Stohs EJ. Beta-lactam allergies, surgical site infections, and prophylaxis in solid organ transplant recipients at a single center: A retrospective cohort study. Transpl Infect Dis 2022; 24:e13907. [PMID: 36254522 PMCID: PMC9787036 DOI: 10.1111/tid.13907] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Beta-lactam allergies (BLAs) are common in hospitalized patients, including transplant recipients. BLA is associated with decreased use of preferred surgical site infection (SSI) prophylaxis and increased SSIs, but this has not been studied in the transplant population. METHODS We reviewed adult heart, kidney, and liver transplant recipients between January 1, 2016 and December 31, 2019 to characterize reported BLA and collect SSI prophylaxis regimens at time of transplant. We compared the use of preferred SSI prophylaxis and SSI incidence based on reported BLA status. Post hoc we collected antibiotic days of therapy (DOT) (excluding pneumocystis prophylaxis) in the 30-day period posttransplant for patients without SSI. We utilized descriptive statistics for comparisons. RESULTS Of 691 patients included (116 heart, 400 kidney, and 175 liver transplant recipients), 118 (17%) reported BLA. Rash and hives were the two most reported BLA reactions (36% and 24%), categorized as potential T-cell mediated and IgE mediated, respectively. Preferred SSI prophylaxis was prescribed in 13 (11%) patients with BLA and 573 (92%) without BLA (p < .001). No difference could be detected in SSI incidence between BLA and non-BLA patients (4.2 vs. 4.3%, p = 1.0). Of 659 without SSI, 169 (25.6%) received antibiotics within 30 days of transplant; mean antibiotic DOT for BLA and non-BLA patients were 3.5 ± 8.0 versus 2.3 ± 5.8, p = .12. CONCLUSION BLA transplant recipients received nonpreferred SSI prophylaxis more frequently than non-BLA recipients, but there was no difference in 30-day SSIs between the groups. One-fourth of solid organ transplant recipients received systemic antibiotics within 30 days of transplant.
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Affiliation(s)
- Clayton Mowrer
- Division of Infectious DiseasesDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Elizabeth Lyden
- Department of BiostatisticsCollege of Public HealthUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Stephen Matthews
- Infection Control and EpidemiologyNebraska MedicineOmahaNebraskaUSA
| | - Anum Abbas
- Division of Infectious DiseasesDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Scott Bergman
- Department of Pharmaceutical and Nutritional CareNebraska MedicineOmahaNebraskaUSA
| | - Bryan T. Alexander
- Department of Pharmaceutical and Nutritional CareNebraska MedicineOmahaNebraskaUSA
| | - Trevor C. Van Schooneveld
- Division of Infectious DiseasesDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Erica J. Stohs
- Division of Infectious DiseasesDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
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26
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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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Alvarez-Cuesta E, Madrigal-Burgaleta R, Broyles AD, Cuesta-Herranz J, Guzman-Melendez MA, Maciag MC, Phillips EJ, Trubiano JA, Wong JT, Ansotegui I. Standards for practical intravenous rapid drug desensitization & delabeling: A WAO committee statement. World Allergy Organ J 2022; 15:100640. [PMID: 35694005 PMCID: PMC9163606 DOI: 10.1016/j.waojou.2022.100640] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/27/2022] [Accepted: 03/03/2022] [Indexed: 12/16/2022] Open
Abstract
Drug hypersensitivity reactions (DHRs) to intravenous drugs can be severe and might leave patients and doctors in a difficult position where an essential treatment or intervention has to be suspended. Even if virtually any intravenous medication can potentially trigger a life-threatening DHR, chemotherapeutics, biologics, and antibiotics are amongst the intravenous drugs most frequently involved in these reactions. Admittedly, suspending such treatments may negatively impact the survival outcomes or the quality of life of affected patients. Delabeling pathways and rapid drug desensitization (RDD) can help reactive patients stay on first-choice therapies instead of turning to less efficacious, less cost-effective, or more toxic alternatives. However, these are high-complexity and high-risk techniques, which usually need expert teams and allergy-specific techniques (skin testing, in vitro testing, drug provocation testing) to ensure safety, an accurate diagnosis, and personalized management. Unfortunately, there are significant inequalities within and among countries in access to allergy departments with the necessary expertise and resources to offer these techniques and tackle these DHRs optimally. The main objective of this consensus document is to create a great benefit for patients worldwide by aiding allergists to expand the scope of their practice and support them with evidence, data, and experience from leading groups from around the globe. This statement of the Drug Hypersensitivity Committee of the World Allergy Organization (WAO) aims to be a comprehensive practical guide on the technical aspects of implementing acute-onset intravenous hypersensitivity delabeling and RDD for a wide range of drugs. Thus, the manuscript does not only focus on clinical pathways. Instead, it also provides guidance on topics usually left unaddressed, namely, internal validation, continuous quality improvement, creating a healthy multidisciplinary environment, and redesigning care (including a specific supplemental section on a real-life example of how to design a dedicated space that can combine basic and complex diagnostic and therapeutic techniques in allergy).
