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Anton-Vazquez V, Ferretti F, Kaya D, Mishra S, Kerneis S, Eden C, Doan H, Leung HF, Baltazar J, Starkey S, Uwagwu J, Dall'Antonia M, Cepeda J. Impact of penicillin allergy records on antimicrobial prescribing in hospitalised patients. Clin Med (Lond) 2024; 24:100024. [PMID: 38382835 DOI: 10.1016/j.clinme.2024.100024] [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] [Indexed: 02/23/2024]
Abstract
BACKGROUND The overdiagnosis of penicillin allergy and misclassification of non-truly allergic reactions is a growing public health problem, associated with the overuse of broad-spectrum and restricted antimicrobials. We aimed to evaluate the impact of penicillin allergy status on antimicrobial prescribing. METHODS A retrospective study of inpatients with a documented penicillin allergy receiving antimicrobials was conducted from 1 April to 1 July 2021. Antimicrobial prescribing and clinical characteristics were compared between patients with an active penicillin allergy label and those whose label was removed following antimicrobial stewardship team review. Antimicrobials were classified in two categories: i) 'Access' (recommended), ii) 'Watch and Reserve' (restricted) according to WHO AWaRe classification, a tool to guide appropriate antibiotic use. RESULTS 437 patients with a documented penicillin allergy receiving antimicrobials were included. 353 patients with an active penicillin allergy label, more frequently received antimicrobials from the 'Watch and Reserve list' (283;80% vs 30;37%; p<0.001). In contrast, 84 patients who were de-labelled received more often antimicrobials from the 'Access list' (53;63% vs 64;18%; p<0.001). CONCLUSIONS Penicillin allergy reviews and de-labelling strategies may reduce the use of restricted antimicrobials under the 'Watch and Reserve list'. This practice should be encouraged and reinforced in all hospitals.
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Affiliation(s)
| | | | - Deniz Kaya
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Shashwat Mishra
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Sven Kerneis
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Charlotte Eden
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Hong Doan
- General Internal Medicine, Lewisham & Greenwich NHS Trust, London, UK
| | - Hiu Fung Leung
- Antimicrobial pharmacy, Lewisham & Greenwich NHS Trust, London, UK
| | | | - Sarah Starkey
- Medical Microbiology, Lewisham & Greenwich NHS Trust, London, UK
| | - Juliet Uwagwu
- Medical Microbiology, Lewisham & Greenwich NHS Trust, London, UK
| | | | - Jorge Cepeda
- Medical Microbiology, Lewisham & Greenwich NHS Trust, London, UK
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Jung N, Schommers P, Leisse C. [Precision medicine in infectious diseases]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:220-227. [PMID: 38038764 DOI: 10.1007/s00108-023-01620-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 12/02/2023]
Abstract
Infectious medicine faces a variety of challenges, such as the increase in antibiotic resistance and the emergence and spread of infectious diseases fueled by climate change and globalization. Precision medicine can provide solutions to many of these challenges. Since an untargeted request for diagnostic tests can lead to test results without clinical relevance, which can increase the use of non-indicated antibiotics, the principle aimed at is: targeted diagnostics (the right test) and consideration of patient characteristics (the right person) to optimize management (the right action). At the same time, one must always decide whether empirical therapy must be immediately initiated, even if the results of the initiated diagnostics are not yet available. In addition, many new diagnostics as well as therapies have recently been developed for the rapid detection and more specific treatment of bacterial infections. Molecular genetic methods, which offer more rapid results than classical bacterial cultures, are gaining ground as new diagnostics. New therapeutics such as bacteriophages, antibodies or antibacterial peptides allow increasingly precise treatment of certain bacterial infections. Precision medicine will also play an increasingly important role in infectious medicine in the future.
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Affiliation(s)
- N Jung
- Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Klinik I für Innere Medizin, Infektiologie, Köln, Deutschland.
| | - P Schommers
- Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Klinik I für Innere Medizin, Infektiologie, Köln, Deutschland
| | - C Leisse
- Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Klinik I für Innere Medizin, Infektiologie, Köln, Deutschland
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3
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Loprete J, Richardson R, Bramah V, Comben S, Li T, Beiglari L, O’Neill R, McEwan C, Carr A, Tong W. Delabeling, safety, and impact of β-lactam allergy testing: A systematic review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100160. [PMID: 37781667 PMCID: PMC10509936 DOI: 10.1016/j.jacig.2023.100160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 07/18/2023] [Accepted: 07/18/2023] [Indexed: 10/03/2023]
Abstract
Background To improve β-lactam delabeling outcomes, we need to understand current practice and the evidence base regarding its outcomes, safety, and impact. Objectives We sought to assess the existing published evidence reporting on the effectiveness of penicillin allergy testing and delabeling. Methods We conducted a systematic review of studies reporting β-lactam delabeling practices and outcomes after testing, including β-lactam use and patient understanding of the delabeling result. Searches of the PubMed, Scopus, and Embase databases; clinical trial registries; and websites of professional organizations were conducted. Data were extracted from the included studies in duplicate, with a third extraction if discrepancies remained. Results We included 284 publications (covering 98,316 participants); 173 were prospective studies, with no randomized controlled trials. The overall study quality was low. In all, 95.6% of individuals who underwent provocation testing were delabeled. Factors associated with successful delabeling could not be determined because of significant heterogeneity between studies. Anaphylaxis due to testing occurred in 0.3% of participants (95 of 31,667). Subjects who did not undergo skin testing (6,980 patients in 31 studies) before challenge had higher rates of provocation test positivity (8.8% vs 4.1% [P < .0001]) and anaphylaxis (15.9% vs 2.7% [P < .0001]) than those subjects who underwent skin testing (51,607 patients in 177 studies). Six studies (2.1%) followed patients after testing to assess their adherence to prescribing recommendations. In all, 136 participants (20.6%) were actively avoiding β-lactams despite delabeling. Conclusions The available data suggest that penicillin allergy testing is safe and effective in delabeling most individuals, but the evidence base is incomplete and more work is required to assess the role of skin testing and the impact that delabeling is having on prescribing habits.
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Affiliation(s)
| | | | | | | | - Timothy Li
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, China
| | | | - Robert O’Neill
- St. Vincent’s Hospital, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine and Health, St. Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | | | - Andrew Carr
- St. Vincent’s Hospital, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine and Health, St. Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Winnie Tong
- St. Vincent’s Hospital, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine and Health, St. Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
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4
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Arnold A, Coventry LL, Foster MJ, Koplin JJ, Lucas M. The Burden of Self-Reported Antibiotic Allergies in Health Care and How to Address It: A Systematic Review of the Evidence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3133-3145.e3. [PMID: 37352931 DOI: 10.1016/j.jaip.2023.06.025] [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: 12/06/2022] [Revised: 05/28/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Antibiotics are the first-line treatment for bacterial infections; however, overuse and inappropriate prescribing have made antibiotics less effective with increased antimicrobial resistance. Unconfirmed reported antibiotic allergy labels create a significant barrier to optimal antimicrobial stewardship in health care, with clinical and economic implications. OBJECTIVE A systematic review was conducted to summarize the impact of patient-reported antibiotic allergy on clinical outcomes and various strategies that have been employed to effectively assess and remove these allergy labels, improving patient care. METHODS The review was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A critical appraisal was conducted on all studies and a narrative synthesis was performed to identify themes. RESULTS Four themes emerged: the prevalence of antibiotic allergy, impact of antibiotic allergy on antimicrobial prescribing, impact of antibiotic allergy on clinical outcomes, and delabeling strategies to improve clinical outcomes. Of the 32 studies, including 1,089,675 participants, the prevalence of reported antibiotic allergy was between 5% and 35%. Patients with a reported antibiotic allergy had poorer concordance with prescribing guidelines in 30% to 60% of cases, with a higher use of alternatives such as quinolone, tetracycline, macrolide, lincosamide, and carbapenem and lower use of beta-lactam antibiotics. Antibiotic allergy delabeling was identified as an intervention and recommendation to advance the state of the science. CONCLUSIONS There is substantial evidence within the literature that antibiotic allergy labels significantly impact patient clinical outcomes and a consensus that systematic assessment of reported antibiotic allergies, commonly referred to as delabeling, improves the clinical management of patients.
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Affiliation(s)
- Annabelle Arnold
- Immunology Department, Perth Children's Hospital, Perth, Australia; School of Nursing and Midwifery, Edith Cowan University, Perth, Australia
| | - Linda L Coventry
- School of Nursing and Midwifery, Edith Cowan University, Perth, Australia; Centre for Nursing Research, Sir Charles Gairdner Hospital, Perth, Australia
| | - Mandie J Foster
- School of Nursing and Midwifery, Edith Cowan University, Perth, Australia; Auckland University of Technology, School of Clinical Sciences, Auckland, New Zealand
| | - Jennifer J Koplin
- University of Queensland, Child Health Research Centre, Brisbane, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Michaela Lucas
- Immunology Department, Perth Children's Hospital, Perth, Australia; Medical School, University of Western Australia, Perth, Australia; Immunology Department, PathWest Laboratory Medicine WA, Perth, Australia; Immunology Department, Sir Charles Gairdner Hospital, Perth, Australia.
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5
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Abbott IJ, Peel TN, Cairns KA, Stewardson AJ. Antibiotic management of urinary tract infections in the post-antibiotic era: a narrative review highlighting diagnostic and antimicrobial stewardship. Clin Microbiol Infect 2023; 29:1254-1266. [PMID: 35640839 DOI: 10.1016/j.cmi.2022.05.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/03/2022] [Accepted: 05/11/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND As one of the most common indications for antimicrobial prescription in the community, the management of urinary tract infections (UTIs) is both complicated by, and a driver of, antimicrobial resistance. OBJECTIVES To highlight the key clinical decisions involved in the diagnosis and treatment of UTIs in adult women, focusing on clinical effectiveness and both diagnostic and antimicrobial stewardship as we approach the post-antimicrobial era. SOURCES Literature reviewed via directed PubMed searches and manual searching of the reference list for included studies to identify key references to respond to the objectives. A strict time limit was not applied. We prioritised recent publications, randomised trials, and systematic reviews (with or without meta-analyses) where available. Searches were limited to English language articles. A formal quality assessment was not performed; however, the strengths and limitations of each paper were reviewed by the authors throughout the preparation of this manuscript. CONTENT We discuss the management of UTIs in ambulatory adult women, with particular focus on uncomplicated infections. We address the diagnosis of UTIs, including the following: definition and categorisation; bedside assessments and point-of-care tests; and the indications for, and use of, laboratory tests. We then discuss the treatment of UTIs, including the following: indications for treatment, antimicrobial sparing approaches, key considerations when selecting a specific antimicrobial agent, specific treatment scenarios, and duration of treatment. We finally outline emerging areas of interest in this field. IMPLICATIONS The steady increase in antimicrobial resistance among common uropathogens has had a substantial affect on the management of UTIs. Regarding both diagnosis and treatment, the clinician must consider both the patient (clinical effectiveness and adverse effects, including collateral damage) and the community more broadly (population-level antimicrobial selection pressure).
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Affiliation(s)
- Iain J Abbott
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia; Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia.
