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Sillcox C, Gabrielli S, O'Keefe A, McCusker C, Abrams EM, Eiwegger T, Atkinson A, Kim V, Copaescu AM, Ben-Shoshan M. Assessing Pediatric Cephalosporin Allergic Reactions Through Direct Graded Oral Challenges. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:156-164.e4. [PMID: 37832819 DOI: 10.1016/j.jaip.2023.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Cephalosporins, β-lactam antibiotics, commonly cause allergic reactions. OBJECTIVE To assess the clinical characteristics and management of pediatric patients with suspected cephalosporin allergy using direct graded oral challenges (GOCs). METHODS Children referred for suspected cephalosporin allergy at 4 Canadian clinics were recruited over 10 years. Data on demographics, clinical reaction characteristics, and management were collected through a questionnaire. Patients underwent a direct GOC (initially 10% of the treatment dose, then 90% after 20 min), and reactions were monitored 1 week postchallenge. Families were contacted annually for up to 5 years to detect subsequent antibiotic reactions. Logistic regression analysis identified factors associated with positive GOC reactions. RESULTS Among the 136 patients reporting cephalosporin allergy, 75 (55.1%) were males with a median age of 3.9 years (interquartile range 2.3-8.7). Cefprozil represented the most common cephalosporin linked to the index reaction (67.6% of cases). Of the 136 direct GOCs, 5.1% had an immediate and 4.4% a nonimmediate reaction, respectively. Positive GOCs conducted in children with a history of skin-limited nonsevere rashes were classified as mild, benign skin rashes. Positive GOCs were more likely in children with food allergies (adjusted odds ratio 1.14; 95% confidence interval [95% CI] 1.00-1.29). CONCLUSIONS Direct GOCs are safe and effective for diagnosing pediatric cases that report nonvesicular skin-limited symptoms while being treated with cephalosporins.
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Affiliation(s)
- Carly Sillcox
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Sofianne Gabrielli
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrew O'Keefe
- Department of Pediatrics, Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Christine McCusker
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Man, Canada
| | - Thomas Eiwegger
- Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria; Department of Pediatric and Adolescent Medicine, University Hospital St. Pölten, St. Pölten, Austria; Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ont, Canada; Department of Immunology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ont, Canada
| | - Adelle Atkinson
- Division of Clinical Immunology and Allergy, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ont, Canada
| | - Vy Kim
- Division of Clinical Immunology and Allergy, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ont, Canada
| | - Ana-Maria Copaescu
- Division of Allergy and Clinical Immunology, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Moshe Ben-Shoshan
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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2
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Sousa-Pinto B, Blumenthal KG, Macy E, Pereira AM, Azevedo LF, Delgado L, Fonseca JA. Penicillin Allergy Testing Is Cost-Saving: An Economic Evaluation Study. Clin Infect Dis 2021; 72:924-938. [PMID: 32107530 DOI: 10.1093/cid/ciaa194] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Having a penicillin allergy label is associated with the use of less appropriate and more expensive antibiotics and increased healthcare utilization. Penicillin allergy testing results in delabeling most allergy claimants and may be cost-saving. This study aimed to project whether penicillin allergy testing in patients reporting a penicillin allergy is cost-saving. METHODS In this economic evaluation study, we built decision models to project the economic impact of 2 strategies for a patient with a penicillin allergy label: (1) perform diagnostic testing (drug challenges, with or without skin tests); and (2) do not perform diagnostic testing. The health service perspective was adopted, considering costs with penicillin allergy tests, and with hospital bed-days/outpatient visits, antibiotic use, and diagnostic testing. Twenty-four base case decision models were built, accounting for differences in the diagnostic workup, setting (inpatient vs outpatient) and geographic region. Uncertainty was explored via probabilistic sensitivity analyses. RESULTS Penicillin allergy testing was cost-saving in all decision models built. For models assessing the performance of both skin tests and drug challenges, allergy testing resulted in average savings (in United States [US] dollars) of $657 for inpatients (US: $1444; Europe: $489) and $2746 for outpatients (US: $256; Europe: $6045). 75% of simulations obtained through probabilistic sensitivity analysis identified testing as the less costly option. CONCLUSIONS Penicillin allergy testing was projected to be cost-saving across different scenarios. These results are devised to inform guidelines, supporting the adoption of policies promoting widespread testing of patients with a penicillin allergy label.
