Identifying opportunities in EHR to improve the quality of antibiotic allergy data

Antibiotic allergy prevalence and documentation quality in Massachusetts long-term care facilities: A cross-sectional survey

BACKGROUND

Antimicrobial resistance poses a significant global health challenge, particularly affecting older adults who are more susceptible to infections and their complications. Accurate diagnosis and documentation of antibiotic allergies are essential for effective antimicrobial stewardship. Despite the recognized overdiagnosis of antibiotic allergies, comprehensive studies on this subject in long-term care (LTC) settings are limited.

OBJECTIVE

To determine the point prevalence of antibiotic allergies and documentation quality in Massachusetts LTC facilities.

METHODS

We conducted a cross-sectional, 1-day point prevalence survey from July 1, 2023, to March 31, 2024, across 20 participating LTC facilities in Massachusetts in partnership with the Massachusetts Department of Public Health. The survey assessed the prevalence and documentation of antibiotic allergies among 2345 residents. Multivariable logistic regression was used to explore associations between documented penicillin allergy and demographic factors, including non-penicillin antibiotic allergies.

RESULTS

The overall point prevalence of documented antibiotic allergies was 39.1%, with the most frequently reported classes being penicillins at 23.1%, sulfonamides at 15.4%, and cephalosporins at 5.2%. Significant documentation gaps were identified, with up to 92.8% of the allergy records found to be incomplete. Factors associated with documented penicillin allergies included female sex (adjusted odds ratio [aOR], 1.50; 95% CI, 1.16-1.94), White race (aOR, 1.92; 95% CI, 1.25-2.94), having allergies to non-penicillin antibiotics (aOR, 2.89; 95% CI, 2.33-3.59), and receipt of antibiotic (aOR, 2.13; 95% CI, 1.68-2.71).

CONCLUSION

The high prevalence of documented antibiotic allergies and the notable deficiencies in their documentation underscore the urgent need for enhanced antibiotic evaluation, documentation practices, and penicillin delabeling in LTC facilities.

Beta-lactam comprehensive allergy management program in a community medical center

Objective

The Beta-lactam Comprehensive Allergy Management Program (CAMP) was implemented to facilitate complete beta-lactam allergy history documentation in the electronic medical record (EMR) and increase beta-lactam utilization. The study objective was to assess the rate of complete allergy histories and days of antimicrobial therapy (DOT) before versus after CAMP implementation.

Design

Quasi-experimental study with interrupted time-series analysis.

Setting

Non-teaching, urban, and community medical center within a multi-hospital health system.

Patients

Adult inpatients with a beta-lactam allergy receiving antimicrobial therapy.

Methods

The multidisciplinary CAMP team screened, interviewed, and collected allergy history details of adult inpatients with a beta-lactam allergy receiving antimicrobial therapy starting January 4, 2021. Patients were stratified as high, moderate, or low risk of IgE-mediated allergy and referred to an allergist for skin testing or drug challenge. The EMR was updated with interview details and drug challenge or skin test results. The primary endpoint was rate of complete allergy history documentation before (12/1/18-4/1/19) compared to after (1/4/21-5/1/21) program implementation. The secondary endpoint was days of inpatient beta-lactam therapy. Implementation logistics, de-labeling rate, and antimicrobial therapy changes were evaluated.

Results

The program evaluated 392 individuals, with 184 and 208 patients comprising the pre- and post-intervention groups, respectively. The post-intervention period was associated with an increase of 19.8% in complete allergy histories (0.359 PPc; R 2 0.26; p = 0.002) and 9.34 beta-lactam DOT per 1,000-days-present (1.106 PPc; R 2 0.194; p = 0.009).

Conclusion

Implementation of a comprehensive beta-lactam allergy management program was associated with higher rates of complete beta-lactam allergy history and beta-lactam use.

Beyond antibiotic prescribing rates: first-line antibiotic selection, prescription duration, and associated factors for respiratory encounters in urgent care

Objective

Assess urgent care (UC) clinician prescribing practices and factors associated with first-line antibiotic selection and recommended duration of therapy for sinusitis, acute otitis media (AOM), and pharyngitis.

Design

Retrospective cohort study.