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kelly A Cairns
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Saravanabavan S, Aulakh A, Douglas J, Elwood C, Erdle S, Grant J, Kang KT, Kwan N, Lacaria K, Lau TTY, Lee C, Leung V, Lin YC, Mah A, Nguyen A, Paquette V, Roberts A, Watt M, Van Schalkwyk J, Zhang BY, Mak R, Wong T. Penicillin de-labelling in vancouver, British Columbia, Canada: comparison of approaches, outcomes and future directions. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:30. [PMID: 37072861 PMCID: PMC10114447 DOI: 10.1186/s13223-023-00777-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/27/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Inaccurate penicillin allergy labels lead to inappropriate antibiotic prescriptions and harmful patient consequences. System-wide efforts are needed to remove incorrect penicillin allergy labels, but more health services research is required on how to best deliver these services. METHODS Data was extracted from five hospitals in Vancouver, British Columbia, Canada from October 2018-May 2022. The primary outcomes of this study were to outline de-labelling protocol designs, identify the roles of various healthcare professionals in de-labelling protocols and identify rates of de-labelling penicillin allergies and associated adverse events at various institutions. Our secondary outcome was to describe de-labelling rates for special populations, including pediatric, obstetric and immunocompromised subpopulations. To achieve these outcomes, participating institutions provided their de-labelling protocol designs and data on program participants. Protocols were then compared to find common themes and differences. Furthermore, adverse events were reviewed and percentages of patients de-labelled at each institution and in total were calculated. RESULTS Protocols demonstrated a high level of variability, including different methods of participant identification, risk-stratification and roles of providers. All protocols used oral and direct oral challenges, heavily involved pharmacists and had physician oversight. Despite the differences, of the 711 patients enrolled in all programs, 697 (98.0%) were de-labelled. There were 9 adverse events (1.3%) with oral challenges with mainly minor symptoms. CONCLUSIONS Our data demonstrates that de-labelling programs effectively and safely remove penicillin allergy labels, including pediatric, obstetric and immunocompromised patients. Consistent with current literature, most patients with a penicillin allergy label are not allergic. De-labelling programs could benefit from increasing clinician engagement by increasing accessibility of resources to providers, including guidance for de-labelling of special populations.
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Affiliation(s)
- Sujen Saravanabavan
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
| | | | | | - Chelsea Elwood
- B.C. Women's Hospital and Health Centre, Vancouver, BC, Canada
| | | | - Jennifer Grant
- Vancouver General Hospital, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Katie Lacaria
- Vancouver General Hospital, Vancouver, BC, Canada
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Tim T Y Lau
- Vancouver General Hospital, Vancouver, BC, Canada
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Colin Lee
- Providence Health Care, Vancouver, BC, Canada
| | - Victor Leung
- Providence Health Care, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Yu-Chen Lin
- Lions Gate Hospital, Vancouver, BC, Canada
- Lower Mainland Pharmacy Services, Vancouver, BC, Canada
| | - Allison Mah
- Vancouver General Hospital, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anne Nguyen
- Lions Gate Hospital, Vancouver, BC, Canada
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Melissa Watt
- B.C. Women's Hospital and Health Centre, Vancouver, BC, Canada
| | | | - Bei Yuan Zhang
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Raymond Mak
- BC Children's Hospital, Vancouver, BC, Canada
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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.
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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
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8
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[Efficiency of the allergological study in the diagnosis of allergic reactions to beta-lactams]. Semergen 2023; 49:101866. [PMID: 36434940 DOI: 10.1016/j.semerg.2022.101866] [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: 08/17/2022] [Revised: 09/14/2022] [Accepted: 10/08/2022] [Indexed: 11/24/2022]
Abstract
AIMS Assessing the rate of β-lactams-allergic patients who are still labelled as such in their medical records after being performed an allergic test; as well as the rate of no allergic patients who were prescribed one of these antibiotics; and pondering whether the allergic test is hence cost-effective. METHODS This is a retrospective study developed from 2019 to 2021 focusing on patients suspected of β-lactams allergy (n=688). By means of an allergy test, it was cleared out if they were actually allergic. Later, we checked if the patient was still labelled as allergic in their medical record. Tracking through the digital health services card, we followed up if the antibiotic was ever prescribed again, and if the drug was then dispensed to the patient. RESULTS 11.3% of the patients showed hypersensitivity to β-lactams. Nonetheless, 33.1% of the patients were still considered allergic to these antibiotics in their medical record even though not being such. 32% of the patients - who had their allergy confirmed - had been labelled without the general practitioner's acknowledgment, and 32.8% had even been prescribed a β-lactam again. CONCLUSIONS Discarding any allergy to β-lactams is as important as registering the allergy on medical records after testing the patient. A remarkable quantity of non-allergic patients is still addressed as actual allergic, in spite not being such. Labelling patients as β-lactams allergic may have consequences, short-term and long-term, for the patient but also for the health service budget.
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9
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Loprete J, Katelaris CH, Evans L, Kane A, McMullan B, Wainstein B, Wong M, Post J, Suan D, Swaminathan S, Richardson R, Rogers J, Torda A, Campbell DE, Kelleher AD, Law M, Carr A, Tong WW. Standardized testing and written communication improve patient understanding of beta-lactam allergy testing outcomes: A multicenter, prospective study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2022; 1:99-105. [PMID: 37781263 PMCID: PMC10509847 DOI: 10.1016/j.jacig.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/25/2022] [Accepted: 05/02/2022] [Indexed: 10/03/2023]
Abstract
Background Historical penicillin allergy is commonly reported, but the lack of standardized allergy clinic practices may diminish the ability to delabel beta-lactam allergy appropriately. Objective We sought to improve beta-lactam allergy testing and patient understanding of their antibiotic allergy status by standardizing testing and communication practices between 7 adult and pediatric hospital centers. Methods Phase 1 prospectively described the beta-lactam allergy testing practices at each center. Following this, practice was standardized to achieve a defined panel of skin testing reagents, pro forma result letters for patients and referring doctors, and provision of medical alert jewelry to those with confirmed allergy. Testing outcomes and patient perception regarding allergy status 8 weeks postassessment were compared before (phase 1) and after standardization (phase 2). Primary outcomes were the percentage of participants delabeled after testing, and concordance rates between participant perception of their allergy status and their status as determined by the treating physician at 8-week follow-up. Results Of 195 adult and pediatric participants (median age, 50 years; 21.5% <18 years; 36.9% males), 75% were delabeled of their beta-lactam allergy. No patient experienced anaphylaxis related to any beta-lactam delabeling testing. In phase 1, 75% of participants received written results, 52% were informed verbally, and 48% received results in more than 1 form. All phase 2 participants received written results (P < .01), 61% received verbal results from a physician as well (P > .05). At 8-week follow-up, 54% of phase 1 participants had concordant perceptions of their allergy status as the testing team versus 91.6% in phase2 (P < .001). Of the 17 participants who were delabeled and treated with a beta-lactam antibiotic during the 8-week follow-up period, there were no reported allergic reactions, although 1 participant experienced anaphylaxis following exposure to amoxicillin-clavulanic acid 1 year after delabeling. Conclusions Standardization of testing and written patient information improved short-term patient perception of beta-lactam allergy status.
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Affiliation(s)
- Jacqueline Loprete
- Immunology and HIV Unit, St Vincent’s Hospital, Sydney, Australia
- St Vincent’s Centre for Applied Medical Research, St Vincent’s Hospital, Sydney, Australia
| | - Constance H. Katelaris
- Campbelltown Hospital, Western Sydney University, Campbelltown, Australia
- School of Medicine, Western Sydney University, Campbelltown, Australia
| | | | - Alisa Kane
- Immunology and HIV Unit, St Vincent’s Hospital, Sydney, Australia
- Liverpool Hospital, Liverpool, Australia
| | - Brendan McMullan
- Sydney Children’s Hospital, Randwick, Australia
- St Vincent’s Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, Australia
| | - Brynn Wainstein
- Sydney Children’s Hospital, Randwick, Australia
- St Vincent’s Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, Australia
| | - Melanie Wong
- Children’s Hospital Westmead, Westmead, Australia
- School of Medicine, Sydney University, Sydney, Australia
| | - Jeffrey Post
- St Vincent’s Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, Australia
- Prince of Wales Hospital, Randwick, Australia
| | - Daniel Suan
- St Vincent’s Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, Australia
- Westmead Hospital, Westmead, Australia
| | - Sanjay Swaminathan
- School of Medicine, Western Sydney University, Campbelltown, Australia
- School of Medicine, Sydney University, Sydney, Australia
- Westmead Hospital, Westmead, Australia
| | - Robyn Richardson
- St Vincent’s Centre for Applied Medical Research, St Vincent’s Hospital, Sydney, Australia
| | - Jamie Rogers
- St Vincent’s Centre for Applied Medical Research, St Vincent’s Hospital, Sydney, Australia
| | - Adrienne Torda
- St Vincent’s Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, Australia
- Prince of Wales Hospital, Randwick, Australia
| | - Dianne E. Campbell
- Children’s Hospital Westmead, Westmead, Australia
- School of Medicine, Sydney University, Sydney, Australia
| | - Anthony D. Kelleher
- Immunology and HIV Unit, St Vincent’s Hospital, Sydney, Australia
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Matthew Law
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Andrew Carr
- Immunology and HIV Unit, St Vincent’s Hospital, Sydney, Australia
- St Vincent’s Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, Australia
| | - Winnie W.Y. Tong
- Immunology and HIV Unit, St Vincent’s Hospital, Sydney, Australia
- St Vincent’s Centre for Applied Medical Research, St Vincent’s Hospital, Sydney, Australia
- St Vincent’s Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, Australia
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10
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Elzagallaai AA, Rieder MJ. Genetic markers of drug hypersensitivity in pediatrics: current state and promise. Expert Rev Clin Pharmacol 2022; 15:715-728. [DOI: 10.1080/17512433.2022.2100345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Abdelbaset A Elzagallaai
- Department of Paediatrics Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Physiology and Pharmacology Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Michael J Rieder
- Department of Physiology and Pharmacology Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Robarts Research Institute, Western University, London, Ontario, Canada
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11
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Hughes KM, Price D, Torriero AAJ, Symonds MRE, Suphioglu C. Impact of Fungal Spores on Asthma Prevalence and Hospitalization. Int J Mol Sci 2022; 23:ijms23084313. [PMID: 35457129 PMCID: PMC9025873 DOI: 10.3390/ijms23084313] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 02/06/2023] Open
Abstract
Despite making up a significant proportion of airborne allergens, the relationship between fungal spores and asthma is not fully explored. Only 80 taxa of fungi have so far been observed to exacerbate respiratory presentations, with Cladosporium spp., Aspergillus spp., Penicillium spp., and Alternaria spp. found to comprise the predominant allergenic airborne spores. Fungal spores have been found in indoor environments, such as hospitals and housing due to poor ventilation. Meanwhile, outdoor fungal spores exhibit greater diversity, and higher abundance and have been associated with hospitalizations from acute asthma presentations. In addition, fungal spores may be the underlying, and perhaps the “missing link”, factor influencing the heightened rate of asthma presentations during epidemic thunderstorm asthma events. To improve our knowledge gap on fungal spores, airborne allergen monitoring must be improved to include not only dominant allergenic fungi but also provide real-time data to accurately and quickly warn the general public. Such data will help prevent future asthma exacerbations and thus save lives. In this review, we examine the health risks of prominent allergenic fungal taxa, the factors influencing spore dispersal and distribution, and why improvements should be made to current sampling methods for public health and wellbeing.
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Affiliation(s)
- Kira M. Hughes
- NeuroAllergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia; (K.M.H.); (D.P.)
- Deakin AIRwatch Pollen and Spore Counting and Forecasting Facility, Deakin University, Burwood, VIC 3125, Australia
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), Deakin University, 75 Pigdons Road, Waurn Ponds, VIC 3216, Australia
| | - Dwan Price
- NeuroAllergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia; (K.M.H.); (D.P.)
- Deakin AIRwatch Pollen and Spore Counting and Forecasting Facility, Deakin University, Burwood, VIC 3125, Australia
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), Deakin University, 75 Pigdons Road, Waurn Ponds, VIC 3216, Australia
- NeuroAllergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 75 Pigdons Road, Waurn Ponds, VIC 3216, Australia
- COVID-19 Response, Department of Health, 50 Lonsdale Street, Melbourne, VIC 3000, Australia
| | - Angel A. J. Torriero
- School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia;
| | - Matthew R. E. Symonds
- Centre for Integrative Ecology, School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia;
| | - Cenk Suphioglu
- NeuroAllergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia; (K.M.H.); (D.P.)