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Affiliation(s)
- Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal.,Basic and Clinical Immunology Unit, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, California, USA
| | - Ana Margarida Pereira
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
| | - Luís Filipe Azevedo
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
| | - Luís Delgado
- Center for Health Technology and Services Research, Porto, Portugal.,Basic and Clinical Immunology Unit, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Almeida Fonseca
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
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3
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Stirbiene N, Rudzeviciene O, Kapitancuke M, Nazarenkaite N, Valiulis A. Knowledge gaps of drug allergy in children: a survey of primary care doctors. Postepy Dermatol Alergol 2021; 38:63-68. [PMID: 34408568 PMCID: PMC8362765 DOI: 10.5114/ada.2021.104280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/13/2019] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION There is still lack of knowledge of drug allergy in children. Proper knowledge and management of drug hypersensitivity reactions is important to physicians. AIM To evaluate the approach of primary care doctors regarding drug allergy in children. MATERIAL AND METHODS A total of 195 primary care doctors were questioned in various parts of Lithuania from 2015 to 2016. An original questionnaire was used. The incidence of a suspected drug allergy, culprit drugs, the clinical pattern and management of the suspected drug hypersensitivity were analysed. RESULTS The majority of primary care doctors (74.4%) reported a suspected drug allergy. The main suspected drugs were antibiotics (95.2%) and nonsteroidal anti-inflammatory drugs (32.4%). Skin symptoms (skin rash (100%) and itching (82.1%)) were the main symptoms of the suspected drug allergy. The vast majority of doctors (93.8%) withdrew the use of a suspected drug and 68.3% of respondents prescribed an alternative drug. The fact that skin tests, blood tests and provocation tests could be used in a drug allergy workup were indicated by 43.6% of doctors. Most doctors (69.2%) knew about the opportunity to test children for drug allergy in Lithuania and 41.4% of doctors referred patients for the further drug allergy workup. CONCLUSIONS The majority of primary care doctors reported a suspected drug allergy in children. The most common suspected drugs were antibiotics and skin symptoms were the main symptoms. Most doctors knew about the possibility to test for the drug allergy but only less than half of them referred patients for the drug allergy workup.
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Affiliation(s)
- Neringa Stirbiene
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Odilija Rudzeviciene
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Monika Kapitancuke
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Neringa Nazarenkaite
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Arunas Valiulis
- Clinic of Children’s Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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4
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Wang AY, Osborne JD, Danila MI, Naidech AM, Liebovitz DM. AllergyMap: An Open Source Corpus of Allergy Mention Normalizations. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2021; 2020:1249-1257. [PMID: 33936501 PMCID: PMC8075505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Allergy mention normalization is challenging because of the wide range of possible allergens including medications, foods, plants, animals, and consumer products. This paper describes the process of mapping free-text allergy information from an electronic health record (EHR) system in a university hospital to standard terminologies and migration of those data into an enterprise EHR system. The review, mapping, and migration revealed interesting issues and challenges with the free-text allergy information and the mapping in preparation for implementation in the new EHR system. These findings provide insights that can form the basis of guidelines for future mapping and migration efforts involving free-text allergy data. As part of this process, we generate and make freely available AllergyMap, a mapping between free-text entered allergy medication to standard non-proprietary ontologies. To our knowledge, this is the first such mapping available and could serve as a public resource for allergy mention normalization and system evaluation.
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Affiliation(s)
- Amy Y Wang
- University of Alabama at Birmingham Informatics Institute, Birmingham, Alabama
| | - John D Osborne
- University of Alabama at Birmingham Informatics Institute, Birmingham, Alabama
| | - Maria I Danila
- University of Alabama at Birmingham Informatics Institute, Birmingham, Alabama
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5
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Baxter M, Bethune C, Powell R, Morgan M. Point prevalence of penicillin allergy in hospital inpatients. J Hosp Infect 2020; 106:65-70. [DOI: 10.1016/j.jhin.2020.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
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Abstract
BACKGROUND Suspected antibiotic hypersensitivity in children is a frequent reason for consultation. Skin test performance and drug provocation test (DPT) duration are controversial issues. The objective of this study was to assess the effectiveness of diagnostic tests used in the study of antibiotic hypersensitivity and to estimate an optimal duration for DPT. METHODS Sixty-two children with a suspected hypersensitivity reaction to antibiotics were studied. Skin tests were performed on all patients. In the case of negative results, DPTs were performed for a duration similar to the time elapsed from the start of treatment until the onset of the reaction. RESULTS The frequency of antibiotic hypersensitivity in the study population was 8.1% (5 of 62). Only 1 patient showed positive skin tests. The other allergic patients were diagnosed by DPT, which reproduced the reaction within the first 6 hours in all but one of them. CONCLUSIONS Shortening DPT duration may decrease the sensitivity of the test for the diagnosis of non-IgE-mediated hypersensitivity; however, it should be considered as an opportunity to reduce the resulting microbial resistances.