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Affiliation(s)
| | - Ricardo Madrigal-Burgaleta
- Allergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
- Drug Desensitisation Centre, Catalan Institute of Oncology (ICO), Barcelona, Spain
| | - Ana D. Broyles
- Division of Allergy & Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Javier Cuesta-Herranz
- Department of Allergy and Immunology, FIIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
- RETIC ARADyAL, Instituto de Salud Carlos III, Spain
| | | | - Michelle C. Maciag
- Division of Allergy & Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth J. Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason A. Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Johnson T. Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
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Devchand M, Nolen A, Stewardson AJ, Warrillow SJ, Garrett K, Trubiano JA. Long-term outcomes of an electronic medical record (EMR)-integrated antimicrobial stewardship (AMS) intensive care unit (ICU) ward round. Infect Control Hosp Epidemiol 2022; 43:670-672. [PMID: 33731236 DOI: 10.1017/ice.2021.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Misha Devchand
- Department of Infectious Diseases Department, Austin Health, Heidelberg, Victoria, Australia
- Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew Nolen
- Department of Infectious Diseases Department, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine (Austin Health), University of Melbourne, Parkville, Victoria, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, The Alfred Hospital, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Stephen J Warrillow
- Department of Medicine (Austin Health), University of Melbourne, Parkville, Victoria, Australia
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Kent Garrett
- Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases Department, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine (Austin Health), University of Melbourne, Parkville, Victoria, Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Victoria, Australia
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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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Schrüfer P, Stoevesandt J, Trautmann A. Outcome of a de-labelling algorithm compared with results of penicillin (β-lactam) allergy testing. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:26. [PMID: 35317861 PMCID: PMC8941741 DOI: 10.1186/s13223-022-00659-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
Background Penicillin allergy labels frequently impede guideline-directed treatment with a penicillin or other β-lactam antibiotics. Despite presumed allergy, targeted questioning may indicate a low probability of sensitization and permit reasonably safe administration of the antibiotic in question. In this study, we evaluated a standardized algorithm aiming to differentiate non-allergic patients from those with true allergic β-lactam hypersensitivity. Methods We retrospectively applied a de-labelling algorithm in 800 consecutive patients with suspected β-lactam hypersensitivity. All had undergone complete allergy work-up permitting to definitely exclude or diagnose β-lactam allergy between 2009 and 2019. Results In 595 (74.4%) out of 800 cases evaluated, β-lactam allergy could be excluded by negative challenge testing. IgE-mediated anaphylaxis was diagnosed in 70 (8.7%) patients, delayed-type hypersensitivity in 135 (16.9%). In 62 (88.6%) anaphylaxis cases, the algorithm correctly advised to use an alternative antibiotic. Accuracy was higher in patients with moderate to severe anaphylaxis (97.7%) compared to those with a history of mild reactions (73.1%). The algorithm correctly identified 122 (90.4%) patients with proven delayed-type hypersensitivity. It permitted de-labelling in 330 (55.5%) out of 595 patients with diagnostic exclusion of penicillin hypersensitivity, but failed to identify the remaining 265 (44.5%) as low-risk cases. Conclusions The algorithm detected 89.8% of cases with penicillin (β-lactam) allergy, sensitivity was optimal for moderate to severe anaphylaxis. Study data justify the implementation of a standardized de-labelling algorithm under close supervision in order to permit guideline-directed treatment and reduce the use of broad-spectrum antibiotics as part of an antibiotic stewardship program. Supplementary Information The online version contains supplementary material available at 10.1186/s13223-022-00659-1.
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Affiliation(s)
- Philipp Schrüfer
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Johanna Stoevesandt
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Axel Trautmann
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany.
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Kufel WD, Blaine BE, Ruehl R, Avery LM. Instruction and Simulation to Improve Pharmacy Students' Knowledge and Confidence Regarding Assessment of Penicillin Allergies. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2022; 86:8688. [PMID: 34301577 PMCID: PMC10159444 DOI: 10.5688/ajpe8688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/30/2021] [Indexed: 05/06/2023]
Abstract
Objective. To evaluate pharmacy students' knowledge of and confidence regarding penicillin allergy assessment and skin testing (PAAST) before and after a focused didactic instruction and simulation (FDIS).Methods. A multicenter, quasi-experimental, cross-sectional survey study was performed among pharmacy students before and after FDIS on PAAST at two schools of pharmacy. The FDIS on PAAST consisted of an infectious disease faculty-led seminar, student-led penicillin allergy counseling interviews, penicillin skin testing simulation, and case studies to assess penicillin allergy scenarios and management. An anonymous, voluntary, electronic survey was distributed to students (n=159) before and after the FDIS. The pre- and post-intervention survey contained 10 PAAST knowledge-based questions and multi-step, five-point Likert scale statements related to students' confidence in PAAST. The post-intervention survey also evaluated students' perceptions of the FDIS on PAAST. Descriptive statistics were performed, and the Student t test was used to compare pre- and post-intervention responses.Results. One hundred forty-three surveys were completed, resulting in a survey response rate of 90%. Students' PAAST knowledge scores (mean±SD) increased overall following the FDIS on PAAST (6.67±1.51 vs 7.81±1.39). Knowledge scores increased considerably for questions related to penicillin allergy consequences, cross-reactivity, and correct steps of PAAST. Pharmacy students' PAAST confidence scores (mean±SD) also improved following the interactive instruction and simulation (2.30±0.7 vs 3.22±0.67) with considerable confidence increases in penicillin skin testing. Pharmacy students' perceptions of the FDIS on PAAST were also positive overall.Conclusion. Pharmacy students' knowledge and confidence of PAAST improved following FDIS. This may be an effective strategy to implement PAAST education during pharmacy school.
