1
|
Drummond K, Vogrin S, Lambros B, Trubiano JA, Mitri E. Effectiveness of direct delabelling of allergy labels in type A adverse drug reactions to penicillin: a multicentre hospitalwide prospective cohort study. J Antimicrob Chemother 2024:dkae270. [PMID: 39078218 DOI: 10.1093/jac/dkae270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 07/12/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Patient-reported penicillin allergy labels (PALs) are associated with adverse patient outcomes and inappropriate antibiotic prescribing. Removal of PALs via direct oral challenge (DOC) is associated with increased penicillin utilization post removal. OBJECTIVES To assess the impact of direct delabelling (allergy label removal via medical reconciliation alone) of type A adverse drug reaction (ADR) PALs on inpatient prescribing. METHODS From January 2019 to December 2022 at two tertiary hospitals in Melbourne, patients aged ≥18 years with type A ADR PALs, as defined by the validated Antibiotic Allergy Assessment Tool, were offered direct delabelling or single-dose DOC. The primary endpoint was antibiotic use pre- and post-assessment (during index admission and 90 days post assessment). The secondary endpoint was the proportion of patients delabelled in the direct delabelling and DOC cohorts in the electronic medical record at 90 days post assessment. RESULTS Allergy labels (n = 4108) were assessed for 488 participants, with 490 individual type A ADR PAL assessments included. Three hundred and thirty-seven patients were directly delabelled, 69 underwent DOC and 84 were not delabelled. There was increased use of any penicillin following direct delabelling (OR 19.19, 95% CI 2.48-148.36) and DOC (OR 56.98, 95% CI 6.82-476.19) during the index admission, higher in the DOC group compared with direct delabelling (OR 2.97, 95% CI 1.39-6.37). Relabelling at 90 days was low with no statistically significant difference between direct delabelling (5/337; 1.5%) and DOC (0/69; 0%). CONCLUSIONS Both direct delabelling and DOC of type A ADR PALs increased penicillin usage; however, the impact was greatest with DOC. Most patients remain delabelled at 90 days.
Collapse
Affiliation(s)
- Kate Drummond
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Sara Vogrin
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute of Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Belinda Lambros
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute of Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elise Mitri
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute of Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
2
|
Kwan N, Kang K, Carr RR, Mak R, Roberts A, Jin F, Bone JN, Rassekh SR, Wong T. True Rate of Allergy among Pediatric Inpatients with Penicillin Allergy Labels (TRIAL). Can J Hosp Pharm 2024; 77:e3531. [PMID: 38988874 PMCID: PMC11210598 DOI: 10.4212/cjhp.3531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/25/2024] [Indexed: 07/12/2024]
Abstract
Background Penicillin allergy is a common drug allergy diagnosis in pediatric patients; however, upon appropriate allergy testing, many of these patients are found not to have a true allergy. For patients with a reported allergy, alternative antibiotics are prescribed, which are less effective, more toxic, or more expensive. There is a lack of data evaluating allergies in hospitalized children and comparing allergy assessments conducted by pediatric allergists and pharmacists. Objective To estimate the percentage of pediatric patients admitted with reported penicillin allergy who did not have a true penicillin allergy. Methods This single-centre prospective cohort study included inpatients between 6 months and 17 years of age, with a documented penicillin allergy, who were admitted to the general pediatric and oncology units of a tertiary care children's hospital between November 2019 and March 2023. The allergy history, evaluation, and risk categorization were performed by pharmacists. The history was reviewed with the allergist, and the patient was then referred, underwent skin testing, or received oral amoxicillin challenge with monitoring for 1 hour. Results Thirty patients were included, of whom 29 (97%) had delabelling of their penicillin allergy. Four patients (13%) had delabelling on the basis of history alone, without risk assessment. Twenty-five (83%) of the patients were assessed as having low risk; 24 of these had delabelling following oral challenge, and 1 did not complete the oral challenge because of transfer to another hospital. One patient (3%) was assessed as having moderate risk, with delabelling on the basis of results of skin testing and oral challenge. The pharmacist's and allergist's risk assessments were in agreement in 29 (97%) of the 30 cases. Conclusions Pediatric patients, including those with oncologic malignancies, are often mislabelled as having a penicillin allergy. Pharmacists are able to accurately determine true allergy risk and delabel penicillin allergies for pediatric patients in the hospital setting.
Collapse
Affiliation(s)
- Natasha Kwan
- BSc(Pharm), ACPR, PharmD, is with the Department of Pharmacy, Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia
| | - Kristopher Kang
- MD, FRCPC, is with the Division of General Pediatrics, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia
| | - Roxane R Carr
- BSc, BSc(Pharm), ACPR, PharmD, FCSHP, BCPS, is with the Department of Pharmacy, Children's and Women's Health Centre of British Columbia, and the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Raymond Mak
- BSc, MD, FRCPC, is with the Division of Allergy and Immunology, Department of Pediatrics, and the Division of Allergy and Immunology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia
| | - Ashley Roberts
- MD, MEd, FRCPC, is with the Division of Infectious Diseases, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia
| | - Falla Jin
- BA, is with the BC Children's Hospital Research Institute, Vancouver, British Columbia
| | - Jeffrey N Bone
- MSc, is with the BC Children's Hospital Research Institute, Vancouver, British Columbia
| | - S Rod Rassekh
- , BSc, MD, MHSc, is with the Division of Hematology, Oncology and Bone Marrow Transplant, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia
| | - Tiffany Wong
- MD, FRCPC, is with the Division of Allergy and Immunology, Department of Pediatrics, and the BC Children's Hospital Research Institute, The University of British Columbia, Vancouver, British Columbia
| |
Collapse
|
3
|
Copaescu AM, Li L, Blumenthal KG, Trubiano JA. How to Define and Manage Low-Risk Drug Allergy Labels. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1095-1106. [PMID: 38724164 DOI: 10.1016/j.jaip.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 06/06/2024]
Abstract
Risk stratification in drug allergy implies that specific risk categories (eg, low, moderate, and high) classify historical drug hypersensitivity reactions. These risk categories can be based on reaction phenotypic characteristics, the timing of the reaction and evaluation, the required reaction management, and individual characteristics. Although a multitude of frameworks have been described in the literature, particularly for penicillin allergy labels, there has yet to be a global consensus, and approaches continue to vary between allergy centers. Immune-mediated drug allergies can sometimes be confirmed using skin testing, but a negative drug challenge is required to demonstrate tolerance and remove the allergy from the electronic health record ("delabel" the allergy). Even for quintessential IgE-mediated drug allergy, penicillin allergy, recent data reveal that a direct oral challenge, without prior skin testing, is an appropriate diagnostic strategy in those who are considered low-risk. Drug allergy pathogenesis and clinical manifestations may vary depending on the culprit drug, and as such, the optimal approach should be based on risk stratification that considers individual patient and reaction characteristics, the likely hypersensitivity reaction phenotype, the drug class, and the patient's clinical needs. This article will describe low-risk drug allergy labels, focusing on β-lactam and sulfonamide antibiotics, nonsteroidal anti-inflammatory drugs, iodinated contrast media, and common chemotherapeutics. This review will also address practical management approaches using currently available risk stratification and clinical decision tools.
Collapse
Affiliation(s)
- Ana Maria Copaescu
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Medicine, Austin Health, the University of Melbourne, Heidelberg, VIC, Australia; Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada; The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada.
| | - Lily Li
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Wash
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, VIC, Australia
| |
Collapse
|
4
|
Mitri E, Reynolds G, Hornung CJ, Trubiano JA. Low-risk penicillin allergy delabeling: a scoping review of direct oral challenge practice, implementation, and multi-disciplinary approaches. Expert Rev Anti Infect Ther 2024; 22:59-69. [PMID: 38098185 DOI: 10.1080/14787210.2023.2296068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/13/2023] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Penicillin allergy is common, and there is increased clinician interest in direct oral challenge (DOC) as a testing strategy for low-risk penicillin allergy. To aid wider implementation of DOC, consensus definitions of low-risk penicillin allergy phenotypes, and standardized approaches to assessment, DOC procedures, and evaluation, are required. AREAS COVERED This review systematically reviews studies that have utilized penicillin DOC in healthcare settings to identify heterogeneity in implementation approaches and synthesize low-risk definitions, procedures, and evaluation. EXPERT OPINION Opportunity exists to standardize penicillin DOC procedures in patients with a low-risk penicillin allergy to optimize antimicrobial prescribing and reduce the burden of penicillin allergy. Standardizing the definitions of 'low-risk' and 'positive challenge,' and improving the evaluation of patient safety, alongside the development of a unified approach to the structure of undertaking an oral challenge, is likely to increase uptake and confidence among non-allergist clinicians.
Collapse
Affiliation(s)
- Elise Mitri
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- National Allergy Centre of Excellence (NACE), Parkville, Victoria, Australia
| | - Gemma Reynolds
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Catherine J Hornung
- National Allergy Centre of Excellence (NACE), Parkville, Victoria, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- National Allergy Centre of Excellence (NACE), Parkville, Victoria, Australia
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| |
Collapse
|
5
|
Wrenn RH, Trubiano JA. Penicillin Allergy Impact and Management. Infect Dis Clin North Am 2023; 37:793-822. [PMID: 37537003 DOI: 10.1016/j.idc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
There is international evidence that penicillin allergies are associated with inferior prescribing and patient outcomes. A host of tools now exist from assessment (risk assessment tools, clinical decision rules) to delabeling (the removal of a beta-lactam allergy via testing or medical reconciliation) to reduce the impact of these "labels" in the hospital and community setting, as a primary antimicrobial stewardship intervention.
Collapse
Affiliation(s)
- Rebekah H Wrenn
- Duke University Medical Center, Durham, NC, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA.
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Melbourne, Australia; Department of Infectious Diseases, University of Melbourne, at The Peter Doherty Institute for Infection and Immunity, Victoria 3000, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| |
Collapse
|
6
|
Copaescu AM, Vogrin S, James F, Chua KYL, Rose MT, De Luca J, Waldron J, Awad A, Godsell J, Mitri E, Lambros B, Douglas A, Youcef Khoudja R, Isabwe GAC, Genest G, Fein M, Radojicic C, Collier A, Lugar P, Stone C, Ben-Shoshan M, Turner NA, Holmes NE, Phillips EJ, Trubiano JA. Efficacy of a Clinical Decision Rule to Enable Direct Oral Challenge in Patients With Low-Risk Penicillin Allergy: The PALACE Randomized Clinical Trial. JAMA Intern Med 2023; 183:944-952. [PMID: 37459086 PMCID: PMC10352926 DOI: 10.1001/jamainternmed.2023.2986] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/17/2023] [Indexed: 07/20/2023]
Abstract
Importance Fewer than 5% of patients labeled with a penicillin allergy are truly allergic. The standard of care to remove the penicillin allergy label in adults is specialized testing involving prick and intradermal skin testing followed by an oral challenge with penicillin. Skin testing is resource intensive, limits practice to specialist-trained physicians, and restricts the global population who could undergo penicillin allergy delabeling. Objective To determine whether a direct oral penicillin challenge is noninferior to the standard of care of penicillin skin testing followed by an oral challenge in patients with a low-risk penicillin allergy. Design, Setting, and Participants This parallel, 2-arm, noninferiority, open-label, multicenter, international randomized clinical trial occurred in 6 specialized centers, 3 in North America (US and Canada) and 3 in Australia, from June 18, 2021, to December 2, 2022. Eligible adults had a PEN-FAST score lower than 3. PEN-FAST is a prospectively derived and internationally validated clinical decision rule that enables point-of-care risk assessment for adults reporting penicillin allergies. Interventions Patients were randomly assigned to either direct oral challenge with penicillin (intervention arm) or a standard-of-care arm of penicillin skin testing followed by oral challenge with penicillin (control arm). Main Outcome and Measure The primary outcome was a physician-verified positive immune-mediated oral penicillin challenge within 1 hour postintervention in the intention-to-treat population. Noninferiority was achieved if a 1-sided 95% CI of the risk difference (RD) did not exceed 5 percentage points (pp). Results A total of 382 adults were randomized, with 377 patients (median [IQR] age, 51 [35-65] years; 247 [65.5%] female) included in the analysis: 187 in the intervention group and 190 in the control group. Most patients had a PEN-FAST score of 0 or 1. The primary outcome occurred in 1 patient (0.5%) in the intervention group and 1 patient (0.5%) in the control group, with an RD of 0.0084 pp (90% CI, -1.22 to 1.24 pp). The 1-sided 95% CI was below the noninferiority margin of 5 pp. In the 5 days following the oral penicillin challenge, 9 immune-mediated adverse events were recorded in the intervention group and 10 in the control group (RD, -0.45 pp; 95% CI, -4.87 to 3.96 pp). No serious adverse events occurred. Conclusions and Relevance In this randomized clinical trial, direct oral penicillin challenge in patients with a low-risk penicillin allergy was noninferior compared with standard-of-care skin testing followed by oral challenge. In patients with a low-risk history, direct oral penicillin challenge is a safe procedure to facilitate the removal of a penicillin allergy label. Trial Registration ClinicalTrials.gov Identifier: NCT04454229.
