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Molina-Molina GJ, Garnica Velandia DR, Andrés-López B, Perales C, Marin-Asensio L, Jurgens Y, Esteso O, Escobar C, Vidal X, Vendrell L, Gómez-Ganda L, Rodríguez D, Montané E, Cardona V, Agustí A. Delabelling beta-lactam allergy. Front Pharmacol 2024; 15:1423719. [PMID: 38994200 PMCID: PMC11237397 DOI: 10.3389/fphar.2024.1423719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 05/30/2024] [Indexed: 07/13/2024] Open
Abstract
Background: Hypersensitivity to beta-lactam (BL) antibiotics is one of the most frequent reported drug allergies. In our population, it is common to find labels of BL allergy in electronic medical records (EMRs) that have not been assessed. The objective of our study was to detect patients with beta-lactam allergy labels in their EMRs and to assess how many of them are false after a correct diagnostic evaluation. Methods: A multicentre prospective study was performed with patients labelled as allergic to BLs in their EMRs in the previous 5 years. Demographical and clinical data, as well as variables regarding the BL allergy label and the characteristics of the index reaction from clinical history and EMRs, were recorded. Then, diagnostic assessments including clinical history, skin tests (STs), and drug provocation tests (DPTs) were conducted in order to confirm or exclude the diagnosis of BL allergy. Results: A total of 249 patients completed the study, of which 160 (64.3%) were women with a median age of 57 years (interquartile range [IQR], 45-68). The most frequent BL allergy labels detected were for penicillin (124), amoxicillin/clavulanic acid (61), and amoxicillin (54). Of the 204 patients who underwent STs, 20.1% were positive. DPTs were performed in 224 patients, showing good tolerance in 87.1% of cases. After the allergy diagnosis work-up, 186 patients (74.7%) were diagnosed as non-allergic to BL antibiotics. Conclusion: In our study population, the number of patients labelled as allergic to BLs in their EMRs was similar to that in previously published studies, with proportions near to 75%-80% being falsely labelled as allergic to BLs.
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Affiliation(s)
| | - Diana Rocío Garnica Velandia
- Allergology Department, Hospital Universitari Santa Maria, Lleida, Spain
- Institut de Recerca Biomèdica de Lleida-Fundació Dr. Pifarré (IRB Lleida), Lleida, Spain
| | - Blanca Andrés-López
- Allergy Department, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Carolina Perales
- Allergology Section, Hospital de Tortosa Verge de La Cinta, Institut D’Investigació Sanitaria Pere I Virgili, Tortosa, Spain
| | - Laura Marin-Asensio
- Allergology Section, Hospital de Tortosa Verge de La Cinta, Institut D’Investigació Sanitaria Pere I Virgili, Tortosa, Spain
| | - Yanina Jurgens
- Allergy Section, University Hospital Germans Trias I Pujol, Badalona, Spain
| | - Olga Esteso
- Allergy Section, Hospital Universitari Joan XXIII de Tarragona, Tarragona, Spain
| | - Carolina Escobar
- Allergy Department, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Xavier Vidal
- Clinical Pharmacology Service, Hospital Universitari Vall D’Hebron, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lourdes Vendrell
- Clinical Pharmacology Service, Hospital Universitari Vall D’Hebron, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
- Vall D’Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Laura Gómez-Ganda
- Pharmacy Department, Hospital Universitari Vall D’Hebron, Barcelona, Spain
| | - Dolores Rodríguez
- Clinical Pharmacology Service, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Spain
| | - Eva Montané
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
- Clinical Pharmacology Service, University Hospital Germans Trias I Pujol, Badalona, Spain
| | - Victoria Cardona
- Vall D’Hebron Institut de Recerca (VHIR), Barcelona, Spain
- Department of Allergy, Hospital Universitari Vall D’Hebron, Barcelona, Spain
| | - Antònia Agustí
- Clinical Pharmacology Service, Hospital Universitari Vall D’Hebron, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
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Lillis RA, Barbee LA, McNeil CJ, Newman L, Fortenberry JD, Alvarez-Arango S, Zenilman JM. Randomized Multicenter Trial for the Validation of an Easy-to-Administer Algorithm to Define Penicillin Allergy Status in Sexually Transmitted Infection Clinic Outpatients. Clin Infect Dis 2024; 78:1131-1139. [PMID: 38325290 PMCID: PMC11093667 DOI: 10.1093/cid/ciae064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Approximately 15% of patients in sexually transmitted infection (STI) clinics report penicillin allergies, complicating treatment for syphilis and gonorrhea. Nonetheless, >90% do not have a penicillin allergy when evaluated. We developed and validated an algorithm to define which patients reporting penicillin allergy can be safely treated at STI clinics with these drugs. METHODS Randomized controlled trial to assess feasibility and safety of penicillin allergy evaluations in STI clinics. Participants with reported penicillin allergy answered an expert-developed questionnaire to stratify risk. Low-risk participants underwent penicillin skin testing (PST) followed by amoxicillin 250 mg challenge or a graded oral challenge (GOC)-amoxicillin 25 mg followed by 250 mg. Reactions were recorded, and participant/provider surveys were conducted. RESULTS Of 284 participants, 72 (25.3%) were deemed high risk and were excluded. Of 206 low-risk participants, 102 (49.5%) underwent PST without reactions and 3 (3%) had mild reactions during the oral challenge. Of 104 (50.5%) participants in the GOC, 95 (91.3%) completed challenges without reaction, 4 (4.2%) had mild symptoms after 25 mg, and 4 (4.2%) after 250-mg doses. Overall, 195 participants (94.7%) successfully completed the study and 11 (5.3%) experienced mild symptoms. Of 14 providers, 12 (85.7%) completed surveys and 11 (93%) agreed on the safety/effectiveness of penicillin allergy assessment in STI clinics. CONCLUSIONS An easy-to-administer risk-assessment questionnaire can safely identify patients for penicillin allergy evaluation in STI clinics by PST or GOC, with GOC showing operational feasibility. Using this approach, 67% of participants with reported penicillin allergy could safely receive first-line treatments for gonorrhea or syphilis. Clinical Trials Registration. Clinicaltrials.gov (NCT04620746).
