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Staudacher M, Hotz JF, Kriz R, Schefberger K, Schneider L, Spettel K, Starzengruber P, Hagemann JB, Leutzendorff A, Burgmann H, Lagler H. Differences in oxazolidinone resistance mechanisms and small colony variants emergence of Staphylococcus aureus induced in an in vitro resistance development model. Emerg Microbes Infect 2024; 13:2292077. [PMID: 38055244 PMCID: PMC10849000 DOI: 10.1080/22221751.2023.2292077] [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: 10/25/2022] [Accepted: 12/03/2023] [Indexed: 12/07/2023]
Abstract
Invasive Staphylococcus aureus infections are associated with a high burden of disease, case fatality rate and healthcare costs. Oxazolidinones such as linezolid and tedizolid are considered potential treatment choices for conditions involving methicillin resistance or penicillin allergies. Additionally, they are being investigated as potential inhibitors of toxins in toxin-mediated diseases. In this study, linezolid and tedizolid were evaluated in an in vitro resistance development model for induction of resistance in S. aureus. Whole genome sequencing was conducted to elucidate resistance mechanisms through the identification of causal mutations. After inducing resistance to both linezolid and tedizolid, several partially novel single nucleotide variants (SNVs) were detected in the rplC gene, which encodes the 50S ribosome protein L3 in S. aureus. These SNVs were found to decrease the binding affinity, potentially serving as the underlying cause for oxazolidinone resistance. Furthermore, in opposite to linezolid we were able to induce phenotypically small colony variants of S. aureus after induction of resistance with tedizolid for the first time in literature. In summary, even if different antibiotic concentrations were required and SNVs were detected, the principal capacity of S. aureus to develop resistance to oxazolidinones seems to differ between linezolid and tedizolid in-vivo but not in vitro. Stepwise induction of resistance seems to be a time and cost-effective tool for assessing resistance evolution. Inducted-resistant strains should be examined and documented for epidemiological reasons, if MICs start to rise or oxazolidinone-resistant S. aureus outbreaks become more frequent.
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Affiliation(s)
- Moritz Staudacher
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
- Department of Angiology, Medical University of Vienna, Vienna, Austria
| | - Julian Frederic Hotz
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Evangelic Hospital Vienna, Vienna, Austria
| | - Richard Kriz
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Katharina Schefberger
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Lisa Schneider
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Kathrin Spettel
- Department of Laboratory Medicine, Division of Clinical Microbiology, Medical University of Vienna, Vienna, Austria
| | - Peter Starzengruber
- Department of Laboratory Medicine, Division of Clinical Microbiology, Medical University of Vienna, Vienna, Austria
| | | | - Amelie Leutzendorff
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Heinz Burgmann
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Heimo Lagler
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
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2
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Saunders H, Shrestha R, Khadka S, Helgeson SA. Patient-reported penicillin allergy and intensive care unit outcomes in sepsis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:519-521. [PMID: 37898174 DOI: 10.1016/j.jaip.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/05/2023] [Accepted: 10/17/2023] [Indexed: 10/30/2023]
Affiliation(s)
- Hollie Saunders
- Department of Pulmonary and Critical Care, Mayo Clinic Jacksonville, Fla.