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Affiliation(s)
- Wesley D Kufel
- Binghamton University, School of Pharmacy and Pharmaceutical Sciences, Binghamton, New York
- State University of New York, Upstate Medical University, Syracuse, New York
- State University of New York, Upstate University Hospital, Syracuse, New York
| | | | - Rachel Ruehl
- Good Samaritan TriHealth Hospital, Cincinnati, Ohio
| | - Lisa M Avery
- Saint John Fisher College, Wegmans School of Pharmacy, Rochester, New York
- Saint Joseph's Health, Syracuse, New York
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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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A novel framework to guide antibiotic stewardship nursing practice. Am J Infect Control 2022; 50:99-104. [PMID: 34492325 DOI: 10.1016/j.ajic.2021.08.029] [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] [Received: 07/12/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND There is a pervasive view among some nurses and health care disciplines that antibiotic stewardship (AS) is solely a physician or pharmacist responsibility. There is an urgent need to alter this view so that nurses can seize every opportunity to prevent patient harm from antibiotics and optimize antibiotic use. One challenge to achieving full nurse engagement as equal members of the AS team is lack of an organizing framework to illustrate relationships of phenomena and concepts inherent to adoption of AS nursing practices. METHODS We sought to create a framework derived from the peer-reviewed literature, systematic and scoping reviews, and professional standards, consensus statements and white papers. The emerging framework went through multiple iterations as it was vetted with nurse clinicians, scholars and educators, physicians, pharmacists, infection preventionists and AS subject matter experts. RESULTS Our evidence-based Antibiotic Stewardship Nursing Practice SCAN-P Framework provides the much-needed context and clarity to help guide local-level nurses to participate in and lead AS nursing practice. CONCLUSIONS Nurses worldwide are ideally situated to provide holistic person-centered care, advocate for judicious use of antibiotics to minimize antibiotic resistance, and be AS educators of their patients, communities and the general public. The Antibiotic Stewardship Nursing Practice SCAN-P Framework provides a tool to do so.
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James R, Nakamachi Y, Morris A, So M, Ponnampalavanar SSLS, Chuki P, Loong LS, Lai PSM, Chen C, Ingram R, Rajkhowa A, Buising K, Thursky K. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlac012. [PMID: 35156035 PMCID: PMC8827555 DOI: 10.1093/jacamr/dlac012] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The National Antimicrobial Prescribing Survey (NAPS) is a web-based qualitative auditing platform that provides a standardized and validated tool to assist hospitals in assessing the appropriateness of antimicrobial prescribing practices. Since its release in 2013, the NAPS has been adopted by all hospital types within Australia, including public and private facilities, and supports them in meeting the national standards for accreditation. Hospitals can generate real-time reports to assist with local antimicrobial stewardship (AMS) activities and interventions. De-identified aggregate data from the NAPS are also submitted to the Antimicrobial Use and Resistance in Australia surveillance system, for national reporting purposes, and to strengthen national AMS strategies. With the successful implementation of the programme within Australia, the NAPS has now been adopted by countries with both well-resourced and resource-limited healthcare systems. We provide here a narrative review describing the experience of users utilizing the NAPS programme in Canada, Malaysia and Bhutan. We highlight the key barriers and facilitators to implementation and demonstrate that the NAPS methodology is feasible, generalizable and translatable to various settings and able to assist in initiatives to optimize the use of antimicrobials.
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Affiliation(s)
- Rodney James
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infection and Immunity, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Corresponding author. E-mail:
| | - Yoshiko Nakamachi
- Sinai Health-University Health Network Antimicrobial Stewardship Program, Toronto General Hospital, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada
| | - Andrew Morris
- Sinai Health-University Health Network Antimicrobial Stewardship Program, Toronto General Hospital, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada
| | - Miranda So
- Sinai Health-University Health Network Antimicrobial Stewardship Program, Toronto General Hospital, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada
| | | | - Pem Chuki
- Jigme Dorji Wangchuck National Referral Hospital, Gongphel Lam, Thimphu, Bhutan
| | - Ly Sia Loong
- University Malaya Medical Centre, Lembah Pantai, Kuala Lumpur 59100, Malaysia
| | | | - Caroline Chen
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infection and Immunity, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Robyn Ingram
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infection and Immunity, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Arjun Rajkhowa
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infection and Immunity, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Kirsty Buising
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infection and Immunity, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Karin Thursky
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infection and Immunity, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
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McLachlan G, Broomfield A, Elliott R. Completeness and accuracy of adverse drug reaction documentation in electronic medical records at a tertiary care hospital in Australia. HEALTH INF MANAG J 2021; 52:108-111. [PMID: 34930047 DOI: 10.1177/18333583211057741] [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: 11/15/2022]
Abstract
Background: A large proportion of patients presenting to hospitals have experienced a previous adverse drug reaction (ADR). Electronic medical records (EMRs) present an opportunity to accurately document ADRs and alert clinicians against inadvertent rechallenge where there is a pre-existing reaction. However, EMR systems are imperfect and rely on the accuracy of the data entered. Objective: To ascertain the completeness of ADR documentation and the accuracy of the classification of ADRs as allergy versus intolerance in the EMR at a major metropolitan hospital in Australia. Method: Cross-sectional audit of the ADR field of the EMR for a sample of patients on four different wards over 3 weeks to ascertain the completeness of ADR documentation and the accuracy of classification of ADRs. Results: Of the 264 patients assessed, 102 (38.6%) had a total of 210 ADRs documented in the EMR. Of these, 105 (50%) were considered to have complete documentation; 63/210 (30.0%) were missing a reaction description and 88/210 (41.9%) were missing severity information. For those ADRs with a reaction description (n = 147), 97 (66.0%) were considered to be appropriately classified as allergy or intolerance. Conclusion: Incomplete and inaccurate ADR documentation was common. These findings highlight a need for optimising ADR documentation to improve appropriate medication use in hospital. Implications: Improved EMR design and education of healthcare workers on the importance of complete and accurate documentation of reactions are needed to improve completeness and accuracy of ADR classification.