Participants

All respiratory UC encounters and clinicians in the Intermountain Health (IH) network, July 1st, 2019-June 30th, 2020.

Methods

Descriptive statistics were used to characterize first-line antibiotic selection rates and the duration of antibiotic prescriptions during pharyngitis, sinusitis, and AOM UC encounters. Patient and clinician characteristics were evaluated. System-specific guidelines recommended 5-10 days of penicillin, amoxicillin, or amoxicillin-clavulanate as first-line. Alternative therapies were recommended for penicillin allergy. Generalized estimating equation modeling was used to assess predictors of first-line antibiotic selection, prescription duration, and first-line antibiotic prescriptions for an appropriate duration.

Results

Among encounters in which an antibiotic was prescribed, the rate of first-line antibiotic selection was 75%, the recommended duration was 70%, and the rate of first-line antibiotic selection for the recommended duration was 53%. AOM was associated with the highest rate of first-line prescriptions (83%); sinusitis the lowest (69%). Pharyngitis was associated with the highest rate of prescriptions for the recommended duration (91%); AOM the lowest (51%). Penicillin allergy was the strongest predictor of non-first-line selection (OR = 0.02, 95% CI [0.02, 0.02]) and was also associated with extended duration prescriptions (OR = 0.87 [0.80, 0.95]).

Conclusions

First-line antibiotic selection and duration for respiratory UC encounters varied by diagnosis and patient characteristics. These areas can serve as a focus for ongoing stewardship efforts.

The Quality and Management of Penicillin Allergy Labels in Pediatric Primary Care

BACKGROUND AND OBJECTIVES

Penicillin allergy labels are the most common drug allergy label. The objective of this study was to describe the quality and management of penicillin allergy labels in the pediatric primary care setting.

METHODS

Retrospective chart review of 500 of 18 015 children with penicillin allergy labels born from January 1, 2010 to June 30, 2020 randomly selected from an outpatient birth cohort from Texas Children's Pediatrics and Children's Hospital of Philadelphia networks. Penicillin allergy risk classification ("not allergy," "low risk," "moderate or high risk," "severe risk," "unable to classify") was determined based on documentation within (1) the allergy tab and (2) electronic healthcare notes. Outcomes of allergy referrals and penicillin re-exposure were noted.

RESULTS

Half of penicillin allergy labels were "unable to classify" based on allergy tab documentation. Risk classification agreement between allergy tabs and healthcare notes was fair (Cohen's ĸ = 0.35 ± 0.02). Primary care physicians referred 84 of 500 (16.8%) children to an allergist, but only 54 (10.8%) were seen in allergy clinic. All children who were challenged (25 of 25) passed skin testing. Removal of allergy labels was uncommon (69 of 500, 13.8%) but occurred more often following allergy appointments (26 of 54, 48%) than not (43 of 446, 9.6%, P < .001). Children delabeled by primary care physicians were as likely to tolerate subsequent penicillin-class antibiotics as those delabeled by an allergist (94% vs 93%, P = .87).

CONCLUSIONS

Penicillin allergy documentation within the allergy tab was uninformative, and children were infrequently referred to allergists. Future quality improvement studies should improve penicillin allergy documentation and expand access to allergy services.

Usability of Graphical User Interfaces With Semiautomatic Delabeling Feature to Improve Drug Allergy Documentation

BACKGROUND

The quality of allergy documentation in electronic health records is frequently poor.

OBJECTIVE

To compare the usability of 3 graphical user interfaces (GUIs) for drug allergy documentation.

METHODS

Physicians tested 3 GUIs by means of 5 fictional drug allergy scenarios: the current GUI (GUI 0), using mainly free-text, and 2 new coded versions (GUI 1 and GUI 2) asking information on allergen category, specific allergen, symptom(s), symptom onset, timing of initial reaction, and diagnosis status with a semiautomatic delabeling feature. Satisfaction was measured by the System Usability Scale questionnaire, efficiency by time to complete the tasks, and effectiveness by a task completion score. Posttest interviews provided more in-depth qualitative feedback.