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7
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Matte G, Shuster J, Guevremont C, Gold P, Leong F, Ngan Z, Bonnici A, Tsoukas C. Standardization and Updating of a Drug Allergy Testing Program: The McGill Experience and Impact on Pharmacy Activities. Can J Hosp Pharm 2020; 73:45-51. [PMID: 32109960 PMCID: PMC7023931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Gilbert Matte
- , BPharm, PhD, is with the Department of Pharmacy, McGill University Health Centre, Montréal, Quebec
| | - Joseph Shuster
- , MD, is with the Department of Medicine, Division of Allergy and Clinical Immunology, McGill University Health Centre, Montréal, Quebec
| | - Chantal Guevremont
- , BPharm, MSc, is with the Department of Pharmacy, McGill University Health Centre, Montréal, Quebec
| | - Phil Gold
- , MD, is with the Department of Medicine, Division of Allergy and Clinical Immunology, McGill University Health Centre, Montréal, Quebec
| | - Fabrice Leong
- , PharmD, is with the Department of Pharmacy, McGill University Health Centre, Montréal, Quebec
| | - Zinquon Ngan
- , PharmD, MSc, is with the Department of Pharmacy, McGill University Health Centre, Montréal, Quebec
| | - André Bonnici
- , BPharm, MSc, is with the Department of Pharmacy, McGill University Health Centre, Montréal, Quebec
| | - Chris Tsoukas
- , MD, is with the Department of Medicine, Division of Allergy and Clinical Immunology, McGill University Health Centre, Montréal, Quebec
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8
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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.
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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
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9
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Kabakov A, Rhodes NJ, Wenzel R. Discrepancies Between Patient Self-Reported and Electronic Health Record Documentation of Medication Allergies and Adverse Reactions in the Acute Care Setting: Room for Improvement. J Pharm Technol 2019; 35:139-145. [PMID: 34861033 DOI: 10.1177/8755122519840700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Allergy information is commonly transcribed into an electronic health record (EHR) for all patients admitted to acute care hospital units by a licensed health care professional. The allergy history is utilized each time a new inpatient medication is prescribed to identify the patient's risk of having an allergic reaction and/or anaphylaxis. There is potential for negative consequences in cases where the allergy history is incorrectly documented. Objective: The objective of this study was to assess the discordance between documented allergy information in the EHR and verbally reported allergy information from a patient interview. Methods: Prospective, observational, nonrandomized study performed within a 2-month period during the Spring of 2016. The study was performed at a teaching community hospital in Chicago, Illinois. A total of 270 patients were interviewed on the general medicine (n = 216) and headache (n = 54) units regarding their medication allergies and reactions. The outcomes were discordance among EHR-documented and verbally stated medication allergies and reactions. Results: The agreement across all medications and reactions between the EHR and patient self-reported interview was 80.9%. There were 31 reactions (6.7%) that were verbally reported by patients but were not documented in the EHR (omissions) and 57 reactions (12.4%) that were verbally reported but were incorrectly documented in the EHR (incorrect documentations). Only 20 out of the 264 verbally reported reactions (7.5%) met the study definition of anaphylaxis. The highest rate of incorrect documentations occurred with opiate agonists, and the highest rate of omissions occurred with anticonvulsants. EHR documentation was more likely to be incorrect among patients who reported gastrointestinal reactions and was more likely to be correct among patients who reported cutaneous reactions. Conclusion: There was a high rate of discordance amid EHR-documented and verbally stated medication allergies and reactions. Errors among opiate agonists, anticonvulsants, and sulfa drugs were most prevalent.
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Affiliation(s)
- Anna Kabakov
- Midwestern University, Downers Grove, IL, USA.,Amita Saint Joseph Hospital-Chicago, IL, USA
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10
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Van Gasse AL, Ebo DG, Chiriac AM, Hagendorens MM, Faber MA, Coenen S, Bridts CH, Mertens CM, De Clerck LS, Sabato V. The Limited Value of Prolonged Drug Challenges in Nonimmediate Amoxicillin (Clavulanic Acid) Hypersensitivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2225-2229.e1. [PMID: 31034997 DOI: 10.1016/j.jaip.2019.04.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/12/2019] [Accepted: 04/04/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Misdiagnosis of amoxicillin (clavulanic acid) (AX(/CL)) hypersensitivity has serious consequences. A drug challenge (DC) is the final diagnostic to affirm or infirm AX(/CL) hypersensitivity. However, uncertainties remain whether a prolonged drug challenge (pDC) should benefit the diagnosis of a nonimmediate AX(/CL) hypersensitivity. OBJECTIVE To assess the added value of a standardized 7-day pDC in the diagnosis of nonimmediate or unclear penicillin hypersensitivity. METHODS A total of 132 patients with a history of a nonimmediate hypersensitivity reaction or an unclear reaction to AX(/CL) or an undefined penicillin with a negative diagnostic workup including a single-day DC (DC) with AX(/CL) were selected. In all these patients, an additional pDC with AX(/CL) was planned. Thirteen patients started the pDC immediately after the DC. To ensure that hypersensitivity symptoms manifesting during the pDC course do not result from the DC, in the remaining 119 patients, the pDC was scheduled after a washout of 1 week. RESULTS A total of 128 patients (12 without washout, 116 with washout) completed the pDC. Three patients reacted with a mild maculopapular exanthema. However, the value of a pDC was evidenced in only 1 patient who reacted during her pDC after an uneventful washout. In 2 patients pDC was cancelled because they reacted during the washout. CONCLUSIONS A pDC is of limited added value to the diagnostic algorithms of nonimmediate hypersensitivity reaction or unclear hypersensitivity reactions to AX(/CL). In our hands, the traditionally recommended diagnostic algorithm that offers a 1-day DC as a final diagnostic in patients with negative workup for AX(/CL) is appropriate.