| | - Rabi Shrestha
- Department of Pulmonary and Critical Care, Mayo Clinic Jacksonville, Fla
| | - Subekshya Khadka
- Department of Pulmonary and Critical Care, Mayo Clinic Jacksonville, Fla
| | - Scott A Helgeson
- Department of Pulmonary and Critical Care, Mayo Clinic Jacksonville, Fla
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3
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Xiang YY, Heriot GS, Jamrozik E. Ethics of antibiotic allergy. JOURNAL OF MEDICAL ETHICS 2023; 50:39-44. [PMID: 37286334 PMCID: PMC7615378 DOI: 10.1136/jme-2022-108648] [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: 09/15/2022] [Accepted: 04/01/2023] [Indexed: 06/09/2023]
Abstract
Antibiotic allergies are commonly reported among patients, but most do not experience reactions on rechallenge with the same agents. These reported allergies complicate management of infections in patients labelled as having penicillin allergy, including serious infections where penicillin-based antibiotics are the first-line (most effective and least toxic) treatment option. Allergy labels are rarely questioned in clinical practice, with many clinicians opting for inferior second-line antibiotics to avoid a perceived risk of allergy. Reported allergies thereby can have significant impacts on patients and public health, and present major ethical challenges. Antibiotic allergy testing has been described as a strategy to circumvent this dilemma, but it carries limitations that often make it less feasible in patients with acute infections or in community settings that lack access to allergy testing. This article provides an empirically informed ethical analysis of key considerations in this clinical dilemma, using Staphylococcus aureus bacteraemia in patients with penicillin allergies as a case study. We argue that prescribing first-line penicillin-based antibiotics to patients with reported allergies may often present a more favourable ratio of benefits to risks, and may therefore be more ethically appropriate than using second-line drugs. We recommend changes to policy-making, clinical research and medical education, in order to promote more ethically acceptable responses to antibiotic allergies than the status quo.
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Affiliation(s)
- Yu Yi Xiang
- Western Health, Footscray, Victoria, Australia
| | - George S Heriot
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Euzebiusz Jamrozik
- Ethox and Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
- Royal Melbourne Hospital Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Monash Bioethics Centre, Monash University, Melbourne, Victoria, Australia
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Kouma MA, Guastadisegni JM, Yang L, Maxwell DN, Storey DF, Arasaratnam RJ. Challenges and opportunities related to penicillin allergy in the Veterans Health Administration: a narrative review. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e174. [PMID: 38028897 PMCID: PMC10644167 DOI: 10.1017/ash.2023.448] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 12/01/2023]
Abstract
The presence of a penicillin allergy label in a patient's medical chart is associated with negative clinical and economic outcomes. Given that less than 10% of reported reactions are truly immunoglobulin E-mediated, removal of unverified penicillin allergy labels is a public health priority and an area of ongoing implementation research. The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States, with almost 9 million veterans currently enrolled. However, studies analyzing the impact of the penicillin allergy label in this population are limited to single facilities and largely focus on short-term outcomes of allergy documentation correction, usage of β-lactams, and avoidance of antibiotic-related side effects. Broader, national VHA studies focusing on health outcomes and costs are lacking. As with non-VHA facilities, penicillin allergy evaluations are limited owing to the absence of formal allergy/immunology services at most VHA facilities. Pharmacy-driven screening and referral for clinic-based penicillin skin testing is a promising and frequently discussed modality in the literature, but its scalability within the VHA is not yet proven. Broader, evidence-based strategies that can be adapted to the available resources of individual VHA facilities, including those without on-site access to allergy providers, are needed.
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Affiliation(s)
- Marcus A. Kouma
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | | | - Linda Yang
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | - Daniel N. Maxwell
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donald F. Storey
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Reuben J. Arasaratnam
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
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5
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Satake K, Iijima K. Ceftriaxone-Induced Neutropenia Successfully Treated With Alternative β-Lactam Antibiotics: A Case Report and Review of the Literature. Cureus 2023; 15:e39176. [PMID: 37332438 PMCID: PMC10276520 DOI: 10.7759/cureus.39176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 06/20/2023] Open
Abstract
Ceftriaxone-induced neutropenia is a rare and severe adverse effect of the drug. It usually resolves in one to three weeks following the cessation of ceftriaxone and the administration of granulocyte colony-stimulating factor (G-CSF). After neutrophil recovery, patients are often treated with non-β-lactam antibiotics instead of ceftriaxone due to the possibility of cross-reactivity associated with β-lactam allergy. However, in some cases, β-lactam antibiotics are superior to non-β-lactam antibiotics. Few cases of the readministration of β-lactam antibiotics for patients who developed ceftriaxone-induced neutropenia have been reported so far. Moreover, its pathogenesis and management have still not been established. We describe a case of successful readministration of β-lactam antibiotics for a patient who had developed ceftriaxone-induced neutropenia. A 37-year-old man with a prosthetic aortic valve was admitted to our hospital with a fever. Blood culture on admission revealed methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, and transesophageal echocardiography (TEE) showed aortic valve vegetation with multiple septic emboli seen on brain CT. We diagnosed MSSA infective endocarditis with central nervous complications. He underwent an operation and was treated with ceftriaxone. On admission day 28, he developed neutropenia (33/μL), and ceftriaxone-induced neutropenia was suspected. Vancomycin was started instead of ceftriaxone, and his neutrophil count recovered within two weeks with the administration of G-CSF. After recovery, on day 40 of admission, ampicillin sodium was administered instead of vancomycin. Although he developed mild eosinophilia, he did not exhibit neutropenia and was discharged with an amoxicillin prescription on day 60 of admission. Our report suggests the possibility that patients who develop ceftriaxone-induced neutropenia can be treated safely with an alternative β-lactam antibiotic, ampicillin sodium, without causing β-lactam cross-reactivity of neutropenia.