RESULTS

Thirty physicians from 7 different medical specialties and with varying degrees of experience participated. The mean System Usability Scale scores for GUI 1 (77.25, adjective rating "Good") and GUI 2 (78.42, adjective rating "Good") were significantly higher than for GUI 0 (56.58, adjective rating "OK") (Z, 6.27, P_adj < .001 and Z, 6.62, P_adj < .001, respectively). There was no significant difference in task time between GUIs. Task completion scores of GUI 1 and GUI 2 were higher than for GUI 0 (Z, 9.59, P_adj < .001 and Z, 11.87, P_adj < .001, respectively). Quantitative and qualitative findings were combined to propose a GUI 3 with high usability.

CONCLUSIONS

The usability and quality of allergy documentation was higher for the newly developed coded GUIs with a semiautomatic delabeling feature without being more time-consuming.

Dynamic reaction picklist for improving allergy reaction documentation: A usability study

OBJECTIVE

To assess novel dynamic reaction picklists for improving allergy reaction documentation compared to a static reaction picklist.

MATERIALS AND METHODS

We developed three web-based user interfaces (UIs) mimicking the Mass General Brigham's EHR allergy module: the first and second UIs (i.e., UI-1D, UI-2D) implemented two dynamic reaction picklists with different ranking algorithms and the third UI (UI-3S) implemented a static reaction picklist like the one used in the current EHR. We recruited 18 clinicians to perform allergy entry for 10 test cases each via UI-1D and UI-3S, and another 18 clinicians via UI-2D and UI-3S. Primary measures were the number of free-text entries and time to complete the allergy entry. Clinicians were also interviewed using 30 questions before and after the data entry.

RESULTS AND DISCUSSIONS

Among 36 clinicians, less than half were satisfied with the current EHR reaction picklists, due to their incomprehensiveness, inefficiency, and lack of intuitiveness. The clinicians used significantly fewer free-text entries when using UI-1D or UI-2D compared to UI-3S (p < 0.05). The clinicians used on average 51 s (15 %) less time via UI-1D and 50 s (16 %) less time via UI-2D in completing the allergy entries versus UI-3S, and there was not a statistically significant difference in documentation time for either group between the dynamic and static UIs. Overall, 15-17 (83-94 %) clinicians rated UI-1D and 13-15 (72-83 %) clinicians rated UI-2D as efficient, easy to use, and useful, while less than half rated the same for UI-3S. Most clinicians reported that the dynamic reaction picklists always or often suggested appropriate reactions (n = 30, 83 %) and would decrease the free-text entries (n = 26, 72 %); nearly all preferred the dynamic picklist over the static picklist (n = 32, 89 %).

CONCLUSION

We found that dynamic reaction picklists significantly reduced the number of free-text entries and could reduce the time for allergy documentation by 15%. Clinicians preferred the dynamic reaction picklist over the static picklist.

Differences in beta-lactam and penicillin allergy: Beyond the West and focusing on Asia-Pacific

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.

Cues to improve antibiotic-allergy registration: A mixed-method study

BACKGROUND

Approximately 2% of patients in primary care practice and up to 25% of hospital patients are registered as being allergic to an antibiotic. However, up to 90% of these registrations are incorrect, leading to unnecessary prescription of 2nd choice antibiotics with the attendant loss of efficacy, increased toxicity and antibiotic resistance. To improve registration, a better understanding is needed of how incorrect labels are attributed.

OBJECTIVE

To investigate the quality of antibiotic allergy registration in primary care and identify determinants to improve registration of antibiotic allergies.

DESIGN

Registration of antibiotic allergies in primary care practices were analysed for 1) completeness and 2) correctness. To identify determinants for improvement, semi-structured interviews with healthcare providers from four healthcare domains were conducted.

PARTICIPANTS

A total of 300 antibiotic allergy registrations were analysed for completeness and correctness. Thirty-four healthcare providers were interviewed.

MAIN MEASURES

A registration was defined as complete when it included a description of all symptoms, time to onset of symptoms and the duration of symptoms. It was defined as correct when the conclusion was concordant with the Salden criteria. Determinants of correct antibiotic allergy registrations were divided into facilitators or obstructers.