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Affiliation(s)
- Athina L Van Gasse
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Didier G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium.
| | - Anca M Chiriac
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; UMR-S 1136 INSERM-Sorbonne Université, Equipe EPAR - IPLESP, Paris, France
| | - Margo M Hagendorens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Margaretha A Faber
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Samuel Coenen
- Faculty of Medicine and Health Sciences, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Chris H Bridts
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Christel M Mertens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Luc S De Clerck
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
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11
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Phillips CJ, Gilchrist M, Cooke FJ, Franklin BD, Enoch DA, Murphy ME, Santos R, Brannigan ET, Holmes AH. Adherence to antibiotic guidelines and reported penicillin allergy: pooled cohort data on prescribing and allergy documentation from two English National Health Service (NHS) trusts. BMJ Open 2019; 9:e026624. [PMID: 30826801 PMCID: PMC6398633 DOI: 10.1136/bmjopen-2018-026624] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To investigate documentation of antimicrobial allergy and to determine prescribing adherence to local antibiotic guidelines for inpatients with and without reported penicillin allergy treated for infection in a National Health Service (NHS) context. SETTING Data were collected at two English hospital NHS trusts over two time-periods: June 2016 and February 2017. DESIGN Cohort study. Trust 1 data were sourced from prospective point prevalence surveys. Trust 2 data were extracted retrospectively from an electronic report. PARTICIPANTS Inpatients treated for urinary tract infection (UTI), community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and skin and soft tissue infection (SSTI). Data on allergy were collected, and antibiotic selection assessed for adherence to trust guidelines with differences between groups presented as adjusted ORs. RESULTS A total of 1497 patients were included, with 2645 antibiotics orders. Patients were treated for CAP (n=495; 33.1%), UTI (407; 27.2%), HAP (330; 22%) and SSTI (265; 17.7%). There were 240 (16%) patients with penicillin allergy. Penicillin allergy was recorded as allergy (n=52; 21.7%), side effect (27; 11.3%) and no documentation (161; 67.1%). Overall, 2184 (82.6%) antibiotic orders were guideline-adherent. Adherence was greatest for those labelled penicillin allergy (453 of 517; 87.6%) versus no allergy (1731 of 2128; 81.3%) (OR 0.52 (95% CI 0.37 to 0.73) p<0.001). Guideline-adherence for CAP was higher if penicillin allergy (151 of 163; 92.6%) versus no allergy (582 of 810; 71.9%) (OR 0.20 (95% CI 0.10 to 0.37) p<0.001). There was no difference in adherence between those with and without penicillin allergy for UTI, HAP or SSTI treatment. CONCLUSIONS A relatively high proportion of patients had a penicillin allergy and two thirds of these had no description of their allergy, which has important implications for patient safety. Patients with penicillin allergy treated for CAP, received more guideline adherent antibiotics than those without allergy. Future studies investigating the clinical impact of penicillin allergy should include data on adherence to antibiotic guidelines.