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Affiliation(s)
- Rebecca A Lillis
- Section of Infectious Diseases, Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | - Lindley A Barbee
- Division of Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Candice J McNeil
- Section of Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Lori Newman
- National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - J Dennis Fortenberry
- Division of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Santiago Alvarez-Arango
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonathan M Zenilman
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Gonzalez-Estrada A, Park MA, Accarino JJO, Banerji A, Carrillo-Martin I, D'Netto ME, Garzon-Siatoya WT, Hardway HD, Joundi H, Kinate S, Plager JH, Rank MA, Rukasin CRF, Samarakoon U, Volcheck GW, Weston AD, Wolfson AR, Blumenthal KG. Predicting Penicillin Allergy: A United States Multicenter Retrospective Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1181-1191.e10. [PMID: 38242531 DOI: 10.1016/j.jaip.2024.01.010] [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: 04/04/2023] [Revised: 12/29/2023] [Accepted: 01/07/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND Using the reaction history in logistic regression and machine learning (ML) models to predict penicillin allergy has been reported based on non-US data. OBJECTIVE We developed ML positive penicillin allergy testing prediction models from multisite US data. METHODS Retrospective data from 4 US-based hospitals were grouped into 4 datasets: enriched training (1:3 case-control matched cohort), enriched testing, nonenriched internal testing, and nonenriched external testing. ML algorithms were used for model development. We determined area under the curve (AUC) and applied the Shapley Additive exPlanations (SHAP) framework to interpret risk drivers. RESULTS Of 4777 patients (mean age 60 [standard deviation: 17] years; 68% women, 91% White, and 86% non-Hispanic) evaluated for penicillin allergy labels, 513 (11%) had positive penicillin allergy testing. Model input variables were frequently missing: immediate or delayed onset (71%), signs or symptoms (13%), and treatment (31%). The gradient-boosted model was the strongest model with an AUC of 0.67 (95% confidence interval [CI]: 0.57-0.77), which improved to 0.87 (95% CI: 0.73-1) when only cases with complete data were used. Top SHAP drivers for positive testing were reactions within the last year and reactions requiring medical attention; female sex and reaction of hives/urticaria were also positive drivers. CONCLUSIONS An ML prediction model for positive penicillin allergy skin testing using US-based retrospective data did not achieve performance strong enough for acceptance and adoption. The optimal ML prediction model for positive penicillin allergy testing was driven by time since reaction, seek medical attention, female sex, and hives/urticaria.
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Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Miguel A Park
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - John J O Accarino
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Michael E D'Netto
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - W Tatiana Garzon-Siatoya
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Heather D Hardway
- Digital Innovation Lab, Department of Health Sciences Research, Mayo Clinic, Jacksonville, Fla
| | - Hajara Joundi
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Susan Kinate
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz
| | - Jessica H Plager
- Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Section of Allergy, Immunology, Division of Pulmonary, Phoenix Children's Hospital, Phoenix, Ariz
| | - Christine R F Rukasin
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Section of Allergy, Immunology, Division of Pulmonary, Phoenix Children's Hospital, Phoenix, Ariz
| | - Upeka Samarakoon
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - Alexander D Weston
- Digital Innovation Lab, Department of Health Sciences Research, Mayo Clinic, Jacksonville, Fla
| | - Anna R Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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Copaescu AM, Li L, Blumenthal KG, Trubiano JA. How to Define and Manage Low-Risk Drug Allergy Labels. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1095-1106. [PMID: 38724164 DOI: 10.1016/j.jaip.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 06/06/2024]
Abstract
Risk stratification in drug allergy implies that specific risk categories (eg, low, moderate, and high) classify historical drug hypersensitivity reactions. These risk categories can be based on reaction phenotypic characteristics, the timing of the reaction and evaluation, the required reaction management, and individual characteristics. Although a multitude of frameworks have been described in the literature, particularly for penicillin allergy labels, there has yet to be a global consensus, and approaches continue to vary between allergy centers. Immune-mediated drug allergies can sometimes be confirmed using skin testing, but a negative drug challenge is required to demonstrate tolerance and remove the allergy from the electronic health record ("delabel" the allergy). Even for quintessential IgE-mediated drug allergy, penicillin allergy, recent data reveal that a direct oral challenge, without prior skin testing, is an appropriate diagnostic strategy in those who are considered low-risk. Drug allergy pathogenesis and clinical manifestations may vary depending on the culprit drug, and as such, the optimal approach should be based on risk stratification that considers individual patient and reaction characteristics, the likely hypersensitivity reaction phenotype, the drug class, and the patient's clinical needs. This article will describe low-risk drug allergy labels, focusing on β-lactam and sulfonamide antibiotics, nonsteroidal anti-inflammatory drugs, iodinated contrast media, and common chemotherapeutics. This review will also address practical management approaches using currently available risk stratification and clinical decision tools.
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Affiliation(s)
- Ana Maria Copaescu
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Medicine, Austin Health, the University of Melbourne, Heidelberg, VIC, Australia; Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada; The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada.
| | - Lily Li
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Wash
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, VIC, Australia
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Boussaïd M, Samama M, Foy JP, Bleibtreu A, Bertolus C, Gellee T. Postoperative infections after sinus lifts and onlay grafts in penicillin allergic patients. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024; 125:101764. [PMID: 38218333 DOI: 10.1016/j.jormas.2024.101764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/26/2023] [Accepted: 01/10/2024] [Indexed: 01/15/2024]
Abstract
INTRODUCTION The primary objective of this retrospective study was to determine whether patients treated with clindamycin due to a reported allergy to penicillin have an increased risk of postsurgical infections after sinus lifts and onlay grafts. MATERIAL AND METHODS A retrospective cohort study was performed on patients who underwent bone reconstruction procedures between October 2018 and December 2020. Data from all patients operated at the Pitié Salpêtrière University Hospital for sinus lifts or onlay grafts were collected. All surgical procedures studied were performed under preoperative and postoperative antibiotic prophylaxis with either amoxicillin (+/- clavulanic acid) or clindamycin for patients with reported penicillin allergy. Bone graft-associated infections as well as graft failures were recorded. RESULTS In this study, 111 patients received bone reconstructions (89 sinus lifts and 148 onlay grafts). In the sinus lifts group, infections occurred in 5 of 89 sites (5.6 %). The infection rate was 28.5 % (7 graft sites) and only 3.9 % (82 graft sites) for clindamycin and for amoxicillin, respectively. In the onlay graft group, infections occurred in 25 of 148 sites (16.8 %). The infection rate was 56 % and only 12 % for clindamycin (18 graft sites) and for amoxicillin, respectively (130 graft sites). Non-Penicillin treated patients had a higher risk of infection with an odd ratio of 7.8 (95 % CI 1.1-54.8, P = 0.04) and 4.8 (95 % CI 1.9-12.3, P = 0.001) compared with patients receiving amoxicillin for onlay grafts and sinus lifts. CONCLUSION Penicillin allergy and clindamycin use after sinus lift and onlay graft procedures were associated with a higher rate of infection and may be a risk factor for complications related to bone reconstruction surgery.