KEY RESULTS

Rates of completeness and correctness of registrations were 0% and 29.3%, respectively. The main perceived barriers for correct antibiotic allergy registration were insufficient knowledge, lack of priority, limitations of registration features in electronic medical records (EMR), fear of medical liability and patients interpreting side-effects as allergies.

CONCLUSIONS

The quality of antibiotic allergy registrations can be improved. Potential interventions include raising awareness of the consequences of incomplete and the importance of correct registrations, by continued education, and above all simplifying registration in an EMR by adequate ICT support.

Factors Associated With Penicillin Allergy Labels in Electronic Health Records of Children in 2 Large US Pediatric Primary Care Networks

Importance

Penicillin allergy labels influence clinical decision-making, yet most children who are labeled do not have type 1 hypersensitivity allergic reactions and instead have a history of predictable adverse reactions or unspecified illness symptoms while receiving penicillin for viral infections. Studies describing penicillin allergy labeling in the pediatric outpatient setting are lacking.

Objective

To describe the epidemiology and factors associated with penicillin allergy labels across 2 large US pediatric primary care networks.

Design, Setting, and Participants

This retrospective, longitudinal birth cohort study was conducted in 90 primary care pediatric practices serving a diverse population of children across Houston, Texas, Austin, Texas, Philadelphia, Pennsylvania, and parts of New Jersey. Participants were children born between January 2010 and June 2020 who had a health care visit in the first 14 days of life and at least 2 additional visits in the first year of life at one of 90 primary care pediatric practices. Censoring criteria were additionally applied to exclude data from children no longer seeking health care in the 90 clinics over time. Statistical analysis was performed from February to May 2021.

Exposures

Basic patient demographics, health care utilization, penicillin exposure, and primary clinic location.

Main Outcomes and Measures

Addition of penicillin allergy label in the electronic medical record.

Results

Among 334 465 children in the birth cohort, 164 173 (49.1%) were female; 72 831 (21.8%) were Hispanic, 59 598 (17.8%) were non-Hispanic Black, and 148 534 (44.4%) were non-Hispanic White; the median (IQR) age at censoring was 3.8 (1.7-6.6) years; 18 015 (5.4%) were labeled as penicillin allergic, but the prevalence of penicillin allergy labeling ranged from 0.9% to 10.2% across practices. Children were labeled at a median (IQR) age of 1.3 (0.9-2.3) years. Non-Hispanic White children were more likely to be labeled compared with non-Hispanic Black children after controlling for potential confounders (adjusted odds ratio, 1.7 [95% CI, 1.6-1.8]). There were 6797 allergic children (37.7%) labeled after receiving 1 penicillin prescription and 1423 (7.9%) labeled after receiving 0 penicillin prescriptions.

Conclusions and Relevance

In this cohort study of more than 330 000 children, penicillin allergy labeling was common and varied widely across practices. Children were labeled early in life, and almost half were labeled after receiving 1 or 0 penicillin prescriptions. These findings raise questions regarding the validity of penicillin allergy labels. Future work exploring the fidelity of and outcomes associated with penicillin allergy-labeling in children is warranted.

The Use of Electronic Health Records to Study Drug-Induced Hypersensitivity Reactions from 2000 to 2021

Electronic health records (EHRs) have revolutionized the field of drug hypersensitivity reaction (DHR) research. In this systematic review, we assessed 140 articles from 2000-2021, classifying them under six themes: observational studies (n=61), clinical documentation (n=27), case management (n=22), clinical decision support (CDS) (n=18), case identification (n=9), and genetic studies (n=3). EHRs provide convenient access to millions of medical records, facilitating epidemiological studies of DHRs. Though the goal of CDS is to promote safe drug prescribing, allergy alerts must be designed and used in a way that supports this effort. Ultimately, accurate allergy documentation is essential for DHR prevention.

An Investigation of Radiation Treatment Learning Opportunities in Relation to the Radiation Oncology Electronic Medical Record: A Single Institution Experience

Purpose

A modern radiation oncology electronic medical record (RO-EMR) system represents a sophisticated human-computer interface with the potential to reduce human driven errors and improve patient safety. As the RO-EMR becomes an integral part of clinical processes, it may be advantageous to analyze learning opportunities (LO) based on their relationship with the RO-EMR. This work reviews one institution's documented LO to: (1) study their relationship with the RO-EMR workflow, (2) identify best opportunities to improve RO-EMR workflow design, and (3) identify current RO-EMR workflow challenges.

