Clinical and Economic Outcomes of Penicillin Skin Testing as an Antimicrobial Stewardship Initiative in a Community Health System

Penicillin Allergy Testing and Delabeling for Patients Who Are Prescribed Penicillin: A Systematic Review for a World Health Organization Guideline

Secondary prevention with penicillin aims to prevent further episodes of acute rheumatic fever and subsequent development of rheumatic heart disease (RHD). Penicillin allergy, self-reported by 10% of the population, can affect secondary prevention programs. We aimed to assess the role for (i) routine penicillin allergy testing and the (ii) safety of penicillin allergy delabeling approaches in this context. We searched MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, WHO ICTRP, ISRCTN, and CPCI-S to identify the relevant reports. We found 2419 records, but no studies addressed our initial question. Following advice from the WHO-Guideline committee and experts, we identified 6 manuscripts on allergy testing focusing on other populations showing that the prevalence of allergy confirmed by testing was low and the incidence of life-threatening reactions to BPG was very low (< 1-3/1000 individuals treated). A subsequent search addressed penicillin allergy delabeling. This found 516 records, and 5 studies addressing the safety of direct oral drug challenge vs. skin testing followed by drug administration in patients with suspected penicillin allergy. Immediate allergic reactions of minor severity were observed for a minority of patients and occurred less frequently in the direct drug challenge group: 2.3% vs. 11.5%; RR = 0.25, 95%CI 0.15-0.45, P < 0.00001, I2 = 0%. No anaphylaxis or deaths were observed. Severe allergic reactions to penicillin are extremely rare and can be recognized and dealt by trained healthcare workers. Confirmation of penicillin allergy diagnosis or delabeling using direct oral drug challenge or penicillin skin testing seems to be safe and is associated with a low rate of adverse reactions.

Penicillin allergy de-labelling by non-allergists: a comparison of testing protocols

Optimizing penicillin allergy de-labelling (PADL) to ensure patients with an incorrect penicillin allergy record are de-labelled with minimal patient harm is important for antibiotic stewardship. The heterogeneity of inclusion and exclusion criteria in the published penicillin allergy testing protocols risks suboptimal delivery of PADL. We compared the similarities and the differences between non-allergist-delivered PADL testing protocols and make suggestions for harmonization. The observed variation in testing practice has two broad elements: (i) definitions and terminology; and (ii) differences in the acceptability of perceived risk. All direct drug provocation testing (DDPT) protocols included patients with benign delayed rash as eligible for testing, although the remoteness of the rash, and the terminology used to describe the rash, differed. Patients with features of potential IgE reactions were excluded from most DDPT protocols, but not all of them. There was differing advice on how to manage patients who had subsequently tolerated penicillin since the index reaction and differences in which patients were considered ineligible for DDPT due to acuity of illness, comorbidities and concomitant medications. Standardization of the terminology used in penicillin allergy testing protocols and consensus on inclusion and exclusion criteria are required for safe and efficient PADL delivery at scale by non-allergists.

The effectiveness of interventions that support penicillin allergy assessment and delabeling of adult and pediatric patients by nonallergy specialists: a systematic review and meta-analysis

OBJECTIVES

Penicillin allergy records are often incorrect and may result in harm. We aimed to systematically review the effectiveness and safety of nonallergist health care worker delivery of penicillin allergy delabeling.

METHODS

We searched EMBASE/MEDLINE/CINAHL (Ovid), PsycInfo, Web of Science, and Cochrane CENTRAL from inception to January 21, 2022 and unpublished studies and gray literature. The proportion of patients allergic to penicillin delabeled and harmed was calculated using random-effects models.

RESULTS

Overall, 5019 patients were delabeled. Using allergy history alone, 14% (95% confidence interval [CI], 9-21%) of 4350 assessed patients were delabeled without reported harm. Direct drug provocation testing resulted in delabeling in 27% (95% CI, 18-37%) of 4207 assessed patients. Of the 1373 patients tested, 98% were delabeled (95% CI, 97-99%), and nonserious harm was reported in 1% (95% CI, 0-2%). Using skin testing, followed by drug provocation testing, 41% (95% CI, 24-59%) of 2890 assessed patients were delabeled. Of the 1294 tested patients, 95.0% (95% CI, 90-99%) were delabeled, and the reported harm was low (0%; (95% CI 0-1%).