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Affiliation(s)
- Mehdi Boussaïd
- Department of Maxillo-facial Surgery, Hôpital Pitié Salpêtrière, Medecine Sorbonne Université, 47-83 Boulevard de l'Hôpital, Paris, 75013, France.
| | - Mickael Samama
- Department of Maxillo-facial Surgery, Hôpital Pitié Salpêtrière, Medecine Sorbonne Université, 47-83 Boulevard de l'Hôpital, Paris, 75013, France
| | - Jean Philippe Foy
- Department of Maxillo-facial Surgery, Hôpital Pitié Salpêtrière, Medecine Sorbonne Université, 47-83 Boulevard de l'Hôpital, Paris, 75013, France
| | - Alexandre Bleibtreu
- Department of Infectiology, Hôpital Pitié Salpêtrière, Medecine Sorbonne Université, 47-83 Boulevard de l'Hôpital, Paris, 75013, France
| | - Chloé Bertolus
- Department of Maxillo-facial Surgery, Hôpital Pitié Salpêtrière, Medecine Sorbonne Université, 47-83 Boulevard de l'Hôpital, Paris, 75013, France
| | - Timothée Gellee
- Department of Maxillo-facial Surgery, Hôpital Pitié Salpêtrière, Medecine Sorbonne Université, 47-83 Boulevard de l'Hôpital, Paris, 75013, France
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Xiang YY, Heriot GS, Jamrozik E. Ethics of antibiotic allergy. JOURNAL OF MEDICAL ETHICS 2023; 50:39-44. [PMID: 37286334 PMCID: PMC7615378 DOI: 10.1136/jme-2022-108648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 04/01/2023] [Indexed: 06/09/2023]
Abstract
Antibiotic allergies are commonly reported among patients, but most do not experience reactions on rechallenge with the same agents. These reported allergies complicate management of infections in patients labelled as having penicillin allergy, including serious infections where penicillin-based antibiotics are the first-line (most effective and least toxic) treatment option. Allergy labels are rarely questioned in clinical practice, with many clinicians opting for inferior second-line antibiotics to avoid a perceived risk of allergy. Reported allergies thereby can have significant impacts on patients and public health, and present major ethical challenges. Antibiotic allergy testing has been described as a strategy to circumvent this dilemma, but it carries limitations that often make it less feasible in patients with acute infections or in community settings that lack access to allergy testing. This article provides an empirically informed ethical analysis of key considerations in this clinical dilemma, using Staphylococcus aureus bacteraemia in patients with penicillin allergies as a case study. We argue that prescribing first-line penicillin-based antibiotics to patients with reported allergies may often present a more favourable ratio of benefits to risks, and may therefore be more ethically appropriate than using second-line drugs. We recommend changes to policy-making, clinical research and medical education, in order to promote more ethically acceptable responses to antibiotic allergies than the status quo.
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Affiliation(s)
- Yu Yi Xiang
- Western Health, Footscray, Victoria, Australia
| | - George S Heriot
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Euzebiusz Jamrozik
- Ethox and Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
- Royal Melbourne Hospital Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Monash Bioethics Centre, Monash University, Melbourne, Victoria, Australia
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Kouma MA, Guastadisegni JM, Yang L, Maxwell DN, Storey DF, Arasaratnam RJ. Challenges and opportunities related to penicillin allergy in the Veterans Health Administration: a narrative review. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e174. [PMID: 38028897 PMCID: PMC10644167 DOI: 10.1017/ash.2023.448] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 12/01/2023]
Abstract
The presence of a penicillin allergy label in a patient's medical chart is associated with negative clinical and economic outcomes. Given that less than 10% of reported reactions are truly immunoglobulin E-mediated, removal of unverified penicillin allergy labels is a public health priority and an area of ongoing implementation research. The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States, with almost 9 million veterans currently enrolled. However, studies analyzing the impact of the penicillin allergy label in this population are limited to single facilities and largely focus on short-term outcomes of allergy documentation correction, usage of β-lactams, and avoidance of antibiotic-related side effects. Broader, national VHA studies focusing on health outcomes and costs are lacking. As with non-VHA facilities, penicillin allergy evaluations are limited owing to the absence of formal allergy/immunology services at most VHA facilities. Pharmacy-driven screening and referral for clinic-based penicillin skin testing is a promising and frequently discussed modality in the literature, but its scalability within the VHA is not yet proven. Broader, evidence-based strategies that can be adapted to the available resources of individual VHA facilities, including those without on-site access to allergy providers, are needed.
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Affiliation(s)
- Marcus A. Kouma
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | | | - Linda Yang
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | - Daniel N. Maxwell
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donald F. Storey
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Reuben J. Arasaratnam
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
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Alagoz E, Saucke M, Balasubramanian P, Lata P, Liebenstein T, Kakumanu S. Barriers to penicillin allergy de-labeling in the inpatient and outpatient settings: a qualitative study. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:88. [PMID: 37821953 PMCID: PMC10568923 DOI: 10.1186/s13223-023-00842-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/08/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Penicillin allergy is the most commonly reported drug allergy in the US. Despite evidence demonstrating that up to 90% of labels are incorrect, scalable interventions are not well established. As part of a larger mixed methods investigation, we conducted a qualitative study to describe the barriers to implementing a risk-based penicillin de-labeling protocol within a single site Veteran's hospital. METHODS We conducted individual and group interviews with multidisciplinary inpatient and outpatient healthcare teams. The interview guides were developed using the Theoretical Domains Framework (TDF) to explore workflows and contextual factors influencing identification and evaluation of patients with penicillin allergy. Three researchers iteratively developed the codebook based on TDF domains and coded the data using thematic analysis. RESULTS We interviewed 20 clinicians. Participants included three hospitalists, five inpatient pharmacists, one infectious disease physician, two anti-microbial stewardship pharmacists, four primary care providers, two outpatient pharmacists, two resident physicians, and a nurse case manager for the allergy service. The factors that contributed to barriers to penicillin allergy evaluation and de-labeling were classified under six TDF domains; knowledge, skills, beliefs about capabilities, beliefs about consequences, professional role and identity, and environmental context and resources. Participants from all groups acknowledged the importance of penicillin de-labeling. However, they lacked confidence in their skills to perform the necessary evaluations, such as test dose challenges. The fear of inducing an allergic reaction and adding further complexity to patient care exacerbated their reluctance to de-label patients. The lack of ownership of de-labeling initiative was another significant obstacle in establishing consistent clinical workflows. Additionally, heavy workloads, competing priorities, and ease of access to alternative antibiotics prevented the prioritization of tasks related to de-labeling. Space limitations and nursing staff shortages added to challenges in outpatient settings. CONCLUSION Our findings demonstrated that barriers to penicillin allergy de-labeling fall under multiple behavioral domains. Better role clarification, opportunities to develop necessary skills, and dedicated resources are needed to overcome these barriers. Future interventions will need to employ a systemic approach that addresses each of the behavioral domains influencing penicillin allergy de-labeling with stakeholder engagement of the inpatient and outpatient health care teams.