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Affiliation(s)
- Kana Satake
- Department of Internal Medicine, Hyogo Prefectural Amagasaki General Medical Center: Hyogo Kenritsu Amagasaki Sogo Iryo Center, Amagasaki, JPN
| | - Kenta Iijima
- Department of Infectious Diseases, Hyogo Prefectural Amagasaki General Medical Center: Hyogo Kenritsu Amagasaki Sogo Iryo Center, Amagasaki, JPN
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Wrynn AF. An overview of penicillin allergies for nurses. Nursing 2023; 53:27-31. [PMID: 37074275 DOI: 10.1097/01.nurse.0000923664.66265.a4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
ABSTRACT Antibiotics are frequently reported as allergies by patients, particularly antibiotics from the penicillin family. Most of these reported allergies are benign, and the consequences of alternative therapies can be significant. This article provides background information on penicillin allergies and serves as a guide to penicillin allergy management.Reprinted with permission from Wrynn, A.F. An overview of penicillin allergies for nurses. Nurse Pract 2022; 47(9): 30-36. Copyright Wolters Kluwer. All rights reserved.
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Affiliation(s)
- Alexander F Wrynn
- Alexander F. Wrynn is an infectious diseases nurse practitioner at Allegheny Health Network in Pittsburgh, Pa
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Kaminsky LW, Ghahramani A, Hussein R, Al-Shaikhly T. Penicillin Allergy Label Is Associated With Worse Clinical Outcomes in Bacterial Pneumonia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3262-3269. [PMID: 36182647 PMCID: PMC10129071 DOI: 10.1016/j.jaip.2022.08.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/19/2022] [Accepted: 08/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Penicillins (PCNs) are a first-line treatment option for bacterial pneumonia. PCN allergy label can delay antimicrobial treatment and result in the use of alternative antibiotic regimens risking an inadequate response to treatment and potentially increased adverse drug reactions. OBJECTIVE To investigate the impact of PCN allergy label on clinical outcomes of bacterial pneumonia. METHODS This retrospective cohort study used TriNetX, a web-based tool for population cohort research, to identify adult patients with and without PCN allergy label diagnosed with bacterial pneumonia. Cohorts were matched for baseline demographics and chronic medical conditions. The 30-day risks of hospitalization, acute respiratory failure, intubation, need for intensive level of care, and mortality were compared. Antibiotics used and their possible adverse reactions were explored. RESULTS After matching, there were 68,748 patients in each cohort. Patients with bacterial pneumonia with PCN allergy label had higher risks of hospitalization (risk ratio [RR], 1.23; 95% confidence interval [CI], 1.22-1.24), acute respiratory failure (RR, 1.14; 95% CI, 1.12-1.15), intubation (RR, 1.18; 95% CI, 1.13-1.22), intensive level of care (RR, 1.11; 95% CI, 1.08-1.14), and mortality (RR, 1.08; 95% CI, 1.04-1.13) compared with patients without PCN allergy label. Patients with PCN allergy label had decreased use of PCNs and cephalosporins and increased utilization of other antibiotic classes compared with patients without PCN allergy label. PCN allergy label was also associated with increased risk of adverse drug reactions. CONCLUSION PCN allergy label is associated with worse clinical outcomes in bacterial pneumonia, and risk mitigation strategies should be considered.