Collapse
Affiliation(s)
- Ana Maria Copaescu
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Department of Medicine, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent’s Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Fiona James
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Kyra Y. L. Chua
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Morgan T. Rose
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Joseph De Luca
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jamie Waldron
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew Awad
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Jack Godsell
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Clinical Immunology and Allergy, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Elise Mitri
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Belinda Lambros
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Abby Douglas
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Rabea Youcef Khoudja
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Ghislaine A. C. Isabwe
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Genevieve Genest
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Michael Fein
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Cristine Radojicic
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ann Collier
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Patricia Lugar
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Cosby Stone
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Moshe Ben-Shoshan
- The Research Institute of the McGill University Health Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Division of Allergy, Immunology and Dermatology, Montreal Children’s Hospital, McGill University Health Centre McGill University, Montreal, Quebec, Canada
| | - Nicholas A. Turner
- Department of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Natasha E. Holmes
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth J. Phillips
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Jason A. Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
7
|
Wilkerson RG. Drug Hypersensitivity Reactions. Immunol Allergy Clin North Am 2023; 43:473-489. [PMID: 37394254 DOI: 10.1016/j.iac.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.
Collapse
Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| |
Collapse
|
8
|
Rose M, Holmes N, Eastwood G, Vogrin S, James F, Phung M, Barnes S, Murfin B, Rogers B, Lambros B, Peel T, Gibney G, Slavin M, Trubiano J. Oral challenge vs routine care to assess low-risk penicillin allergy in critically ill hospital patients (ORACLE): a pilot randomised controlled trial. Pilot Feasibility Stud 2023; 9:126. [PMID: 37475038 DOI: 10.1186/s40814-023-01337-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/07/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Self-reported penicillin allergies are highly prevalent in hospitalised patients and are associated with poor health and health service outcomes. Critically ill patients have historically been underrepresented in prospective delabelling studies in part due to concerns around clinical stability and reliability of penicillin skin testing. Allergy assessment tools exist to identify low-risk penicillin allergy phenotypes and facilitate direct oral challenge delabelling. PEN-FAST is a clinical decision rule that has been validated to predict true penicillin allergy in a cohort of non-critically ill patients. There is however limited evidence regarding the feasibility, safety and efficacy of direct oral challenges and the use of delabelling clinical decisions rules in the intensive care setting. METHODS Critically ill patients in the intensive care unit (ICU) with low-risk penicillin allergy phenotypes (PEN-FAST score < 3) will be randomised 1:1 to direct oral penicillin challenge (single dose 250 mg oral amoxicillin or implicated penicillin) or routine care, followed by a 2-h observation period. Patients will receive a second oral challenge/observation prior to hospital discharge (with subsequent observation for 2 h). An assessment for antibiotic-associated adverse events will also be undertaken at 24 h and 5 days post each challenge/observation and again at 90 days post-randomisation. The primary outcome measures are feasibility (proportion of eligible patients recruited and protocol compliance) and safety (proportion of patients who experience an antibiotic-associated immune-mediated adverse event or serious adverse event). DISCUSSION We will report the feasibility and safety of point-of-care penicillin direct oral challenge in this first randomised controlled trial of low-risk penicillin allergy in critically ill hospitalised patients. Upon completion of the project, important findings will inform the design of planned large prospective multi-centre clinical trials in Australian and international ICUs, further examining safety and efficacy and exploring antimicrobial prescribing-related outcomes following penicillin oral challenge. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry Registration Number: ACTRN12621000051842 Date registered: 20/01/2021 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379735&isReview=true.
Collapse
Affiliation(s)
- Morgan Rose
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia.
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
| | - Natasha Holmes
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- Department of Infectious Diseases, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, Austin Health/University of Melbourne, Heidelberg, VIC, Australia
- Department of Critical Care, The University of Melbourne, Parkville, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Sara Vogrin
- Department of Medicine (St Vincent's Hospital), University of Melbourne, Melbourne, VIC, Australia
| | - Fiona James
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Michelle Phung
- Pharmacy Department, Monash Health, Clayton, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Sara Barnes
- Monash Lung Sleep Allergy and Immunology, Monash Health, Clayton, VIC, Australia
| | - Brendan Murfin
- Intensive Care Unit, Monash Health, Clayton, VIC, Australia
| | - Ben Rogers
- Monash Infectious Diseases, Monash Health, Clayton, VIC, Australia
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Belinda Lambros
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Trisha Peel
- Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Department of Infectious Diseases, Alfred Health, Melbourne, VIC, Australia
| | - Grace Gibney
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Monica Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Immunocompromised Host Infection Service, Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jason Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| |
Collapse
|
9
|
De Luca JF, James F, Vogrin S, Chua K, Fletcher L, Nazareth J, Guha R, Hardidge A, Douglas N, Carruthers J, Stewardson A, Cheng AC, Johnson D, Douglass J, Peel T, Trubiano J. Study protocol for PREPARE: a phase II feasibility/safety randomised controlled trial on PeRiopErative Penicillin AlleRgy TEsting. BMJ Open 2023; 13:e067653. [PMID: 36828661 PMCID: PMC9972415 DOI: 10.1136/bmjopen-2022-067653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/23/2023] [Indexed: 02/26/2023] Open
Abstract
INTRODUCTION Patient-reported antibiotic allergy labels (AALs) are common. These labels have been demonstrated to have a negative impact on use of appropriate antibiotics and patient-related health outcomes. These patients are more likely to receive suboptimal antibiotics, have increased rates of surgical site infections and are more likely to be colonised with multidrug-resistant organisms. Increasing recognition that antibiotic allergy forms a key part of good antimicrobial stewardship has led to calls for greater access to antibiotic allergy assessment.PREPARE is a pilot randomised controlled trial of beta-lactam allergy assessment and point of care delabelling in perioperative patients utilising a validated antibiotic allergy assessment tool that has been repurposed into a smartphone application. The aim of the study is to assess the feasibility and safety of this approach in the perioperative outpatient setting. METHODS AND ANALYSIS Adult participants requiring elective surgery and are likely to require prophylactic intravenous antibiotics will be recruited. During the intervention phase, participants will be randomised to the intervention or control arm, with control patients receiving usual standard of care. Those randomised to intervention undertake a risk assessment via the smartphone application, with those deemed low risk proceeding to direct oral provocation with either a penicillin or cephalosporin. Study outcomes will be evaluated in the postintervention phase, 30 and 90 days after surgery.Feasibility of intervention delivery and recruitment will be reported as proportions with respective 95% CIs. Participants who experience an antibiotic adverse event will be reported by group with respective 95% CIs and compared using modified Poisson regression model with robust SE estimation. ETHICS AND DISSEMINATION This protocol has received approval from the Austin Health human research and ethics committee, Heidelberg, Victoria, Australia (HREC/17/Austin/575). Results will be disseminated via publication in peer-reviewed journals as well as presentation at international conferences. TRIAL REGISTRATION NUMBER ACTRN12620001295932.
Collapse
Affiliation(s)
- Joseph F De Luca
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Fiona James
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Sara Vogrin
- St Vincent's Department of Medicine, The University of Melbourne, Fitzroy, Victoria, Australia
| | - Kyra Chua
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Luke Fletcher
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Justin Nazareth
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Ranjan Guha
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew Hardidge
- Department of Orthopaedic Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Ned Douglas
- Department of Anaesthesia, Melbourne Health, Parkville, Victoria, Australia
| | - John Carruthers
- Department of Anaesthesia, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew Stewardson
- Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
- Infectious Diseases, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine Clinical Trials Centre, Monash University, Melbourne, Victoria, Australia
| | - Douglas Johnson
- Department of General Medicine, Melbourne Health, Parkville, Victoria, Australia
- Department of Medicine RMH, The University of Melbourne, Parkville, Victoria, Australia
| | - Jo Douglass
- Department of Medicine RMH, The University of Melbourne, Parkville, Victoria, Australia
| | - Trisha Peel
- Infectious Diseases, Monash University, Melbourne, Victoria, Australia
- Infectious Diseases, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| |
Collapse
|
10
|
Gorsline CA, Afghan AK, Stone CA, Phillips EJ, Satyanarayana G. Safety and value of pretransplant antibiotic allergy delabeling in a quaternary transplant center. Transpl Infect Dis 2022; 24:e13885. [PMID: 35765165 PMCID: PMC9588656 DOI: 10.1111/tid.13885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/23/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Self-reported antibiotic allergies, also known as antibiotic allergy labels, are common and may lead to worse patient outcomes. Within immunocompromized patients, antibiotic allergy labels can lead to inappropriate use of antimicrobials and may limit options for prophylactic and therapeutic options in the posttransplant period. While antibiotic allergy delabeling is considered an important aspect of antibiotic stewardship protocols, evidence and awareness of its application in transplant recipients is limited. METHODS We describe our experience with an antibiotic allergy delabeling intervention in the pretransplant evaluation period and its impact on posttransplant antimicrobial utilization. This was a retrospective analysis of patients with an antibiotic allergy label who underwent evaluation for solid organ or stem cell transplantation between 2015 and 2020. Patients included in this analysis were those who completed pretransplant antibiotic allergy delabeling through our Drug Allergy Clinic and were retained in care for 6 months after transplant. RESULTS Twenty-six of 27 patients underwent pretransplant antibiotic allergy delabeling and safely received the delabeled antibiotic posttransplant. There were no reported side effects to the delabeled antibiotic within 6 months posttransplant. Specific examination of sulfonamide (sulfa)-antibiotic delabeling showed cost savings of $254 to $2910 per patient in the posttransplant period compared to the use of alternative antibiotics for prophylaxis protocol. CONCLUSION Antibiotic allergy delabeling prior to transplant is safe, is of high value, and should be considered in the pretransplant evaluation period. More resources are needed for the development of delabeling guidelines and support for broad implementation of pretransplant antibiotic allergy delabeling programs.
Collapse
Affiliation(s)
- Chelsea A Gorsline
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Abaseen K Afghan
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gowri Satyanarayana
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
11
|
Antibiotic Allergy De-Labeling: A Pathway against Antibiotic Resistance. Antibiotics (Basel) 2022; 11:antibiotics11081055. [PMID: 36009924 PMCID: PMC9404790 DOI: 10.3390/antibiotics11081055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 12/10/2022] Open
Abstract
Antibiotics are one of the most frequently prescribed drugs. Unfortunately, they also are the most common cause for self-reported drug allergy, limiting the use of effective therapies. However, evidence shows that more than 90% of patients labeled as allergic to antibiotics are not allergic. Importantly, the label of antibiotic allergy, whether real or not, constitutes a major public health problem as it directly impacts antimicrobial stewardship: it has been associated with broad-spectrum antibiotic use, often resulting in the emergence of bacterial resistance. Therefore, an accurate diagnosis is crucial for de-labeling patients who claim to be allergic but are not really allergic. This review presents allergy methods for achieving successful antibiotic allergy de-labeling. Patient clinical history is often inaccurately reported, thus not being able to de-label most patients. In vitro testing offers a complementary approach but it shows limitations. Immunoassay for quantifying specific IgE is the most used one, although it gives low sensitivity and is limited to few betalactams. Basophil activation test is not validated and not available in all centers. Therefore, true de-labeling still relies on in vivo tests including drug provocation and/or skin tests, which are not risk-exempt and require specialized healthcare professionals for results interpretation and patient management. Moreover, differences on the pattern of antibiotic consumption cause differences in the diagnostic approach among different countries. A multidisciplinary approach is recommended to reduce the risks associated with the reported penicillin allergy label.