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Affiliation(s)
- Esra Alagoz
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA.
| | - Megan Saucke
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Paul Lata
- William S. Middleton Veterans Memorial Hospital Madison, Madison, WI, USA
| | - Tyler Liebenstein
- William S. Middleton Veterans Memorial Hospital Madison, Madison, WI, USA
| | - Sujani Kakumanu
- William S. Middleton Veterans Memorial Hospital Madison, Madison, WI, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care, University of Wisconsin-Madison, Madison, WI, USA
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9
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Samarakoon U, Accarino J, Wurcel AG, Jaggers J, Judd A, Blumenthal KG. Penicillin allergy delabeling: Opportunities for implementation and dissemination. Ann Allergy Asthma Immunol 2023; 130:554-564. [PMID: 36563744 DOI: 10.1016/j.anai.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/01/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Although existing as a safety measure to prevent iatrogenic harm, unconfirmed penicillin allergy labels have a negative impact on personal and public health. One downstream effect of unconfirmed penicillin allergy is the continued emergence and transmission of resistant bacteria and their associated health care costs. Recognizing the consequences of inaccurate penicillin allergy labels, professional and public health organizations have started promoting the adoption of proactive penicillin allergy evaluations, with the ultimate goal of removing the penicillin allergy label when the allergy is disproved, also known as penicillin allergy "delabeling." A penicillin allergy evaluation includes a comprehensive allergy history often followed by drug challenge, sometimes with preceding skin testing. Currently, penicillin allergy delabeling is largely carried out by allergy specialists in outpatient settings. Penicillin allergy delabeling is performed on inpatients, albeit rarely, often at the time of need, as a point-of-care procedure. Access to penicillin allergy evaluation services is limited. Recent studies demonstrate the feasibility of expanding penicillin allergy evaluations and delabeling to internists, pediatricians, emergency medicine physicians, infectious diseases specialists, and clinical pharmacists. However, reducing the impact of mislabeled penicillin allergy will require comprehensive efforts and new investments. In this review, we summarize the current practices of penicillin allergy delabeling and discuss expansion opportunities for penicillin allergy delabeling as quality improvement.
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Affiliation(s)
- Upeka Samarakoon
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John Accarino
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Alysse G Wurcel
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts; Tufts University School of Medicine, Boston, Massachusetts
| | - Jordon Jaggers
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Allen Judd
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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10
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Powell N, Stephens J, Kohl D, Owens R, Ahmed S, Musicha C, Upton M, Kent B, Tonkin-Crine S, Sandoe J. The effectiveness of interventions that support penicillin allergy assessment and delabeling of adult and pediatric patients by nonallergy specialists: a systematic review and meta-analysis. Int J Infect Dis 2023; 129:152-161. [PMID: 36450321 PMCID: PMC10017351 DOI: 10.1016/j.ijid.2022.11.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Penicillin allergy records are often incorrect and may result in harm. We aimed to systematically review the effectiveness and safety of nonallergist health care worker delivery of penicillin allergy delabeling. METHODS We searched EMBASE/MEDLINE/CINAHL (Ovid), PsycInfo, Web of Science, and Cochrane CENTRAL from inception to January 21, 2022 and unpublished studies and gray literature. The proportion of patients allergic to penicillin delabeled and harmed was calculated using random-effects models. RESULTS Overall, 5019 patients were delabeled. Using allergy history alone, 14% (95% confidence interval [CI], 9-21%) of 4350 assessed patients were delabeled without reported harm. Direct drug provocation testing resulted in delabeling in 27% (95% CI, 18-37%) of 4207 assessed patients. Of the 1373 patients tested, 98% were delabeled (95% CI, 97-99%), and nonserious harm was reported in 1% (95% CI, 0-2%). Using skin testing, followed by drug provocation testing, 41% (95% CI, 24-59%) of 2890 assessed patients were delabeled. Of the 1294 tested patients, 95.0% (95% CI, 90-99%) were delabeled, and the reported harm was low (0%; (95% CI 0-1%). CONCLUSION Penicillin allergy delabeling by nonallergists is efficacious and safe. The proportion of assessed patients who can be delabeled increases with the complexity of testing method, but substantial numbers can be delabeled without skin testing.
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Affiliation(s)
- Neil Powell
- Pharmacy Department, Royal Cornwall Hospital, Truro, United Kingdom TR1 3LJ / School of Biomedical Sciences, University of Plymouth, Plymouth, United Kingdom.
| | - Jennie Stephens
- Intensive Care Department, Royal Cornwall Hospital, Truro, United Kingdom
| | - Declan Kohl
- School of Biomedical Sciences, University of Leeds, Leeds, United Kingdom
| | - Rhys Owens
- Core Medical Trainee, Royal Cornwall Hospital, Truro, United Kingdom
| | - Shadia Ahmed
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Crispin Musicha
- Medical Statistics, Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - Mathew Upton
- School of Biomedical Sciences, University of Plymouth, Plymouth, United Kingdom
| | - Bridie Kent
- School of Nursing and Midwifery, University of Plymouth, Plymouth, United Kingdom
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jonathan Sandoe
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
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11
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White BP, Barber KE, Chastain DB. Variation Among Infectious Diseases Pharmacists for the Treatment of Staphylococcus aureus Bacteremia. J Pharm Pract 2023; 36:295-302. [PMID: 34399064 DOI: 10.1177/08971900211038864] [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: 11/15/2022]
Abstract
Introduction: Staphylococcus aureus bacteremia (SAB) remains complex, in that optimal treatment for patients, including complicated or persistent infection, remains unclear. Two recent surveys have demonstrated practice variations in SAB among infectious diseases (ID) physicians. Objectives: The purpose of this survey was to examine practice variations in SAB among ID pharmacists. Methods: A thirty-five-question survey was electronically distributed to the American College of Clinical Pharmacy (ACCP) Infectious Diseases Practice and Research Network (IDPRN) in Fall 2019 to determine differences in SAB management. Data were analyzed utilizing Pearson's Chi-Square or Fisher's Exact Test. Results: A total of 106 ID pharmacists responded. Only 28% of pharmacists practiced at hospitals with mandatory ID consultation for SAB. A majority (75%) had rapid diagnostic technology (RDT) for identifying SABSI, but 32% of those facilities with RDT did not notify pharmacy with results. Anti-staphylococcal penicillins were preferred for MSSA blood stream infections (BSI) in patients with central nervous system infection and endocarditis, whereas cefazolin was favored for other MSSA BSI. For persistent MRSA BSI, 34% selected daptomycin alone while 38% elected to combine daptomycin and ceftaroline. Pharmacists at hospitals less than 500 beds were more likely to use daptomycin, while those at larger hospitals were more likely to use daptomycin and ceftaroline for persistent MRSA BSI (P < .05). Conclusions: A survey of ID pharmacists showed variation in the management of SABs, as well as the definition and treatment of persistent SAB. Mandatory ID consultation and RDT use to improve SAB management have not been optimized.