- Deakin AIRwatch Pollen and Spore Counting and Forecasting Facility, Deakin University, Burwood, VIC 3125, Australia
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), Deakin University, 75 Pigdons Road, Waurn Ponds, VIC 3216, Australia
- NeuroAllergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 75 Pigdons Road, Waurn Ponds, VIC 3216, Australia
- Correspondence: ; Tel.: +61-3-5227-2886
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12
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English KR, Knight K, Radke A, Sammells B, Walter C, Halliday D. Assessment of the validity of the beta-lactam antibiotic allergy assessment tool for use in the rural context, QLD. Aust J Rural Health 2022; 30:697-701. [PMID: 35384106 DOI: 10.1111/ajr.12868] [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: 12/05/2020] [Revised: 02/24/2022] [Accepted: 03/07/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE(S) The objective of the study was to validate a clinical aid to guide the assessment and management of a patient's listed beta-lactam antibiotic allergy for use in rural areas of Australia. DESIGN Rural generalists, pharmacists and junior doctors completed an online assessment of eight patient case studies using the tool. SETTING The study was conducted in the Southern Downs, QLD. PARTICIPANTS Twenty-seven rural generalists, nine pharmacists and eight junior doctors. MAIN OUTCOME MEASURES The sensitivity of the selected allergy phenotype and management option for each case study was calculated by profession and overall. Hazardous responses were reported by management category and profession. RESULTS The sensitivity overall for phenotype selection was 82.4% (95% CI, 78.0-86.2) and for management 88.1% (95% CI, 84.2-91.2). The sensitivity for phenotype selection was lower for junior doctors than other professions 73.4% (95% CI, 60.9-83.7), but did not reach statistical significance (p = 0.08). A total of 10/308 responses for management recommended the least restrictive option of direct delabelling or oral challenge, where the correct answer was skin prick testing or referral to an allergist. CONCLUSION(S) With further education the tool could be a key component of increased antimicrobial stewardship in rural areas in Australia.
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Affiliation(s)
| | - Kay Knight
- Queensland Health, Stanthorpe, Queensland, Australia
| | - Alexandra Radke
- Queensland Health, Stanthorpe, Queensland, Australia.,Griffith University, Nathan, Queensland, Australia
| | - Bethany Sammells
- Queensland Health, Stanthorpe, Queensland, Australia.,Griffith University, Nathan, Queensland, Australia
| | - Claire Walter
- Queensland Health, Stanthorpe, Queensland, Australia
| | - Daniel Halliday
- Queensland Health, Stanthorpe, Queensland, Australia.,Griffith University, Nathan, Queensland, Australia
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13
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Boesch TS, Eischen E, M AR, Quinn A, Dave A, Beezhold DW. Promoting β-lactam utilization through suppression of electronic medical record cross-allergy alerts. Am J Health Syst Pharm 2022; 79:S43-S52. [PMID: 35136927 DOI: 10.1093/ajhp/zxac040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Current literature surrounding management of patients with reported β-lactam allergies focuses on allergy delabeling. Standard clinical decision support tools have not been optimized to be compatible with the currently accepted cross-reaction rate of 1% to 2%. This potentially promotes use of non-β-lactam antibiotics, which are often not first-line therapy and may carry increased risks. The impact of electronic medical record (EMR) clinical decision support tool optimization on utilization of β-lactam antibiotics in β-lactam-allergic patients was evaluated. METHODS A retrospective pre-post β-lactam cross-allergy EMR alert suppression quality improvement intervention cohort study of β-lactam-allergic adult inpatients prescribed antibiotics was conducted. Preintervention baseline data were collected for an initial cohort admitted during September 2018. The intervention, in which clinical decision support rules were updated to display β-lactam cross-sensitivity allergy alerts only for β-lactam-allergic patients with documentation of organization-defined high-severity reactions of anaphylaxis, hives, and shortness of breath, was implemented August 20, 2019. The postintervention cohort included patients admitted during September 2019. RESULTS A 91% increase in the percentage of β-lactam-allergic patients who received a β-lactam agent at any time during their admission was noted after the intervention (26.6% vs 51%, P < 0.001). Statistically significant decreases in prescribing of alternative antibiotic classes were seen for fluoroquinolones (decrease from 45.3% to 26%, P < 0.001), aminoglycosides (decrease from 9.4% to 2.9%, P = 0.002), and aztreonam (decrease from 30% to 16.7%, P < 0.001). CONCLUSION EMR β-lactam cross-allergy alert optimization consistent with current literature significantly improved the utilization of alternative β-lactam subclasses, mostly through β-lactam prescribing as initial therapy in β-lactam-allergic patients.
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Affiliation(s)
- Teryl S Boesch
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Edward Eischen
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Amanda Ries M
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Andrea Quinn
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Ankur Dave
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
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14
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Liu HH, Mutneja H, Buckley M, Cushinotto L. Trends in Antimicrobial Allergies in Patients Seen in Infectious Disease Consultation During Selected Periods 2007–2016. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Burden of antibiotic allergy labels in Australian aged care residents: Findings from a national point-prevalence survey. Infect Control Hosp Epidemiol 2021; 41:641-644. [PMID: 32188526 DOI: 10.1017/ice.2020.53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the prevalence of antibiotic allergy labels (AALs) in Australian aged care residents and to describe the impact of labels on antibiotic prescribing practices. DESIGN Point-prevalence survey. SETTING Australian residential aged care facilities. PARTICIPANTS We surveyed 1,489 residents in 407 aged care facilities. METHODS Standardized data were collected on a single day between June 1 and August 31, 2018, for residents prescribed an antibiotic. An AAL was reported if it was documented in the resident's health record. Resident-level data were used to calculate overall prevalence, and antibiotic-level data were used to report relative frequency of AALs for individual antibiotics and classes. RESULTS Among 1,489 residents, 356 (24%) had 1 or more documented AALs. The AALs for penicillin (28.3%), amoxicillin or amoxicillin/clavulanic acid (10.5%), cefalexin (7.2%), and trimethoprim (7.0%) were most commonly reported. The presence of an AAL was associated with significantly less prescribing of penicillins (OR, 0.43; 95% CI, 0.31-0.62; P < .001) and significantly more prescribing of lincosamides (OR, 4.81; P < .001), macrolides (OR, 2.03; P = .007), and tetracyclines (OR, 1.54; P = .033). Of residents with AALs, 7 residents (1.9%) were prescribed an antibiotic that was listed on the allergy section of their health record. CONCLUSIONS A high prevalence of AALs was observed among residents of Australian aged care facilities, comparable to the prevalence of AALs in high-risk hospitalized patients. Significant increases in prescribing of lincosamide, macrolide, and tetracycline agents poses a potential risk to aged populations, and future studies must evaluate the benefits of AAL delabelling programs tailored for aged care settings.
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16
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Catalano AC, Pittet LF, Choo S, Segal A, Stephens D, Cranswick NE, Gwee A. Impact of Antibiotic Allergy Labels on Patient Outcomes in a Tertiary Paediatric Hospital. Br J Clin Pharmacol 2021; 88:1107-1114. [PMID: 34388858 DOI: 10.1111/bcp.15038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Antibiotic allergies are reported in 5 to 15% of children. This study aimed to evaluate the impact of common β-lactam antibiotic allergy labels (AALs) on hospital treatment, focussing on length of stay and appropriateness of antibiotic prescribing. STUDY DESIGN Retrospective cohort study over 21-months at the Royal Children's Hospital Melbourne, Australia. A subset of children with the most common β-lactam allergies, and who required admission for intravenous antibiotics over a 12-month period, was analysed for appropriateness of prescribing. Non-allergic patients were matched to evaluate associations between AALs and hospital treatment. RESULTS There were 98,912 children admitted over the study period, of whom 938 (1%) had at least one AAL on first admission. Of all encounters, 5145 (2.5%) were for children with AALs. The most common AALs were to amoxicillin and amoxicillin-clavulanic acid combinations (40.8%), cefalexin (14.4%) and trimethoprim-sulfamethoxazole (9.7%). For the subset, there were 66 admissions for children who required intravenous antibiotics. Documentation was adequate for 27% of AALs. Inappropriate prescribing occurred in almost half (47%). Hospital stay was longer for children with AALs (median 4.7 days; IQR 2.3 to 9.2) compared to non-allergic controls (median 3.9 days; IQR 1.9 to 6.8; P=0.02). Children with AALs were more likely to receive restricted antibiotics (aOR 3.03; 95%CI, 1.45 to 6.30; p=0.003). CONCLUSION This is the first study to demonstrate high rates of inappropriate prescribing in children with AALs. Children with AALs were significantly more likely to receive restricted antibiotics and had a longer length of stay compared with non-allergic controls.
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Affiliation(s)
- Anthony C Catalano
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Laure F Pittet
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia
| | - Sharon Choo
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Allergy and Immunology, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Ahuva Segal
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia
| | - David Stephens
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Noel E Cranswick
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | - Amanda Gwee
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia
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17
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Yuson C, Shakib S, Smith W. Prevalence of drug allergy in South Australia. Intern Med J 2021; 52:1957-1961. [PMID: 34160122 DOI: 10.1111/imj.15440] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Drug allergy is commonly reported in patient notes and electronic health records. The prevalence of self-reported drug allergy in the general Australian population has not previously been studied. METHODS We surveyed a representative sample of the South Australian adult population regarding their own perception of drug allergy, including drug type and severity as well as the use of medical alert devices. Data were weighted to correspond to age and sex of the South Australian population. RESULTS 22.2% of adults in South Australia consider themselves allergic to one or more drugs, 9.3% declared themselves to be allergic to penicillin, 5% to an antibiotic other than penicillin, and 13% to one or more antibiotics. Drug allergy and penicillin allergy was significantly more prevalent in females, and increased with age. Thirteen percent of those with an antibiotic allergy reported a severe reaction, of whom 27% wore a medical notification device. Of those allergic to penicillin, 75% had their index reaction more than 10 years ago and did not report severe features. DISCUSSION Self-reported drug allergy is common in the general population, as it is in medical clinic and hospital populations. The majority of those reporting penicillin allergy would be considered low-risk and suitable for delabelling procedures. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Carlo Yuson
- Immunology and Allergy Department, Royal Adelaide Hospital, Adelaide, Australia
| | - Sepehr Shakib
- Clinical Pharmacology Department, Royal Adelaide Hospital, Adelaide, Australia
| | - William Smith
- Immunology and Allergy Department, Royal Adelaide Hospital, Adelaide, Australia
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18
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Hall V, Wong M, Munsif M, Stevenson BR, Elliott K, Lucas M, Baird AJ, Athan E, Young M, Pickles R, Cheng AC, Stewardson AJ, Aung AK, Trubiano JA. Antimicrobial anaphylaxis: the changing face of severe antimicrobial allergy. J Antimicrob Chemother 2021; 75:229-235. [PMID: 31637446 DOI: 10.1093/jac/dkz422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/25/2019] [Accepted: 09/10/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES The epidemiology, clinical characteristics and outcomes of antimicrobial-associated anaphylaxis remain ill-defined. We sought to examine antimicrobial anaphylaxis with regard to: (i) the frequency of implicated antimicrobials; (ii) attributable mortality; and (iii) referral for definitive allergy assessment. METHODS This was conducted through a national retrospective multicentre cohort study at five Australian tertiary hospitals (January 2010 to December 2015). Cases of antimicrobial anaphylaxis were identified from ICD-10 coding and adverse drug reaction committee databases. RESULTS There were 293 participants meeting the case definition of antimicrobial anaphylaxis and 310 antimicrobial anaphylaxis episodes. Of 336 implicated antimicrobials, aminopenicillins (62/336, 18.5%) and aminocephalosporins (57/336, 17%) were implicated most frequently. ICU admission occurred in 43/310 (13.9%) episodes; however, attributable mortality was low (3/310, 1%). The rate of anaphylaxis to IV antibiotics was 3.5 (95% CI=2.9-4.3) per 100 000 DDDs and the rate of hospital-acquired anaphylaxis was 1.9 (95% CI=2.1-3.3) per 100 000 occupied bed-days. We observed overall low rates of hospital discharge documentation (222/310, 71.6%) and follow-up by specialist allergy services (73/310, 23.5%), which may compromise medication safety and antimicrobial prescribing in future. CONCLUSIONS This study demonstrated that a high proportion of severe immediate hypersensitivity reactions presenting or acquired in Australian hospitals are secondary to aminopenicillins and aminocephalosporins. Overall rates of hospital-acquired anaphylaxis, predominantly secondary to cephalosporins, are low, and also associated with low inpatient mortality.