CONCLUSION

Penicillin allergy delabeling by nonallergists is efficacious and safe. The proportion of assessed patients who can be delabeled increases with the complexity of testing method, but substantial numbers can be delabeled without skin testing.

Penicillin Allergy Label Is Associated With Worse Clinical Outcomes in Bacterial Pneumonia

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.

How Well Are Pharmacists Represented in National Institutes of Health R01 Funding to United States Schools of Pharmacy?

Pharmacists are essential healthcare providers but historically are not well represented as principal investigators (PIs) of R01 grants by the United States (US) National Institutes of Health (NIH). Pharmacy organizations have taken steps to provide pharmacists with research training to improve their chances of achieving PI status. We conducted a retrospective cohort study using data from the NIH RePORTER website about R01 grants awarded to PIs affiliated with US Schools of Pharmacy (SOPs) for the fiscal years 2005−2019. Information regarding professional degrees was supplemented using data from the PIs’ institutional website profiles and other internet-based sources. Only doctorate degrees obtained within the US were included for clinically related degrees. Data regarding more than one year of funding for the same project, equipment supplements, and diversity supplements were excluded to focus on unique projects in year one of funding. PhDs were the primary unique PIs of R01 grants at US SOPs (>90%). Pharmacist representation as unique PIs increased over the 15 years but was still only 10.1% for the years 2015−2019. There was a higher percentage of female pharmacists as unique PIs than female non-pharmacists. Pharmacists are currently underrepresented as unique PIs for NIH R01 grants. This conclusion is limited by not knowing how many pharmacist R01 applications were submitted.

A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2020

The number of articles related to antimicrobial stewardship published each year has increased significantly over the last decade. Keeping up with the literature, particularly the most innovative, well-designed, or applicable to one’s own practice area, can be challenging. The Southeastern Research Group Endeavor (SERGE-45) network reviewed antimicrobial stewardship–related, peer-reviewed literature from 2020 that detailed actionable interventions. The top 13 publications were summarized following identification using a modified Delphi technique. This article highlights the selected interventions and may serve as a key resource for teaching and training, and to identify novel or optimized stewardship opportunities within one’s institution.

Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta-analysis

BACKGROUND

Patients with a penicillin allergy label tend to have worse clinical outcomes and increased healthcare use. Drug provocation tests (DPT) are the gold-standard in the diagnostic workup of penicillin allergy, but safety concerns may hinder their performance. We aimed to assess the frequency of severe reactions following a DPT in patients with reported allergy to penicillins or other β-lactams.

METHODS

We performed a systematic review, searching MEDLINE, Scopus, and Web of Science. We included primary studies assessing participants with a penicillin allergy label who underwent a DPT. We performed a Bayesian meta-analysis to estimate the pooled frequency of severe reactions to penicillin DPTs. Sources of heterogeneity were explored by subgroup and metaregression analyses.

RESULTS

We included 112 primary studies which included a total of 26,595 participants. The pooled frequency of severe reactions was estimated at 0.06% (95% credible interval [95% CrI] = 0.01%-0.13%; I2  = 57.9%). Most severe reactions (80/93; 86.0%) consisted of anaphylaxis. Compared to studies where the index reaction was immediate, we observed a lower frequency of severe reactions for studies assessing non-immediate index reactions (OR = 0.05; 95% CrI = 0-0.31). Patients reporting anaphylaxis as their index reaction were found to be at increased risk of developing severe reactions (OR = 13.5; 95% CrI = 7.7-21.5; I2  = 0.3%). Performance of direct DPTs in low-risk patients or testing with the suspected culprit drug were not associated with clinically relevant increased risk of severe reactions.