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Affiliation(s)
- Lauren W Kaminsky
- Section of Allergy, Asthma, and Immunology, Department of Medicine, Penn State College of Medicine, Hershey, Pa.
| | | | - Rezhan Hussein
- Division of Infectious Diseases, Department of Medicine, Penn State College of Medicine, Hershey, Pa
| | - Taha Al-Shaikhly
- Section of Allergy, Asthma, and Immunology, Department of Medicine, Penn State College of Medicine, Hershey, Pa
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8
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Penicillin allergies: A guide for NPs. Nurse Pract 2022; 47:30-36. [PMID: 36006817 DOI: 10.1097/01.npr.0000855312.11145.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Antibiotics are frequently reported as allergies by patients, particularly antibiotics from the penicillin family. Most of these reported allergies are benign, and the consequences of alternative therapies can be significant. This article will deliver background information on penicillin allergies and serve as a guide to penicillin allergy management.
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9
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DesBiens MT, Calderwood MS, Reigh EL. Expanding Penicillin Allergy Evaluation in Hospitalized Patients. Am J Med 2022; 135:958-963.e13. [PMID: 35339433 DOI: 10.1016/j.amjmed.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/08/2021] [Accepted: 12/08/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Martha T DesBiens
- Department of Medicine, Section of Infectious Disease, Nuvance Health, Southbury, Conn; The Robert Larner M.D. College of Medicine at The University of Vermont, Burlington; Department of Medicine, Section of Infectious Disease & International Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - Michael S Calderwood
- Department of Medicine, Section of Infectious Disease & International Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Erin L Reigh
- Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Medicine, Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Sakamoto K, Yamamoto-Hanada K, Kubota M, Ishiguro A, Ohya Y. Type B adverse drug reactions to antibiotics and antibiotic allergy in infants and children. Pediatr Int 2022; 64:e15126. [PMID: 35616171 DOI: 10.1111/ped.15126] [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: 08/25/2021] [Revised: 12/23/2021] [Accepted: 01/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Distinguishing allergic reactions from non-allergic type B adverse drug reactions (ADRs) to antibiotics is challenging, particularly in children, because we lack epidemiological information that can be used in primary care situations. This study aimed to investigate the characteristics of type B ADRs to antibiotics and antibiotic allergy (AA) in previously healthy children. METHODS This was a retrospective cohort study of previously healthy children admitted for treating urinary tract infections over a 10 year period. The primary outcome was the frequency of type B ADRs and AAs that were assessed by pediatricians. Secondary outcomes include demographic data about patients' backgrounds, infections, treatments, ADRs, and action against ADRs. All the data were collected via patients' medical records. RESULTS Out of 791 participants, type B ADRs were reported in 77 children (9.7%), and AA labeling was performed in six children (0.8%). Physicians assessed 30.4% of type B ADRs as severe or life-threatening symptoms. All patients were discharged without long-term complications. Physicians detected the primary cause (individual patient host factors or environmental risks) in 39 cases of type B ADRs. CONCLUSION Type B ADRs to antibiotics were frequently reported even in previously healthy children. Physicians should use appropriate techniques (e.g., specialist consulting and skin testing) when they suspect that a type B ADR might be an AA. Labeling and de-labeling programs and tools for type B ADRs related to antibiotics should be implemented to prevent the mislabeling of AA.