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Affiliation(s)
- Victoria Hall
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Hospital, VIC, Australia.,Department of Infectious Diseases, Alfred Health, VIC, Australia
| | - Micah Wong
- School of Medicine, University of Melbourne, VIC, Australia
| | - Maitri Munsif
- Department of General Medicine, Alfred Hospital, Monash University, VIC, Australia
| | - Brittany R Stevenson
- Department of Immunology, Sir Charles Gairdner Hospital, WA, Australia.,PathWest Immunology, Nedlands, WA, Australia
| | - Katie Elliott
- School of Medicine, University of Western Australia, WA, Australia
| | - Michaela Lucas
- Department of Immunology, Sir Charles Gairdner Hospital, WA, Australia.,PathWest Immunology, Nedlands, WA, Australia
| | - Ashleigh J Baird
- University Hospital Geelong Barwon Health, Geelong, VIC, Australia
| | - Eugene Athan
- University Hospital Geelong Barwon Health, Geelong, VIC, Australia.,Deakin University, School of Medicine, Geelong, VIC, Australia
| | - Melissa Young
- Hunter New England Local Health District, John Hunter Hospital, NSW, Australia
| | - Robert Pickles
- Departments of Infectious Diseases and General Medicine, John Hunter Hospital, Hunter New England Local Health District, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, NSW, Australia
| | - Allen C Cheng
- Department of Infectious Diseases, Alfred Health, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, VIC, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, Alfred Health, VIC, Australia.,ASID Clinical Research Network, Sydney, NSW, Australia
| | - Ar K Aung
- Department of Infectious Diseases, Alfred Health, VIC, Australia.,Department of General Medicine, Alfred Hospital, Monash University, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Hospital, VIC, Australia.,Department of Medicine, University of Melbourne, VIC, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, VIC, Australia
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19
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The impact of antibiotic allergy labels on antibiotic exposure, clinical outcomes, and healthcare costs: A systematic review. Infect Control Hosp Epidemiol 2020; 42:530-548. [PMID: 33059777 DOI: 10.1017/ice.2020.1229] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE A growing body of evidence suggests that antibiotic allergy labels as documented in medical records are a risk factor for poor clinical outcomes. In this systematic review, we aimed to determine how antibiotic allergy labels influence 3 domains: antibiotic use and exposure, clinical outcomes, and healthcare-related costs. DESIGN We performed a systematic review to identify studies reporting outcomes in patients with antibiotic allergy labels compared to nonallergic counterparts. The search included PubMed, EMBASE, Cochrane CENTRAL, EBSCO, Cochrane Database of Abstracts of Reviews of Effects and Web of Science. Two reviewers independently screened studies for inclusion and abstracted data. Studies were graded using the Newcastle-Ottawa quality assessment scale. Study outcomes included antibiotic use, clinical outcomes, and economic outcomes. RESULTS In total, 41 studies met our criteria for inclusion. These studies varied in medical specialty, patient population, healthcare delivery system, and design, but most were conducted among adults age >18 years (85%) in the inpatient setting (82.5%). Among 34 studies examining antibiotic exposure, 32 (94%) found that patients with antibiotic allergy labels received more broad-spectrum antibiotics. Moreover, 31 studies examined clinical outcomes such as length of hospitalization, ICU admission, hospital readmission, multidrug-resistant or opportunistic infection, or mortality, and 27 (87%) found that allergy-labeled patients had at least 1 negative outcome. Of 9 studies examining healthcare costs, 7 (78%) found that allergy-labeled patients incurred significantly higher drug or hospital-related costs. CONCLUSIONS Antibiotic allergy labels have negative effects on antibiotic use, clinical outcomes, and economic outcomes in a variety of clinical settings and populations.
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Kuang X, Gong X, Zhang X, Pan H, Teng Z. Genetic diversity of group A rotavirus in acute gastroenteritis outpatients in Shanghai from 2017 to 2018. BMC Infect Dis 2020; 20:596. [PMID: 32787859 PMCID: PMC7425067 DOI: 10.1186/s12879-020-05279-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 07/20/2020] [Indexed: 12/20/2022] Open
Abstract
Background Group A Rotavirus (RVA), despite being an important pathogen in hospitalized children, is less studied in pediatric outpatients, and even rarely investigated in adults. This study aims to understand the genetic diversity of RVA in outpatients across all age groups in Shanghai, and thus providing a molecular basis for vaccine implementation and evaluation. Methods Stool samples were first screened by Real-time Reverse Transcription Polymerase Chain Reaction (rRT-PCR). RVA genotyping was performed through the amplification of partial VP7 and VP4 gene. Strains of interest were further sequenced and analyzed using MEGA 6.0. Results Four thousand nine hundred one samples were collected, from which 7.61% (373 cases) were screened positive for RVA. RVA prevalence was higher in children (9.30%) than in adults (7.21%) (χ2 = 4.72, P < 0.05). 9.38% RVA positive cases had taken antibiotics before hospital visit while 49.60% had been prescribed antibiotics afterwards. RVA displayed a strong seasonality in both adults and children with a shared commonality in genotype repertoire, where G9P[8] was the most prevalent strain (67.96%) followed by G3P[8] (15.49%) and G1P[8] (12.32%). Meanwhile the first local case of fecal shedding of the G10P[15] vaccine strain was also discovered. Conclusions While the prevalence of rotavirus is highest during cold seasons, it is revealed for the first time that G9P[8] is the predominant genotype in both adults and pediatric outpatients. Clinically, higher occurrence of nausea or vomiting was observed in RVA positive cases. Antibiotic overuse was implicated in both non-clinical and clinical settings. The finding emphasizes the importance of RVA genotyping in surveillance as it provides the basis for new vaccine application as well as a baseline for future vaccine efficacy evaluation.
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Affiliation(s)
- Xiaozhou Kuang
- Shanghai Municipal Center for Disease Control and Prevention, 1380 Zhongshan Road (west), Shanghai, 200336, China
| | - Xiaohuan Gong
- Shanghai Municipal Center for Disease Control and Prevention, 1380 Zhongshan Road (west), Shanghai, 200336, China
| | - Xi Zhang
- Shanghai Municipal Center for Disease Control and Prevention, 1380 Zhongshan Road (west), Shanghai, 200336, China
| | - Hao Pan
- Shanghai Municipal Center for Disease Control and Prevention, 1380 Zhongshan Road (west), Shanghai, 200336, China.
| | - Zheng Teng
- Shanghai Institutes of Preventive Medicine, 1380 Zhongshan Road (west), Shanghai, 200336, China.
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21
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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.
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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
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22
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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.
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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
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Yuson C, Kumar K, Le A, Ahmadie A, Banovic T, Heddle R, Kette F, Smith W, Hissaria P. Immediate cephalosporin allergy. Intern Med J 2020; 49:985-993. [PMID: 30667130 DOI: 10.1111/imj.14229] [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] [Received: 08/13/2018] [Revised: 12/18/2018] [Accepted: 01/09/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients who suffer from acute IgE-mediated allergy to a cephalosporin antibiotic are frequently assumed to be at high risk of allergy to other cephalosporins and penicillins. AIM To define cross-reactivity patterns in patients with confirmed allergy to a cephalosporin. METHODS Subjects presenting with a history of immediate allergy to a cephalosporin-family antibiotic between March 2009 and July 2017 were investigated with specific IgE testing to penicillin, amoxycillin and cefaclor, followed by skin prick testing, intradermal testing and drug provocation testing with a panel of penicillins and cephalosporins. RESULTS Out of 564 subjects with a reported beta-lactam allergy, 90 identified a cephalosporin as their index drug. Fifty-five (61.1%) of the 90 subjects tested had a history consistent with an IgE-mediated reaction, of whom 24 (43.6%) were proven to be allergic to their index cephalosporin. Twenty (83.3%) of the 24 were allergic only to their index cephalosporin. Of the four remaining subjects, two were co-sensitised to another beta-lactam with a similar side chain, while the other two had no specific cross-reactivity pattern. Major and minor penicillin determinants were negative for all cephalosporin-allergic individuals. CONCLUSION In our cohort, cephalosporin allergy does not appear to be a class effect, with most cases found allergic only to their index cephalosporin. Co-sensitisation to other cephalosporins or penicillins was uncommon, and when it occurred, was usually consistent with side chain cross-reactivity.
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Affiliation(s)
- Carlo Yuson
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Kimti Kumar
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adriana Le
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Aida Ahmadie
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tatjana Banovic
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Robert Heddle
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Frank Kette
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - William Smith
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Pravin Hissaria
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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24
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Delabelling Antibiotic Hypersensitivity in Children Is Critical for Future Treatments. CURRENT TREATMENT OPTIONS IN ALLERGY 2020. [DOI: 10.1007/s40521-020-00249-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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25
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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.
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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
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26
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Wilcock M, Powell N, Sandoe J. A UK hospital survey to explore healthcare professional views and attitudes to patients incorrectly labelled as penicillin allergic: an antibiotic stewardship patient safety project. Eur J Hosp Pharm 2019; 26:329-333. [PMID: 31798856 PMCID: PMC6855872 DOI: 10.1136/ejhpharm-2017-001451] [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: 11/15/2017] [Revised: 04/26/2018] [Accepted: 05/01/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To ascertain the views, beliefs and attitudes of hospital staff to incorrect penicillin allergy records in order to determine healthcare worker motivation for the implementation of a penicillin de-labelling antibiotic stewardship intervention at the study hospital. METHODS An electronic questionnaire (SurveyMonkey) was distributed to medical, nursing and pharmacy staff at a 750-bed teaching district general hospital with no specialist allergy service. RESULTS 193 staff responded (58% medical, 31% nursing and 11% pharmacy). Virtually all staff had encountered patients who believed themselves to be penicillin allergic, but felt the patient's belief to be erroneous. The potential negative consequences of an incorrectly assigned penicillin allergy label were acknowledged by the majority of respondents. In total, 188/190 (99%) of staff thought patients having an incorrect allergy status to penicillin was a problem and required a solution. Staff reported they would feel confident using a validated evidence-based question tool to de-label patients incorrectly labelled as penicillin allergic if the process was supported by Trust management, although many still felt apprehensive about de-labelling patients for fear of patient harm through inappropriate de-labelling. CONCLUSIONS A penicillin allergy de-labelling intervention would be well supported by healthcare workers at the study hospital, demonstrating a receptive environment for this behavioural change intervention. Further exploration of the barriers and levers to introducing an intervention is required using behavioural change methodology in order to design a successful de-labelling intervention.