Collapse
|
12
|
Alvarez-Cuesta E, Madrigal-Burgaleta R, Broyles AD, Cuesta-Herranz J, Guzman-Melendez MA, Maciag MC, Phillips EJ, Trubiano JA, Wong JT, Ansotegui I. Standards for practical intravenous rapid drug desensitization & delabeling: A WAO committee statement. World Allergy Organ J 2022; 15:100640. [PMID: 35694005 PMCID: PMC9163606 DOI: 10.1016/j.waojou.2022.100640] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/27/2022] [Accepted: 03/03/2022] [Indexed: 12/16/2022] Open
Abstract
Drug hypersensitivity reactions (DHRs) to intravenous drugs can be severe and might leave patients and doctors in a difficult position where an essential treatment or intervention has to be suspended. Even if virtually any intravenous medication can potentially trigger a life-threatening DHR, chemotherapeutics, biologics, and antibiotics are amongst the intravenous drugs most frequently involved in these reactions. Admittedly, suspending such treatments may negatively impact the survival outcomes or the quality of life of affected patients. Delabeling pathways and rapid drug desensitization (RDD) can help reactive patients stay on first-choice therapies instead of turning to less efficacious, less cost-effective, or more toxic alternatives. However, these are high-complexity and high-risk techniques, which usually need expert teams and allergy-specific techniques (skin testing, in vitro testing, drug provocation testing) to ensure safety, an accurate diagnosis, and personalized management. Unfortunately, there are significant inequalities within and among countries in access to allergy departments with the necessary expertise and resources to offer these techniques and tackle these DHRs optimally. The main objective of this consensus document is to create a great benefit for patients worldwide by aiding allergists to expand the scope of their practice and support them with evidence, data, and experience from leading groups from around the globe. This statement of the Drug Hypersensitivity Committee of the World Allergy Organization (WAO) aims to be a comprehensive practical guide on the technical aspects of implementing acute-onset intravenous hypersensitivity delabeling and RDD for a wide range of drugs. Thus, the manuscript does not only focus on clinical pathways. Instead, it also provides guidance on topics usually left unaddressed, namely, internal validation, continuous quality improvement, creating a healthy multidisciplinary environment, and redesigning care (including a specific supplemental section on a real-life example of how to design a dedicated space that can combine basic and complex diagnostic and therapeutic techniques in allergy).
Collapse
Affiliation(s)
| | - Ricardo Madrigal-Burgaleta
- Allergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
- Drug Desensitisation Centre, Catalan Institute of Oncology (ICO), Barcelona, Spain
- Corresponding author. Allergy & Severe Asthma Service, Respiratory Department, 4th Floor, King George V Building, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Ana D. Broyles
- Division of Allergy & Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Javier Cuesta-Herranz
- Department of Allergy and Immunology, FIIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
- RETIC ARADyAL, Instituto de Salud Carlos III, Spain
| | | | - Michelle C. Maciag
- Division of Allergy & Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth J. Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason A. Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Johnson T. Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Steering Committee AuthorsAliF. RunaMBBS, PhD, FRCPaxAngel-PereiraDenisseMDlBanerjiAleenaMDayBerges-GimenoMaria PilarMD, PhDmBernal-RubioLorenaMDmBrockowKnutMDnCardona VillaRicardoMDoCastellsMariana C.MD, PhDpCaubetJean-ChristophMDqChangYoon-SeokMD, PhDrEnsinaLuis FelipeMD, MSc, PhDsChikhladzeMananaPhDtChiriacAnca MirelaMD, PhDuChungWeng-HungMD, PhDvEbisawaMotohiroMD, PhDwFernandesBryanMBBS, MRCPaxGarveyLene HeiseMD, PhDxawGomezMaximilianoMD, PhDyGomez VeraJavierMDzGonzalez DiazSandraMD, PhDaaHongDavid I.MDpIvancevichJuan CarlosMDabKangHye-RyunMD, PhDacKhanDavid A.MDadKuruvillaMerinMDaeLarco SousaJose IgnacioMDafLatour-StaffeldPatriciaMDagLiuAnne Y.MDahMacyEricMDaiMallingHans JorgenMDajMasperoJorgeMDakMaySara M.MDalMayorgaCristobalinaPhDamParkMiguel A.MDanPeterJonathanMBChB, PhDaoPicardMatthieuMD, FRCPCapRodriguez-BouzaTitoMD, PhDaq2RomanoAntoninoMDarSanchez-BorgesMarioMDazbaTannoLuciana KaseMD, PhDuTorresMaria JoseMD, PhDamUreña-TaveraAliciaMDasValluzziRocco L.MDatVolcheckGerald W.MDauYamaguchiMasaoMD, PhDavHospital Universitario de Canarias, Tenerife, SpainAllergy Division, Ramon y Cajal University Hospital, Madrid, SpainDepartment of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, GermanyUniversidad de Antioquia, Medellín, ColombiaDivision of Allergy and Clinical Immunology, Department of Medicine, Brigham & Women's Hospital, Boston, MA, USAPediatric Allergy Unit, Geneva University Hospitals, Geneva, SwitzerlandDivision of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of KoreaDivision of Allergy, Clinical Immunology and Rheumatology, Department of Pediatrics, Federal University of Sao Paulo, BrazilMedical Faculty at Akaki Tsereteli State University, KuTaisi, Tskaltubo, GeorgiaDivision of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, FranceDepartment of Dermatology, Chang Gung Memorial Hospital, Taipei, Linko and Keelung, TaiwanClinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Kanagawa, JapanAllergy Clinic, Copenhagen University Hospital Gentofte, Copenhagen, DenmarkSchool of Health Sciences, Catholic University of Salta, ArgentinaInstitute of Security and Social Services of State Workers, López Mateos Regional Hospital, Mexico City, MexicoRegional Center of Allergy and Clinical Immunology, University Hospital “Dr. José Eleuterio González”, Gonzalitos y Madero s/n Colonia Mitras Centro, Monterrey, MexicoServicio de Alergia e Immunologia, Clinica Santa Isabel, Buenos Aires, ArgentinaInstitute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of KoreaDepartment of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USADivision of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USAAllergy Department, Clinica San Felipe, Lima, PeruCentro Avanzado de Alergia y Asma de Santo Domingo, Santo Domingo, Dominican RepublicStanford University School of Medicine, Palo Alto, CA, USASouthern California Permanente Medical Group, Kaiser Permanente Southern California, San Diego Medical Center, San Diego, CA, USADanish Allergy Centre, University of Copenhagen, Copenhagen, DenmarkAllergy and Respiratory Research Unit, Fundación CIDEA, Buenos Aires, ArgentinaDivision of Pulmonary, Critical Care, Sleep & Allergy, University of Nebraska Medical Center, Omaha, NE, USAAllergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, SpainDivision of Allergic Diseases, Mayo Clinic, Rochester, MN, USADivision of Allergology and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South AfricaDepartment of Medicine, Division of Allergy and Immunology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, CanadaCentro de Patología Alérgica, Hospital Quirón Palmaplanas, Palma, SpainOasi Research Institute – IRCCS, Troina, ItalyClinica Union Medica del Norte, Santiago, Dominican RepublicMultifactorial and Systemic Diseases Research Area, Predictive and Preventive Medicine Research Unit, Division of Allergy, Bambino Gesù Children's Hospital IRCCS, Rome, ItalyDivision of Allergic Diseases, Mayo Clinic, Rochester, MN, USADivision of Respiratory Medicine, Third Department of Medicine, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, JapanDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, DenmarkAllergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UKDivision of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USAAllergy and Clinical Immunology Department, Centro Médico Docente La Trinidad, Caracas, VenezuelaAllergy and Clinical Immunology Department, Clínica El Avila, Caracas, Venezuela
| | | |
Collapse
|
13
|
Schrüfer P, Stoevesandt J, Trautmann A. Outcome of a de-labelling algorithm compared with results of penicillin (β-lactam) allergy testing. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:26. [PMID: 35317861 PMCID: PMC8941741 DOI: 10.1186/s13223-022-00659-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
Background Penicillin allergy labels frequently impede guideline-directed treatment with a penicillin or other β-lactam antibiotics. Despite presumed allergy, targeted questioning may indicate a low probability of sensitization and permit reasonably safe administration of the antibiotic in question. In this study, we evaluated a standardized algorithm aiming to differentiate non-allergic patients from those with true allergic β-lactam hypersensitivity. Methods We retrospectively applied a de-labelling algorithm in 800 consecutive patients with suspected β-lactam hypersensitivity. All had undergone complete allergy work-up permitting to definitely exclude or diagnose β-lactam allergy between 2009 and 2019. Results In 595 (74.4%) out of 800 cases evaluated, β-lactam allergy could be excluded by negative challenge testing. IgE-mediated anaphylaxis was diagnosed in 70 (8.7%) patients, delayed-type hypersensitivity in 135 (16.9%). In 62 (88.6%) anaphylaxis cases, the algorithm correctly advised to use an alternative antibiotic. Accuracy was higher in patients with moderate to severe anaphylaxis (97.7%) compared to those with a history of mild reactions (73.1%). The algorithm correctly identified 122 (90.4%) patients with proven delayed-type hypersensitivity. It permitted de-labelling in 330 (55.5%) out of 595 patients with diagnostic exclusion of penicillin hypersensitivity, but failed to identify the remaining 265 (44.5%) as low-risk cases. Conclusions The algorithm detected 89.8% of cases with penicillin (β-lactam) allergy, sensitivity was optimal for moderate to severe anaphylaxis. Study data justify the implementation of a standardized de-labelling algorithm under close supervision in order to permit guideline-directed treatment and reduce the use of broad-spectrum antibiotics as part of an antibiotic stewardship program. Supplementary Information The online version contains supplementary material available at 10.1186/s13223-022-00659-1.
Collapse
Affiliation(s)
- Philipp Schrüfer
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Johanna Stoevesandt
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Axel Trautmann
- Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, 97080, Würzburg, Germany.
| |
Collapse
|
14
|
|
15
|
Arıkoğlu T, Kuyucu S, Caubet JC. New diagnostıc perspectives in the management of pediatrıc beta-lactam allergy. Pediatr Allergy Immunol 2022; 33:e13745. [PMID: 35338725 DOI: 10.1111/pai.13745] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 12/15/2022]
Abstract
Since overdiagnosis of beta-lactam (BL) allergy is common in the pediatric population, delabeling is a critical part of antimicrobial stewardship. Undesirable consequences of inaccurate BL allergy labeling can be handled by incorporating traditional delabeling or newer risk-based strategies into antibiotic stewardship programs. Conventional assessment of BL allergy relies upon a stepwise algorithm including a clinical history with skin testing followed by drug provocation tests (DPTs). However, a growing number of studies highlighted the suboptimal diagnostic value of skin testing in children. Recently, there has been a paradigm shift in the practice of BL allergy assessment due to recent challenging data which emphasize the safety and accuracy of direct DPTs in children with a suspicion of non-immediate mild cutaneous reactions such as maculopapular eruption, delayed urticaria, and possibly also for benign immediate reactions such as urticaria/angioedema. Identifying low-risk BL allergy patients, in whom skin tests can be skipped and proceeding directly to DPTs could be safe, has become a hot topic in recent years. New risk stratification and predictive modeling studies that have the potential to better predict BL allergy risk status have recently been introduced into the field of drug allergy, particularly in adults. However, in contrast to adults, risk assessment studies in children are rare, and optimal risk definitions are controversial. In the coming years, promising potential methods to elucidate the predictors of BL allergy in children will require multidimensional approaches that may include predictive analytics, artificial intelligence techniques, and point-of-care clinical decision tools.