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Affiliation(s)
- Kei Sakamoto
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan.,Center for Postgraduate Education and Training, National Center for Child Health and Development, Tokyo, Japan
| | | | - Mitsuru Kubota
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Akira Ishiguro
- Center for Postgraduate Education and Training, National Center for Child Health and Development, Tokyo, Japan
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
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Turner NA, Wrenn R, Sarubbi C, Kleris R, Lugar PL, Radojicic C, Moehring RW, Anderson DJ. Evaluation of a Pharmacist-Led Penicillin Allergy Assessment Program and Allergy Delabeling in a Tertiary Care Hospital. JAMA Netw Open 2021; 4:e219820. [PMID: 33983399 PMCID: PMC8120333 DOI: 10.1001/jamanetworkopen.2021.9820] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Penicillin allergies are frequently mislabeled, which may contribute to use of less-preferred alternative antibiotics. OBJECTIVE To evaluate a pharmacist-led allergy assessment program's association with antimicrobial use and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS A pharmacist-led allergy assessment program was launched in 2 phases (June 1, 2015, and November 2, 2016) at a single-center tertiary referral hospital. The longitudinal cross-sectional study included all study period adult admissions; hospitalwide outcomes were assessed by segmented regression. Individual outcomes were assessed within an embedded propensity score-matched case-control study of inpatients undergoing comprehensive allergy assessment following self-report of penicillin allergy. Analysis occurred from March 1, 2020, to February 29, 2020. EXPOSURES The longitudinal study analyzed hospital-level outcomes over 3 periods: preintervention (15 months), phase 1 (structured allergy history alone, 16 months), and phase 2 (comprehensive assessment including penicillin skin testing, 52 months). The case-control study defined cases as individuals undergoing comprehensive allergy assessment. MAIN OUTCOMES AND MEASURES Hospital-level outcomes included antibiotic days of therapy per 1000 patient-days and hospital-acquired Clostridioides difficile infection (CDI) incidence per 10 000 patient-days. Individual outcomes included antibiotic selection, overall survival, and CDI-free survival. RESULTS Longitudinal analysis spanned 2014-2020 (median admissions, 46 416 per year; interquartile range [IQR], 46 001-50 091 per year). Hospitalwide, allergy histories were temporally associated with decreased use of nonpenicillin alternative antibiotics (rate ratio, 0.87; 95% CI, 0.79-0.97) and high-CDI-risk antibiotics (rate ratio, 0.91; 95% CI, 0.85-0.98). Penicillin skin testing was temporally associated with lower hospital-acquired CDI rates (rate ratio, 0.61; 95% CI, 0.43-0.86). The embedded case-control study included 272 cases and 819 controls. Median age was 63 years (interquartile range, 51-73 years), 553 (50.7%) patients were women, and 229 (21.0%) patients were Black. Allergy-assessed patients were less likely to receive high-CDI-risk antibiotics at discharge (odds ratio, 0.66; 95% CI, 0.44-0.98). Estimated reductions in mortality (hazard ratio, 0.77; 95% CI, 0.55-1.07) and hospital-acquired CDI risk (hazard ratio, 0.53; 95% CI, 0.18-1.55) were not statistically significant. CONCLUSIONS AND RELEVANCE Pharmacist-led allergy assessments may be associated with reduced high-CDI-risk antibiotic use at both hospitalwide and individual levels. Although individual reductions in mortality and CDI risk did not achieve significance, divergence of survival curves suggest longer-term benefits of allergy delabeling warrant future study.