Methods and Materials

Internal LO reports for an 11-year contiguous period were categorized by their relationship to the RO-EMR. We also identify the specific components of the RO-EMR used or involved in each LO. Additionally, contributing factor categories from the ASTRO/AAPM sponsored Radiation Oncology Incident Learning System's (RO-ILS) nomenclature was used to characterize LO directly linked to the RO-EMR.

Results

A total of 163 LO from the 11-year period were reviewed and analyzed. Most (77.2%) LO involved the RO-EMR in some way. The majority of the LO were the results of human/manual operations. The most common RO-EMR components involved in the studied LO were documentation related to patient setup, treatment session schedule functionality, RO-EMR used as a communication/note-delivery tool, and issues with treatment accessories. Most of the LO had staff lack of attention and policy not followed as 2 of the highest occurring contributing factors.

Conclusions

We found that the majority of LO were related to RO-EMR workflow processes. The high-risk areas were related to manual data entry or manual treatment execution. An evaluation of LO as a function of their relationship with the RO-EMR allowed for opportunities for improvement. In addition to regular radiation oncology quality improvement review and policy update, automated functions in RO-EMR remain highly desirable.

Impact of Antibiotic Allergy Labels on Patient Outcomes in a Tertiary Paediatric Hospital

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.

The impact of patient-reported penicillin or cephalosporin allergy on surgical site infections

OBJECTIVE

To determine the impact of a documented penicillin or cephalosporin allergy on the development of surgical site infections (SSIs).

BACKGROUND

Appropriate preoperative antibiotic prophylaxis reduces SSI risk, but documented antibiotic allergies influence the choice of prophylactic agents. Few studies have examined the relationship between a reported antibiotic allergy and risk of SSI and to what extent this relationship is modified by the antibiotic class given for prophylaxis.

METHODS

We conducted a retrospective cohort study of adult patients undergoing coronary artery bypass, craniotomy, spinal fusion, laminectomy, hip arthroplasty and knee arthroplasty at 3 hospitals from July 1, 2013, to December 31, 2017. We built a multivariable logistic regression model to calculate the adjusted odds ratio (aOR) of developing an SSI among patients with and without patient-reported penicillin or cephalosporin allergies. We also examined effect measure modification (EMM) to determine whether surgical prophylaxis affected the association between reported allergy and SSI.

RESULTS

We analyzed 39,972 procedures; 1,689 (4.2%) with a documented patient penicillin or cephalosporin allergy, and 374 (0.9%) resulted in an SSI. Patients with a reported penicillin or cephalosporin allergy were more likely to develop an SSI compared to patients who did not report an allergy to penicillin or cephalosporins (adjusted odds ratio, 3.26; 95% confidence interval, 2.71-3.93). Surgical prophylaxis did not have significant EMM on this association.

CONCLUSIONS

Patients who reported a penicillin or cephalosporin allergy had higher odds of developing an SSI than nonallergic patients. However, the increase in odds is not completely mediated by the type of surgical prophylaxis. Instead, a reported allergy may be a surrogate marker for a more complicated patient population.

β-lactam exposure outcome among patients with a documented allergy to penicillins post-implementation of a new electronic medical record system and alerting rules

BACKGROUND

Recent studies suggest that type I hypersensitivity cross-reactivity between β-lactam antibiotics is due to side chain similarity and not the common β-lactam ring. As a result, the prescriber-alerting rules of an electronic medical record (EMR) system were adjusted to only flag prescribers when prescribing penicillins or β-lactams with similar side chains (viz, cephalexin, cefadroxil, and cefoxitin) to patients with a documented allergy to penicillins. This study was conducted to assess and confirm the safety of the adjusted alerting rules; the primary outcome was the prevalence of anaphylaxis on β-lactam re-exposure.