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Affiliation(s)
- Gina McLachlan
- Pharmacy Department, 3805Austin Health, Heidelberg, Victoria, Australia
| | - Airley Broomfield
- Pharmacy Department, 3805Austin Health, Heidelberg, Victoria, Australia
| | - Rohan Elliott
- Pharmacy Department, 3805Austin Health, Heidelberg, Victoria, Australia
- Centre for Medicine Use and Safety, 63634Monash University, Parkville, Victoria, Australia
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Thursky KA, Hardefeldt LY, Rajkhowa A, Ierano C, Bishop J, Hawes L, Biezen R, Saha SK, Dowson L, Bailey KE, Scarborough R, Little SB, Gotterson F, Hur B, Khanina A, Urbancic K, Crabb HK, Richards S, Sri A, James R, Kong DCM, Marshall C, Mazza D, Peel T, Stuart RL, Manski-Nankervis JA, Friedman ND, Bennett N, Schulz T, Billman-Jacobe H, Buono E, Worth L, Bull A, Richards M, Ayton D, Gilkerson JR, Browning GF, Buising KL. Antimicrobial stewardship in Australia: the role of qualitative research in programme development. JAC Antimicrob Resist 2021; 3:dlab166. [PMID: 34806005 PMCID: PMC8600289 DOI: 10.1093/jacamr/dlab166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.
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Affiliation(s)
- Karin A Thursky
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne and Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Laura Y Hardefeldt
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Arjun Rajkhowa
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Courtney Ierano
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Jaclyn Bishop
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Pharmacy Department, Ballarat Health Services, 1 Drummond Street North, Ballarat, Victoria 3353, Australia
| | - Lesley Hawes
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
| | - Ruby Biezen
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
- Department of General Practice, University of Melbourne, 780 Elizabeth Street, Melbourne, Victoria 3010, Australia
| | - Sajal K Saha
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
| | - Leslie Dowson
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Kirsten E Bailey
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Ri Scarborough
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Stephen B Little
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Fiona Gotterson
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Brian Hur
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Anna Khanina
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne and Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Karen Urbancic
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Helen K Crabb
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Suzanna Richards
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Anna Sri
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Rodney James
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - David C M Kong
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Pharmacy Department, Ballarat Health Services, 1 Drummond Street North, Ballarat, Victoria 3353, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Caroline Marshall
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Danielle Mazza
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
| | - Trisha Peel
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, The Alfred and Central Clinical School, Burnet Institute, Monash University and Alfred Health, 85 Commercial Road, Monash University, Melbourne, Victoria 3004, Australia
| | - Rhonda L Stuart
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Departments of Infectious Diseases and Infection Control and Epidemiology, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Jo-Anne Manski-Nankervis
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, University of Melbourne, 780 Elizabeth Street, Melbourne, Victoria 3010, Australia
| | - N Deborah Friedman
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, University Hospital Geelong, Barwon Health, Bellerine Street, Geelong, Victoria 3220, Australia
| | - Noleen Bennett
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- VICNISS Coordinating Centre, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Thomas Schulz
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Helen Billman-Jacobe
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Evette Buono
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- New South Wales Clinical Excellence Commission, 1 Reserve Road, St Leonards, New South Wales 2065, Australia
| | - Leon Worth
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne and Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Ann Bull
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- VICNISS Coordinating Centre, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Michael Richards
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
- VICNISS Coordinating Centre, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Darshini Ayton
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria 3004, Australia
| | - James R Gilkerson
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Glenn F Browning
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Kirsty L Buising
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Peter Doherty Institute of Infection and Immunity, 792 Elizabeth Street, Melbourne Victoria, 3000, Australia
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Catalano AC, Pittet LF, Choo S, Segal A, Stephens D, Cranswick NE, Gwee A. Impact of Antibiotic Allergy Labels on Patient Outcomes in a Tertiary Paediatric Hospital. Br J Clin Pharmacol 2021; 88:1107-1114. [PMID: 34388858 DOI: 10.1111/bcp.15038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Antibiotic allergies are reported in 5 to 15% of children. This study aimed to evaluate the impact of common β-lactam antibiotic allergy labels (AALs) on hospital treatment, focussing on length of stay and appropriateness of antibiotic prescribing. STUDY DESIGN Retrospective cohort study over 21-months at the Royal Children's Hospital Melbourne, Australia. A subset of children with the most common β-lactam allergies, and who required admission for intravenous antibiotics over a 12-month period, was analysed for appropriateness of prescribing. Non-allergic patients were matched to evaluate associations between AALs and hospital treatment. RESULTS There were 98,912 children admitted over the study period, of whom 938 (1%) had at least one AAL on first admission. Of all encounters, 5145 (2.5%) were for children with AALs. The most common AALs were to amoxicillin and amoxicillin-clavulanic acid combinations (40.8%), cefalexin (14.4%) and trimethoprim-sulfamethoxazole (9.7%). For the subset, there were 66 admissions for children who required intravenous antibiotics. Documentation was adequate for 27% of AALs. Inappropriate prescribing occurred in almost half (47%). Hospital stay was longer for children with AALs (median 4.7 days; IQR 2.3 to 9.2) compared to non-allergic controls (median 3.9 days; IQR 1.9 to 6.8; P=0.02). Children with AALs were more likely to receive restricted antibiotics (aOR 3.03; 95%CI, 1.45 to 6.30; p=0.003). CONCLUSION This is the first study to demonstrate high rates of inappropriate prescribing in children with AALs. Children with AALs were significantly more likely to receive restricted antibiotics and had a longer length of stay compared with non-allergic controls.