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Affiliation(s)
- Cameron J Phillips
- Imperial College Healthcare NHS Trust, London, UK
- NIHR, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Clinical Microbiology and Public Health Laboratory, National Infection Service, Public Health England, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Mark Gilchrist
- Imperial College Healthcare NHS Trust, London, UK
- NIHR, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Fiona J Cooke
- Clinical Microbiology and Public Health Laboratory, National Infection Service, Public Health England, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Bryony D Franklin
- NIHR, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, National Infection Service, Public Health England, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michael E Murphy
- Clinical Microbiology and Public Health Laboratory, National Infection Service, Public Health England, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Reem Santos
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Alison H Holmes
- Imperial College Healthcare NHS Trust, London, UK
- NIHR, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
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Penicillin skin testing in methicillin-sensitive staphylococcus aureus bacteremia: A cost-effectiveness analysis. PLoS One 2019; 14:e0210271. [PMID: 30615655 PMCID: PMC6322731 DOI: 10.1371/journal.pone.0210271] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/19/2018] [Indexed: 12/24/2022] Open
Abstract
Background Beta-lactams are the mainstay for treating methicillin-susceptible Staphylococcus aureus (MSSA) infections complicated by bacteremia due to superior outcomes compared with vancomycin. With approximately 11% of inpatients reporting a penicillin (PCN) allergy, many patients receive suboptimal treatment for MSSA bacteremia. Objective Evaluate the cost-effectiveness of penicillin skin testing (PST) in adult patients with self-reported PCN allergy in an inpatient setting undergoing treatment for MSSA bacteremia. Methods A decision analytic model was developed comparing an acute care PST intervention to a scenario with no confirmatory allergy testing. The primary outcome was the incremental cost-effectiveness ratio (ICER) from the health-sector perspective over a 1-year time horizon using quality-adjusted life years (QALYs) as the measure for effectiveness. One-way and probabilistic sensitivity analyses were conducted to assess the uncertainty of the ICER estimation. Results Over a 1-year time horizon, PST services applied to all MSSA bacteremia patients reporting a PCN-allergy would result in a cost per patient of $12,559 and 0.73 QALYs while no PST services would have a higher cost per patient of $13,219 and 0.66 QALYs per patient. This resulted in a cost-effectiveness estimate of -$9,429 per QALY gained. Varying the cost of implementing PST services determined a break-even point of $959.98 where any PST cost less than this amount would actually be cost saving. Conclusions Patients reporting a PCN allergy on admission may receive sub-optimal alternative therapies to beta-lactams, such as vancomycin, for MSSA bacteremia. This economic analysis demonstrates that inpatient PST services confirming PCN allergy are cost-effective for patients with MSSA bacteremia.
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Moussa Y, Shuster J, Matte G, Sullivan A, Goldstein RH, Cunningham D, Ben-Shoshan M, Baldini G, Carli F, Tsoukas C. De-labeling of β-lactam allergy reduces intraoperative time and optimizes choice in antibiotic prophylaxis. Surgery 2018; 164:S0039-6060(18)30127-2. [PMID: 29751965 DOI: 10.1016/j.surg.2018.03.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/26/2018] [Accepted: 03/19/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Suspected penicillin allergic individuals receive suboptimal non-β-lactams for intraoperative prophylaxis which may prolong operations and have negative clinical outcomes. We therefore studied if β-lactam de-labeling optimized choice of prophylactic antibiotics and improved intraoperative time efficiency. METHODS A multistep approach was used. It included a risk assessment tool by an allergist, β-lactam skin testing and oral provocation. To determine the value of de-labeling, we appraised intraoperative antibiotic choices and correlated them with time to first incision. RESULTS A total of 194 patients were evaluated preoperatively. Four patients were diagnosed β-lactam allergic on skin testing. Of the remaining 190 skin test negative patients, 146 were β-lactam challenged. Only 5% reacted and were considered β-lactam allergic. Cefazolin became the perioperative antibiotic of choice for 77% of patients requiring antibiotic prophylaxis. Only 5 confirmed β-lactam allergic patients received intraoperative vancomycin. Patients avoiding use of vancomycin saved an average of 22 minutes in operative time. Of the 44 patients not having a β-lactam challenge, 36 received antibiotics and 18 (50%) of these were prescribed intraoperative cefazolin. CONCLUSION Using this three step process, almost all of those claiming penicillin allergy were de-labeled. In most patients that were drug challenged, β-lactam antibiotics became the perioperative drug of choice. In cases where oral challenge was not used in the assessment only 50% were given a β-lactam. The reduced use of vancomycin minimized delays in initiation of incision time, thus improving operative efficiency. Ultimately, randomized controlled studies are required to objectively determine the effectiveness of this approach.
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Affiliation(s)
- Yara Moussa
- Department of Medicine, Division of Allergy and Clinical Immunology, McGill University, Montreal, Quebec, Canada; Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Joseph Shuster
- Department of Medicine, Division of Allergy and Clinical Immunology, McGill University, Montreal, Quebec, Canada; Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Gilbert Matte
- Department of Pharmacy, McGill University Health Center, Montreal, Quebec, Canada
| | - Andrew Sullivan
- Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Robert H Goldstein
- Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Dayle Cunningham
- Department of Medicine, Division of Allergy and Clinical Immunology, McGill University, Montreal, Quebec, Canada
| | - Moshe Ben-Shoshan
- Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada; Department of Pediatrics, Divisions of Allergy, Immunology and Dermatology, McGill University, Montreal, Quebec, Canada
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada
| | - Christos Tsoukas
- Department of Medicine, Division of Allergy and Clinical Immunology, McGill University, Montreal, Quebec, Canada; Division of Experimental Medicine, The Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada.