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Affiliation(s)
- Michael Wilcock
- Pharmacy Department, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Neil Powell
- Pharmacy Department, Royal Cornwall Hospitals NHS Trust, Truro, UK
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27
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Mason J, Kiel A, White A, Clark CM, Wattengel BA, Sellick JA, Mergenhagen KA. Impact of Beta-lactam Allergy on Treatment of Outpatient Infections. Clin Ther 2019; 41:2529-2539. [PMID: 31662217 DOI: 10.1016/j.clinthera.2019.10.001] [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] [Received: 07/24/2019] [Revised: 09/28/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The most commonly reported medication allergies in the United States involve beta-lactam antibiotics, creating an important consideration for prescribers when choosing optimal treatment of infections. Currently, few data exist on outpatient prescribing patterns in response to patients with a beta-lactam allergy. This study sought to evaluate the appropriateness of outpatient antibiotic therapy in patients with documented beta-lactam allergies within a Veterans Affairs health care system to evaluate areas of improvement in prescribing practices. METHODS Patients receiving outpatient oral antibiotics were prospectively identified through real-time electronic alerts from June 2017 through February 2018. Prescriptions were then reviewed retrospectively to identify appropriateness of antibiotic, drug choice, dose, and duration based on current guideline recommendations. Data were compared between patients with a listed beta-lactam allergy and patients without a beta-lactam allergy to determine the impact on prescribing patterns and outcomes. Baseline characteristics were compared by using descriptive statistics. Significant risk factors for inappropriate prescribing were identified through a multivariable analysis. FINDINGS The cohort included 1844 antibiotic prescriptions (documented beta-lactam allergy, 221; no beta-lactam allergy, 1623). Appropriate drug, dose, and duration for antibiotics prescribed in patients reporting a beta-lactam allergy versus nonallergic patients were 44.3% versus 53.0% (P = 0.02), 91.4% versus 86.2% (P = 0.03), and 75.1% versus 76.2% (P = 0.83), respectively. Patients with a reported beta-lactam allergy were 31% less likely to receive the correct drug for indication empirically (95% CI, 0.52-0.92) in the multivariable regression model when adjusted for fluoroquinolone use. In addition, patients reporting a beta-lactam allergy were 2.2 times (95% CI, 1.6-3.0) more likely to receive a fluoroquinolone antibiotic. Antibiotics were considered overall inappropriate based on at least one aspect of therapy in 79.6% of patients reporting a beta-lactam allergy and in 71% of nonallergic patients. IMPLICATIONS Antibiotic therapy in patients with a documented beta-lactam allergy was less likely to be appropriate overall, suggesting an area of improvement for prescribing habits. Future interventions should focus on prescriber education regarding first-line and alternative treatments for patients with beta-lactam allergies to ensure that optimal treatment is being provided.
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Affiliation(s)
- Jessica Mason
- University at Buffalo School of Pharmacy, Buffalo, NY, USA
| | - Alyssa Kiel
- Department of Pharmacy, Veterans Affairs Western New York Healthcare System, Buffalo, NY, USA
| | - Alexis White
- Department of Pharmacy, Veterans Affairs Western New York Healthcare System, Buffalo, NY, USA
| | - Collin M Clark
- University at Buffalo School of Pharmacy, Buffalo, NY, USA; Department of Pharmacy, Veterans Affairs Western New York Healthcare System, Buffalo, NY, USA
| | - Bethany A Wattengel
- Department of Pharmacy, Veterans Affairs Western New York Healthcare System, Buffalo, NY, USA
| | - John A Sellick
- Department of Infectious Diseases, Veterans Affairs Western New York Healthcare System, Buffalo, NY, USA
| | - Kari A Mergenhagen
- Department of Pharmacy, Veterans Affairs Western New York Healthcare System, Buffalo, NY, USA.
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28
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Li J, Shahabi-Sirjani A, Figtree M, Hoyle P, Fernando SL. Safety of direct drug provocation testing in adults with penicillin allergy and association with health and economic benefits. Ann Allergy Asthma Immunol 2019; 123:468-475. [PMID: 31419490 DOI: 10.1016/j.anai.2019.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/15/2019] [Accepted: 08/07/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nonprescription of penicillin-containing antibiotics in patients diagnosed with penicillin allergy is associated with morbidity and mortality. Adverse reactions to penicillins comprise type A and B reactions. OBJECTIVE To assess the feasibility of penicillin allergy evaluation without penicillin skin testing (PST) for adult patients with type B reactions and the health and economic benefits of this process. METHODS Inpatients at an Australian tertiary hospital between April 1, 2017, and April 30, 2018, with a diagnosis of type B penicillin allergy, requiring a penicillin-containing antibiotic for treatment, were included. All patients underwent clinical history review, PST, and drug provocation testing (DPT). RESULTS Seventy-one patients were enrolled. Sixty-three reported a history of type B or unknown adverse reactions. No patients had a history of anaphylaxis requiring intubation or epinephrine within the last 10 years or a history suggesting Gell and Coombs type 2, 3, or 4 (severe) hypersensitivity reaction. Seven did not complete DPT because the treating team used a β-lactam antibiotic other than amoxicillin. Fifty-four of 56 remaining patients (96%) completed 3-day DPT to amoxicillin with no adverse reaction. Two experienced mild cutaneous reactions. Penicillin allergy evaluation was significantly associated with reduced length of stay, reduced hospital expenditure on bed and second-line antibiotics, and reduced readmission rates. CONCLUSION Penicillin allergy evaluation with DPT without PST may be feasible for all adult patients with a reported history of type B reactions to penicillins who do not have a history of anaphylaxis within the last 10 years or a type 2, 3, or 4 (severe) hypersensitivity reaction.
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Affiliation(s)
- Jamma Li
- Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, Australia; New South Wales Health Pathology, Sydney, Australia.
| | | | - Melanie Figtree
- New South Wales Health Pathology, Sydney, Australia; Department of Infectious Diseases, Royal North Shore Hospital, Sydney, Australia
| | - Philip Hoyle
- Executive Unit, Northern Sydney Local Health District, Sydney, Australia
| | - Suran L Fernando
- Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, Australia; New South Wales Health Pathology, Sydney, Australia; University of Sydney, Sydney, Australia
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29
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Powell N, Wilcock M, Roberts N, Sandoe J, Tonkin-Crine S. Focus group study exploring the issues and the solutions to incorrect penicillin allergy-labelled patients: an antibiotic stewardship patient safety initiative. Eur J Hosp Pharm 2019; 28:71-75. [PMID: 33608433 DOI: 10.1136/ejhpharm-2019-001863] [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: 01/11/2019] [Revised: 04/17/2019] [Accepted: 04/30/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Approximately 10% of the general population are reported to have a penicillin allergy, but more than 90% of these patients are able to tolerate penicillins after formal assessment. Patients with penicillin allergy labels have poorer health outcomes and incorrect labels impact negatively on healthcare systems. Identifying patients with incorrect penicillin allergy labels (those who can safely take penicillin) has the potential to benefit patients and healthcare systems. This study explores barriers and enablers towards identifying and removing incorrect penicillin allergy labels in inpatients ('delabelling'). METHODS Two focus groups were completed with a total of 17 doctors, nurses and pharmacists at a 750-bed district general hospital in England. RESULTS Thematic analysis identified four main themes: managing penicillin allergic patients, environmental barriers, education for patients and staff and a future delabelling process. Staff reported that identifying and delabelling incorrect penicillin allergy records was a complex task and not a priority during the acute presentation. Participants felt confident removing erroneous allergy records if the patient was able to describe the reaction. Balancing time to confirm and delabel with competing duties was felt to be a challenge. Revisiting the discussion with the patient when time was less pressured was offered as a solution to the problem. The lack of provision to translate uncertainty about allergy status in the electronic health record was mentioned as a barrier to accurate documentation of allergy history. Ensuring all patient records were amended to reflect the new allergy status was identified as a challenge. A delabelling process involving nurses, doctors and pharmacist was discussed. CONCLUSIONS Delabelling patients with erroneous penicillin allergy labels was recognised as a complex problem. A patient pathway involving nurses, doctors and pharmacist is likely to be the optimal method to safely delabel patients.
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Affiliation(s)
- Neil Powell
- Pharmacy Department, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Michael Wilcock
- Pharmacy Department, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Neil Roberts
- Pharmacy Department, University Hositals Plymouth NHS Trust, Plymouth, UK
| | | | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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30
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Lucas M, Arnold A, Sommerfield A, Trevenen M, Braconnier L, Schilling A, Abass F, Slevin L, Knezevic B, Blyth C, Murray K, von Ungern-Sternberg B, Rueter K. Antibiotic Allergy Labels in Children Are Associated with Adverse Clinical Outcomes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:975-982. [DOI: 10.1016/j.jaip.2018.09.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 08/21/2018] [Accepted: 09/02/2018] [Indexed: 11/17/2022]
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31
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Moran R, Devchand M, Smibert O, Trubiano JA. Antibiotic allergy labels in hospitalized and critically ill adults: A review of current impacts of inaccurate labelling. Br J Clin Pharmacol 2019; 85:492-500. [PMID: 30521088 DOI: 10.1111/bcp.13830] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 11/04/2018] [Accepted: 11/19/2018] [Indexed: 11/29/2022] Open
Abstract
Antibiotic allergy labels (AALs) are reported by approximately 20% of hospitalized patients, yet over 85% will be negative on formal allergy testing. Hospitalized patients with an AAL have inferior patient outcomes, increased colonization with multidrug-resistant organisms and frequently receive inappropriate antimicrobials. Hospitalized populations have been well studied but, to date, the impact of AALs on patients with critical illness remains less well defined. We review the prevalence and impact of AALs on hospitalized patients, including those in in critical care.
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Affiliation(s)
- Rebekah Moran
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Misha Devchand
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of Pharmacy, Austin Health, Heidelberg, VIC, Australia
| | - Olivia Smibert
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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32
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Devchand M, Urbancic KF, Khumra S, Douglas AP, Smibert O, Cohen E, Sutherland M, Phillips EJ, Trubiano JA. Pathways to improved antibiotic allergy and antimicrobial stewardship practice: The validation of a beta-lactam antibiotic allergy assessment tool. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:1063-1065.e5. [PMID: 30172019 DOI: 10.1016/j.jaip.2018.07.048] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 07/19/2018] [Accepted: 07/25/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Misha Devchand
- Department of Pharmacy, Austin Health, Melbourne, Australia; Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Melbourne, Australia
| | - Karen F Urbancic
- Department of Pharmacy, Austin Health, Melbourne, Australia; Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Melbourne, Australia
| | - Sharmila Khumra
- Department of Pharmacy, Austin Health, Melbourne, Australia; Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Melbourne, Australia
| | - Abby P Douglas
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Olivia Smibert
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Emma Cohen
- Department of Cancer Services, Austin Health, Melbourne, Australia
| | - Michael Sutherland
- Department of Respiratory and Allergy, Alfred Health, Melbourne, Australia
| | - Elizabeth J Phillips
- Institute of Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia; Department of Infectious Diseases, Vanderbilt University Medical Centre, Nashville, Tenn
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Melbourne, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Medicine (Austin Health), University of Melbourne, Melbourne, Australia; The National Centre for Infections in Cancer, Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.
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33
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Iftikhar S, Sarwar MR, Saqib A, Sarfraz M. Causality and preventability assessment of adverse drug reactions and adverse drug events of antibiotics among hospitalized patients: A multicenter, cross-sectional study in Lahore, Pakistan. PLoS One 2018; 13:e0199456. [PMID: 29949616 PMCID: PMC6021047 DOI: 10.1371/journal.pone.0199456] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 06/07/2018] [Indexed: 12/29/2022] Open
Abstract
Background and objectives Adverse drug events (ADEs) are the fifth leading cause of death and thus responsible for a large number of hospital admissions in all over the globe. This study was aimed to assess the antibiotics associated preventability of ADEs and causality of adverse drug reactions (ADRs) among hospitalized patients. Methods A prospective, cross-sectional, observational study was conducted in four tertiary care public sector hospitals of Lahore, Pakistan. Study population consisted of hospitalized patients who were prescribed with one or more antibiotics. Data were collected between 1st January, 2017 and 31st June, 2017 from 1,249 patients (384 patients aged ≤ 18 years and 865 patients aged >18 years). Schumock and Thornton scale was used to assess the preventability of the ADEs. Medication errors (MEs) that caused preventable ADEs were assessed by MEs tracking form while Naranjo score was used to evaluate the causal relation of ADRs with the antibiotics. Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) and Microsoft Excel (MS Office, 2010) were used for data analysis. Results 2,686 antibiotics were prescribed to 1,249 patients. Among them, fluoroquinolones (11.8%), macrolides (11.6%) and cephalosporins (10.9%) were the most frequently prescribed antibiotics. The most affected organ system by antibiotics associated ADEs was gastrointestinal tract. A total of 486 ADEs were found. The preventability assessment revealed that most of the ADEs (58.4%) were preventable (43.6% of the ADEs were definitely preventable while 14.8% were probably preventable) and caused by MEs including wrong drug (40.1%) and monitoring errors (25.0%), during the stage of physician ordering (22.2%) and patient monitoring (21.1%). The errors were caused due to non-adherence of policies (38.4%) and lack of information about antibiotics (32%). Most of the non-preventable ADEs or ADRs among adults and children were “probable” (35.5%) and “possible” (35.8%), respectively. Logistic regression analysis revealed that ADEs were significantly less among females (OR = 0.047, 95%CI = 0.018–0.121, p-value = <0.001), patients aged 18–52 years (OR = 0.041, 95%CI = 0.013–0.130, p-value = <0.001), tuberculosis patients (OR = 0.304, 95%CI = 0.186–0.497, p-value = <0.001), patients with acute respiratory tract infections (OR = 0.004, 95%CI = 0.01−0.019, p-value = <0.001) and among the patients prescribed with 2 antibiotics per prescription (OR = 0.455, 95%CI = 0.319–0.650, p-value = <0.001). Conclusion According to preventability assessment most of the ADEs were definitely preventable and caused by MEs due to non-adherence of policies and lack of information about antibiotics. The causality assessment of non-preventable ADEs showed that most of the ADRs were probable and possible.