METHODS

Retrospective chart review was conducted for patients who, under the reformed alerting rules, received a β-lactam antibiotic post-documentation of an allergy to penicillins in their EMR from April 2018 to July 2019 at a 268-bed community hospital. Given the volume of eligible patients, a 25% sample was randomly selected for review from initiation of the β-lactam antibiotic up to 30 days post-exposure to determine the prevalence of anaphylaxis.

RESULTS

Of the 325 charts reviewed, 300 patients (92.3%) received a β-lactam antibiotic with a different side chain than penicillins (not alerted on prescribing). Chart review of these 300 patients confirmed no reports of anaphylaxis secondary to β-lactam exposure (0%), and two patients developed non-anaphylactic delayed reactions (rash).

CONCLUSIONS

There were no reports of immediate life-threatening anaphylaxis under the reformed alerting rules, despite 25 patients (7.7%) receiving an alerted drug, such as piperacillin-tazobactam. The reformed alerting rules better reflect current literature and reduce the risk of prescriber-alerting fatigue without compromising patient safety. The occurrence of delayed reactions reinforced the need to monitor for these reactions on β-lactam antibiotic prescribing.

Prevalence of Antibiotic Allergy Labels in a Tertiary Referral Center in Belgium

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.

Fidelity of Electronic Documentation for Reactions Prompting Premedication to Iodinated Contrast Media

PURPOSE

The aims of this study were to assess the fidelity of electronic health record documentation prompting premedication to iodinated contrast media and to determine the appropriateness of administered premedication on the basis of that documentation.

METHODS

In this retrospective quality assurance cohort study, medication adverse events recorded in electronic health records between January 1, 2018, and August 31, 2019, to "iodine," "iodine-containing products," and "iodinated contrast media" were identified (N = 4,309); entries missing documentation (n = 1,651) and breakthrough reactions (n = 22) were excluded. Reaction description, severity, and free-text comments were used to categorize each entry as concordant (documentation matches recorded severity per the ACR Manual on Contrast Media version 10.3), discordant (description-severity mismatch, agent unrelated to iodinated contrast media, not a hypersensitivity reaction), or unclear. A subset of patients undergoing premedication was identified, and premedication was categorized as appropriate, inappropriate, or unsure on the basis of the index reaction using the aforementioned framework. Descriptive statistics were calculated.

RESULTS

There were 2,636 adverse event entries in 2,441 patients: 59.9% (1,578 of 2,636) were classified as concordant, 30.2% (797 of 2,636) as discordant (n = 377 not a hypersensitivity reaction, n = 317 description-severity mismatch, and n = 103 unrelated agent), and 9.9% (n = 261) as unclear documentation. For the premedicated subset, concordance classification was feasible for 202 unique patients premedicated 335 times. Premedication was appropriate in 72% (240 of 335) and inappropriate in 22% (73 of 335); 17% of premedication events (56 of 335) were inappropriately administered for a prior physiologic reaction.

CONCLUSIONS

Premedication prompts in the electronic health record are often erroneous because of inaccurate coding, incomplete data, and reaction misclassification. These errors result in inappropriate premedication for a substantial minority of patients.

Reducing Cesarean Delivery Surgical Site Complications

Cesarean delivery (CD) wound complications disrupt the time a mother spends with her newborn. Surgical site infections (SSI) may result in unplanned office visits, emergency room visits, and hospital readmissions. Despite increasing attention to preoperative preparation, the CD SSI rate remains high. Local practices must be evaluated, and new methods to reduce CD SSI must be used.

Antibiotic allergy labels in hospitalized and critically ill adults: A review of current impacts of inaccurate labelling

Antibiotic allergy labels (AALs) are reported by approximately 20% of hospitalized patients, yet over 85% will be negative on formal allergy testing. Hospitalized patients with an AAL have inferior patient outcomes, increased colonization with multidrug-resistant organisms and frequently receive inappropriate antimicrobials. Hospitalized populations have been well studied but, to date, the impact of AALs on patients with critical illness remains less well defined. We review the prevalence and impact of AALs on hospitalized patients, including those in in critical care.