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Mattingly TJ, Fulton A, Lumish RA, Williams AMC, Yoon S, Yuen M, Heil EL. The Cost of Self-Reported Penicillin Allergy: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1649-1654.e4. [PMID: 29355644 DOI: 10.1016/j.jaip.2017.12.033] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/11/2017] [Accepted: 12/28/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients who report a penicillin (PCN) allergy receive suboptimal antibiotic therapy compared with patients not reporting an allergy. However, a majority of patients who report PCN allergy are not truly allergic on confirmatory testing. Ruling out PCN allergy by testing may improve clinical and economic outcomes for patients with reported allergies requiring antibiotic therapy. OBJECTIVE The objective of this study was to summarize clinical and economic outcomes associated with PCN allergy and provide recommendations for future cost-effectiveness analyses for PCN allergy testing. METHODS A literature search was conducted using SCOPUS, EMBASE, and PubMed, including all articles published any date through April 25, 2017 (PROSPERO Registration number 42017064112). A total of 1518 abstracts were found during the initial search with 96 duplicates, for a total of 1422 articles for screening. Thirty articles were included for qualitative synthesis and full data extraction. RESULTS The majority of the studies included had an observational design focusing on inpatient admissions. The most frequently measured outcome in the context of PCN allergy was optimizing antibiotic therapy. Patients with PCN allergy were found to have direct drug costs during inpatient admission ranging from no difference to an additional $609/patient compared with patients without PCN allergy. Outpatient prescription costs were estimated from $14 to $193/patient higher for PCN allergic patients. Total inpatient costs were less for patients without PCN allergy with average savings from $1145 to $4254/patient. CONCLUSIONS Evaluations of clinical and economic outcomes of PCN allergy are primarily observational and focus on inpatient populations. Long-term relationships between PCN allergy and clinical and economic outcomes are unknown.
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Affiliation(s)
- T Joseph Mattingly
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md.
| | - Anne Fulton
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - Rachel A Lumish
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - Anne M C Williams
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - SeJeong Yoon
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - Melissa Yuen
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
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Blumenthal KG, Li Y, Banerji A, Yun BJ, Long AA, Walensky RP. The Cost of Penicillin Allergy Evaluation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:1019-1027.e2. [PMID: 28958738 DOI: 10.1016/j.jaip.2017.08.006] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Unverified penicillin allergy leads to adverse downstream clinical and economic sequelae. Penicillin allergy evaluation can be used to identify true, IgE-mediated allergy. OBJECTIVE To estimate the cost of penicillin allergy evaluation using time-driven activity-based costing (TDABC). METHODS We implemented TDABC throughout the care pathway for 30 outpatients presenting for penicillin allergy evaluation. The base-case evaluation included penicillin skin testing and a 1-step amoxicillin drug challenge, performed by an allergist. We varied assumptions about the provider type, clinical setting, procedure type, and personnel timing. RESULTS The base-case penicillin allergy evaluation costs $220 in 2016 US dollars: $98 for personnel, $119 for consumables, and $3 for space. In sensitivity analyses, lower cost estimates were achieved when only a drug challenge was performed (ie, no skin test, $84) and a nurse practitioner provider was used ($170). Adjusting for the probability of anaphylaxis did not result in a changed estimate ($220); although other analyses led to modest changes in the TDABC estimate ($214-$246), higher estimates were identified with changing to a low-demand practice setting ($268), a 50% increase in personnel times ($269), and including clinician documentation time ($288). In a least/most costly scenario analyses, the lowest TDABC estimate was $40 and the highest was $537. CONCLUSIONS Using TDABC, penicillin allergy evaluation costs $220; even with varied assumptions adjusting for operational challenges, clinical setting, and expanded testing, penicillin allergy evaluation still costs only about $540. This modest investment may be offset for patients treated with costly alternative antibiotics that also may result in adverse consequences.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass.