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Affiliation(s)
- Sadia Iftikhar
- Akhtar Saeed College of Pharmaceutical Sciences, Lahore, Pakistan
| | - Muhammad Rehan Sarwar
- Akhtar Saeed College of Pharmaceutical Sciences, Lahore, Pakistan
- Department of Pharmacy, The Islamia University of Bahawalpur Bahawalpur, Punjab, Pakistan
- * E-mail:
| | - Anum Saqib
- Department of Pharmacy, The Islamia University of Bahawalpur Bahawalpur, Punjab, Pakistan
| | - Muhammad Sarfraz
- Department of Pharmacy, The Islamia University of Bahawalpur Bahawalpur, Punjab, Pakistan
- College of Pharmacy, Al Ain University of Science and Technology, Al Ain, Abu Dhabi, UAE
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34
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Saqib A, Sarwar MR, Sarfraz M, Iftikhar S. Causality and preventability assessment of adverse drug events of antibiotics among inpatients having different lengths of hospital stay: a multicenter, cross-sectional study in Lahore, Pakistan. BMC Pharmacol Toxicol 2018; 19:34. [PMID: 29941052 PMCID: PMC6019808 DOI: 10.1186/s40360-018-0222-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 06/10/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND A large number of hospital admissions are attributed to adverse drug reactions (ADRs) and they are the fifth leading cause of death worldwide. The present study aimed to assess the causality and preventability of adverse drug events (ADEs) of antibiotics among inpatients having different lengths of hospital stay. METHODS A prospective, observational study was conducted in four tertiary-care public sector hospitals of Lahore, Pakistan. Study population consisted of hospitalized patients who were prescribed one or more antibiotics. Data were collected between 1st January, 2017 and 30th June, 2017 from 1249 patients. Naranjo score, modified Schumock and Thornton scale were used for causality and preventability assessments, respectively. Medication errors (MEs) were assessed by MEs tracking form. SPSS and Microsoft Excel were used for data analysis. RESULTS A total of 2686 antibiotics were prescribed to 1249 patients and 486 ADEs were found. The preventability assessment revealed that most of the ADEs (78.8%) were found among patients having long length of stay (LOS) in hospital and were preventable (59.3% of the ADEs were definitely preventable while 44.7% were probably preventable) and caused by MEs including wrong drug (40.1%) and monitoring errors (25%). The errors were caused due to non-adherence of policies (38.4%) and lack of information about antibiotics (32%). Most of the non-preventable ADEs or ADRs among patients having long and short LOS in hospital were "probable" (35.5%) and "possible" (35.8%), respectively. Logistic regression analysis revealed that ADEs were significantly less among females (OR = 0.047, 95% CI = 0.018─0.121, p-value = < 0.001), patients aged 18─52 years (OR = 0.041, 95% CI = 0.013─0.130, p-value = < 0.001), patients with ARTIs (OR = 0.004, 95% CI = 0.01-0.019, p-value = < 0.001), patients prescribed with 2 antibiotics per prescription (OR = 0.455, 95% CI = 0.319─0.650, p-value = < 0.001) and patients with long LOS (OR = 14.825, 95% CI = 11.198─19.627, p-value = < 0.001). CONCLUSION Antibiotics associated definitely preventable ADEs were more commonly found in patients having long LOS in the inpatient departments because of MEs and lack of proper pharmacovigilance system. The ADRs showed a probable and possible causal association with both β-lactams and non β-lactams antibiotics.
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Affiliation(s)
- Anum Saqib
- Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Punjab, Pakistan
| | - Muhammad Rehan Sarwar
- Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Punjab, Pakistan. .,Akhtar Saeed College of Pharmaceutical Sciences, Lahore, Pakistan.
| | - Muhammad Sarfraz
- College of Pharmacy, Al Ain University of Science and Technology, Al Ain, Abu Dhabi, UAE
| | - Sadia Iftikhar
- Akhtar Saeed College of Pharmaceutical Sciences, Lahore, Pakistan
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Krishna MT, Huissoon AP, Li M, Richter A, Pillay DG, Sambanthan D, Raman SC, Nasser S, Misbah SA. Enhancing antibiotic stewardship by tackling "spurious" penicillin allergy. Clin Exp Allergy 2018; 47:1362-1373. [PMID: 29028276 DOI: 10.1111/cea.13044] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Approximately 90-99% of patients with a label of penicillin allergy (PenA) are not allergic when comprehensively investigated. An inaccurate label of PenA has major public health implications-longer hospital stay, more frequent hospital admissions, greater use of fluoroquinolones, glycopeptides, cephalosporins and other expensive antibiotics resulting in significantly higher costs to the health service and predisposing to Clostridium difficile, methicillin-resistant Staphylococcus aureus infections and vancomycin-resistant enterococcus. We describe lessons learnt from recent studies regarding possible reasons contributing to an inaccurate label of PenA as well as propose a concerted multidisciplinary approach to address this important public health problem. Given the unmet need for allergy services in the UK and several other countries and knowledge gaps regarding PenA amongst healthcare professionals, we describe the potential role for a computerized clinical decision support system to enable non-specialists rapidly identify and de-label "low-risk" hospitalized patients with a label of PenA thereby obviating the need for allergy tests. This approach however needs rigorous evaluation for feasibility, safety, patient and physician acceptability, cost-effectiveness and its compatibility with information technology systems currently employed in the health service.
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Affiliation(s)
- M T Krishna
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK.,Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, UK
| | - A P Huissoon
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
| | - M Li
- Department of Microbiology, University Hospital of Coventry and Warwickshire, Coventry, UK
| | - A Richter
- Clinical Immunology Service, Birmingham Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - D G Pillay
- Department of Microbiology, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
| | - D Sambanthan
- Tata Consultancy Services Ltd, Thoraipakkam, Chennai, India
| | - S C Raman
- Tata Consultancy Services Ltd, Thoraipakkam, Chennai, India
| | - S Nasser
- Department of Allergy, Cambridge University Hospitals, Cambridge, UK
| | - S A Misbah
- Department of Clinical Immunology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Torda A, Chan V. Antibiotic allergy labels-the impact of taking a clinical history. Int J Clin Pract 2018; 72:e13058. [PMID: 29341373 DOI: 10.1111/ijcp.13058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 12/20/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Many patients admitted to hospital have an antibiotic allergy (AAL) documented in their medical record. In many of these, the reaction is not a hypersensitivity reaction or may no longer be relevant. Despite this, the label adversely affects patient care directly in terms of antibiotic selection, and indirectly in terms of patient costs and the development of antimicrobial resistance. AIMS To estimate the prevalence of AALs in a cohort of hospitalised patients, to investigate the feasibility of de-labelling through re-challenge based solely upon clinical grounds. DESIGN This is a cross-sectional study conducted over a 6-month period on adult inpatients. An allergy history was taken from each patient and compared with medical record data regarding allergy. Antibiotic selection data were collected (if relevant). It was then determined whether immediate de-labelling was appropriate, if direct provocation test (DPT) could be relatively safely performed, and if antibiotic selection was appropriate. RESULTS Three thousand eight hundred and fifty five patients were screened, 553 (14.35%) had an AAL, and 352 were interviewed. There were 426 AALs; 276 (64.8%) towards a penicillin. After taking a detailed clinical history of the type of reaction, approximately 20% could be immediately de-labelled and educated (non-allergic, non-severe reactions) and another 38% with either a definite or vague history of mild cutaneous reaction would be suitable for an attempt at clinical de-labelling DPT. CONCLUSIONS These simple measures to 'de-label' patients appropriately, would increase the quality of care of this group known to have higher costs, infection with more resistant bacteria and worse health outcomes that 'non-labelled' patients.
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Affiliation(s)
- Adrienne Torda
- Prince of Wales Clinical School, University of New South Wales, Randwick, NSW, Australia
- Prince of Wales Hospital, Randwick, NSW, Australia
| | - Victor Chan
- Prince of Wales Clinical School, University of New South Wales, Randwick, NSW, Australia
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Urbancic K, Ierino F, Phillips E, Mount P, Mahony A, Trubiano J. Taking the challenge: A protocolized approach to optimize Pneumocystis pneumonia prophylaxis in renal transplant recipients. Am J Transplant 2018; 18:462-466. [PMID: 28898546 PMCID: PMC5790633 DOI: 10.1111/ajt.14498] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/05/2017] [Accepted: 09/06/2017] [Indexed: 01/25/2023]
Abstract
While trimethoprim-sulfamethoxazole is considered first-line therapy for Pneumocystis pneumonia prevention in renal transplant recipients, reported adverse drug reactions may limit use and increase reliance on costly and less effective alternatives, often aerosolized pentamidine. We report our experience implementing a protocolized approach to trimethoprim-sulfamethoxazole adverse drug reaction assessment and rechallenge to optimize prophylaxis in this patient cohort. We retrospectively reviewed 119 patients receiving Pneumocystis pneumonia prophylaxis prior to and after protocol implementation. Forty-two patients (35%) had 48 trimethoprim-sulfamethoxazole adverse drug reactions documented either at baseline or during the prophylaxis period, of which 83% were non-immune-mediated and 17% were immune-mediated. Significantly more patients underwent trimethoprim-sulfamethoxazole rechallenge after protocol implementation (4/22 vs 23/27; P = .0001), with no recurrence of adverse drug reactions in 74%. In those who experienced a new or recurrent reaction (26%), all were mild and self-limiting with only 1 recurrence of an immune-mediated reaction. After protocol implementation, aerosolized pentamidine-associated costs were reduced. The introduction of a standard approach to trimethoprim-sulfamethoxazole rechallenge in the context of both prior immune and non-immune-mediated reactions was safe and successful in improving the uptake of first-line Pneumocystis pneumonia prophylaxis in renal transplant recipients.