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Affiliation(s)
- Anthony C Catalano
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Laure F Pittet
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia
| | - Sharon Choo
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Allergy and Immunology, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Ahuva Segal
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia
| | - David Stephens
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Noel E Cranswick
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | - Amanda Gwee
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia
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Chua KYL, Vogrin S, Bury S, Douglas A, Holmes NE, Tan N, Brusco NK, Hall R, Lambros B, Lean J, Stevenson W, Devchand M, Garrett K, Thursky K, Grayson ML, Slavin MA, Phillips EJ, Trubiano JA. The Penicillin Allergy Delabeling Program: A Multicenter Whole-of-Hospital Health Services Intervention and Comparative Effectiveness Study. Clin Infect Dis 2021; 73:487-496. [PMID: 32756983 DOI: 10.1093/cid/ciaa653] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/23/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Penicillin allergies are associated with inferior patient and antimicrobial stewardship outcomes. We implemented a whole-of-hospital program to assess the efficacy of inpatient delabeling for low-risk penicillin allergies in hospitalized inpatients. METHODS Patients ≥ 18 years of age with a low-risk penicillin allergy were offered a single-dose oral penicillin challenge or direct label removal based on history (direct delabeling). The primary endpoint was the proportion of patients delabeled. Key secondary endpoints were antibiotic utilization pre- (index admission) and post-delabeling (index admission and 90 days). RESULTS Between 21 January 2019 and 31 August 2019, we assessed 1791 patients reporting 2315 antibiotic allergies, 1225 with a penicillin allergy. Three hundred fifty-five patients were delabeled: 161 by direct delabeling and 194 via oral penicillin challenge. Ninety-seven percent (194/200) of patients were negative upon oral penicillin challenge. In the delabeled patients, we observed an increase in narrow-spectrum penicillin usage (adjusted odds ratio [OR], 10.51 [95% confidence interval {CI}, 5.39-20.48]), improved appropriate antibiotic prescribing (adjusted OR, 2.13 [95% CI, 1.45-3.13]), and a reduction in restricted antibiotic usage (adjusted OR, 0.38 [95% CI, .27-.54]). In the propensity score analysis, there was an increase in narrow-spectrum penicillins (OR, 10.89 [95% CI, 5.09-23.31]) and β-lactam/β-lactamase inhibitors (OR, 6.68 [95% CI, 3.94-11.35]) and a reduction in restricted antibiotic use (OR, 0.52 [95% CI, .36-.74]) and inappropriate prescriptions (relative risk ratio, 0.43 [95% CI, .26-.72]) in the delabeled group compared with the group who retained their allergy label. CONCLUSIONS This health services program using a combination of direct delabeling and oral penicillin challenge resulted in significant impacts on the use of preferred antibiotics and appropriate prescribing.
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Affiliation(s)
- Kyra Y L Chua
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Australia
| | - Susan Bury
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Pharmacy, Austin Health, Heidelberg, Australia
| | - Abby Douglas
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Natasha E Holmes
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Nixon Tan
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Natasha K Brusco
- Alpha Crucis Group, Health Economics, Langwarrin, Australia.,Rehabilitation, Ageing and Independent Living Research Centre, Monash University, Frankston, Australia
| | - Rebecca Hall
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Belinda Lambros
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Jacinta Lean
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Wendy Stevenson
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Misha Devchand
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Pharmacy, Austin Health, Heidelberg, Australia
| | - Kent Garrett
- Department of Pharmacy, Austin Health, Heidelberg, Australia
| | - Karin Thursky
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia.,National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Melbourne, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Parkville, Australia
| | - M Lindsay Grayson
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia
| | - Monica A Slavin
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Parkville, Australia
| | - Elizabeth J Phillips
- Department of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia
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Carra S, Schatz M, Mertes PM, Torres MJ, Fuchs F, Senna G, Castells MC, Demoly P, Tanno LK. ANAPHYLAXIS AND PREGNANCY: A SYSTEMATIC REVIEW AND CALL FOR PUBLIC HEALTH ACTIONS. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4270-4278. [PMID: 34365055 DOI: 10.1016/j.jaip.2021.07.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although rare, anaphylaxis during pregnancy implies a risk to both mothers and newborns. OBJECTIVE This systematic review is intended to identify key issues in the diagnosis and management of this condition in order to support prevention strategies and decrease the risk of death related to anaphylaxis during pregnancy. METHODS We searched MEDLINE, Cochrane, Lilacs, Scielo and Science Direct databases for manuscripts concerning terms "anaphylaxis during pregnancy" without language restrictions. We screened studies, extracted data, and assessed risk of bias independently in duplicate. RESULTS We selected 12 articles. Frequency of anaphylaxis during pregnancy is estimated between 1.5 to 3.8 per 100 000 maternities. Only one study provided anaphylaxis mortality data in pregnant women, and the rate of anaphylaxis-related maternal mortality is estimated at 0.05 per 100 000 live births. No standard definition of anaphylaxis severity has been utilized. Forty-nine percent to 74% of anaphylaxis cases were described during caesarean sections. Beta-lactam antibiotics (58%), latex (25%) and anaesthetic agents (17%) were the main culprits. In 17% of papers, causative agents were proven by allergy testing. Seventy two percent of articles proposed the same management and treatment for a clinical episode of anaphylaxis during pregnancy as in non-pregnant patients, and, use of epinephrine in the patient's care during anaphylaxis in pregnancy. CONCLUSION Few studies address anaphylaxis during pregnancy, and the majority have been produced by non-allergy specialists. Collaboration between different specialists involved in the care of pregnant women should be established in order to support preventive strategies and reduce avoidable deaths.