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Affiliation(s)
- Bryan P White
- Department of Pharmacy, 6195OU Medical Center, Oklahoma City, OK, USA
- College of Medicine, Infectious Diseases Section, 12308University of Oklahoma, Oklahoma City, OK, USA
| | - Katie E Barber
- College of Pharmacy, 15516University of Mississippi, Jackson, MS, USA
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12
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Arasaratnam RJ, Chow TG, Liu AY, Khan DA, Blumenthal KG, Wurcel AG. Penicillin Allergy Evaluation and Health Equity: A Call to Action. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:422-428. [PMID: 36521831 DOI: 10.1016/j.jaip.2022.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022]
Abstract
Allergists have been at the forefront of addressing the burden of unverified penicillin allergy labels. Coordinated national efforts with infectious diseases, antimicrobial stewardship experts, and pharmacy societies to advocate for formal evaluation of patient-reported penicillin allergy have resulted in improvements in delabeling efforts. Given the poorer health outcomes associated with the penicillin allergy label and the potential health benefits that can be gained with delabeling, improving access to penicillin allergy evaluation is of the utmost importance. Health disparities are widely recognized to impact all aspects of health care, and multilevel interventions at the patient, clinician, and systems level are required to ensure equitable care delivery. Structural racism underpins many social determinants of health and is a key driver of racial and ethnic health disparities. In this Rostrum, we use a conceptual framework from the 2015 National Academy of Medicine report Improving Diagnosis in Health Care to explore how inequities are related to the evaluation of penicillin allergy. We use the National Institute on Minority Health and Health Disparities Strategies to Advance Health Disparities to elucidate areas of important study. Building upon existing efforts to address disparities in Allergy/Immunology, we highlight the urgent importance of understanding and eliminating health disparities in penicillin allergy evaluation and delabeling.
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Affiliation(s)
- Reuben J Arasaratnam
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center and Veterans Affairs North Texas Health Care System, Dallas, Texas.
| | - Timothy G Chow
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas; University of Texas Southwestern Medical Center, Dallas, Texas
| | - Anne Y Liu
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, and Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - David A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Alysse G Wurcel
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Mass; Tufts University School of Medicine, Boston, Mass
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13
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Banerji A, Solensky R, Phillips EJ, Khan DA. Drug Allergy Practice Parameter Updates to Incorporate Into Your Clinical Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:356-368.e5. [PMID: 36563781 DOI: 10.1016/j.jaip.2022.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
The drug allergy practice parameter was developed to provide guidance on the diagnosis and management of drug hypersensitivity reactions. It was last updated in 2010. With the growth of research and evidence-based data since then, experts came together to update the practice parameter with a focus on sections that the work group deemed to have significant changes (or were not addressed) in the previous practice parameter. This review is a focused update on aspects of the practice parameter deemed to have the greatest impact on clinical practice and includes significant updates on diagnosis of antibiotic allergy including penicillin, cephalosporin, sulfonamide, fluoroquinolone, and macrolide allergies. Other topics include the evolution in our management approach to patients with aspirin/nonsteroidal anti-inflammatory drug allergy, diagnostic testing for delayed drug hypersensitivity and allergy to chemotherapeutics and biologics, and the key consensus-based statements for clinical practice. Specifically, the updated practice parameter helps allergists understand the place of 1- or 2-step drug challenges that are valuable tools often without the need for skin testing in many clinical situations. A proactive approach to delabeling penicillin allergy as well as unnecessary avoidance of safe antibiotic alternatives for patients with proven penicillin allergy is emphasized. New guidance is provided on management of patients with different phenotypes of aspirin and nonsteroidal anti-inflammatory drug hypersensitivity reactions. Approaches to delayed drug hypersensitivity and use of delayed intradermal and patch testing for specific phenotypes are reviewed. Lastly, practical approaches to management of patients with reactions to chemotherapeutics and biologics are discussed.
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Affiliation(s)
- Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
| | - Roland Solensky
- The Corvallis Clinic and Oregon State University/Oregon Health & Science University College of Pharmacy, Corvallis, Ore
| | - Elizabeth J Phillips
- Departments of Medicine, Dermatology, Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - David A Khan
- Department of Internal Medicine, Allergy and Immunology, The University of Texas Southwestern Medical Center, Dallas, Tex
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14
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Fanizza FA, Stump H, Carter E, Prohaska E. Evaluation of a pharmacist-led penicillin allergy testing service in a community health system. J Am Pharm Assoc (2003) 2023; 63:169-172. [PMID: 36041964 DOI: 10.1016/j.japh.2022.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/02/2022] [Accepted: 08/02/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Roughly 10% of the U.S. population has a documented penicillin (PCN) allergy. Among these individuals, over 95% are able to tolerate PCNs. The inability to use PCNs can result in suboptimal outcomes. In August 2019, Lawrence Memorial Hospital Health System implemented a pharmacist-led PCN allergy testing service to assist with delabeling PCN allergies and increase access to this class of antibiotics. OBJECTIVES The primary objective was to describe the number of patients who underwent PCN allergy testing and were delabeled from PCN allergy. A secondary objective was to report the number of patients who received and tolerated PCN antibiotics after being delabeled from PCN allergy. METHODS This retrospective chart review was conducted during the initial 17 months of a pharmacist-led PCN allergy testing service. Eligible patients with a history of an immunoglobulin E (IgE)-mediated reaction underwent a 3-step test that consisted of a scratch test, an intradermal test, and an oral challenge. Eligible patients who did not have a history of IgE-mediated reaction underwent a 2-step graded oral challenge. Descriptive statistics were used for data analysis. RESULTS Between August 2019 and January 2022, 70 patients underwent testing, and 66 patients were delabeled from PCN allergy. Four patients who underwent the 3-step test developed reactions of mild to moderate severity. All patients who underwent the graded oral challenge were delabeled from PCN allergy. The rate of PCN allergy was 5.7%, whereas the rate of type I IgE-mediated reaction was 1.4%. All 23 patients who received an antibiotic from the PCN class after a negative allergy test tolerated the PCN antibiotic without an incident. CONCLUSION PCN allergy testing is an effective way to delabel PCN allergies from most patients presenting with a PCN allergy history. Skin testing followed by an oral challenge or a graded oral challenge alone are safe methods for conducting PCN allergy testing in the primary care setting.
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15
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Bragg JT, Sudah SY, Moverman MA, Puzzitiello RN, Pagani NR, Menendez ME. Preoperative allergy testing for patients reporting penicillin and cephalosporin allergies is economically justified in preventing infection after total shoulder arthroplasty. J Shoulder Elbow Surg 2023; 32:186-191. [PMID: 36108882 DOI: 10.1016/j.jse.2022.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/05/2022] [Accepted: 07/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of alternative antibiotics to cefazolin has been associated with increased risk of infection after shoulder arthroplasty. Routine preoperative allergy testing in patients reporting penicillin and cephalosporin allergies increases the number able to receive cefazolin and may reduce the occurrence of infection after shoulder arthroplasty, but the financial viability of this practice is unclear. We used break-even modeling to determine the economic viability of routine preoperative allergy testing for infection prevention in total shoulder arthroplasty patients reporting penicillin and cephalosporin allergies. METHODS Allergy testing cost ($248.24), infection rates after shoulder arthroplasty following use of noncefazolin antibiotics (3.09%), and infection-related care costs ($55,243) were derived from the literature. A break-even equation using these variables was developed to determine the absolute risk reduction (ARR) in the infection rate that would economically justify the routine implementation of preoperative allergy testing. The number needed to treat was calculated from the ARR. RESULTS Preoperative allergy testing is considered economically justified if it prevents at least 1 infection out of 223 shoulder arthroplasties (ARR = 0.45%). These protocols remained economically viable at varying allergy testing costs, initial infection rates, and infection-related care costs. CONCLUSIONS Routine preoperative penicillin allergy testing is an economically justified infection prevention strategy among patients reporting penicillin and cephalosporin allergies in the setting of elective shoulder arthroplasty. Widespread implementation of this practice may considerably reduce the economic and societal burden associated with prosthetic infections.