CONCLUSIONS

In patients with a penicillin allergy label, severe reactions resulting from DPTs are rare. Therefore, except for patients with potentially life-threatening index reactions or patients with positive skin tests-who were mostly not assessed in this analysis -, the safety of DPTs supports their performance in the diagnostic assessment of penicillin allergy.

Penicillin Allergy Delabeling: A Multidisciplinary Opportunity

The penicillin allergy label has been consistently linked with deleterious effects that span the health care spectrum, including suboptimal clinical outcomes, the emergence of bacterial resistance, and increased health care expenditures. These risks have recently motivated professional organizations and public health institutes to advocate for the implementation of penicillin allergy delabeling initiatives; however, the burden of delabeling millions of patients is too expansive for any one discipline to bear alone. This review presents the unique perspectives and roles of various stakeholder groups involved in penicillin allergy diagnosis, assessment, and delabeling; we emphasize opportunities, barriers, and promising areas of innovation. We summarize penicillin allergy methods and tools that have proven successful in delabeling efforts. A multidisciplinary approach to delabeling patients with reported penicillin allergy, bolstered by evidence-based clinical practices, is recommended to reduce the risks that associate with the penicillin allergy label.

Penicillin Allergy Testing Is Cost-Saving: An Economic Evaluation Study

BACKGROUND

Having a penicillin allergy label is associated with the use of less appropriate and more expensive antibiotics and increased healthcare utilization. Penicillin allergy testing results in delabeling most allergy claimants and may be cost-saving. This study aimed to project whether penicillin allergy testing in patients reporting a penicillin allergy is cost-saving.

METHODS

In this economic evaluation study, we built decision models to project the economic impact of 2 strategies for a patient with a penicillin allergy label: (1) perform diagnostic testing (drug challenges, with or without skin tests); and (2) do not perform diagnostic testing. The health service perspective was adopted, considering costs with penicillin allergy tests, and with hospital bed-days/outpatient visits, antibiotic use, and diagnostic testing. Twenty-four base case decision models were built, accounting for differences in the diagnostic workup, setting (inpatient vs outpatient) and geographic region. Uncertainty was explored via probabilistic sensitivity analyses.

RESULTS

Penicillin allergy testing was cost-saving in all decision models built. For models assessing the performance of both skin tests and drug challenges, allergy testing resulted in average savings (in United States [US] dollars) of $657 for inpatients (US: $1444; Europe: $489) and $2746 for outpatients (US: $256; Europe: $6045). 75% of simulations obtained through probabilistic sensitivity analysis identified testing as the less costly option.

CONCLUSIONS

Penicillin allergy testing was projected to be cost-saving across different scenarios. These results are devised to inform guidelines, supporting the adoption of policies promoting widespread testing of patients with a penicillin allergy label.

Skin Testing for Penicillin Allergy: a Review of the Literature

PURPOSE OF REVIEW

Self-reported penicillin allergies are frequently reported, though more than 95% of those are not truly allergic when challenged. These patients are more likely to receive alternative antibiotic regimens resulting in the use of broad-spectrum antibiotics that may be less effective, more toxic, and/or more expensive than preferred agents. Given the significant burden on patient outcomes and the healthcare system, the ability to reconcile an allergy and broaden future antibiotic options is essential.

RECENT FINDINGS

This is a narrative review describing risk stratification for penicillin skin testing, practical advice for implementation, and future directions. A summary of studies within the last 5 years is provided. The trend over the past several years has been to offer oral drug challenges to low-risk patients and skin testing to high-risk patients with a reported penicillin allergy. This review provides support for risk stratification assessment of reported penicillin allergy to optimize antibiotic use and prevent emergence of antimicrobial resistance.