| | - Yu Li
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Brian J Yun
- Harvard Medical School, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Aidan A Long
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Mass
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Chen JR, Tarver SA, Alvarez KS, Tran T, Khan DA. A Proactive Approach to Penicillin Allergy Testing in Hospitalized Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:686-693. [PMID: 27888034 DOI: 10.1016/j.jaip.2016.09.045] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 09/23/2016] [Accepted: 09/28/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Penicillin allergy testing is underutilized in inpatients despite its potential to immediately impact antibiotic treatment. Although most tested patients are able to tolerate penicillin, limited availability and awareness of this tool leads to the use of costly and harmful substitutes. OBJECTIVE We established an inpatient service at a large academic hospital to identify and test patients with a history of penicillin allergy with the goals of removing inaccurate diagnoses, reducing the use of beta-lactam alternatives, and educating patients and clinicians about the procedure. METHODS Eligible inpatients were flagged daily through the electronic medical record and prioritized via a specialized algorithm. A trained clinical pharmacist performed penicillin skin tests and challenges preemptively or by provider request. Clinical characteristics and antibiotic use were analyzed in tested patients. RESULTS A total of 1203 applicable charts were detected by our system leading to 252 direct evaluations over 18 months. Overall, 228 subjects (90.5%) had their penicillin allergy removed. Of these, 223 were cleared via testing and 5 by discovery of prior penicillin tolerance. Among patients testing negative, 85 (38%) subsequently received beta-lactams, preventing 504 inpatient days and 648 outpatient days on alternative agents. CONCLUSIONS Penicillin allergy testing using a physician-pharmacist team model effectively removes reported allergies in hospitalized patients. The electronic medical record is a valuable asset for locating and stratifying individuals who benefit most from intervention. Proactive testing substantially reduces unnecessary inpatient and outpatient use of beta-lactam alternatives that may otherwise go unaddressed.
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Affiliation(s)
- Justin R Chen
- Division of Allergy & Immunology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Tex
| | - Scott A Tarver
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Tex
| | - Kristin S Alvarez
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Tex
| | - Trang Tran
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Tex
| | - David A Khan
- Division of Allergy & Immunology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Tex.
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van Dijk SM, Gardarsdottir H, Wassenberg MWM, Oosterheert JJ, de Groot MCH, Rockmann H. The High Impact of Penicillin Allergy Registration in Hospitalized Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:926-31. [PMID: 27131826 DOI: 10.1016/j.jaip.2016.03.009] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/07/2016] [Accepted: 03/23/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Suspected penicillin allergy (Pen-A) is often not verified or excluded by diagnostic testing. OBJECTIVE To assess the prevalence and impact of Pen-A registration in a Dutch University Medical Center. METHODS In a prospective matched cohort study, all admitted patients (July 2013-July 2014) who underwent a pharmacotherapeutic interview were selected. Patients with a registered Pen-A were matched on age, sex, and department of admission with up to 3 patients without a registered Pen-A. Relative risks (RRs) of receiving a reserve antibiotic, death during hospitalization, and rehospitalization were compared in the 2 cohorts. The number and type of antibiotics prescribed during admission and duration of hospitalization were compared. RESULTS Of 17,959 patients, 1010 (5.6%) patients (66.7% women; median age, 55 years) had a Pen-A registration. These patients had a higher risk of receiving reserve antibiotics (RR, 1.38; 95% CI, 1.22-1.56) and of being rehospitalized within 12 weeks (RR, 1.28; 95% CI, 1.10-1.49). A significantly larger proportion of Pen-A registered patients received reserve antibiotics such as tetracyclines (1.8% vs 0.8%), macrolides/lincosamides/streptogramins (12.5% vs 4.9%), and quinolones (7.9% vs 4.3%) or received 2 or more types of antibiotics during hospitalization (21.7% vs 16.9%). CONCLUSIONS Prevalence of Pen-A registration in hospitalized patients is high, has high impact on antibiotic prescribing, and is associated with a higher risk of readmission. Verification of the Pen-A in hospitalized patients might restrict the use of reserve antibiotics and improve patient outcome.
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Affiliation(s)
- Savannah M van Dijk
- Department of Dermatology and Allergology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Helga Gardarsdottir
- Division of Laboratory and Pharmacy, Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Marjan W M Wassenberg
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mark C H de Groot
- Division of Laboratory and Pharmacy, Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heike Rockmann
- Department of Dermatology and Allergology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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Penicillin allergy: optimizing diagnostic protocols, public health implications, and future research needs. Curr Opin Allergy Clin Immunol 2016; 15:308-13. [PMID: 26110680 DOI: 10.1097/aci.0000000000000173] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Unverified penicillin allergy is being increasingly recognized as a public health concern. The ideal protocol for verifying true clinically significant IgE-mediated penicillin allergy needs to use only commercially available materials, be well tolerated and easy to perform in both the inpatient and outpatient settings, and minimize false-positive determinations. This review concentrates on articles published in 2013 and 2014 that present new data relating to the diagnosis and management of penicillin allergy. RECENT FINDINGS Penicillin allergy can be safely evaluated at this time, in patients with an appropriate clinical history of penicillin allergy, using only penicilloyl-poly-lysine and native penicillin G as skin test reagents, if an oral challenge with amoxicillin 250 mg, followed by 1 h of observation, is given to all skin test negative individuals. SUMMARY Millions of individuals falsely labeled with penicillin allergy need to be evaluated to safely allow them to use penicillin-class antibiotics and avoid morbidity associated with penicillin avoidance. Further research is needed to determine optimal protocol(s). There will still be a 1-2% rate of adverse reactions reported with all future therapeutic penicillin-class antibiotic use, even with optimal methods used to determine acute penicillin tolerance. Only a small minority of these new reactions will be IgE-mediated.