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Affiliation(s)
- Jack T Bragg
- Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Suleiman Y Sudah
- Department of Orthopaedic Surgery, Monmouth Medical Center, Long Branch, NJ, USA
| | - Michael A Moverman
- Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.
| | - Richard N Puzzitiello
- Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Nicholas R Pagani
- Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
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16
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Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J, Khan DA, Golden DBK, Shaker M, Stukus DR, Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333-1393. [PMID: 36122788 DOI: 10.1016/j.jaci.2022.08.028] [Citation(s) in RCA: 164] [Impact Index Per Article: 82.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Aleena Banerji
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Roland Solensky
- Corvallis Clinic, Oregon State University/Oregon Health Science University College of Pharmacy, Corvallis, Ore
| | - Andrew A White
- Department of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St Joe's Hamilton, Hamilton, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew J Greenhawt
- Food Challenge and Research Unit Section of Allergy and Immunology, Children's Hospital Colorado University of Colorado School of Medicine, Aurora, Colo
| | - Caroline C Horner
- Department of Pediatrics, Division of Allergy Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla; James A. Haley Veterans Affairs Hospital, Tampa, Fla
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | - John Oppenheimer
- Division of Allergy, Rutgers New Jersey Medical School, Rutgers, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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17
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Mabilat C, Gros MF, Van Belkum A, Trubiano JA, Blumenthal KG, Romano A, Timbrook TT. Improving antimicrobial stewardship with penicillin allergy testing: a review of current practices and unmet needs. JAC Antimicrob Resist 2022; 4:dlac116. [PMID: 36415507 PMCID: PMC9675589 DOI: 10.1093/jacamr/dlac116] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Penicillin allergy, the most frequently reported drug allergy, has been associated with suboptimal antibiotic therapy, increased antimicrobial resistance, increased rates of Clostridioides difficile colonization and infection, as well as extended hospital length of stay and increased cost. Although up to 10% of all patients may report penicillin allergy, most penicillin allergies are not confirmed. As such, most patients with a penicillin allergy can still safely use penicillin and related drugs following a more precise assessment. Herein, we review the current practices and unmet needs in penicillin allergy testing. The diagnostic algorithm is mostly based on a clinical history assessment followed by in vivo testing, i.e. skin test and/or drug challenge. As these tests are labour and resource intensive, there is increased interest in point-of-care penicillin allergy de-labelling solutions incorporated into Antimicrobial Stewardship Programmes including digital assessment tools. These can be locally parameterized on the basis of characteristics of target populations, incidence of specific allergies and local antibiotic usage to perform clinical risk stratification. Safely ruling out any residual risk remains essential and in vivo drug challenge and/or skin testing should be systematically encouraged. Gradual understanding and convergence of the risk stratification of the clinical presentation of penicillin allergy is enabling a wider implementation of this essential aspect of antimicrobial stewardship through digitalized decision tools and in vivo testing. More research is needed to deliver point of care in vitro diagnostic tools to democratize this de-labelling practice, which would be highly beneficial to patient care. This progress, together with better education of patients and clinicians about the availability, efficacy and safety of penicillin allergy testing, will increase the dissemination of penicillin allergy assessment as an important component of Antimicrobial Stewardship Programmes.
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Affiliation(s)
| | - Marie-Françoise Gros
- bioMérieux, Medical Affairs, 100 Rue Louis Pasteur, F-69280 Marcy l'Etoile, France
| | - Alex Van Belkum
- Current address:BaseClear, Sylviusweg 74, 2333 BE Leiden, The Netherlands
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, 145 Studley Road, Heidelberg, Victoria, 3084Australia
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | | | - Tristan T Timbrook
- bioMérieux, BioFire Diagnostics, Global Medical Affairs, 515 Colorow Drive, Salt Lake City, UT 84108, USA
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Antibiotic Allergy De-Labeling: A Pathway against Antibiotic Resistance. Antibiotics (Basel) 2022; 11:antibiotics11081055. [PMID: 36009924 PMCID: PMC9404790 DOI: 10.3390/antibiotics11081055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 12/10/2022] Open
Abstract
Antibiotics are one of the most frequently prescribed drugs. Unfortunately, they also are the most common cause for self-reported drug allergy, limiting the use of effective therapies. However, evidence shows that more than 90% of patients labeled as allergic to antibiotics are not allergic. Importantly, the label of antibiotic allergy, whether real or not, constitutes a major public health problem as it directly impacts antimicrobial stewardship: it has been associated with broad-spectrum antibiotic use, often resulting in the emergence of bacterial resistance. Therefore, an accurate diagnosis is crucial for de-labeling patients who claim to be allergic but are not really allergic. This review presents allergy methods for achieving successful antibiotic allergy de-labeling. Patient clinical history is often inaccurately reported, thus not being able to de-label most patients. In vitro testing offers a complementary approach but it shows limitations. Immunoassay for quantifying specific IgE is the most used one, although it gives low sensitivity and is limited to few betalactams. Basophil activation test is not validated and not available in all centers. Therefore, true de-labeling still relies on in vivo tests including drug provocation and/or skin tests, which are not risk-exempt and require specialized healthcare professionals for results interpretation and patient management. Moreover, differences on the pattern of antibiotic consumption cause differences in the diagnostic approach among different countries. A multidisciplinary approach is recommended to reduce the risks associated with the reported penicillin allergy label.
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19
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Solensky R. Antibiotic allergies and hospital length of stay. Ann Allergy Asthma Immunol 2022; 129:5-6. [PMID: 35717135 DOI: 10.1016/j.anai.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Roland Solensky
- The Corvallis Clinic, 3680 NW Samaritan Drive, Corvallis, Oregon.