Financial Analysis of Dalbavancin for Acute Bacterial Skin and Skin Structure Infections for Self-Pay Patients

Introduction

Acute bacterial skin and skin structure infections (ABSSSI) are an increasing cause of admission in the self-pay population. We previously reported that patients with ABSSSI discharged to receive dalbavancin showed a decreased length of stay (LOS) and total direct costs without increasing 30-day readmission rate. For patients who are financially eligible, a dalbavancin vial replacement program can offset costs. The objective of this study was to determine cost differences in treating ABSSSI in self-pay inpatients discharged to receive dalbavancin compared to standard of care (SOC).

Methods

This retrospective cohort within a community health system compared self-pay adult inpatients with ABSSSI from February 3, 2016 to August 5, 2019 discharged to receive dalbavancin at an outpatient infusion center with SOC intravenous antibiotics. Patients were included with cellulitis, abscess, or postoperative wound infections diagnoses on the basis of International Classification of Disease, Tenth Revision (ICD-10) codes. Excluded populations were patients without dalbavancin vial replacement performed, pregnant, infections caused exclusively by gram-negative bacteria or fungi, or ICD-10 codes not consistent with ABSSSI. The primary outcome was direct cost of hospital stay. Secondary outcomes included length of stay (LOS), 30-day readmission rates, adverse events (AE), and indirect hospital costs. On the basis of previous studies, a one-sided Student’s t test was performed on financial data.

Results

Twelve dalbavancin and 263 SOC patients met inclusion criteria. Direct cost ($2758 vs $4010, p = 0.105) and indirect hospital cost ($2913 vs $3646 , p = 0.162) per patient were less in the dalbavancin group. There was no significant difference between median LOS (4 vs 4, p = 0.888), AE (0% vs 14.8%), and 30-day readmission rates for dalbavancin vs SOC group (8.3% vs 7.2%, p = 0.604).

Conclusion

Self-pay patients with ABSSSI discharged to receive dalbavancin with vial replacement resulted in decreased direct and indirect costs per patient with similar 30-day readmission rates, AE, and LOS. More studies targeted toward this population are warranted to determine ultimate benefit.

The economics of drug allergy

PURPOSE OF REVIEW

As drug allergy research aims to inform clinical practice, implementation of best practices may be influenced by financial resources required to incorporate new interventions and the resulting clinical and economic returns on those resource investments. The present review summarizes new insights into the economics of drug allergy over the past year.

RECENT FINDINGS

While considering economic implications of recent drug allergy research, many studies have addressed different contextual factors related to the setting, provider, or outcomes. Advances in technology have enabled specialized allergists to support remote settings through telemedicine consultation. Training opportunities and interdisciplinary approaches to address drug allergy challenges have enabled multiple provider types to play a role in screening, diagnosis, and management. Penicillin allergy testing has been a major focus for many institutions, with several studies focused on de-labeling strategies including confirmatory skin testing and direct oral challenges.

SUMMARY

Studies over the past year provide new opportunities for the field of drug allergy research. The focus of current research to capture direct health costs or savings associated with drug allergy interventions demonstrates opportunity for more cost-effective care delivery and opportunity to explore greater benefits to society.

Palliative care and infection management at end of life in nursing homes: A descriptive survey

BACKGROUND

Infections are common occurrences at end of life that are associated with high rates of morbidity and mortality among frail elderly individuals. The problem of infections in nursing homes has led to a subsequent overuse and misuse of antibiotics in this already-frail population. Improving palliative care in nursing homes has been proposed as a key strategy to reduce the use of antibiotics.

AIM

The aim of this study was to describe the current status of how nursing homes integrates palliative care and infection management at end of life across the nation.

DESIGN

This is a cross-sectional survey of nationally representative US nursing homes.

SETTING/PARTICIPANTS

Between November 2017 and October 2018, a survey was conducted with a nationally representative random sample of nursing homes and 892 surveys were completed (49% response rate). The weighted study sample represented 15,381 nursing homes across the nation.

RESULTS

Most nursing homes engaged in care plan documentation on what is important to residents (90.43%) and discussed spiritual needs of terminally ill residents (89.50%). In the event of aspiration pneumonia in terminally ill residents, 59.43% of nursing homes responded that resident would be transferred to the hospital. In suspected urinary tract infection among terminally ill residents, 66.62% of nursing homes responded that the resident will be treated with antibiotics.