Exploring the nurses' role in antibiotic stewardship: A multisite qualitative study of nurses and infection preventionists

BACKGROUND

There is a growing recognition of the need to partner with nurses to promote effective antibiotic stewardship. In this study, we explored the attitudes of nurses and infection preventionists toward 5 nurse-driven antibiotic stewardship practices: 1) questioning the need for urine cultures; 2) ensuring proper culturing technique; 3) recording an accurate penicillin drug allergy history; 4) encouraging the prompt transition from intravenous (IV) to oral (PO) antibiotics; and 5) initiating an antibiotic timeout.

METHODS

Nine focus groups and 4 interviews with 49 clinical nurses, 5 nurse managers, and 7 infection preventionists were conducted across 2 academic pediatric and adult hospitals.

RESULTS

Nurse-driven antibiotic stewardship was perceived as an extension of the nurses' role as patient advocate. Three practices were perceived most favorably: questioning the necessity of urinary cultures, ensuring proper culturing techniques, and encouraging the prompt transition from IV to PO antibiotics. Remaining recommendations were perceived to lack relevance or to challenge traditionally held nursing responsibilities. Prescriber and family engagement were noted to assist the implementation of select recommendations. Infection preventionists welcomed the opportunity to assist in providing nurse stewardship education.

CONCLUSIONS

Nurses appeared to be enthusiastic about participating in antibiotic stewardship. Efforts to engage nurses should address knowledge needs and consider the contexts in which nurse-driven antibiotic stewardship occurs.

The 3 Cs of Antibiotic Allergy-Classification, Cross-Reactivity, and Collaboration

Antibiotic allergy labeling is highly prevalent and negatively impacts patient outcomes and antibiotic appropriateness. Reducing the prevalence and burden of antibiotic allergies requires the engagement of key stakeholders such as allergists, immunologists, pharmacists, and infectious diseases physicians. To help address this burden of antibiotic allergy overlabeling, we review 3 key antibiotic allergy domains: (1) antibiotic allergy classification, (2) antibiotic cross-reactivity, and (3) multidisciplinary collaboration. We review the available evidence and research gaps of currently used adverse drug reaction classification systems, antibiotic allergy cross-reactivity, and current and future models of antibiotic allergy care.

Associations between bacterial infections and blood pressure in pregnancy

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Antibiotic use in pregnancy was associated with a 2–3 mmHg rise in blood pressure.

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It was related more to changes in diastolic than systolic blood pressure.

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The most likely cause is exposure to bacterial infections.

Objectives

To test the hypothesis that bacterial infections in pregnancy are related to maternal blood pressure.

Study design

Bacterial infection was assessed using antibiotic usage as a surrogate and its association with blood pressure in pregnancy tested in the Cambridge Baby Growth Study.

Main outcome measures

Antibiotic usage in pregnancy was self-reported in questionnaires. Blood pressure measurements at four time points in pregnancy were collected from the hospital notes of 622 women.

Results

Using all the available blood pressure readings (adjusted for weeks gestation) antibiotic usage was associated with a higher mean arterial blood pressure across pregnancy: antibiotics used 85 (84, 87) mmHg vs. no antibiotics used 83 (83, 84) mmHg (β = 2.3 (0.6, 4.0) mmHg, p = 9.6 × 10⁻³, from 621 individuals). Further analysis revealed that antibiotic usage was associated with diastolic (β = 2.3 (0.6, 4.0) mmHg; p = 7.0 × 10⁻³) more than systolic blood pressure (β = 1.4 (−0.9, 3.7) mmHg; p = 0.2). The effect size associated with antibiotic usage appeared to rise slightly after the first trimester.

Conclusions

Bacterial infection in pregnancy, as assessed by self-reported antibiotic usage, is associated with small rises in blood pressure.

Improving Antimicrobial Stewardship by Antibiotic Allergy Delabeling: Evaluation of Knowledge, Attitude, and Practices Throughout the Emerging Infections Network

Antibiotic allergy testing (AAT) practices of Emerging Infections Network infectious disease physicians were surveyed. Although AAT was perceived to be necessary for removal of inappropriate or unnecessary allergy labels, there was limited access to any form of testing. In this study, we discuss current antibiotic allergy knowledge gaps and the development of AAT practices within antimicrobial stewardship programs, which will potentially improve antimicrobial prescribing.