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Affiliation(s)
- Nicholas A. Turner
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Rebekah Wrenn
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | | | - Renee Kleris
- Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Patricia L. Lugar
- Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Christine Radojicic
- Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Rebekah W. Moehring
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Deverick J. Anderson
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
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Sousa-Pinto B, Blumenthal KG, Courtney L, Mancini CM, Jeffres MN. Assessment of the Frequency of Dual Allergy to Penicillins and Cefazolin: A Systematic Review and Meta-analysis. JAMA Surg 2021; 156:e210021. [PMID: 33729459 PMCID: PMC7970387 DOI: 10.1001/jamasurg.2021.0021] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/17/2020] [Indexed: 12/15/2022]
Abstract
Importance Cefazolin is the preoperative antibiotic of choice because it is safer and more efficacious than second-line alternatives. Surgical patients labeled as having penicillin allergy are less likely to prophylactically receive cefazolin and more likely to receive clindamycin or vancomycin, which results in higher rates of surgical site infections. Objective To examine the incidence of dual allergy to cefazolin and natural penicillins. Data Sources MEDLINE/PubMed, Web of Science, and Embase were searched without language restrictions for relevant articles published from database inception until July 31, 2020. Study Selection In this systematic review and meta-analysis, a search of MEDLINE/PubMed, Web of Science, and Embase was performed for articles published from database inception to July 31, 2020, for studies that included patients who had index allergies to a natural penicillin and were tested for tolerability to cefazolin or that included patients who had index allergies to cefazolin and were tested for tolerability to a natural penicillin. A total of 3228 studies were identified and 2911 were screened for inclusion. Data Extraction and Synthesis Data were independently extracted by 2 authors. Bayesian meta-analysis was used to estimate the frequency of allergic reactions. Main Outcomes and Measures Dual allergy to cefazolin and a natural penicillin. Results Seventy-seven unique studies met the eligibility criteria, yielding 6147 patients. Cefazolin allergy was identified in 44 participants with a history of penicillin allergy, resulting in a dual allergy meta-analytical frequency of 0.7% (95% credible interval [CrI], 0.1%-1.7%; I2 = 74.9%). Such frequency was lower for participants with unconfirmed (0.6%; 95% CrI, 0.1%-1.3%; I2 = 54.3%) than for those with confirmed penicillin allergy (3.0%; 95% CrI, 0.01%-17.0%; I2 = 88.2%). Thirteen studies exclusively assessed surgical patients (n = 3884), among whom 0.7% (95% CrI, 0%-3.3%; I2 = 85.5%) had confirmed allergy to cefazolin. Low heterogeneity was observed for studies of patients with unconfirmed penicillin allergy who had been exposed to perioperative cefazolin (0.1%; 95% CrI, 0.1%-0.3%; I2 = 13.1%). Penicillin allergy was confirmed in 16 participants with a history of cefazolin allergy, resulting in a meta-analytical frequency of 3.7% (95% CrI, 0.03%-13.3%; I2 = 64.4%). The frequency of penicillin allergy was 4.4% (95% CrI, 0%-23.0%; I2 = 75%) for the 8 studies that exclusively assessed surgical patients allergic to cefazolin. Conclusions and Relevance These findings suggest that most patients with a penicillin allergy history may safely receive cefazolin. The exception is patients with confirmed penicillin allergy in whom additional care is warranted.
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Affiliation(s)
- Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Center for Health Technology and Services Research, University of Porto, Porto, Portugal
- Basic and Clinical Immunology Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- The Mongan Institute, Massachusetts General Hospital, Boston
| | - Lindsay Courtney
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
| | - Christian M. Mancini
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| | - Meghan N. Jeffres
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
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Gateman DP, Rumble JE, Protudjer JLP, Kim H. Amoxicillin oral provocation challenge in a primary care clinic: a descriptive analysis. CMAJ Open 2021; 9:E394-E399. [PMID: 33863797 PMCID: PMC8084548 DOI: 10.9778/cmajo.20200077] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Penicillin is the most frequently reported drug allergen; however, most of these allergies are not true allergies and do not justify the prescription of alternative, less effective and more expensive antibiotic drugs. We aimed to show that patients at low risk of amoxicillin allergy can safely and efficiently undergo oral provocation challenge (OPC) by their primary care physician. METHODS In this descriptive analysis, we conducted a retrospective chart review of all primary care patients who had undergone OPC from November 2017 to October 2019 in the Amoxicillin Allergy Clinic at the North Perth Family Health Team, Listowel, Ontario. Eligibility for OPC among patients 18 months and older was determined through review of a self-reported patient intake form asking about symptoms, onset, duration, history and family history of allergic reactions, as well as the patient's electronic medical record. Patients were considered to be at low risk of true penicillin allergy if there was no history of anaphylaxis or severe cutaneous reactions. Those with low-risk allergic reactions returned for testing with an OPC to amoxicillin. We collected data on clinical characteristics, antibiotic exposure, parental drug allergy, response to OPC and wait time from referral. We used t tests to describe and compare these variables. Our primary outcome was reaction to OPC by severity as categorized by the World Allergy Organization grading system. Our secondary outcome was the time from referral to completed testing. RESULTS In total, we included 99 patients (mean age 28.3, standard deviation [SD] 21.2 yr); 72 (73%) were female. Of those tested, 97% (n = 96) completed the OPC with no reaction, 3% (n = 3) had mild immediate reactions, and no serious immediate reactions developed. Mean wait time to testing was 59.0 (SD 69.8) days, with a median (interquartile range) of 39.5 (13.5-70.0) days. INTERPRETATION Oral provocation challenge presents a safe and accessible opportunity for primary care providers to address erroneous allergy labels to penicillin and related drugs within the primary care office setting. There could be positive public health implications if OPC to penicillin drugs is implemented in primary care.