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Affiliation(s)
- Sophie Carra
- Department of Allergy, University Hospital of Montpellier, Montpellier, France
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente, San Diego, California, USA
| | - Paul-Michel Mertes
- Department of Anaesthesia and Critical Care, Strasbourg University Hospital, EA 3072, FMTS Strasbourg, France 1 Place de l'Hôpital - BP 426 67091 STRASBOURG CEDEX
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Florence Fuchs
- Departement of gynecology and obstetric, University Hospital of Montpellier, Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, University of Montpellier, France; Inserm, CESP Centre de recherche en Epidémiologie et Santé des Populations, U1018, Reproduction et Développement de l'enfant, 94807 Villejuif, France
| | - Gianenrico Senna
- Asthma Center and Allergy Unit, Verona University and General Hospital, Verona, Italy
| | - Mariana C Castells
- Brigham and Women's Hospital, Boston (M.C.C.); and the Department of Medicine, Vanderbilt University Medical Center, Nashville (E.J.P.), USA
| | - Pascal Demoly
- Department of Allergy, University Hospital of Montpellier, Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, University of Montpellier, France; WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Luciana Kase Tanno
- Department of Allergy, University Hospital of Montpellier, Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, University of Montpellier, France; WHO Collaborating Centre on Scientific Classification Support, Montpellier, France; Hospital Sírio-Libanês.
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McMullan BJ, Hall L, James R, Mostaghim M, Jones CA, Konecny P, Blyth CC, Thursky KA. Antibiotic appropriateness and guideline adherence in hospitalized children: results of a nationwide study. J Antimicrob Chemother 2021; 75:738-746. [PMID: 31697335 DOI: 10.1093/jac/dkz474] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/01/2019] [Accepted: 10/16/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Information on the nature and appropriateness of antibiotic prescribing for children in hospitals is important, but scarce. OBJECTIVES To analyse antimicrobial prescribing and appropriateness, and guideline adherence, in hospitalized children across Australia. PATIENTS AND METHODS We analysed data from the National Antimicrobial Prescribing Survey (NAPS) from 2014 to 2017. Surveys were performed in hospital facilities of all types (public and private; major city, regional and remote). Participants were admitted children <18 years old. Risk factors associated with inappropriate prescribing were explored using logistic regression models. RESULTS Among 6219 prescriptions for 3715 children in 253 facilities, 19.6% of prescriptions were deemed inappropriate. Risk factors for inappropriate prescribing included non-tertiary paediatric hospital admission [OR 1.37 (95% CI 1.20-1.55)] and non-major city hospital location [OR 1.52 (95% CI 1.30-1.77)]. Prescriptions for neonates, immunocompromised children and those admitted to an ICU were less frequently inappropriate. If a restricted antimicrobial was prescribed and not approved, the prescription was more likely to be inappropriate [OR 12.9 (95% CI 8.4-19.8)]. Surgical prophylaxis was inappropriate in 59% of prescriptions. CONCLUSIONS Inappropriate antimicrobial prescribing in children was linked to specific risk factors identified here, presenting opportunities for targeted interventions to improve prescribing. This information, using a NAPS dataset, allows for analysis of antimicrobial prescribing among different groups of hospitalized children. Further exploration of barriers to appropriate prescribing and facilitators of best practice in this population is recommended.
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Affiliation(s)
- Brendan J McMullan
- National Centre for Infections in Cancer, University of Melbourne, Melbourne, Australia.,Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, Sydney, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Lisa Hall
- School of Public Health, University of Queensland, Brisbane, Australia
| | - Rodney James
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Mona Mostaghim
- Department of Pharmacy, Sydney Children's Hospital, Randwick, Sydney, Australia
| | - Cheryl A Jones
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Pamela Konecny
- Department of Infectious Diseases, Immunology & Sexual Health, St George Hospital, Kogarah, Sydney, Australia.,St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia
| | - Christopher C Blyth
- School of Medicine, University of Western Australia, Perth, Australia.,Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Australia.,Department of Paediatric Infectious Diseases, Perth Children's Hospital, Perth, Australia.,Department of Microbiology, PathWest Laboratory Medicine, QEII Medical Centre, Perth, Australia
| | - Karin A Thursky
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
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Hughes Y, Comninos N. Contact dermatitis masquerading as fixed drug eruption: making a critical distinction. BMJ Case Rep 2021; 14:e240805. [PMID: 33622756 PMCID: PMC7907844 DOI: 10.1136/bcr-2020-240805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Yasmin Hughes
- Western Sydney Sexual Health Centre, Western Sydney Local Health District, Parramatta, New South Wales, Australia
| | - Nicholas Comninos
- Western Sydney Sexual Health Centre, Western Sydney Local Health District, Parramatta, New South Wales, Australia
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43
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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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44
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Anforderungen an die Infektionsprävention bei der medizinischen Versorgung von immunsupprimierten Patienten. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021; 64:232-264. [PMID: 33394069 PMCID: PMC7780910 DOI: 10.1007/s00103-020-03265-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Hills T, Arroll N, Duffy E, Capstick J, Jordan A, Fitzharris P. Penicillin Allergy De-labeling Results in Significant Changes in Outpatient Antibiotic Prescribing Patterns. FRONTIERS IN ALLERGY 2020; 1:586301. [PMID: 35386932 PMCID: PMC8974713 DOI: 10.3389/falgy.2020.586301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/14/2020] [Indexed: 11/13/2022] Open
Abstract
Unverified penicillin allergies are common but most patients with a penicillin allergy label can safely use penicillin antibiotics. Penicillin allergy labels are associated with poor clinical outcomes and overuse of second-line antibiotics. There is increasing focus on penicillin allergy "de-labeling" as a tool to improve antibiotic prescribing and antimicrobial stewardship. The effect of outpatient penicillin allergy de-labeling on long-term antibiotic use is uncertain. We performed a retrospective pre- and post- study of antibiotic dispensing patterns, from an electronic dispensing data repository, in patients undergoing penicillin allergy assessment at Auckland City Hospital, New Zealand. Over a mean follow-up of 4.55 years, 215/304 (70.7%) of de-labeled patients were dispensed a penicillin antibiotic. Rates of penicillin antibiotic dispensing were 0.24 (0.18-0.30) penicillin courses per year before de-labeling and 0.80 (0.67-0.93) following de-labeling with a reduction in total antibiotic use from 2.30 (2.06-2.54) to 1.79 (1.59-1.99) antibiotic courses per year. In de-labeled patients, the proportion of antibiotic courses that were penicillin antibiotics increased from 12.81 to 39.62%. Rates of macrolide, cephalosporin, trimethoprim/co-trimoxazole, fluoroquinolone, "other" non-penicillin antibiotic use, and broad-spectrum antibiotic use were all lower following de-labeling. Further, antibiotic costs were lower following de-labeling. In this study, penicillin allergy de-labeling was associated with significant changes in antibiotic dispensing patterns.