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20
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Lanoue D, van Walraven C. Association of antibiotic allergy labels with hospital length of stay. Ann Allergy Asthma Immunol 2022; 128:705-712. [PMID: 35292364 DOI: 10.1016/j.anai.2022.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Many antibiotic allergy labels (AAL) are invalid. Excluding true allergy in people with AAL ("delabeling") could improve health outcomes and decrease costs. Several studies with limited covariate adjustment have associated AAL with a prolonged hospital length of stay (LOS). OBJECTIVE This study determined whether AAL's association with LOS persisted after extensive adjustment for potential confounders and covariates. METHODS All nonpsychiatric admissions to a tertiary care teaching hospital from 2012 to 2015 were included. Generalized estimating equation methods were used to model the daily discharge likelihood as a function of AAL and other important factors (death risk score, daily discharge score, daily severity of illness score, antibiotic use, hospital day and location, weekend-holiday status, and service). RESULTS A total of 111,611 admissions (76,460 patients) were studied, in which 16,489 (14.8%) had recorded AAL. Patients with an AAL had a notably greater disease burden: they were older and had more comorbidities, greater health system utilization, and higher death risk. In the univariate analysis, AAL was associated with a significantly decreased daily discharge likelihood (odds ratio [OR], 0.93; [95% confidence interval, 0.90-0.95]). After adjustment for potential confounders and covariates, AAL was not associated with daily discharge likelihood (adjusted OR [aOR] without antibiotics: 1.00 [0.98-1.03]; aOR with antibiotics: 1.02 [0.99-1.04]). Similar results were also seen with penicillin AAL (aOR without antibiotics: 0.99 [0.95-1.02]; aOR with antibiotics: 1.00 [0.96-1.03]). CONCLUSION Antibiotic allergy label was strongly associated with a greater disease burden. After adjusting for important covariates, our analysis found no significant association between AAL and hospital LOS.
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Affiliation(s)
- Derek Lanoue
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Carl van Walraven
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada; Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada; International Credential Evaluation Service (ICES), British Columbia, Canada.
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21
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Vivo A, Durkin MJ, Kale I, Boyer T, Fitzpatrick MA, Evans CT, Jurasic MM, Gibson G, Suda KJ. Opportunities for penicillin allergy evaluation in dental clinics. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e58. [PMID: 36483385 PMCID: PMC9726497 DOI: 10.1017/ash.2022.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To evaluate opportunities for assessing penicillin allergies among patients presenting to dental clinics. DESIGN Retrospective cross-sectional study. SETTING VA dental clinics. PATIENTS Adult patients with a documented penicillin allergy who received an antibiotic from a dentist between January 1, 2015, and December 31, 2018, were included. METHODS Chart reviews were completed on random samples of 100 patients who received a noncephalosporin antibiotic and 200 patients who received a cephalosporin. Each allergy was categorized by severity. These categories were used to determine patient eligibility for 3 testing groups based on peer-reviewed algorithms: (1) no testing, (2) skin testing, and (3) oral test-dose challenge. Descriptive and bivariate statistics were used to compare facility and patient demographics first between true penicillin allergy, pseudo penicillin allergy, and missing allergy documentation, and between those who received a cephalosporin and those who did not at the dental visit. RESULTS Overall, 19% lacked documentation of the nature of allergic reaction, 53% were eligible for skin testing, 27% were eligible for an oral test-dose challenge, and 1% were contraindicated from testing. Male patients and African American patients were less likely to receive a cephalosporin. CONCLUSIONS Most penicillin-allergic patients in the VA receiving an antibiotic from a dentist are eligible for penicillin skin testing or an oral penicillin challenge. Further research is needed to understand the role of dentists and dental clinics in assessing penicillin allergies.
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Affiliation(s)
- Amanda Vivo
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans’ Affairs (VA) Medical Center, Hines, Illinois
| | | | - Ibuola Kale
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans’ Affairs (VA) Medical Center, Hines, Illinois
| | - Taylor Boyer
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania
| | - Margaret A. Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans’ Affairs (VA) Medical Center, Hines, Illinois
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Charlesnika T. Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans’ Affairs (VA) Medical Center, Hines, Illinois
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - M. Marianne Jurasic
- Veterans’ Health Administration Office of Dentistry, Washington, DC
- Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Gretchen Gibson
- Veterans’ Health Administration Office of Dentistry, Washington, DC
| | - Katie J. Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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22
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Taylor MG, Joerger T, Li Y, Scheurer ME, Russo ME, Gerber JS, Palazzi DL. Factors Associated With Penicillin Allergy Labels in Electronic Health Records of Children in 2 Large US Pediatric Primary Care Networks. JAMA Netw Open 2022; 5:e222117. [PMID: 35285918 PMCID: PMC9907342 DOI: 10.1001/jamanetworkopen.2022.2117] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/19/2022] [Indexed: 12/17/2022] Open
Abstract
Importance Penicillin allergy labels influence clinical decision-making, yet most children who are labeled do not have type 1 hypersensitivity allergic reactions and instead have a history of predictable adverse reactions or unspecified illness symptoms while receiving penicillin for viral infections. Studies describing penicillin allergy labeling in the pediatric outpatient setting are lacking. Objective To describe the epidemiology and factors associated with penicillin allergy labels across 2 large US pediatric primary care networks. Design, Setting, and Participants This retrospective, longitudinal birth cohort study was conducted in 90 primary care pediatric practices serving a diverse population of children across Houston, Texas, Austin, Texas, Philadelphia, Pennsylvania, and parts of New Jersey. Participants were children born between January 2010 and June 2020 who had a health care visit in the first 14 days of life and at least 2 additional visits in the first year of life at one of 90 primary care pediatric practices. Censoring criteria were additionally applied to exclude data from children no longer seeking health care in the 90 clinics over time. Statistical analysis was performed from February to May 2021. Exposures Basic patient demographics, health care utilization, penicillin exposure, and primary clinic location. Main Outcomes and Measures Addition of penicillin allergy label in the electronic medical record. Results Among 334 465 children in the birth cohort, 164 173 (49.1%) were female; 72 831 (21.8%) were Hispanic, 59 598 (17.8%) were non-Hispanic Black, and 148 534 (44.4%) were non-Hispanic White; the median (IQR) age at censoring was 3.8 (1.7-6.6) years; 18 015 (5.4%) were labeled as penicillin allergic, but the prevalence of penicillin allergy labeling ranged from 0.9% to 10.2% across practices. Children were labeled at a median (IQR) age of 1.3 (0.9-2.3) years. Non-Hispanic White children were more likely to be labeled compared with non-Hispanic Black children after controlling for potential confounders (adjusted odds ratio, 1.7 [95% CI, 1.6-1.8]). There were 6797 allergic children (37.7%) labeled after receiving 1 penicillin prescription and 1423 (7.9%) labeled after receiving 0 penicillin prescriptions. Conclusions and Relevance In this cohort study of more than 330 000 children, penicillin allergy labeling was common and varied widely across practices. Children were labeled early in life, and almost half were labeled after receiving 1 or 0 penicillin prescriptions. These findings raise questions regarding the validity of penicillin allergy labels. Future work exploring the fidelity of and outcomes associated with penicillin allergy-labeling in children is warranted.