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Affiliation(s)
- K.F Urbancic
- Pharmacy Department, Austin Health, Heidelberg, VIC, Australia,Infectious Diseases Department, Austin Health, Heidelberg, VIC, Australia,National Centre for Infections in Cancer, National Health and Medical Research Council Centre of Research Excellence, Peter MacCallum Cancer Centre, Department of Oncology, University of Melbourne, Parkville, VIC, Australia,Department of Medicine, University of Melbourne, Parkville, VIC Australia
| | - F Ierino
- Nephrology Department, St Vincent's Hospital, Melbourne, VIC, Australia
| | - E Phillips
- Infectious Diseases Department, Vanderbilt University Medical Center, Nashville, Tennessee, U.S
| | - P.F Mount
- Nephrology Department, Austin Health, Heidelberg, VIC, Australia
| | - A Mahony
- Infectious Diseases Department, Austin Health, Heidelberg, VIC, Australia,Department of Medicine, University of Melbourne, Parkville, VIC Australia
| | - J.A Trubiano
- Infectious Diseases Department, Austin Health, Heidelberg, VIC, Australia,National Centre for Infections in Cancer, National Health and Medical Research Council Centre of Research Excellence, Peter MacCallum Cancer Centre, Department of Oncology, University of Melbourne, Parkville, VIC, Australia,Department of Medicine, University of Melbourne, Parkville, VIC Australia
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Antibiotic-Related Adverse Drug Reactions at a Tertiary Care Hospital in South Korea. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4304973. [PMID: 29457026 PMCID: PMC5804292 DOI: 10.1155/2017/4304973] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/19/2017] [Indexed: 12/13/2022]
Abstract
Background Adverse drug reactions (ADRs) are any unwanted/uncomfortable effects from medication resulting in physical, mental, and functional injuries. Antibiotics account for up to 40.9% of ADRs and are associated with several serious outcomes. However, few reports on ADRs have evaluated only antimicrobial agents. In this study, we investigated antibiotic-related ADRs at a tertiary care hospital in South Korea. Methods This is a retrospective cohort study that evaluated ADRs to antibiotics that were reported at a 2400-bed tertiary care hospital in 2015. ADRs reported by physicians, pharmacists, and nurses were reviewed. Clinical information reported ADRs, type of antibiotic, causality assessment, and complications were evaluated. Results 1,277 (62.8%) patients were considered antibiotic-related ADRs based on the World Health Organization-Uppsala Monitoring Center criteria (certain, 2.2%; probable, 35.7%; and possible, 62.1%). Totally, 44 (3.4%) patients experienced serious ADRs. Penicillin and quinolones were the most common drugs reported to induce ADRs (both 16.0%), followed by third-generation cephalosporins (14.9%). The most frequently experienced side effects were skin manifestations (45.1%) followed by gastrointestinal disorders (32.6%). Conclusion Penicillin and quinolones are the most common causative antibiotics for ADRs and skin manifestations were the most frequently experienced symptom.
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Trubiano JA, Stone CA, Grayson ML, Urbancic K, Slavin MA, Thursky KA, Phillips EJ. The 3 Cs of Antibiotic Allergy-Classification, Cross-Reactivity, and Collaboration. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:1532-1542. [PMID: 28843343 PMCID: PMC5681410 DOI: 10.1016/j.jaip.2017.06.017] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/08/2017] [Accepted: 06/16/2017] [Indexed: 12/22/2022]
Abstract
Antibiotic allergy labeling is highly prevalent and negatively impacts patient outcomes and antibiotic appropriateness. Reducing the prevalence and burden of antibiotic allergies requires the engagement of key stakeholders such as allergists, immunologists, pharmacists, and infectious diseases physicians. To help address this burden of antibiotic allergy overlabeling, we review 3 key antibiotic allergy domains: (1) antibiotic allergy classification, (2) antibiotic cross-reactivity, and (3) multidisciplinary collaboration. We review the available evidence and research gaps of currently used adverse drug reaction classification systems, antibiotic allergy cross-reactivity, and current and future models of antibiotic allergy care.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Karen Urbancic
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia; Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia; National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Elizabeth J Phillips
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Pathology, Microbiology, Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University Medical School, Nashville, Tenn
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Knezevic B, Sprigg D, Seet J, Trevenen M, Trubiano J, Smith W, Jeelall Y, Vale S, Loh R, McLean-Tooke A, Lucas M. The revolving door: antibiotic allergy labelling in a tertiary care centre. Intern Med J 2017; 46:1276-1283. [PMID: 27530619 DOI: 10.1111/imj.13223] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 06/13/2016] [Accepted: 07/18/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients frequently report antibiotic allergies; however, only 10% of labelled patients have a true allergy. AIM We investigated the documentation of antibiotic 'allergy' labels (AAL) and the effect of labelling on clinical outcomes, in a West Australian adult tertiary hospital. METHODS Retrospective cross-sectional analysis of patients captured in the 2013 and 2014 National Antimicrobial Prescribing Surveys was carried out. Data were collected on documented antibiotic adverse drug reactions, antibiotic cost, prescribing appropriateness, prevalence of multi-drug resistant organisms, length of stay, intensive care admission and readmissions. RESULTS Of the 687 patients surveyed, 278 (40%) were aged 70 or above, 365 (53%) were male and 279 (41%) were prescribed antibiotics. AAL were recorded in 122 (18%) patients and the majority were penicillin labels (n = 87; 71%). Details of AAL were documented for 80 of 141 (57%) individual allergy labels, with 61 describing allergic symptoms. Patients with beta-lactam allergy labels received fewer penicillins (P = 0.0002) and more aminoglycosides (P = 0.043) and metronidazole (P = 0.021) than patients without beta-lactam labels. Five patients received an antibiotic that was contraindicated according to their allergy status. Patients with AAL had significantly more hospital readmissions within 4 weeks (P = 0.001) and 6 months (P = 0.025) of discharge, compared with unlabelled patients. The majority (81%) of readmitted labelled patients had major infections. CONCLUSIONS AAL are common, but poorly documented in hospital records. Patients with AAL are significantly more likely to require alternative antibiotics and hospital readmissions. There may be a role for antibiotic allergy delabelling to mitigate the clinical and economic burdens for patients with invalid allergy labels.
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Affiliation(s)
- B Knezevic
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia.
| | - D Sprigg
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - J Seet
- Department of Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - M Trevenen
- Department of Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Centre for Applied Statistics, University of Western Australia, Perth, Western Australia, Australia
| | - J Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
| | - W Smith
- Department of Immunology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Y Jeelall
- School of Medicine and Pharmacology, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - S Vale
- Drug Allergy Working Party, Australasian Society of Clinical Immunology and Allergy, Sydney, New South Wales, Australia
| | - R Loh
- Department of Clinical Immunology, Princess Margaret Hospital, Perth, Western Australia, Australia.,Pathwest Laboratory, Queen Elizabeth II Campus, Perth, Western Australia, Australia
| | - A McLean-Tooke
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia.,Pathwest Laboratory, Queen Elizabeth II Campus, Perth, Western Australia, Australia
| | - M Lucas
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia.,Pathwest Laboratory, Queen Elizabeth II Campus, Perth, Western Australia, Australia.,Department of Clinical Immunology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
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Trubiano JA, Thursky KA, Stewardson AJ, Urbancic K, Worth LJ, Jackson C, Stevenson W, Sutherland M, Slavin MA, Grayson ML, Phillips EJ. Impact of an Integrated Antibiotic Allergy Testing Program on Antimicrobial Stewardship: A Multicenter Evaluation. Clin Infect Dis 2017; 65:166-174. [PMID: 28520865 PMCID: PMC5849110 DOI: 10.1093/cid/cix244] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 05/12/2017] [Indexed: 01/03/2023] Open
Abstract
Background Despite the high prevalence of patient-reported antibiotic allergy (so-called antibiotic allergy labels [AALs]) and their impact on antibiotic prescribing, incorporation of antibiotic allergy testing (AAT) into antimicrobial stewardship (AMS) programs (AAT-AMS) is not widespread. We aimed to evaluate the impact of an AAT-AMS program on AAL prevalence, antibiotic usage, and appropriateness of prescribing. Methods AAT-AMS was implemented at two large Australian hospitals during a 14-month period beginning May 2015. Baseline demographics, AAL history, age-adjusted Charlson comorbidity index, infection history, and antibiotic usage for 12 months prior to testing (pre-AAT-AMS) and 3 months following testing (post-AAT-AMS) were recorded for each participant. Study outcomes included the proportion of patients who were "de-labeled" of their AAL, spectrum of antibiotic courses pre- and post-AAT-AMS, and antibiotic appropriateness (using standard definitions). Results From the 118 antibiotic allergy-tested patients, 226 AALs were reported (mean, 1.91/patient), with 53.6% involving 1 or more penicillin class drug. AAT-AMS allowed AAL de-labeling in 98 (83%) patients-56% (55/98) with all AALs removed. Post-AAT, prescribing of narrow-spectrum penicillins was more likely (adjusted odds ratio [aOR], 2.81, 95% confidence interval [CI], 1.45-5.42), as was narrow-spectrum β-lactams (aOR, 3.54; 95% CI, 1.98-6.33), and appropriate antibiotics (aOR, 12.27; 95% CI, 5.00-30.09); and less likely for restricted antibiotics (aOR, 0.16; 95% CI, .09-.29), after adjusting for indication, Charlson comorbidity index, and care setting. Conclusions An integrated AAT-AMS program was effective in both de-labeling of AALs and promotion of improved antibiotic usage and appropriateness, supporting the routine incorporation of AAT into AMS programs.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- Department of Medicine, University of Melbourne, Parkville
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
| | | | - Karen Urbancic
- Department of Infectious Diseases, Austin Health, Heidelberg
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
- Department of Pharmacy, Austin Health, Heidelberg
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
| | - Cheryl Jackson
- Department of Pharmacy, Peter MacCallum Cancer Centre, VCCC, Parkville, and
| | - Wendy Stevenson
- Department of Infectious Diseases, Austin Health, Heidelberg
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, and
| | - Michael Sutherland
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, and
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg
- Department of Medicine, University of Melbourne, Parkville
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia; and
- Departments of Medicine and Pharmacology, Vanderbilt University Medical Centre, Nashville, Tennessee
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Konvinse KC, Phillips EJ, White KD, Trubiano JA. Old dog begging for new tricks: current practices and future directions in the diagnosis of delayed antimicrobial hypersensitivity. Curr Opin Infect Dis 2016; 29:561-576. [PMID: 27753687 PMCID: PMC5113146 DOI: 10.1097/qco.0000000000000323] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Antimicrobials are a leading cause of severe T cell-mediated adverse drug reactions (ADRs). The purpose of this review is to address the current understanding of antimicrobial cross-reactivity and the ready availability of and evidence for in-vitro, in-vivo, and ex-vivo diagnostics for T cell-mediated ADRs. RECENT FINDINGS Recent literature has evaluated the efficacy of traditional antibiotic allergy management, including patch testing, skin prick testing, intradermal testing, and oral challenge. Although patch and intradermal testing are specific for the diagnosis of immune-mediated ADRs, they suffer from drug-specific limitations in sensitivity. The use of ex-vivo diagnostics, especially enzyme-linked immunospot, has been highlighted as a promising new approach to assigning causality. Knowledge of true rates of antimicrobial cross-reactivity aids empirical antibiotic choice in the setting of previous immune-mediated ADRs. SUMMARY In an era of increasing antimicrobial resistance and use of broad-spectrum antimicrobial therapy, ensuring patients are assigned the correct 'allergy label' is essential. Re-exposure to implicated antimicrobials, especially in the setting of severe adverse cutaneous reaction, is associated with significant morbidity and mortality. The process through which an antibiotic label gets assigned, acted on and maintained is still imprecise. Predicting T cell-mediated ADRs via personalized approaches, including human leukocyte antigen-typing, may pave future pathways to safer antimicrobial prescribing guidelines.