Old but not forgotten: Antibiotic allergies in General Medicine (the AGM Study)

OBJECTIVES

To determine the nature, prevalence and description accuracy of recorded antibiotic allergy labels (AALs) in a cohort of general medical inpatients, and to assess the feasibility of an oral antibiotic re-challenge study.

DESIGN

Multicentre cross-sectional study.

SETTING AND PARTICIPANTS

All patients admitted to the general medical units of Austin Health and Alfred Health, 18 May - 5 June 2015.

MAIN OUTCOME MEASURES

Baseline demographics, medical and allergy history, infection diagnoses and antibiotic prescribing data for general medical inpatients were collected. A questionnaire was administered to clarify AAL history, followed by correlation of responses with electronic and admissions record descriptions. A hypothetical oral re-challenge in a supervised setting was offered to patients with low risk allergy phenotypes (non-immediate reaction, non-severe cutaneous adverse reaction, or unknown reaction more than 10 years ago).

RESULTS

Of the 453 inpatients, 107 (24%) had an AAL (median age, 82 years; interquartile range, 74-87 years); 160 individual AALs were recorded, and there was a mismatch in AAL description between recording platforms in 25% of cases. Most patients with an AAL were women (64%; P < 0.001), and more presented with concurrent immunosuppression than those without an AAL (23% v 8%; P < 0.001). β-Lactam penicillins were employed less frequently in patients with an AAL (16% v 35%; P = 0.02), while ceftriaxone (32% v 20%; P = 0.02) and fluoroquinolones (6% v 2%; P = 0.04) were used more often. Fifty-four per cent of patients with AALs were willing to undergo oral re-challenge, of whom 48% had a low risk allergy phenotype.

CONCLUSIONS

AAL prevalence in general medical inpatients was 24%, and was associated with excessive use of broad spectrum antibiotics. Allergies in a large proportion of patients with AALs were incorrectly documented, and were non-immune-mediated and potentially amenable to oral re-challenge. A direct oral re-challenge study in carefully selected patients with low risk allergy phenotypes appears feasible.

Antimicrobial allergy 'labels' drive inappropriate antimicrobial prescribing: lessons for stewardship

BACKGROUND

The presence of antimicrobial allergy designations ('labels') often substantially reduces prescribing options for affected patients, but the frequency, accuracy and impacts of such labels are unknown.

METHODS

The National Antimicrobial Prescribing Survey (NAPS) is an annual de-identified point prevalence audit of Australian inpatient antimicrobial prescribing using standardized definitions of guideline compliance, appropriateness and indications. Data were extracted for 2 years (2013-14) and compared for patients with an antimicrobial allergy label (AAL) and with no AAL (NAAL).

RESULTS

Among 21 031 patients receiving antimicrobials (33 421 prescriptions), an AAL was recorded in 18%, with inappropriate antimicrobial use significantly higher in the AAL group versus the NAAL group (OR 1.12, 95% CI 1.05-1.22, P < 0.002). Patterns of antimicrobial use were significantly influenced by AAL, with lower β-lactam use (AAL versus NAAL; OR 0.47, 95% CI 0.43-0.50, P < 0.001) and higher quinolone (OR 2.07, 95% CI 1.83-2.34, P < 0.0001), glycopeptide (OR 1.59, 95% CI 1.38-1.83, P < 0.0001) and carbapenem (OR 1.74, 95% CI 1.43-2.13, P < 0.0001) use. In particular, among immunocompromised patients, AAL was associated with increased rates of inappropriate antimicrobial use (OR 1.68, 95% CI 1.21-2.30, P = 0.003), as well as increased use of quinolones (OR 1.88, 95% CI 1.16-3.03, P = 0.02) and glycopeptides (OR 1.82, 95% CI 1.17-2.84, P = 0.01).

CONCLUSIONS

AALs are common and appear to be associated with higher rates of inappropriate prescribing and increased use of broad-spectrum antimicrobials. Improved accuracy in defining AALs is likely to be important for effective antimicrobial stewardship (AMS), with efforts to 'de-label' inappropriate AAL patients a worthwhile feature of future AMS initiatives.