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A Predictive Model for the Diagnosis of Allergic Drug Reactions According to the Medical History. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:292-300.e3. [DOI: 10.1016/j.jaip.2015.11.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 10/04/2015] [Accepted: 11/04/2015] [Indexed: 11/22/2022]
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Pineda F, Ariza A, Mayorga C, Arribas F, González-Mendiola R, Blanca-López N, Davila G, Cabañes N, Canto G, Laguna JJ, Senent C, Stahl-Skov P, Palacios R, Blanca M, Torres MJ. Role of Histamine Release Test for the Evaluation of Patients with Immediate Hypersensitivity Reactions to Clavulanic Acid. Int Arch Allergy Immunol 2016; 168:233-40. [PMID: 26894754 DOI: 10.1159/000443274] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 12/09/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Immediate hypersensitivity reactions to clavulanic acid (CLV) seem to be on the increase. Diagnosis is mainly based on skin testing and the drug provocation test (DPT), procedures that are not risk free. The aim of this study was to evaluate whether the histamine release test (HRT) could help evaluate patients with selective hypersensitivity to CLV. METHODS Eighteen patients with immediate selective hypersensitivity reactions to CLV (positive skin tests to CLV but negative to the major and minor determinants of benzylpenicillin and amoxicillin; negative DPT to benzylpenicillin and amoxicillin) and 21 controls with tolerance to CLV were included. Direct and passive HRT, using patient whole blood or 'IgE-stripped' donor blood sensitized by patient serum, respectively, were performed by stimulating the blood with CLV, and basophil histamine release was detected by fluorometric determination. RESULTS The clinical symptoms were anaphylaxis (n = 6), urticaria (n = 9) and urticaria-angioedema (n = 3). The median time interval between the reaction and the study was 225 days (interquartile range, IQR: 120-387.5) and between drug intake and the development of symptoms 30 min (IQR: 6.25-30). We obtained similar data for both the direct and passive HRT, with a sensitivity and specificity of 55 and 85%, respectively, a positive predictive value of 76% and a negative predictive value of 69%. CONCLUSIONS The sensitivity of both the direct and passive HRT for diagnosing patients with immediate allergy to CLV is less than 60%. However, the passive HRT has the advantage that it is based on the testing of serum samples that can be handled more easily than fresh blood samples.
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Mirakian R, Leech SC, Krishna MT, Richter AG, Huber PAJ, Farooque S, Khan N, Pirmohamed M, Clark AT, Nasser SM. Management of allergy to penicillins and other beta-lactams. Clin Exp Allergy 2015; 45:300-27. [PMID: 25623506 DOI: 10.1111/cea.12468] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 10/29/2014] [Accepted: 11/07/2014] [Indexed: 12/15/2022]
Abstract
The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and an expert panel have prepared this guidance for the management of immediate and non-immediate allergic reactions to penicillins and other beta-lactams. The guideline is intended for UK specialists in both adult and paediatric allergy and for other clinicians practising allergy in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking, the panel reached consensus. During the development of the guideline, all BSACI members were consulted using a Web-based process and all comments carefully considered. Included in the guideline are epidemiology of allergic reactions to beta-lactams, molecular structure, formulations available in the UK and a description of known beta-lactam antigenic determinants. Sections on the value and limitations of clinical history, skin testing and laboratory investigations for both penicillins and cephalosporins are included. Cross-reactivity between penicillins and cephalosporins is discussed in detail. Recommendations on oral provocation and desensitization procedures have been made. Guidance for beta-lactam allergy in children is given in a separate section. An algorithm to help the clinician in the diagnosis of patients with a history of penicillin allergy has also been included.
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Affiliation(s)
- R Mirakian
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Ben Hayoun M, Bourrier T, Pognonec C, Sanfiorenzo C, Marquette C, Leroy S. Impact du bilan d’allergie aux bêta-lactamines sur les médecins généralistes dans une cohorte de 154 patients. REVUE FRANÇAISE D'ALLERGOLOGIE 2015. [DOI: 10.1016/j.reval.2015.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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