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Affiliation(s)
- Katherine C Konvinse
- aDepartment of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA bInstitute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia cDepartment of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA dDepartment of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA eDepartment of Infectious Diseases, Austin Hospital, Victoria, Australia fDepartment of Infectious Diseases, Alfred Hospital, Victoria, Australia gDepartment of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria, Australia hDepartment of Medicine, University of Melbourne, Victoria, Australia
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Trubiano JA, Worth LJ, Urbancic K, Brown TM, Paterson DL, Lucas M, Phillips E. Return to sender: the need to re-address patient antibiotic allergy labels in Australia and New Zealand. Intern Med J 2016; 46:1311-1317. [PMID: 27527526 PMCID: PMC5096978 DOI: 10.1111/imj.13221] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/04/2016] [Accepted: 08/08/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND/AIM Antibiotic allergies are frequently reported and have significant impacts upon appropriate prescribing and clinical outcomes. We surveyed infectious diseases physicians, allergists, clinical immunologists and hospital pharmacists to evaluate antibiotic allergy knowledge and service delivery in Australia and New Zealand. METHODS An online multi-choice questionnaire was developed and endorsed by representatives of the Australasian Society of Clinical Immunology and Allergy (ASCIA) and the Australasian Society of Infectious Diseases (ASID). The 37-item survey was distributed in April 2015 to members of ASCIA, ASID, the Society of Hospital Pharmacists of Australia and the Royal Australasian College of Physicians. RESULTS Of 277 respondents, 94% currently use or would utilise antibiotic allergy testing (AAT) and reported seeing up to 10 patients/week labelled as antibiotic-allergic. Forty-two per cent were not aware of or did not have AAT available. Most felt that AAT would aid antibiotic selection, antibiotic appropriateness and antimicrobial stewardship (79, 69 and 61% respectively). Patients with the histories of immediate hypersensitivity were more likely to be referred than those with delayed hypersensitivities (76 vs 41%, P = 0.0001). Lack of specialist physicians (20%) and personal experience (17%) were barriers to service delivery. A multidisciplinary approach was a preferred AAT model (53%). Knowledge gaps were identified, with the majority overestimating rates of penicillin/cephalosporin (78%), penicillin/carbapenem (57%) and penicillin/monobactam (39%) cross-reactivity. CONCLUSIONS A high burden of antibiotic allergy labelling and demand for AAT is complicated by a relative lack availability or awareness of AAT services in Australia and New Zealand. Antibiotic allergy education and deployment of AAT, accessible to community and hospital-based clinicians, may improve clinical decisions and reduce antibiotic allergy impacts. A collaborative approach involving infectious diseases physicians, pharmacists and allergists/immunologists is required.
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Affiliation(s)
- J A Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.
| | - L J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - K Urbancic
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
- Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia
| | - T M Brown
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - D L Paterson
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - M Lucas
- Department of Clinical Immunology, Pathwest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - E Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
- Department of Medicine, Vanderbilt Medical Center, Nashville, Tennessee, USA
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Trubiano JA, Pai Mangalore R, Baey YW, Le D, Graudins LV, Charles PGP, Johnson DF, Aung AK. Old but not forgotten: Antibiotic allergies in General Medicine (the AGM Study). Med J Aust 2016; 204:273. [PMID: 27078602 DOI: 10.5694/mja15.01329] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 01/19/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the nature, prevalence and description accuracy of recorded antibiotic allergy labels (AALs) in a cohort of general medical inpatients, and to assess the feasibility of an oral antibiotic re-challenge study. DESIGN Multicentre cross-sectional study. SETTING AND PARTICIPANTS All patients admitted to the general medical units of Austin Health and Alfred Health, 18 May - 5 June 2015. MAIN OUTCOME MEASURES Baseline demographics, medical and allergy history, infection diagnoses and antibiotic prescribing data for general medical inpatients were collected. A questionnaire was administered to clarify AAL history, followed by correlation of responses with electronic and admissions record descriptions. A hypothetical oral re-challenge in a supervised setting was offered to patients with low risk allergy phenotypes (non-immediate reaction, non-severe cutaneous adverse reaction, or unknown reaction more than 10 years ago). RESULTS Of the 453 inpatients, 107 (24%) had an AAL (median age, 82 years; interquartile range, 74-87 years); 160 individual AALs were recorded, and there was a mismatch in AAL description between recording platforms in 25% of cases. Most patients with an AAL were women (64%; P < 0.001), and more presented with concurrent immunosuppression than those without an AAL (23% v 8%; P < 0.001). β-Lactam penicillins were employed less frequently in patients with an AAL (16% v 35%; P = 0.02), while ceftriaxone (32% v 20%; P = 0.02) and fluoroquinolones (6% v 2%; P = 0.04) were used more often. Fifty-four per cent of patients with AALs were willing to undergo oral re-challenge, of whom 48% had a low risk allergy phenotype. CONCLUSIONS AAL prevalence in general medical inpatients was 24%, and was associated with excessive use of broad spectrum antibiotics. Allergies in a large proportion of patients with AALs were incorrectly documented, and were non-immune-mediated and potentially amenable to oral re-challenge. A direct oral re-challenge study in carefully selected patients with low risk allergy phenotypes appears feasible.
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Affiliation(s)
| | | | | | - Duy Le
- Austin Health, Melbourne, VIC
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Impact of Reported Beta-Lactam Allergy on Inpatient Outcomes: A Multicenter Prospective Cohort Study. Clin Infect Dis 2016; 63:904-910. [DOI: 10.1093/cid/ciw462] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 06/15/2016] [Indexed: 01/20/2023] Open
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Trubiano JA, Aung AK, Nguyen M, Fehily SR, Graudins L, Cleland H, Padiglione A, Peleg AY. A Comparative Analysis Between Antibiotic- and Nonantibiotic-Associated Delayed Cutaneous Adverse Drug Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:1187-1193. [PMID: 27283055 DOI: 10.1016/j.jaip.2016.04.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/28/2016] [Accepted: 04/29/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The difference in clinical presentation, causality assessments, and outcomes of patients with delayed antibiotic-associated cutaneous adverse drug reactions (AA-cADR) and nonantibiotic-associated (NA)-cADR is ill defined. OBJECTIVE We examined the etiology of AA-cADR, with regard to the type of antibiotic exposure, allergy labeling, and patient outcomes, in comparison with NA-cADR. METHODS A retrospective observational inpatient cohort study of cADR was performed from January 2004 to August 2014. Patients were divided into AA-cADR and NA-cADR groups for analysis. cADR was defined as erythema multiforme, fixed drug eruption, acute generalized erythematous pustulosis, drug reaction with eosinophilia and systemic symptoms (DRESS), drug-associated linear IgA disease, Stevens-Johnson syndrome, and toxic epidermal necrolysis. RESULTS Of the 84 patients with cADR, 48% were AA-cADR. Male sex (60% vs 32%, P = .004), median length of stay (14.5 vs 11 days, P = .05), median Charlson comorbidity index (3 vs 1, P = .03), and inpatient mortality (20% vs 5%, P = .04) were higher in AA-cADR compared with NA-cADR. The median drug latency was lower in AA-cADR (6 vs 20 days, P = .001). Sulfonamide antibiotics and glycopeptides were implicated in 20% of AA-cADR. DRESS was more frequently reported in AA-cADR. After cADR diagnosis, further antibiotic therapy was administered in 64% of patients, higher in AA-cADR (75%, 30 of 40) compared with NA-cADR (55%, 24 of 44) (P = .06). Fluoroquinolones (53% vs 21%, P = .02), glycopeptides (vancomycin and teicoplanin; 70% vs 38%, P = .05), and carbapenems (33% vs 13%, P = .11) were used more commonly in AA-cADR. CONCLUSIONS Antibiotics were the cause of cADR requiring hospital admission in 48% of episodes, and were associated with longer length of stay, higher age-adjusted Charlson comorbidity index, shorter drug latency, and mortality. In AA-cADR, glycopeptide and sulfonamide antibiotic exposure predominated.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Victoria, Australia; Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.
| | - Ar Kar Aung
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Victoria, Australia; Department of General Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Mary Nguyen
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Victoria, Australia
| | - Sasha R Fehily
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Victoria, Australia
| | - Linda Graudins
- Department of Pharmacy, Alfred Health & Monash University, Melbourne, Victoria, Australia
| | | | - Alex Padiglione
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Victoria, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Victoria, Australia
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Trubiano JA, Chen C, Cheng AC, Grayson ML, Slavin MA, Thursky KA. Antimicrobial allergy 'labels' drive inappropriate antimicrobial prescribing: lessons for stewardship. J Antimicrob Chemother 2016; 71:1715-22. [PMID: 26895771 DOI: 10.1093/jac/dkw008] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 01/07/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The presence of antimicrobial allergy designations ('labels') often substantially reduces prescribing options for affected patients, but the frequency, accuracy and impacts of such labels are unknown. METHODS The National Antimicrobial Prescribing Survey (NAPS) is an annual de-identified point prevalence audit of Australian inpatient antimicrobial prescribing using standardized definitions of guideline compliance, appropriateness and indications. Data were extracted for 2 years (2013-14) and compared for patients with an antimicrobial allergy label (AAL) and with no AAL (NAAL). RESULTS Among 21 031 patients receiving antimicrobials (33 421 prescriptions), an AAL was recorded in 18%, with inappropriate antimicrobial use significantly higher in the AAL group versus the NAAL group (OR 1.12, 95% CI 1.05-1.22, P < 0.002). Patterns of antimicrobial use were significantly influenced by AAL, with lower β-lactam use (AAL versus NAAL; OR 0.47, 95% CI 0.43-0.50, P < 0.001) and higher quinolone (OR 2.07, 95% CI 1.83-2.34, P < 0.0001), glycopeptide (OR 1.59, 95% CI 1.38-1.83, P < 0.0001) and carbapenem (OR 1.74, 95% CI 1.43-2.13, P < 0.0001) use. In particular, among immunocompromised patients, AAL was associated with increased rates of inappropriate antimicrobial use (OR 1.68, 95% CI 1.21-2.30, P = 0.003), as well as increased use of quinolones (OR 1.88, 95% CI 1.16-3.03, P = 0.02) and glycopeptides (OR 1.82, 95% CI 1.17-2.84, P = 0.01). CONCLUSIONS AALs are common and appear to be associated with higher rates of inappropriate prescribing and increased use of broad-spectrum antimicrobials. Improved accuracy in defining AALs is likely to be important for effective antimicrobial stewardship (AMS), with efforts to 'de-label' inappropriate AAL patients a worthwhile feature of future AMS initiatives.
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Affiliation(s)
- J A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - C Chen
- NHMRC National Centre of Antimicrobial Stewardship, Peter Doherty Institute, Parkville, VIC, Australia Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - A C Cheng
- Department of Epidemiology & Infectious Diseases, Alfred Health and Monash University, Melbourne, VIC, Australia
| | - M L Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - M A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - K A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia NHMRC National Centre of Antimicrobial Stewardship, Peter Doherty Institute, Parkville, VIC, Australia Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, VIC, Australia
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Savlevich EL, Kozlov VS, Zharkykh MA. [A study of the efficacy and safety of new cephalosporin in the treatment of acute bacterial rhinosinusitis]. Vestn Otorinolaringol 2016; 81:73-77. [PMID: 28091482 DOI: 10.17116/otorino201681673-77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Acute rhinosinusitis is leading in frequency of antibiotic prescribing all over the world. At the same time the problem of antibiotic resistance and safety of antimicrobial drugs becomes more relevant and international. The article describes the basic mechanisms of bacterial resistance and growth of side effects when using macrolides, respiratory fluoroquinilones and β-lactam antibiotics of different types. Formation of IgE-mediated cephalosporin allergy is associated with the side R1 chain. The R1 structure of cephalosporins I and II generations is similar to penicillins, thus creating conditions for cross-allergy progression. R1 of cephalosporins III and IV generations is represented by a qualitatively different chemical compound (aminothiazol-oxime group) that increases the level of tolerance to these antibiotic types. The data of surveillance study are given to evaluate the efficacy and safety of the new drug Spectracef (active substance is cephalosporin of III generation Cefditoren) when treating acute bacterial rhinosinusitis on an outpatient basis.
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Affiliation(s)
- E L Savlevich
- Central State Medical Academy of Department for Presidential Affairs of the Russian Federation, Moscow, Russia, 121359
| | - V S Kozlov
- Central State Medical Academy of Department for Presidential Affairs of the Russian Federation, Moscow, Russia, 121359
| | - M A Zharkykh
- Polyclinic #5 of Department for Presidential Affairs of the Russian Federation, Moscow, Russia, 119121
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