Collapse
Affiliation(s)
- Tuğba Arıkoğlu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
| |
Collapse
|
16
|
Trubiano JA, Vogrin S, Copaescu A, Nasra M, Douglas A, Holmes NE, Chua KYL. Direct oral penicillin challenge for penicillin allergy delabeling as a health services intervention: A multicenter cohort study. Allergy 2022; 77:1038-1042. [PMID: 34735748 DOI: 10.1111/all.15169] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/26/2021] [Accepted: 10/31/2021] [Indexed: 01/21/2023]
Affiliation(s)
- Jason A. Trubiano
- Department of Infectious Diseases Centre for Antibiotic Allergy and ResearchAustin Health Heidelberg VIC Australia
- Department of Medicine The University of Melbourne Fitzroy VIC Australia
| | - Sara Vogrin
- Department of Medicine The University of Melbourne Fitzroy VIC Australia
| | - Ana Copaescu
- Department of Infectious Diseases Centre for Antibiotic Allergy and ResearchAustin Health Heidelberg VIC Australia
- Department of Clinical Immunology and Allergy McGill University Health Center Montreal QC Canada
| | - Mohamed Nasra
- Department of Infectious Diseases Centre for Antibiotic Allergy and ResearchAustin Health Heidelberg VIC Australia
| | - Abby Douglas
- Department of Infectious Diseases The National Centre for Infections in CancerPeter MacCallum Cancer Centre Parkville VIC Australia
| | - Natasha E. Holmes
- Department of Infectious Diseases Centre for Antibiotic Allergy and ResearchAustin Health Heidelberg VIC Australia
| | - Kyra Y. L. Chua
- Department of Infectious Diseases Centre for Antibiotic Allergy and ResearchAustin Health Heidelberg VIC Australia
| |
Collapse
|
17
|
Awad A, Trubiano JA. New Clinical Insights Into Pediatric DRESS to Tailor Future Care? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:275-276. [PMID: 35000735 DOI: 10.1016/j.jaip.2021.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/22/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Andrew Awad
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Hospital, Heidelberg, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Hospital, Heidelberg, VIC, Australia; Department of Medicine (Austin Health), the University of Melbourne, Heidelberg, VIC, Australia.
| |
Collapse
|
18
|
Rischin KJ, Mostaghim M, Rao A, Smith B, O'Brien TA, Trubiano JA, Frith K, McMullan B. ESCAPE-Allergy: Evaluating screening for children and adolescents with penicillin allergy. J Paediatr Child Health 2022; 58:83-89. [PMID: 34323321 DOI: 10.1111/jpc.15657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/31/2022]
Abstract
AIM Penicillin allergy labels are frequently encountered in children and are associated with significant harms. Most children are falsely labelled and can safely tolerate a penicillin but delabelling strategies are underutilised and paediatric-specific resources are lacking. The aim of this study was to evaluate an allergy assessment tool for children in hospital. METHODS We evaluated a paediatric-adapted penicillin allergy assessment tool, using an online survey of clinicians in a tertiary paediatric hospital, with 10 hypothetical potential penicillin allergy or adverse reaction cases (including non-allergy reactions). For each case, respondents were asked to use the tool to assign a reaction phenotype and recommend management. We determined the tool's sensitivity, specificity and acceptability to end users. RESULTS We evaluated 30 complete survey responses from senior and junior medical staff, nurses and pharmacists. The tool's overall sensitivity was 80.7% (95% confidence interval (CI) 74.2-87.1%) for assigning the correct reaction phenotype and 85.3% (95% CI 79.4-91.3%) for appropriate management. The tool had high sensitivity for identifying immediate hypersensitivity reactions at 95.6% (95% CI 90.2-100%). Most respondents agreed or strongly agreed that they would use the tool in their practice (22/30, 73.3%). CONCLUSION This survey evaluated a paediatric-adapted penicillin allergy assessment tool in a tertiary paediatric hospital among multidisciplinary clinician groups. The tool performed well overall and had high safety in identifying immediate hypersensitivity reactions. Further research to support implementation of allergy assessment and delabelling programmes among children is required.
Collapse
Affiliation(s)
- Kobi J Rischin
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia
| | - Mona Mostaghim
- Pharmacy Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Arjun Rao
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Bridget Smith
- Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Tracey A O'Brien
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Katie Frith
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia.,Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Brendan McMullan
- School of Women's and Children's Heath, University of New South Wales, Sydney, New South Wales, Australia.,Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
19
|
Thursky KA, Hardefeldt LY, Rajkhowa A, Ierano C, Bishop J, Hawes L, Biezen R, Saha SK, Dowson L, Bailey KE, Scarborough R, Little SB, Gotterson F, Hur B, Khanina A, Urbancic K, Crabb HK, Richards S, Sri A, James R, Kong DCM, Marshall C, Mazza D, Peel T, Stuart RL, Manski-Nankervis JA, Friedman ND, Bennett N, Schulz T, Billman-Jacobe H, Buono E, Worth L, Bull A, Richards M, Ayton D, Gilkerson JR, Browning GF, Buising KL. Antimicrobial stewardship in Australia: the role of qualitative research in programme development. JAC Antimicrob Resist 2021; 3:dlab166. [PMID: 34806005 PMCID: PMC8600289 DOI: 10.1093/jacamr/dlab166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.
Collapse
Affiliation(s)
- Karin A Thursky
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne and Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Laura Y Hardefeldt
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Arjun Rajkhowa
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Courtney Ierano
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Jaclyn Bishop
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Pharmacy Department, Ballarat Health Services, 1 Drummond Street North, Ballarat, Victoria 3353, Australia
| | - Lesley Hawes
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
| | - Ruby Biezen
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
- Department of General Practice, University of Melbourne, 780 Elizabeth Street, Melbourne, Victoria 3010, Australia
| | - Sajal K Saha
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
| | - Leslie Dowson
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Kirsten E Bailey
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Ri Scarborough
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Stephen B Little
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Fiona Gotterson
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Brian Hur
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Anna Khanina
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne and Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Karen Urbancic
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Helen K Crabb
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Suzanna Richards
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Anna Sri
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Rodney James
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - David C M Kong
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Pharmacy Department, Ballarat Health Services, 1 Drummond Street North, Ballarat, Victoria 3353, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Caroline Marshall
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Danielle Mazza
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
| | - Trisha Peel
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, The Alfred and Central Clinical School, Burnet Institute, Monash University and Alfred Health, 85 Commercial Road, Monash University, Melbourne, Victoria 3004, Australia
| | - Rhonda L Stuart
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Departments of Infectious Diseases and Infection Control and Epidemiology, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Jo-Anne Manski-Nankervis
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, University of Melbourne, 780 Elizabeth Street, Melbourne, Victoria 3010, Australia
| | - N Deborah Friedman
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, University Hospital Geelong, Barwon Health, Bellerine Street, Geelong, Victoria 3220, Australia
| | - Noleen Bennett
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- VICNISS Coordinating Centre, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Thomas Schulz
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Helen Billman-Jacobe
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Evette Buono
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- New South Wales Clinical Excellence Commission, 1 Reserve Road, St Leonards, New South Wales 2065, Australia
| | - Leon Worth
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne and Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Ann Bull
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- VICNISS Coordinating Centre, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Michael Richards
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
- VICNISS Coordinating Centre, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Darshini Ayton
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria 3004, Australia
| | - James R Gilkerson
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Glenn F Browning
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Kirsty L Buising
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Peter Doherty Institute of Infection and Immunity, 792 Elizabeth Street, Melbourne Victoria, 3000, Australia
| |
Collapse
|
20
|
Abstract
Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.
Collapse
Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| |
Collapse
|
21
|
Arikoglu T, Kont AO, Demirhan A, Yuksek BC, Tokmeci N, Kuyucu S. Risk stratification in beta-lactam allergy. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00295-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
22
|
Yoon YK, Kwon KT, Jeong SJ, Moon C, Kim B, Kiem S, Kim HS, Heo E, Kim SW. Guidelines on Implementing Antimicrobial Stewardship Programs in Korea. Infect Chemother 2021; 53:617-659. [PMID: 34623784 PMCID: PMC8511380 DOI: 10.3947/ic.2021.0098] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022] Open
Abstract
These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.
Collapse
Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Korean Society for Antimicrobial Therapy, Seoul, Korea
| | - Ki Tae Kwon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Korean Society of Infectious Diseases, Seoul, Korea
| | - Chisook Moon
- Korean Society of Infectious Diseases, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Bongyoung Kim
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungmin Kiem
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyung-Sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Eunjeong Heo
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Shin-Woo Kim
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
| | | | | | | |
Collapse
|
23
|
Chua KYL, Vogrin S, Bury S, Douglas A, Holmes NE, Tan N, Brusco NK, Hall R, Lambros B, Lean J, Stevenson W, Devchand M, Garrett K, Thursky K, Grayson ML, Slavin MA, Phillips EJ, Trubiano JA. The Penicillin Allergy Delabeling Program: A Multicenter Whole-of-Hospital Health Services Intervention and Comparative Effectiveness Study. Clin Infect Dis 2021; 73:487-496. [PMID: 32756983 DOI: 10.1093/cid/ciaa653] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/23/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Penicillin allergies are associated with inferior patient and antimicrobial stewardship outcomes. We implemented a whole-of-hospital program to assess the efficacy of inpatient delabeling for low-risk penicillin allergies in hospitalized inpatients. METHODS Patients ≥ 18 years of age with a low-risk penicillin allergy were offered a single-dose oral penicillin challenge or direct label removal based on history (direct delabeling). The primary endpoint was the proportion of patients delabeled. Key secondary endpoints were antibiotic utilization pre- (index admission) and post-delabeling (index admission and 90 days). RESULTS Between 21 January 2019 and 31 August 2019, we assessed 1791 patients reporting 2315 antibiotic allergies, 1225 with a penicillin allergy. Three hundred fifty-five patients were delabeled: 161 by direct delabeling and 194 via oral penicillin challenge. Ninety-seven percent (194/200) of patients were negative upon oral penicillin challenge. In the delabeled patients, we observed an increase in narrow-spectrum penicillin usage (adjusted odds ratio [OR], 10.51 [95% confidence interval {CI}, 5.39-20.48]), improved appropriate antibiotic prescribing (adjusted OR, 2.13 [95% CI, 1.45-3.13]), and a reduction in restricted antibiotic usage (adjusted OR, 0.38 [95% CI, .27-.54]). In the propensity score analysis, there was an increase in narrow-spectrum penicillins (OR, 10.89 [95% CI, 5.09-23.31]) and β-lactam/β-lactamase inhibitors (OR, 6.68 [95% CI, 3.94-11.35]) and a reduction in restricted antibiotic use (OR, 0.52 [95% CI, .36-.74]) and inappropriate prescriptions (relative risk ratio, 0.43 [95% CI, .26-.72]) in the delabeled group compared with the group who retained their allergy label. CONCLUSIONS This health services program using a combination of direct delabeling and oral penicillin challenge resulted in significant impacts on the use of preferred antibiotics and appropriate prescribing.