CONCLUSION

The study found wide variations in nursing home palliative care practices, particularly for timing of end-of-life care discussions, and suboptimal care reported for antibiotic usage. Further education for nursing home staff on appropriate antibiotic usage and best practices to integrate infection management in palliative care at the end of life is needed.

Pharmacist-driven penicillin skin testing service for adults prescribed nonpreferred antibiotics in a community hospital

PURPOSE

Results of a study evaluating the implementation and impact of a pharmacist-driven penicillin skin testing (PST) service for patients prescribed alternative antibiotics in the community hospital setting are reported.

METHODS

A prospective pilot service in which patients with a documented penicillin allergy (type I, immunoglobulin E [IgE]-mediated) who were prescribed alternative antibiotics received PST by a trained pharmacist was implemented; if test results were negative, the allergy was de-labeled from their electronic medical record. The primary objective was the percentage of patients switched to first-line antibiotics. Secondary objectives included length of stay (LOS) and inpatient antimicrobial costs to the health system.

RESULTS

Twenty-two patients were proactively identified and received PST by a pharmacist. Of those tested, all were negative, with no type I (IgE-mediated) hypersensitivity reactions to the test itself or to the beta-lactam antibiotic administered thereafter; 68.2% (15/22) were successfully transitioned to a beta-lactam after PST. As a result, a decrease in the use of fluoroquinolones and vancomycin and an increase in use of narrow penicillin-based antibiotics and first- and second-generation cephalosporins were observed. The mean ± S.D. LOS per patient was 7.41 ± 6.1 days, and the total cost of inpatient antimicrobial therapy to the health system was $1,698.88.

CONCLUSION

A pharmacist-driven PST service was successfully implemented in a community hospital setting.

A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2018

With an increasing number of antimicrobial stewardship-related articles published each year, attempting to stay current is challenging. The Southeastern Research Group Endeavor (SERGE-45) identified antimicrobial stewardship-related peer-reviewed literature that detailed an actionable intervention for 2018. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight the actionable intervention used by antimicrobial stewardship programs to provide key stewardship literature for teaching and training as well as to identify potential intervention opportunities within one's institution.

Penicillin Allergy Assessment and Skin Testing in the Outpatient Setting

Penicillin allergies are among of the most commonly reported allergies, yet only 10% of these patients are truly allergic. This leads to potential inadvertent negative consequences for patients and makes treatment decisions challenging for clinicians. Thus, allergy assessment and penicillin skin testing (PST) are important management strategies to reconcile and clarify labeled penicillin allergies. While PST is more common in the inpatient setting where the results will immediately impact antibiotic management, this process is becoming of increasing importance in the outpatient setting. PST in the outpatient setting allows clinicians to proactively de-label and educate patients accordingly so beta-lactam antibiotics may be appropriately prescribed when necessary for future infections. While allergists have primarily been responsible for PST in the outpatient setting, there is an increasing role for pharmacist involvement in the process. This review highlights the importance of penicillin allergy assessments, considerations for PST in the outpatient setting, education and advocacy for patients and clinicians, and the pharmacist’s role in outpatient PST.

Penicillin Allergy Skin Testing in the Inpatient Setting

The consequences of a documented penicillin allergy in the medical record are especially troublesome in acutely ill, hospitalized patients. A penicillin allergy label may lead to alternative or second line therapies resulting in adverse drug events, negative clinical outcomes and increased costs. Reconciling penicillin allergies is a necessity to facilitate early, optimal therapy and is a shared responsibility among the healthcare team. Penicillin skin testing (PST) has been utilized successfully in hospitalized patients to de-label erroneous penicillin allergies and optimize antibiotic therapy. This targeted review aims to discuss the practical development and implementation of PST in the inpatient setting. This includes a needs assessment checklist with common considerations allowing for customization to one’s institution based on available personnel, time, and technological resources.