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Affiliation(s)
- Thomas Hills
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Nicola Arroll
- Health Information and Technology Service, Auckland District Health Board, Auckland, New Zealand
| | - Eamon Duffy
- Depatment of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand
| | - Janice Capstick
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
| | - Anthony Jordan
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
| | - Penny Fitzharris
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
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Imlay H, Krantz EM, Stohs EJ, Lan KF, Zier J, Kim HN, Rakita RM, Limaye AP, Wald A, Pergam SA, Liu C. Reported β-Lactam and Other Antibiotic Allergies in Solid Organ and Hematopoietic Cell Transplant Recipients. Clin Infect Dis 2020; 71:1587-1594. [PMID: 31621829 PMCID: PMC8241219 DOI: 10.1093/cid/ciz1025] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/11/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients with reported β-lactam antibiotic allergies (BLAs) are more likely to receive broad-spectrum antibiotics and experience adverse outcomes. Data describing antibiotic allergies among solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients are limited. METHODS We reviewed records of adult SOT or allogeneic HCT recipients from 1 January 2013 to 31 December 2017 to characterize reported antibiotic allergies at time of transplantation. Inpatient antibiotic use was examined for 100 days posttransplant. Incidence rate ratios (IRRs) comparing antibiotic use in BLA and non-BLA groups were calculated using multivariable negative binomial models for 2 metrics: days of therapy (DOT) per 1000 inpatient days and percentage of antibiotic exposure-days. RESULTS Among 2153 SOT (65%) and HCT (35%) recipients, 634 (29%) reported any antibiotic allergy and 347 (16%) reported BLAs. Inpatient antibiotics were administered to 2020 (94%) patients during the first 100 days posttransplantation; average antibiotic exposure was 41% of inpatient-days (interquartile range, 16.7%-62.5%). BLA patients had significantly higher DOT for vancomycin (IRR, 1.4 [95% confidence interval {CI}, 1.2-1.7]; P < .001), clindamycin (IRR, 7.6 [95% CI, 2.2-32.4]; P = .001), and aztreonam in HCT (IRR, 9.7 [95% CI, 3.3-35.0]; P < .001), and fluoroquinolones in SOT (IRR, 2.9 [95% CI, 2.1-4.0]; P < .001); these findings were consistent when using percentage of antibiotic exposure-days. CONCLUSIONS Transplant recipients are frequently exposed to antibiotics and have a high prevalence of reported antibiotic allergies. Reported BLA was associated with greater use of β-lactam antibiotic alternatives. Pretransplant antibiotic allergy evaluation may optimize antibiotic use in this population.
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Affiliation(s)
- Hannah Imlay
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Elizabeth M Krantz
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Erica J Stohs
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Seattle, Washington, USA, and Omaha, Nebraska, USA
| | - Kristine F Lan
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jacqlynn Zier
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - H Nina Kim
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Robert M Rakita
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Ajit P Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Anna Wald
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| | - Steven A Pergam
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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The impact of antibiotic allergy labels on antibiotic exposure, clinical outcomes, and healthcare costs: A systematic review. Infect Control Hosp Epidemiol 2020; 42:530-548. [PMID: 33059777 DOI: 10.1017/ice.2020.1229] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE A growing body of evidence suggests that antibiotic allergy labels as documented in medical records are a risk factor for poor clinical outcomes. In this systematic review, we aimed to determine how antibiotic allergy labels influence 3 domains: antibiotic use and exposure, clinical outcomes, and healthcare-related costs. DESIGN We performed a systematic review to identify studies reporting outcomes in patients with antibiotic allergy labels compared to nonallergic counterparts. The search included PubMed, EMBASE, Cochrane CENTRAL, EBSCO, Cochrane Database of Abstracts of Reviews of Effects and Web of Science. Two reviewers independently screened studies for inclusion and abstracted data. Studies were graded using the Newcastle-Ottawa quality assessment scale. Study outcomes included antibiotic use, clinical outcomes, and economic outcomes. RESULTS In total, 41 studies met our criteria for inclusion. These studies varied in medical specialty, patient population, healthcare delivery system, and design, but most were conducted among adults age >18 years (85%) in the inpatient setting (82.5%). Among 34 studies examining antibiotic exposure, 32 (94%) found that patients with antibiotic allergy labels received more broad-spectrum antibiotics. Moreover, 31 studies examined clinical outcomes such as length of hospitalization, ICU admission, hospital readmission, multidrug-resistant or opportunistic infection, or mortality, and 27 (87%) found that allergy-labeled patients had at least 1 negative outcome. Of 9 studies examining healthcare costs, 7 (78%) found that allergy-labeled patients incurred significantly higher drug or hospital-related costs. CONCLUSIONS Antibiotic allergy labels have negative effects on antibiotic use, clinical outcomes, and economic outcomes in a variety of clinical settings and populations.