Collapse
Affiliation(s)
- Kyra Y L Chua
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Australia
| | - Susan Bury
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Pharmacy, Austin Health, Heidelberg, Australia
| | - Abby Douglas
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Natasha E Holmes
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Nixon Tan
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Natasha K Brusco
- Alpha Crucis Group, Health Economics, Langwarrin, Australia.,Rehabilitation, Ageing and Independent Living Research Centre, Monash University, Frankston, Australia
| | - Rebecca Hall
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Belinda Lambros
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Jacinta Lean
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Wendy Stevenson
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Misha Devchand
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Pharmacy, Austin Health, Heidelberg, Australia
| | - Kent Garrett
- Department of Pharmacy, Austin Health, Heidelberg, Australia
| | - Karin Thursky
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia.,National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Melbourne, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Parkville, Australia
| | - M Lindsay Grayson
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia
| | - Monica A Slavin
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Parkville, Australia
| | - Elizabeth J Phillips
- Department of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia
| |
Collapse
|
24
|
Carra S, Schatz M, Mertes PM, Torres MJ, Fuchs F, Senna G, Castells MC, Demoly P, Tanno LK. ANAPHYLAXIS AND PREGNANCY: A SYSTEMATIC REVIEW AND CALL FOR PUBLIC HEALTH ACTIONS. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4270-4278. [PMID: 34365055 DOI: 10.1016/j.jaip.2021.07.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although rare, anaphylaxis during pregnancy implies a risk to both mothers and newborns. OBJECTIVE This systematic review is intended to identify key issues in the diagnosis and management of this condition in order to support prevention strategies and decrease the risk of death related to anaphylaxis during pregnancy. METHODS We searched MEDLINE, Cochrane, Lilacs, Scielo and Science Direct databases for manuscripts concerning terms "anaphylaxis during pregnancy" without language restrictions. We screened studies, extracted data, and assessed risk of bias independently in duplicate. RESULTS We selected 12 articles. Frequency of anaphylaxis during pregnancy is estimated between 1.5 to 3.8 per 100 000 maternities. Only one study provided anaphylaxis mortality data in pregnant women, and the rate of anaphylaxis-related maternal mortality is estimated at 0.05 per 100 000 live births. No standard definition of anaphylaxis severity has been utilized. Forty-nine percent to 74% of anaphylaxis cases were described during caesarean sections. Beta-lactam antibiotics (58%), latex (25%) and anaesthetic agents (17%) were the main culprits. In 17% of papers, causative agents were proven by allergy testing. Seventy two percent of articles proposed the same management and treatment for a clinical episode of anaphylaxis during pregnancy as in non-pregnant patients, and, use of epinephrine in the patient's care during anaphylaxis in pregnancy. CONCLUSION Few studies address anaphylaxis during pregnancy, and the majority have been produced by non-allergy specialists. Collaboration between different specialists involved in the care of pregnant women should be established in order to support preventive strategies and reduce avoidable deaths.
Collapse
Affiliation(s)
- Sophie Carra
- Department of Allergy, University Hospital of Montpellier, Montpellier, France
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente, San Diego, California, USA
| | - Paul-Michel Mertes
- Department of Anaesthesia and Critical Care, Strasbourg University Hospital, EA 3072, FMTS Strasbourg, France 1 Place de l'Hôpital - BP 426 67091 STRASBOURG CEDEX
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Florence Fuchs
- Departement of gynecology and obstetric, University Hospital of Montpellier, Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, University of Montpellier, France; Inserm, CESP Centre de recherche en Epidémiologie et Santé des Populations, U1018, Reproduction et Développement de l'enfant, 94807 Villejuif, France
| | - Gianenrico Senna
- Asthma Center and Allergy Unit, Verona University and General Hospital, Verona, Italy
| | - Mariana C Castells
- Brigham and Women's Hospital, Boston (M.C.C.); and the Department of Medicine, Vanderbilt University Medical Center, Nashville (E.J.P.), USA
| | - Pascal Demoly
- Department of Allergy, University Hospital of Montpellier, Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, University of Montpellier, France; WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Luciana Kase Tanno
- Department of Allergy, University Hospital of Montpellier, Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, University of Montpellier, France; WHO Collaborating Centre on Scientific Classification Support, Montpellier, France; Hospital Sírio-Libanês.
| |
Collapse
|
25
|
Fernandez J, Jimenez-Rodriguez TW, Blanca-Lopez N. Classifying cephalosporins: from generation to cross-reactivity. Curr Opin Allergy Clin Immunol 2021; 21:346-354. [PMID: 34074874 DOI: 10.1097/aci.0000000000000755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW To review the most recent literature studying the classifications, immunochemistry, and crossreactivity of allergy reactions to cephalosporins. RECENT FINDINGS Over the last five years, research interest has focused on three areas related to cephalosporin allergy: cross-reactivity among cephalosporins and with other beta-lactams; the incidence of adverse reactions in penicillin allergy patients or in reported penicillin allergy labels; and new cephalosporins structures involved in the immunological recognition. SUMMARY Meta-analysis of a substantial number of studies shows that cephalosporins are safer than previously thought. Evidence supports two main conclusions in that regard. First, there is a relatively low percentage of cross-reactivity between cephalosporins and other beta-lactams with penicillins in penicillin allergy patients. Second, there is a very low incidence of allergy reactions in nonselected as well as in selected penicillin allergy patients when cephalosporins are used prior to surgical intervention.On the other hand, few structures have been discovered related to the immune mechanism of cephalosporin allergy reactions, and these are far from being ready to use in clinical practice.
Collapse
Affiliation(s)
- Javier Fernandez
- Allergy Section, Alicante General University Hospital, ISABIAL-UMH, Alicante
| | | | | |
Collapse
|
26
|
Overview of Beta-Lactam Allergy and the Role of the Pharmacist in Management. ALLERGIES 2021. [DOI: 10.3390/allergies1020011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Unverified beta-lactam allergies are a substantial public health problem, as the majority of patients labeled as beta-lactam allergic do not have clinically significant allergies that may hinder the use beta-lactam therapy when indicated. Outdated or inaccurate beta-lactam or penicillin allergies can result in serious consequences, including suboptimal antibiotic therapy, increased risk of adverse effects, and use of broader spectrum antibiotics than indicated, which may contribute to antimicrobial resistance. The purpose of this review is to provide an overview of beta-lactam allergy and highlight the role of pharmacists in managing beta-lactam allergies. Studies have shown that pharmacists can play a vital role in allergy assessment, penicillin skin testing, beta-lactam desensitization, evaluation of beta-lactam cross-reactivity and recommending appropriate antibiotic therapy in patients with beta-lactam allergies.
Collapse
|
27
|
Penicillin Allergy Delabeling: A Multidisciplinary Opportunity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2858-2868.e16. [PMID: 33039010 DOI: 10.1016/j.jaip.2020.04.059] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022]
Abstract
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.
Collapse
|
28
|
Abstract
Up to 10% of hospitalized patients have an antibiotic allergy label in their medical file, most frequently concerning penicillins. However, the vast majority of reported allergies to antibiotics does not represent a "true" allergy but are due to drug intolerance, idiosyncratic reactions or symptoms of the concurrent infectious disease. Since antibiotic allergy labels result in deviation from first-choice antimicrobial therapy, tackling the issue of incorrect antibiotic allergy labelling, already at young age, is a core element of antibiotic stewardship. In this article, we describe the structured approach to the patient with a presumed antibiotic allergy with emphasis on key elements of allergy-specific history taking and the limited risk of cross-allergic reactions between beta-lactam subclasses.
Collapse
|
29
|
Taylor M, Anvari S, Palazzi D. Unconfirmed penicillin allergy labels in the paediatric outpatient setting: A call for research and quality improvement initiatives. J Paediatr Child Health 2021; 57:607-610. [PMID: 33724610 DOI: 10.1111/jpc.15445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/26/2021] [Accepted: 03/07/2021] [Indexed: 01/20/2023]
Abstract
Over the last 10 years, the electronic medical record has redefined medical documentation, and physicians rely on accurate records to make clinical decisions. Penicillin allergy labels (PALs) are important pieces of the medical history that guide physicians in selecting specific antibiotic classes for the treatment of infectious diseases. However, most children labelled as penicillin-allergic do not have an IgE-mediated (immediate) allergic reaction to penicillin or its derivatives. In the absence of confirmatory penicillin allergy testing or additional history, these children receive alternative, often broad-spectrum and second-line, antibiotics. Addressing unconfirmed PALs requires an understanding of how and why labels get added to the electronic medical record. This viewpoint highlights the knowledge gaps in paediatric outpatient penicillin allergy labelling and proposes an acronym ('LABEL') that primary care providers and antimicrobial stewards can utilise when designing initiatives to address unconfirmed PALs in the community.
Collapse
Affiliation(s)
- Margaret Taylor
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, United States
| | - Sara Anvari
- Department of Pediatrics, Section of Immunology, Allergy, and Retrovirology, Baylor College of Medicine, Houston, Texas, United States
| | - Debra Palazzi
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, United States
| |
Collapse
|
30
|
Trubiano JA, Soria A, Torres MJ, Trautmann A. Treating Through Drug-Associated Exanthems in Drug Allergy Management: Current Evidence and Clinical Aspects. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2984-2993. [PMID: 33878455 DOI: 10.1016/j.jaip.2021.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/01/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
In the setting of an acute cutaneous adverse drug reaction there is increasing interest in selected phenotypes and hosts to continue drug therapy, especially in settings in which there are limited therapeutic options. This concept of "treating through," defined as the continued use of a drug in the setting of, in particular maculopapular exanthema, potentially avoids unnecessary drug discontinuation. A review of the recent literature, historical viewpoints, and expert opinion are provided within to form recommendations and algorithms for a "treating-through" approach.
Collapse
Affiliation(s)
- Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia.
| | - Angèle Soria
- Sorbonne Universités, Paris, France; Service de Dermatologie et d'Allergologie, Hôpital Tenon, Paris HUEP, APHP, Paris, France; Centre d'Immunologie et des Maladies Infectieuses - Paris (Cimi-Paris), INSERM U1135, Paris, France
| | - Maria J Torres
- Allergy Unit, IBIMA-Regional University Hospital of Malaga UMA, Malaga, Spain; Andalusian Center for Nanomedicine and Biotechnology - BIONAND, Malaga, Spain
| | - Axel Trautmann
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany
| |
Collapse
|
31
|
Hughes Y, Comninos N. Contact dermatitis masquerading as fixed drug eruption: making a critical distinction. BMJ Case Rep 2021; 14:e240805. [PMID: 33622756 PMCID: PMC7907844 DOI: 10.1136/bcr-2020-240805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Yasmin Hughes
- Western Sydney Sexual Health Centre, Western Sydney Local Health District, Parramatta, New South Wales, Australia
| | - Nicholas Comninos
- Western Sydney Sexual Health Centre, Western Sydney Local Health District, Parramatta, New South Wales, Australia
| |
Collapse
|
32
|
Goh SH, Chong KW, Chiang WC, Goh A, Loh W. Outcome of drug provocation testing in children with suspected beta-lactam hypersensitivity. Asia Pac Allergy 2021; 11:e3. [PMID: 33604273 PMCID: PMC7870368 DOI: 10.5415/apallergy.2021.11.e3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 01/11/2021] [Indexed: 11/19/2022] Open
Abstract
Background Suspicion of beta-lactam (BL) hypersensitivity is often based on parental report. Evaluation is important as incorrect labelling has clinical consequence. Objective To describe the outcomes of drug provocation test (DPT) in children with suspected hypersensitivity. Methods A retrospective study of patients who completed BL DPT from 1 August 2016 to 31 December 2017 at a paediatric allergy centre in Singapore. Suspected hypersensitivity reactions were classified as immediate (onset ≤1 hour) or delayed (onset > 1 hour). Patients with immediate reactions underwent skin prick test (SPT) followed by DPT if SPT was negative. Patients with delayed reactions underwent DPT directly. Results We identified 120 children who reported 121 suspected hypersensitivity reactions. The median age at reaction was 2.0 years (interquartile range [IQR], 1.0–5.0 years) and the median age at DPT was 7.4 years (IQR, 4.2–11.1 years). The timing of suspected hypersensitivity reaction was immediate in 21% (25 of 121), delayed in 66% (80 of 121), and uncertain in 13% (16 of 121). Commonly implicated drugs were amoxicillin in 45% (54 of 121), amoxicillin-clavulanate in 37% (45 of 121), and cephalexin in 8% (10 of 121). Commonly reported symptoms were maculopapular rash 44% (53 of 121), urticaria 34% (41 of 121), and angioedema 22% (27 of 121). All SPTs (n = 26) were negative. There were 118 diagnostic DPTs to index drug and 3 DPTs to alternative drug. A negative challenge result was obtained in 93% (110 of 118) of diagnostic DPTs: 92% (96 of 104) and 100% (14 of 14) of DPTs to penicillin group and cephalosporins respectively. All challenge reactions were mild. Conclusion Our study supports the opinion that prior skin tests may not be necessary for children who report nonsevere reactions and directly performing diagnostic DPT is a safe approach in the evaluation of suspected childhood BL hypersensitivity.