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Affiliation(s)
- Derek Paul Gateman
- Department of Family Medicine (Gateman), McMaster University, Kitchener, Ont.; Department of Family Medicine (Gateman), Western University, Kitchener, Ont.; North Perth Family Health Team (Rumble), Listowel, Ont.; Departments of Pediatrics and Child Health, and Food and Human Nutritional Sciences (Protudjer), University of Manitoba; George & Fay Yee Centre for Healthcare Innovation (Protudjer); The Children's Hospital Research Institute of Manitoba (Protudjer), Winnipeg, Man.; Department of Medicine (Kim), Western University; Department of Medicine (Kim), McMaster University, Kitchener, Ont.
| | - Jessie Erin Rumble
- Department of Family Medicine (Gateman), McMaster University, Kitchener, Ont.; Department of Family Medicine (Gateman), Western University, Kitchener, Ont.; North Perth Family Health Team (Rumble), Listowel, Ont.; Departments of Pediatrics and Child Health, and Food and Human Nutritional Sciences (Protudjer), University of Manitoba; George & Fay Yee Centre for Healthcare Innovation (Protudjer); The Children's Hospital Research Institute of Manitoba (Protudjer), Winnipeg, Man.; Department of Medicine (Kim), Western University; Department of Medicine (Kim), McMaster University, Kitchener, Ont
| | - Jennifer L P Protudjer
- Department of Family Medicine (Gateman), McMaster University, Kitchener, Ont.; Department of Family Medicine (Gateman), Western University, Kitchener, Ont.; North Perth Family Health Team (Rumble), Listowel, Ont.; Departments of Pediatrics and Child Health, and Food and Human Nutritional Sciences (Protudjer), University of Manitoba; George & Fay Yee Centre for Healthcare Innovation (Protudjer); The Children's Hospital Research Institute of Manitoba (Protudjer), Winnipeg, Man.; Department of Medicine (Kim), Western University; Department of Medicine (Kim), McMaster University, Kitchener, Ont
| | - Harold Kim
- Department of Family Medicine (Gateman), McMaster University, Kitchener, Ont.; Department of Family Medicine (Gateman), Western University, Kitchener, Ont.; North Perth Family Health Team (Rumble), Listowel, Ont.; Departments of Pediatrics and Child Health, and Food and Human Nutritional Sciences (Protudjer), University of Manitoba; George & Fay Yee Centre for Healthcare Innovation (Protudjer); The Children's Hospital Research Institute of Manitoba (Protudjer), Winnipeg, Man.; Department of Medicine (Kim), Western University; Department of Medicine (Kim), McMaster University, Kitchener, Ont
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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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Kleris R, Tang M, Radojicic C, Lugar PL. Pricking away at penicillin allergy with a dedicated outpatient clinic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1358-1359.e1. [PMID: 30967194 DOI: 10.1016/j.jaip.2018.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 11/25/2022]
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