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Chakravorty A, Binder E, Rawlins M, Trevenen M, Ingram PR, McKeogh A, Murray K, Dyer J, Lucas M. Antibiotic allergy labels and optimal antimicrobial stewardship. Intern Med J 2020; 52:396-402. [PMID: 32743883 DOI: 10.1111/imj.15003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although common, antimicrobial allergy labels (AAL) rarely reflect immunologically-mediated hypersensitivity and can lead to poorer outcomes from alternative antimicrobial agents. Antimicrobial stewardship programs are ideally placed to assess AAL early as a means of improving antimicrobial use. OBJECTIVES To quantify the prevalence of AAL in patients referred for antimicrobial stewardship review and assess their impact on antibiotic prescribing, patient mortality, hospital length of stay, readmission, and rates of multidrug-resistant infections. METHODS We conducted a retrospective analysis of adult patients referred for inpatient antimicrobial prospective audit and feedback rounds (PAFR) via an electronic referral system (eReferrals) over a 12-month period in 2015. Outcome data was collected for a period of 36 months following the initial review. RESULTS Of the 639 patient records reviewed, 630 met inclusion criteria; 103 (16%) had an AAL, of which 82 (13%) had reported allergies to β-lactam antibiotics. Those with AAL were significantly less likely to be receiving guideline-recommended antimicrobial therapy (50% versus 64%, p=0.0311), however there were no significant difference in mortality, hospital length of stay, readmission or increased incidence of multidrug-resistant infections. CONCLUSIONS Our cohort demonstrated that AAL was associated with reduced adherence to antibiotic guidelines. The lack of association with adverse outcomes may reflect limitations within the study including retrospective cohort study numbers and observational nature, further skewed by high rates of poor documentation. A clear opportunity exists for antimicrobial stewardship programs to incorporate allergy assessment, delabelling, challenge and referral into these rounds. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | | | | | - Michelle Trevenen
- Centre for Applied Statistics, The University of Western Australia, Perth, WA, Australia
| | - Paul Robert Ingram
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia.,Department of Pathology and Laboratory Medicine, The University of Western Australia, Perth, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, Australia
| | - Anna McKeogh
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
| | - Kevin Murray
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - John Dyer
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
| | - Michaela Lucas
- Department of Immunology, Sir Charles Gairdner Hospital, Perth, Australia.,Department of Immunology, PathWest Laboratory Medicine, Perth, Australia.,School of Medicine, The University of Western Australia, Perth, Australia
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du Plessis T, Walls G, Jordan A, Holland DJ. Implementation of a pharmacist-led penicillin allergy de-labelling service in a public hospital. J Antimicrob Chemother 2020; 74:1438-1446. [PMID: 30753497 DOI: 10.1093/jac/dky575] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/13/2018] [Accepted: 12/23/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Inaccurate allergy labelling results in inappropriate antimicrobial management of the patient, which may affect clinical outcome, increase the risk of adverse events and increase costs. Inappropriate use of alternative antibiotics has implications for antimicrobial stewardship programmes and microbial resistance. METHODS All adult inpatients labelled as penicillin allergic were identified and screened for eligibility by the study pharmacist. An accurate allergy and medication history was taken. Patients were 'de-labelled', underwent oral challenge or were referred to an immunology clinic, if study criteria were met. All patients included in the study were followed-up 1 year after intervention. RESULTS Two hundred and fifty eligible patients with a label of 'penicillin allergy' were identified. The prevalence of reported penicillin allergy at Middlemore Hospital was 11%. We found that 80% of study patients could be 'de-labelled'. Of those, 80% were 'de-labelled' after an interview with the pharmacist alone, 16% had an uneventful oral challenge and 4% were deemed to be inappropriately labelled after referral to an immunology clinic. Appropriately labelled patients accounted for 20% of the study population. Changes to inpatient antibiotic therapy were recommended in 61% of 'de-labelled' patients, of which no patients had adverse events after commencing on penicillin antibiotics. At the 1 year follow-up, 98% of patients who were 'de-labelled' had no adverse events to repeated administration of penicillin antibiotics. CONCLUSIONS This study showed that a pharmacist-led allergy management service is a safe option to promote antimicrobial stewardship and appropriate allergy labelling.
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Affiliation(s)
| | - Genevieve Walls
- Infection Services, Middlemore Hospital, Auckland, New Zealand
| | - Anthony Jordan
- Department of Immunology, Auckland City Hospital, Auckland, New Zealand
| | - David J Holland
- Infection Services, Middlemore Hospital, Auckland, New Zealand
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Patient perspectives on antibiotic allergy delabeling: Enablers and barriers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3637-3639.e5. [PMID: 32712200 DOI: 10.1016/j.jaip.2020.07.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/25/2020] [Accepted: 07/10/2020] [Indexed: 11/22/2022]
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