Collapse
Affiliation(s)
- Si Hui Goh
- Allergy Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Kok Wee Chong
- Allergy Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Wen Chin Chiang
- Allergy Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Anne Goh
- Allergy Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Wenyin Loh
- Allergy Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| |
Collapse
|
33
|
Bhogal R, Hussain A, Balaji A, Bermingham WH, Marriott JF, Krishna MT. The role of a clinical pharmacist in spurious Penicillin allergy: a narrative review. Int J Clin Pharm 2021; 43:461-475. [PMID: 33439428 DOI: 10.1007/s11096-020-01226-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/30/2020] [Indexed: 12/31/2022]
Abstract
Background A label of penicillin allergy is held by 6-10% of the general population and 15-20% of inpatients. > 90% of these labels are found to be spurious after formal allergy assessment. Carrying an unnecessary label of penicillin allergy is not benign. Such patients may receive second line, more expensive antibiotics, representing a significant impediment to antimicrobial stewardship. Aim of the review To (a) Explain the burden of spurious penicillin allergy, and evaluate the safety of direct oral penicillin challenge in 'low risk' patients (b) appraise the place for a clinical pharmacist-led penicillin allergy de-labelling programme. Method Narrative review. Search engines: PubMed, Google Scholar and Cochrane reviews. Search criteria: English language; search terms: penicillin allergy, antimicrobial stewardship, antimicrobial resistance, clostridium difficile, vancomycin resistant enterococci, risk stratification, clinical pharmacist and direct oral provocation test Results Penicillin allergy labels are associated with: longer hospital stay, higher readmission rates, enhanced risk of surgical site infections, risk of Clostridioides difficile infection and Methicillin resistant Staphylococcus aureus infection, a delay in the first dose of an antibiotic in sepsis and higher healthcare costs. A direct oral penicillin challenge in 'low risk' patients has proven to be safe. Discussion Recent studies including those led by a clinical pharmacist have demonstrated safety of a direct oral penicillin challenge in 'low risk' patients. This intervention needs validation within individual health services. Conclusion Direct oral penicillin challenge reduces the adverse impact of spurious penicillin allergy. A pharmacist-led penicillin allergy de-labelling program needs further validation in prospective multi-centre studies.
Collapse
Affiliation(s)
- Rashmeet Bhogal
- Department of Pharmacy, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B9 5SS, UK.
| | - Abid Hussain
- Birmingham Public Health Laboratory, National Infection Service, Public Health England, Birmingham, UK
| | - Ariyur Balaji
- Department of Acute Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - William H Bermingham
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John F Marriott
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Mamidipudi T Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, UK
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
34
|
Copaescu A, Gibson A, Li Y, Trubiano JA, Phillips EJ. An Updated Review of the Diagnostic Methods in Delayed Drug Hypersensitivity. Front Pharmacol 2021; 11:573573. [PMID: 33597867 PMCID: PMC7883592 DOI: 10.3389/fphar.2020.573573] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/23/2020] [Indexed: 12/19/2022] Open
Abstract
Delayed drug hypersensitivity reactions are clinically diverse reactions that vary from isolated benign skin conditions that remit quickly with no or symptomatic treatment, drug discontinuation or even continued drug treatment, to the other extreme of severe cutaneous adverse reactions (SCARs) that are associated with presumed life-long memory T-cell responses, significant acute and long-term morbidity and mortality. Diagnostic "in clinic" approaches to delayed hypersensitivity reactions have included patch testing (PT), delayed intradermal testing (IDT) and drug challenges for milder reactions. Patch and IDT are, in general, performed no sooner than 4-6 weeks after resolution of the acute reaction at the maximum non-irritating concentrations. Functional in vitro and ex vivo assays have largely remained the province of research laboratories and include lymphocyte transformation test (LTT) and cytokine release enzyme linked ImmunoSpot (ELISpot) assay, an emerging diagnostic tool which uses cytokine release, typically IFN-γ, after the patient's peripheral blood mononuclear cells are stimulated with the suspected drug(s). Genetic markers such as human leukocyte antigen have shown recent promise for both pre-prescription screening as well as pre-emptive and diagnostic testing strategies.
Collapse
Affiliation(s)
- Ana Copaescu
- Department of Infectious Diseases, Austin Health, Center for Antibiotic Allergy and Research, Heidelberg, VIC, Australia
| | - Andrew Gibson
- Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia.,Clinical Immunology and Allergy, McGill University Health Center, Montréal, Canada
| | - Yueran Li
- Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Center for Antibiotic Allergy and Research, Heidelberg, VIC, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Center, The University of Melbourne, Parkville, VIC, Australia.,Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, VIC, Australia.,The National Center for Infections in Cancer, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia.,Department of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, United States
| |
Collapse
|
35
|
Hills T, Arroll N, Duffy E, Capstick J, Jordan A, Fitzharris P. Penicillin Allergy De-labeling Results in Significant Changes in Outpatient Antibiotic Prescribing Patterns. FRONTIERS IN ALLERGY 2020; 1:586301. [PMID: 35386932 PMCID: PMC8974713 DOI: 10.3389/falgy.2020.586301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/14/2020] [Indexed: 11/13/2022] Open
Abstract
Unverified penicillin allergies are common but most patients with a penicillin allergy label can safely use penicillin antibiotics. Penicillin allergy labels are associated with poor clinical outcomes and overuse of second-line antibiotics. There is increasing focus on penicillin allergy "de-labeling" as a tool to improve antibiotic prescribing and antimicrobial stewardship. The effect of outpatient penicillin allergy de-labeling on long-term antibiotic use is uncertain. We performed a retrospective pre- and post- study of antibiotic dispensing patterns, from an electronic dispensing data repository, in patients undergoing penicillin allergy assessment at Auckland City Hospital, New Zealand. Over a mean follow-up of 4.55 years, 215/304 (70.7%) of de-labeled patients were dispensed a penicillin antibiotic. Rates of penicillin antibiotic dispensing were 0.24 (0.18-0.30) penicillin courses per year before de-labeling and 0.80 (0.67-0.93) following de-labeling with a reduction in total antibiotic use from 2.30 (2.06-2.54) to 1.79 (1.59-1.99) antibiotic courses per year. In de-labeled patients, the proportion of antibiotic courses that were penicillin antibiotics increased from 12.81 to 39.62%. Rates of macrolide, cephalosporin, trimethoprim/co-trimoxazole, fluoroquinolone, "other" non-penicillin antibiotic use, and broad-spectrum antibiotic use were all lower following de-labeling. Further, antibiotic costs were lower following de-labeling. In this study, penicillin allergy de-labeling was associated with significant changes in antibiotic dispensing patterns.
Collapse
Affiliation(s)
- Thomas Hills
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Nicola Arroll
- Health Information and Technology Service, Auckland District Health Board, Auckland, New Zealand
| | - Eamon Duffy
- Depatment of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand
| | - Janice Capstick
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
| | - Anthony Jordan
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
| | - Penny Fitzharris
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
| |
Collapse
|
36
|
Maher D, Larcombe R, Potts SD, Wiersema UF. Antimicrobial stewardship in intensive care: identifying areas for improvement. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2020. [DOI: 10.1002/jppr.1667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Dorsa Maher
- Pharmacist Flinders Medical Centre SA Pharmacy Bedford Park Australia
- PhD Candidate Clinical and Health Sciences University of South Australia Adelaide Australia
| | - Rebecca Larcombe
- Deputy Director Pharmacy Flinders Medical Centre SA Pharmacy Bedford Park Australia
| | - Simon D. Potts
- Senior Pharmacist, Intensive and Critical Care Unit Flinders Medical Centre SA Pharmacy Bedford Park Australia
| | - Ubbo F. Wiersema
- Consultant, Intensive and Critical Care Unit Flinders Medical Centre Bedford Park Australia
| |
Collapse
|
37
|
Blumenthal KG, Phillips EJ. Positioning Drug Allergy Delabeling as a Critical Tool for Precision Medicine, Quality Improvement, and Public Health. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2916-2919. [PMID: 32781047 DOI: 10.1016/j.jaip.2020.07.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 07/31/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
| |
Collapse
|
38
|
du Plessis T, Walls G, Jordan A, Holland DJ. Implementation of a pharmacist-led penicillin allergy de-labelling service in a public hospital. J Antimicrob Chemother 2020; 74:1438-1446. [PMID: 30753497 DOI: 10.1093/jac/dky575] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/13/2018] [Accepted: 12/23/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Inaccurate allergy labelling results in inappropriate antimicrobial management of the patient, which may affect clinical outcome, increase the risk of adverse events and increase costs. Inappropriate use of alternative antibiotics has implications for antimicrobial stewardship programmes and microbial resistance. METHODS All adult inpatients labelled as penicillin allergic were identified and screened for eligibility by the study pharmacist. An accurate allergy and medication history was taken. Patients were 'de-labelled', underwent oral challenge or were referred to an immunology clinic, if study criteria were met. All patients included in the study were followed-up 1 year after intervention. RESULTS Two hundred and fifty eligible patients with a label of 'penicillin allergy' were identified. The prevalence of reported penicillin allergy at Middlemore Hospital was 11%. We found that 80% of study patients could be 'de-labelled'. Of those, 80% were 'de-labelled' after an interview with the pharmacist alone, 16% had an uneventful oral challenge and 4% were deemed to be inappropriately labelled after referral to an immunology clinic. Appropriately labelled patients accounted for 20% of the study population. Changes to inpatient antibiotic therapy were recommended in 61% of 'de-labelled' patients, of which no patients had adverse events after commencing on penicillin antibiotics. At the 1 year follow-up, 98% of patients who were 'de-labelled' had no adverse events to repeated administration of penicillin antibiotics. CONCLUSIONS This study showed that a pharmacist-led allergy management service is a safe option to promote antimicrobial stewardship and appropriate allergy labelling.
Collapse
Affiliation(s)
| | - Genevieve Walls
- Infection Services, Middlemore Hospital, Auckland, New Zealand
| | - Anthony Jordan
- Department of Immunology, Auckland City Hospital, Auckland, New Zealand
| | - David J Holland
- Infection Services, Middlemore Hospital, Auckland, New Zealand
| |
Collapse
|
39
|
Devchand M, Kirkpatrick CMJ, Stevenson W, Garrett K, Perera D, Khumra S, Urbancic K, Grayson ML, Trubiano JA. Evaluation of a pharmacist-led penicillin allergy de-labelling ward round: a novel antimicrobial stewardship intervention. J Antimicrob Chemother 2020; 74:1725-1730. [PMID: 30869124 DOI: 10.1093/jac/dkz082] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/15/2019] [Accepted: 02/04/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Antibiotic allergy labels (AALs), reported by up to 25% of hospitalized patients, are a significant barrier to appropriate prescribing and a focus of antimicrobial stewardship (AMS) programmes. METHODS A prospective audit of a pharmacist-led AMS penicillin allergy de-labelling ward round at Austin Health (Melbourne, Australia) was evaluated. Eligible inpatients with a documented penicillin allergy receiving an antibiotic were identified via an electronic medical report and then reviewed by a pharmacist-led AMS team. The audit outcomes evaluated were: (i) AMS post-prescription review recommendations; (ii) direct de-labelling; (iii) inpatient oral rechallenge referral; (iv) skin prick testing/intradermal testing referral; and (v) outpatient antibiotic allergy clinic assessment. RESULTS Across a 5 month period, 106 patients were identified from a real-time electronic prescribing antibiotic allergy report. The highest rate of penicillin allergy de-labelling was demonstrated in patients who were referred for an inpatient oral rechallenge with 95.2% (n = 21) successfully having their penicillin AAL removed. From the 22 patients with Type A reactions, 63.6% had their penicillin AAL removed. We demonstrated a significant decrease in the prescribing of restricted antibiotics (defined as third- or fourth-generation cephalosporins, fluoroquinolones, glycopeptides, carbapenems, piperacillin/tazobactam, lincosamides, linezolid or daptomycin) in patients reviewed (pre 42.5% versus post 17.9%, P = 0.0002). CONCLUSIONS A pharmacist-led AMS penicillin allergy de-labelling ward round reduced penicillin AALs and the prescribing of restricted antibiotics. This model could be implemented at other hospitals with existing AMS programmes.
Collapse
Affiliation(s)
- M Devchand
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia.,Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - C M J Kirkpatrick
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - W Stevenson
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia
| | - K Garrett
- Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia
| | - D Perera
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia.,Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia
| | - S Khumra
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia.,Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - K Urbancic
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia.,Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Victoria, Australia
| | - M L Grayson
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Parkville, Victoria, Australia
| | - J A Trubiano
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
40
|
Rose MT, Slavin M, Trubiano J. The democratization of de-labeling: a review of direct oral challenge in adults with low-risk penicillin allergy. Expert Rev Anti Infect Ther 2020; 18:1143-1153. [PMID: 32662696 DOI: 10.1080/14787210.2020.1792775] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Penicillin antibiotic allergy labels (AALs) are common and lead to significant negative health and health system outcomes. Direct oral challenge offers a rapid and cost-effective way of removing inaccurate AALs and improving outcomes. AREAS COVERED A narrative review (Medline, May 2020) of direct oral challenge in low-risk penicillin allergy in adults is described, and the evidence for the safety and efficacy of this approach in inpatients, outpatients, and special patient groups is presented. EXPERT OPINION Whilst the current literature demonstrates the safety and efficacy of direct oral challenge in de-labeling low-risk penicillin allergy in adults, novel approaches are needed to improve access to antibiotic allergy assessment and address the growing global need.
Collapse
Affiliation(s)
- Morgan Thomas Rose
- Department of Infectious Diseases, Austin Health , Melbourne, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Parkville, Australia.,Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre , Melbourne, Australia
| | - Monica Slavin
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Parkville, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne , Parkville, Australia
| | - Jason Trubiano
- Department of Infectious Diseases, Austin Health , Melbourne, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Parkville, Australia.,Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre , Melbourne, Australia.,Department of Medicine (Austin Health), University of Melbourne , Parkville, Australia
| |
Collapse
|
41
|
Heng YK, Liew YCC, Kong YL, Lim YL. β-Lactam allergy testing and delabeling-Experiences and lessons from Singapore. IMMUNITY INFLAMMATION AND DISEASE 2020; 8:371-379. [PMID: 32506796 PMCID: PMC7416033 DOI: 10.1002/iid3.318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/11/2020] [Accepted: 05/21/2020] [Indexed: 01/08/2023]
Abstract
Background β‐Lactam allergy is over‐reported and this leads to greater healthcare costs. Allergy testing has inherent risks, yet patients who test negative may continue avoiding β‐lactams. Objective To evaluate the safety and diagnostic value of β‐lactams allergy testing locally and usage of antibiotics following negative testing. Methods We performed a retrospective medical record review and follow‐up survey of patients who underwent β‐lactam testing between 2010 and 2016 at the National Skin Centre, Singapore. Results We reviewed the records of 166 patients, with a total of 173 β‐lactam allergy labels. Eighty (46.2%) labels were to penicillin, 75 (43.1%) to amoxicillin/amoxicillin‐clavulanic acid, 11 (6.4%) to cephalexin, and 5 (2.9%) to others. Skin tests were performed in 142 patients and drug provocation tests (DPTs) in 141 patients. Eleven (6.6%) patients defaulted DPTs after skin testing. Out of 166 patients, 22 (13.3%) patients were proven allergic by either skin tests (16) or DPTs (6). Patients who tested positive had nonsevere reactions. Out of 155 patients who were conclusively evaluated, 133 (85.8%) were not allergic. Of these patients, 30 (22.6%) used the tested β‐lactam subsequently, with one reporting a mild reaction. Fifty‐one (38.3%) patients were uncontactable or uncertain if they consumed a β‐lactam since testing negative. Fifty‐two (39.1%) patients had no re‐exposure (35 had no indication, 17 were fearful of reactions). Conclusion Drug allergy testing was safe and removed inappropriate labels. Clinical Implication Allergy testing is efficacious, but fears of subsequent rechallenge should be addressed to maximize the effectiveness of allergy delabeling.
Collapse
|
42
|
Lam W, Staicu ML, Conn KM, Ramsey AC. Is there a higher prevalence of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) colonization in patients with antibiotic allergy labels? Am J Infect Control 2020; 48:663-667. [PMID: 31735590 DOI: 10.1016/j.ajic.2019.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/23/2019] [Accepted: 09/24/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND A penicillin allergy label has been associated with significantly higher rates of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) colonization, and correspondingly poorer clinical outcomes. However, there are limited data examining the association between any antibiotic label and colonization rates. We sought to evaluate if there is a relationship between patients with an antibiotic allergy label and prevalence of MRSA or VRE colonization. METHODS We retrospectively reviewed all patients with an MRSA surveillance culture between December 15, 2014 and January 31, 2015, or a VRE surveillance culture between January 1, 2013 and January 31, 2015, at a tertiary community-based teaching hospital. Our primary objective was to evaluate the prevalence of MRSA or VRE colonization among patients with and without antibiotic allergies. Bivariate analyses included the χ² test and the Student t test to determine statistical significance for categorical and continuous variables, respectively. RESULTS We included a total of 1,053 unique patients screened for MRSA, and 290 unique patients screened for VRE. The rate of MRSA and VRE colonization was 5.8% (62 of 1,053) and 32.4% (94 of 290), respectively, in our cohort. Antibiotic allergies were documented in approximately 1 out of 3 patients, 337 (32%) for the MRSA group and 94 (32%) for VRE group. There was a significant difference in MRSA colonization between patients with and without an antibiotic allergy, 28 of 337 (8.3%) versus 34 of 716 (4.7%) (P = .025), respectively. In contrast, there was no significant difference in antibiotic allergy rates with and without VRE colonization, 34 of 94 (36.2%) versus 92 of 196 (46.9%) (P = .10), respectively. CONCLUSIONS An antibiotic allergy label was associated with significantly higher rates of MRSA colonization but no statistical difference with VRE colonization.
Collapse
|
43
|
Trubiano JA, Vogrin S, Chua KYL, Bourke J, Yun J, Douglas A, Stone CA, Yu R, Groenendijk L, Holmes NE, Phillips EJ. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med 2020; 180:745-752. [PMID: 32176248 PMCID: PMC7076536 DOI: 10.1001/jamainternmed.2020.0403] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Penicillin allergy is a significant public health issue for patients, antimicrobial stewardship programs, and health services. Validated clinical decision rules are urgently needed to identify low-risk penicillin allergies that potentially do not require penicillin skin testing by a specialist. OBJECTIVE To develop and validate a penicillin allergy clinical decision rule that enables point-of-care risk assessment of patient-reported penicillin allergies. DESIGN, SETTING, AND PARTICIPANTS In this diagnostic study, a multicenter prospective antibiotic allergy-tested cohort of 622 patients from 2 tertiary care sites in Melbourne, Australia (Austin Health and Peter MacCallum Cancer Centre) was used for derivation and internal validation of a penicillin allergy decision rule. Backward stepwise logistic regression was used to derive the model, including clinical variables predictive of a positive penicillin allergy test result. Internal validation of the final model used bootstrapped samples and the model scoring derived from the coefficients. External validation was performed in retrospective penicillin allergy-tested cohorts consisting of 945 patients from Sydney and Perth, Australia, and Nashville, Tennessee. Patients who reported a penicillin allergy underwent penicillin allergy testing using skin prick, intradermal, or patch testing and/or oral challenge (direct or after skin testing). Data were collected from June 26, 2008, to June 3, 2019, and analyzed from January 9 to 12, 2019. MAIN OUTCOMES AND MEASURES The primary outcome for the model was any positive result of penicillin allergy testing performed during outpatient or inpatient assessment. RESULTS From an internal derivation and validation cohort of 622 patients (367 female [59.0%]; median age, 60 [interquartile range{IQR}, 48-71] years) and an external validation cohort of 945 patients (662 female [70.1%]; median age, 55 [IQR, 38-68] years), the 4 features associated with a positive penicillin allergy test result on multivariable analysis were summarized in the mnemonic PEN-FAST: penicillin allergy, five or fewer years ago, anaphylaxis/angioedema, severe cutaneous adverse reaction (SCAR), and treatment required for allergy episode. The major criteria included an allergy event occurring 5 or fewer years ago (2 points) and anaphylaxis/angioedema or SCAR (2 points); the minor criterion (1 point), treatment required for an allergy episode. Internal validation showed minimal mean optimism of 0.003 with internally validated area under the curve of 0.805. A cutoff of less than 3 points for PEN-FAST was chosen to classify a low risk of penicillin allergy, for which only 17 of 460 patients (3.7%) had positive results of allergy testing, with a negative predictive value of 96.3% (95% CI, 94.1%-97.8%). External validation resulted in similar findings. CONCLUSIONS AND RELEVANCE In this study, PEN-FAST was found to be a simple rule that accurately identified low-risk penicillin allergies that do not require formal allergy testing. The results suggest that a PEN-FAST score of less than 3, associated with a high negative predictive value, could be used by clinicians and antimicrobial stewardship programs to identify low-risk penicillin allergies at the point of care.
Collapse
Affiliation(s)
- Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia.,Peter MacCallum Cancer Centre, Department of Infectious Diseases and The National Centre for Infections in Cancer, Parkville, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Australia
| | - Kyra Y L Chua
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Australia
| | - Jack Bourke
- Department of Allergy and Immunology, Fiona Stanley Hospital, Murdoch, Australia
| | - James Yun
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Abby Douglas
- Peter MacCallum Cancer Centre, Department of Infectious Diseases and The National Centre for Infections in Cancer, Parkville, Australia
| | - Cosby A Stone
- Department of Infectious Diseases, Vanderbilt University Medical Centre, Nashville, Tennessee
| | - Roger Yu
- Department of Infectious Diseases, Vanderbilt University Medical Centre, Nashville, Tennessee
| | | | - Natasha E Holmes
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Australia
| | - Elizabeth J Phillips
- Department of Infectious Diseases, Vanderbilt University Medical Centre, Nashville, Tennessee.,Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| |
Collapse
|
44
|
A Practical Guide for Managing Antibiotic Allergies in the Emergency Department. Adv Emerg Nurs J 2020; 41:306-315. [PMID: 31687994 DOI: 10.1097/tme.0000000000000264] [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
Up to 30% of patients report at least one antibiotic allergy, but oftentimes these antibiotic allergies are misdiagnosed. In fact, of the 10% of patients reporting penicillin allergies, 90%-98% are not truly allergic. In an era of increasing antibiotic resistance coupled with a limited number of new antibiotics, evaluating antibiotic allergies is critical in providing optimal patient care. Differentiating adverse drug reactions from antibiotic allergies may seem like a daunting task for clinicians and providers, especially in the emergency department, where decisions are made quickly. However, a systemic approach, including medical record review coupled with patient and/or family interview, is vital in managing patients with antibiotic allergies. Inappropriate, alternative antibiotics are frequently chosen due to patient allergies, and data suggest higher rates of broad-spectrum antibiotic use, antibiotic resistance, and poor outcomes as a result. Herein, we review antibiotic selection in patients reporting antibiotic allergies in the emergency department.
Collapse
|
45
|
Stone CA, Trubiano J, Coleman DT, Rukasin CRF, Phillips EJ. The challenge of de-labeling penicillin allergy. Allergy 2020; 75:273-288. [PMID: 31049971 DOI: 10.1111/all.13848] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 03/28/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Even though 8%-25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de-labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. METHODS We performed an evidence-based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de-labeling. Over the period 1928-2018 in Pubmed and Medline, search terms used included "penicillin allergy" or "penicillin hypersensitivity" alone or in combination with "adverse events," "testing," "evaluation," "effects," "label," "de-labeling," "prick or epicutaneous," and "intradermal" skin testing, "oral challenge or provocation," "cross-reactivity," and "antimicrobial stewardship". RESULTS Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. CONCLUSIONS Operationalizing penicillin allergy de-labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de-labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.
Collapse
Affiliation(s)
- Cosby A. Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
| | - Jason Trubiano
- Department of Infectious Diseases Austin Health Heidelberg Victoria Australia
- Department of Infectious Diseases Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Medicine (Austin Health) University of Melbourne Parkville Victoria Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Parkville Victoria Australia
| | - David T. Coleman
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
| | - Christine R. F. Rukasin
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
| | - Elizabeth J. Phillips
- Division of Infectious Diseases, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
- Department of Pharmacology Vanderbilt University School of Medicine Nashville Tennessee
- Department of Pathology, Microbiology and Immunology Vanderbilt University Medical Center Nashville Tennessee
- Institute for Immunology & Infectious Diseases Murdoch University Murdoch Western Australia Australia
| |
Collapse
|
46
|
Jimenez-Rodriguez TW, Blanca-Lopez N, Ruano-Zaragoza M, Soriano-Gomis V, Esteban-Rodriguez A, Riera-Sendra G, Palazon-Bru A, Blanca M, Ramos-Rincon JM, Fernandez-Sanchez J. Allergological Study of 565 Elderly Patients Previously Labeled as Allergic to Penicillins. J Asthma Allergy 2019; 12:421-435. [PMID: 31853189 PMCID: PMC6916685 DOI: 10.2147/jaa.s232787] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 11/21/2019] [Indexed: 12/13/2022] Open
Abstract
Purpose Elderly people thought to have an allergy to beta-lactams (BLs) may tolerate the drugs in subsequent exposures due to initial false labeling of allergies, the spontaneous loss of sensitivity to BLs over time or age-related decline in sensitization. As a result, they may be treated with less appropriate antibiotics, causing more side effects and entailing increased costs for health systems. The aim of this investigation was to assess whether patients in the third and fourth age with previously confirmed allergies to BLs had lost sensitization and could tolerate these antibiotics. Patients and methods Patients allergic to BLs were divided into group A (aged 60-79 years) and B (aged ≥80 years). Clinical history, skin testing, drug challenge tests (DCT) and evaluation of resensitization were used to classify participants as showing immediate reactions, non-immediate reactions, or tolerance. We compared clinical entities, drugs involved, and final outcome by age group. Results Of 1362 cases evaluated, 565 underwent an allergological study. The skin was the most common organ involved. Anaphylaxis and side chain reactions were more frequent in group A (p<0.01), as were positive DCT. Classical benzylpenicillin determinants (benzylpenicilloyl and/or minor determinant mixture) were more frequent triggers in group B (p< 0.01). Resensitization after challenge occurred in very few participants. Conclusion The risk for allergy to BLs decreases with age and a history of anaphylaxis by BLs is a predictor of positive results in skin tests (ST). Both immunoglobin E (IgE) and T-cell-mediated responses can disappear in elderly people, who can develop tolerance to these antibiotics. These results are of clinical relevance to patients who need to be treated with antibiotics from this family.
Collapse
Affiliation(s)
- Teodorikez Wilfox Jimenez-Rodriguez
- Allergy Section, Alicante General University Hospital-ISABIAL, Alicante, Spain.,ARADyAL Spanish Network, Madrid, Spain.,PhD Program in Public Health, Medical and Surgical Sciences, Miguel Hernandez University, Alicante, Spain
| | - Natalia Blanca-Lopez
- ARADyAL Spanish Network, Madrid, Spain.,Allergy Section, Infanta Leonor University Hospital, Madrid, Spain
| | - Maria Ruano-Zaragoza
- Allergy Section, Alicante General University Hospital-ISABIAL, Alicante, Spain.,ARADyAL Spanish Network, Madrid, Spain.,PhD Program in Public Health, Medical and Surgical Sciences, Miguel Hernandez University, Alicante, Spain
| | - Victor Soriano-Gomis
- Allergy Section, Alicante General University Hospital-ISABIAL, Alicante, Spain.,ARADyAL Spanish Network, Madrid, Spain.,Clinical Medicine Department, Miguel Hernandez University, Alicante, Spain
| | | | | | | | - Miguel Blanca
- ARADyAL Spanish Network, Madrid, Spain.,Allergy Section, Infanta Leonor University Hospital, Madrid, Spain
| | - Jose Manuel Ramos-Rincon
- Clinical Medicine Department, Miguel Hernandez University, Alicante, Spain.,Internal Medicine Department, Alicante General University Hospital, Alicante, Spain
| | - Javier Fernandez-Sanchez
- Allergy Section, Alicante General University Hospital-ISABIAL, Alicante, Spain.,ARADyAL Spanish Network, Madrid, Spain.,Clinical Medicine Department, Miguel Hernandez University, Alicante, Spain
| |
Collapse
|
47
|
Gelincik A, Cavkaytar O, Kuyucu S. An Update on the Management of Severe Cutaneous Drug Hypersensitivity Reactions. Curr Pharm Des 2019; 25:3881-3901. [DOI: 10.2174/1381612825666191106115556] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/01/2019] [Indexed: 12/15/2022]
Abstract
Severe cutaneous drug hypersensitivity reactions involve of different mechanisms , some of which are
life-threatening, such as Stevens-Johnson syndrome/toxic epidermal necrolysis, drug reaction with eosinophilia
and systemic symptoms, acute generalized exanthematous pustulosis, generalized bullous fixed drug eruptions,
serum sickness and serum sickness-like reaction and drug-induced vasculitis. These reactions may have substantial
morbidity and mortality. In the past years, successive studies have provided new evidence regarding the
pathogenesis of some of these severe reactions and revealed that underlying mechanisms are highly variable.
Since these reactions have unique presentations and distinct pathomechanisms, the treatment methods and response
rates might be different among various entities. Although supportive and local therapies are sufficient in
some of these reactions, targeted immunosuppressive treatments and even mechanistic therapies such as plasmapheresis
may be required in severe ones. However, there is still insufficient evidence to support the best treatment
options for these patients since number of patients and large-scale studies are limited. In this review, conventional
and new treatment options for severe cutaneous drug hypersensitivity reactions are presented in detail in
order to provide the contemporary approaches to lessen the morbidity and mortality relevant to these severe iatrogenic
diseases.
Collapse
Affiliation(s)
- Aslı Gelincik
- Division of Immunology and Allergy, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University, Faculty of Medicine, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Mersin University, Faculty of Medicine, Mersin, Turkey
| |
Collapse
|
48
|
Pryor JB, Olyaei AJ, Kirsch D, Strasfeld L. Sulfonamide desensitization in solid organ transplant recipients: A protocol-driven approach during the index transplant hospitalization. Transpl Infect Dis 2019; 21:e13191. [PMID: 31596538 DOI: 10.1111/tid.13191] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/16/2019] [Accepted: 09/29/2019] [Indexed: 12/11/2022]
Abstract
Trimethoprim-sulfamethoxazole (TMP-SMX) is the first-line agent for Pneumocystis jiroveci pneumonia (PJP) prophylaxis for solid organ transplant (SOT) recipients because of its efficacy for this indication, extended antimicrobial coverage, and favorable cost. Reported sulfonamide allergy is not uncommon and often results in TMP-SMX avoidance. Desensitization offers an efficacious and cost-effective alternative to TMP-SMX avoidance. Herein, we reviewed our experience with desensitization during the index transplant hospitalization among 52 SOT recipients with history of a non-anaphylactic sulfonamide allergy. Of those enrolled in the desensitization protocol, 92% (48/52) completed the protocol, with nearly 80% (41/52) still on TMP-SMX at 3 months without adverse reaction. Eleven patients discontinued TMP-SMX (7 for allergic reactions and 4 for non-allergic reasons) and switched to pentamidine. A cost savings of $575 per desensitization was calculated based on annual wholesale drug prices, for a total savings of $23 575. Additionally, the protocol did not delay discharge in any patient nor was it associated with any severe allergic reactions. These findings suggest TMP-SMX desensitization is safe and effective in SOT recipients with a history of non-anaphylactic, non-life-threatening sulfonamide hypersensitivity.
Collapse
Affiliation(s)
- Joseph B Pryor
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Ali J Olyaei
- Department of Pharmacology, Oregon Health & Science University/Oregon State University, Portland, OR, USA
| | - Denise Kirsch
- Department of Infectious Diseases, Beaumont Hospital, Dearborn, MI, USA
| | - Lynne Strasfeld
- Division of Infectious Diseases, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
49
|
Modi AR, Majhail NS, Rybicki L, Athans V, Carlstrom K, Srinivas P, Lang DM, Sobecks R, Kovacs CS. Penicillin allergy skin testing as an antibiotic stewardship intervention reduces alternative antibiotic exposures in hematopoietic stem cell transplant recipients. Transpl Infect Dis 2019; 21:e13175. [PMID: 31539459 DOI: 10.1111/tid.13175] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/14/2019] [Accepted: 09/14/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antibiotic allergy de-labeling using penicillin allergy skin testing (PAST) can reduce the use and cost of alternative, non-β-lactam antibiotics in general inpatient populations. This strategy's role in hematopoietic stem cell transplant (HSCT) recipients is unclear. METHODS This study aimed to determine the effect of a pre-transplant PAST protocol on antibiotic use, days of therapy (DOT), and cost in an immunocompromised population at a single center from 7/1/2010-2/1/2019. Patients who received chimeric antigen receptor (CAR) T-cell therapy and those who underwent transplantation in the outpatient setting were excluded. RESULTS Of 1560 patients who underwent inpatient HSCT during the study period, 208 reported β-lactam allergy (136/844 [16%] pre- and 72/716 [10%] post-implementation; P < .001). PAST was performed on 7% and 54% of HSCT recipients pre- and post-implementation, respectively. Only two positive PAST were noted. There were no adverse reactions to PAST. There were no significant differences in the disease and transplant characteristics between the two groups. Days of therapy and cost of alternative antibiotics significantly decreased post-implementation (mean 788 vs 627 days, P = .01; mean $24 425 vs $17 518, P = .009). CONCLUSION Penicillin allergy skin testing adjudicates reported β-lactam allergy in HSCT recipients, lowering use, DOT, and cost of alternative antibiotics and promoting effective formulary agents to treat immunocompromised HSCT recipients.
Collapse
Affiliation(s)
- Anita R Modi
- Department of Infectious Diseases, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Navneet S Majhail
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Lisa Rybicki
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Vasilios Athans
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kelley Carlstrom
- Department of Pharmacy Services, Cleveland Clinic, Cleveland, OH, USA
| | - Pavithra Srinivas
- Department of Pharmacy Services, Cleveland Clinic, Cleveland, OH, USA
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ronald Sobecks
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Christopher S Kovacs
- Department of Infectious Diseases, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
50
|
Trubiano JA, Slavin MA, Thursky KA, Grayson ML, Phillips EJ. Beta-Lactam and Sulfonamide Allergy Testing Should Be a Standard of Care in Immunocompromised Hosts. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2151-2153. [PMID: 31253580 DOI: 10.1016/j.jaip.2019.05.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/19/2019] [Accepted: 05/28/2019] [Indexed: 12/19/2022]
Abstract
Antibiotic allergies are reported in up to 1 in 4 immunocompromised hosts with significant impacts on antibiotic utilization and patient outcomes. Health services programs focused on de-labeling beta-lactam and sulfonamide allergy labels should be a standard of care in immunocompromised hosts.
Collapse
Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, VIC, Australia; Department of Medicine (Austin Health), University of Melbourne, Parkville, VIC, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, VIC, Australia.
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, VIC, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, VIC, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, VIC, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, VIC, Australia; National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Medicine (Austin Health), University of Melbourne, Parkville, VIC, Australia
| | - Elizabeth J Phillips
- Department of Infectious Diseases, Vanderbilt University Medical Centre, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| |
Collapse
|