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Affiliation(s)
- Margaret G. Taylor
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston
| | - Torsten Joerger
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Now with Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital Stanford, Stanford
| | - Yun Li
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children’s, Phildelphia
| | - Michael E. Scheurer
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston
| | - Michael E. Russo
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jeffrey S. Gerber
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Debra L. Palazzi
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston
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23
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Powell N, Kohl D, Ahmed S, Kent B, Sandoe J, Tonkin-Crine S, Owens R, Stephens J, Upton M. Effectiveness of interventions that support penicillin allergy assessment and de-labelling of patients by non-allergy specialists: a systematic review protocol. JBI Evid Synth 2021; 20:624-632. [PMID: 34698707 DOI: 10.11124/jbies-21-00075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE This review will systematically examine and synthesize the evidence evaluating the effectiveness and safety of interventions that enable non-allergy specialist health care workers to assess allergy risk in patients with reported penicillin allergies and subsequently remove erroneous allergy records. INTRODUCTION The potential benefits of removing erroneous penicillin allergy labels (de-labeling) are wide-ranging. Penicillin allergy assessment and de-labeling is an antibiotic stewardship priority. Delivery of such assessment and de-labeling by non-allergy specialists has been reported in several studies, but the effectiveness and safety have not been formally synthesized. This is a necessary step in the upscaling of penicillin allergy assessment services. INCLUSION CRITERIA This review will consider quantitative studies using appropriate designs. The studies will include adults and pediatric patients who have undergone penicillin allergy assessment and de-labeling by non-allergy specialists in any health care setting. METHODS A range of databases will be searched to identify studies published in English, with no date limit. Unpublished studies and gray literature will also be searched. Title and abstract screening, and assessment of selected full texts against the inclusion criteria will be conducted by at least two independent reviewers. Identified studies will be assessed for methodological quality using standardized critical appraisal instruments. Data will be extracted and categorized using the EPOC taxonomy, and the effectiveness and safety of the intervention will be determined. Where possible, data will be pooled to facilitate meta-analysis. Data from heterogeneous studies will be reported narratively. The GRADE approach for grading the certainty of evidence will be followed. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020219044.
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Affiliation(s)
- Neil Powell
- Pharmacy Department, Royal Cornwall Hospital Trust, Truro, Cornwall, UK School of Biomedical Sciences, University of Plymouth, Plymouth, Devon, UK School of Biomedical Sciences, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence, Faculty of Health, University of Plymouth, Plymouth, Devon, UK Leeds Institute of Medical Research, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK Department of Critical Care, Royal Cornwall Hospital Trust, Truro, Cornwall, UK Department of Medicine, Royal Cornwall Hospital Trust, Truro, Cornwall, UK
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24
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Development and Validation of a Mobile Clinical Decision Support Tool for the Diagnosis of Drug Allergy in Adults: The Drug Allergy App. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4410-4418.e4. [PMID: 34506965 DOI: 10.1016/j.jaip.2021.07.057] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/07/2021] [Accepted: 07/20/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Penicillin allergy overdiagnosis has been associated with inappropriate antibiotic prescribing, increased antimicrobial resistance, worse clinical outcomes, and increased health care costs. OBJECTIVE To develop and validate a questionnaire-based algorithm built in a mobile application to support clinicians in collecting accurate history of previous reactions and diagnosing drug allergy appropriately. METHODS A survey was completed by 164 medical and nonmedical prescribers to understand barriers to best practice. Based on the survey recommendations, we created a 10-item questionnaire-based algorithm to allow classification of drug allergy history in line with the National Institute for Health and Care Excellence guidelines on drug allergy. The algorithm was incorporated into a mobile application and retrospectively validated using anonymized clinical databases at regional immunology and dermatology centers in Manchester, United Kingdom. RESULTS A total of 55.2% of prescribers (95% confidence interval, 47% to 63.4%) thought it impossible to draw a firm conclusion based on history alone and 59.4% (95% CI, 51.4% to 67.5%) believed that regardless of the details of the penicillin allergy history, they would avoid all β-lactams. A drug allergy mobile application was developed and retrospectively validated, which revealed a low risk for misclassification of outcomes compared with reference standard drug allergy investigations in the allergy and dermatology clinics. CONCLUSIONS Perceived lack of time and preparedness to collect an accurate drug allergy history appear to be important barriers to appropriate antimicrobial prescribing. The Drug Allergy App may represent a useful clinical decision support tool to diagnose drug allergy correctly and support appropriate antibiotic prescribing.
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25
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Lee OC, Cheng DC, Paul JL, Ross BJ, Hawkins BJ, Sherman WF. Economic Burden of Patient-Reported Penicillin Allergy on Total Hip and Total Knee Arthroplasty. J Arthroplasty 2021; 36:3067-3072. [PMID: 34053750 DOI: 10.1016/j.arth.2021.04.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/15/2021] [Accepted: 04/26/2021] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Self-reported penicillin allergies in patients undergoing total joint arthroplasty often results in the use of second-line prophylactic antibiotics. A higher risk of prosthetic joint infection (PJI) is associated with suboptimal antibiotics vs first generation cephalosporins, which have historically been grouped with other beta-lactam antibiotics such as penicillin for potential allergic reactions. This study evaluates the economic burden of self-reported penicillin allergies in total joint arthroplasty (TJA). METHODS Data from studies reporting true incidence of IgE-mediated penicillin allergies, infection-free survivorship of TJA, and cost of PJI attributed to use of second-line antibiotics were obtained. Projected cost of preoperative penicillin allergy testing and potentially avoidable PJI associated with second-line antibiotic usage were calculated. This was compared with projected cost of PJI in the current state to estimate cost savings. RESULTS Implementation of preoperative penicillin allergy testing leads to a potential savings of nearly $37 million to payors in the first year based on 1-year survivorship. This savings increases to $411.6 million over a 10-year span and $1.18 billion over a 20-year span. CONCLUSION Preoperative penicillin allergy testing or risk stratification via thorough history should be implemented as standard of care for patients with self-reported penicillin allergies before TJA and would result in decreased cost of PJI.
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Affiliation(s)
- Olivia C Lee
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center and Southeast Louisiana Veterans Healthcare System, New Orleans, LA; Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Darren C Cheng
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Jonathan L Paul
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Bailey J Ross
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Barrett J Hawkins
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
| | - William F Sherman
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
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26
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Sousa-Pinto B, Blumenthal KG, Macy E, Pereira AM, Azevedo LF, Delgado L, Fonseca JA. Penicillin Allergy Testing Is Cost-Saving: An Economic Evaluation Study. Clin Infect Dis 2021; 72:924-938. [PMID: 32107530 DOI: 10.1093/cid/ciaa194] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Having a penicillin allergy label is associated with the use of less appropriate and more expensive antibiotics and increased healthcare utilization. Penicillin allergy testing results in delabeling most allergy claimants and may be cost-saving. This study aimed to project whether penicillin allergy testing in patients reporting a penicillin allergy is cost-saving. METHODS In this economic evaluation study, we built decision models to project the economic impact of 2 strategies for a patient with a penicillin allergy label: (1) perform diagnostic testing (drug challenges, with or without skin tests); and (2) do not perform diagnostic testing. The health service perspective was adopted, considering costs with penicillin allergy tests, and with hospital bed-days/outpatient visits, antibiotic use, and diagnostic testing. Twenty-four base case decision models were built, accounting for differences in the diagnostic workup, setting (inpatient vs outpatient) and geographic region. Uncertainty was explored via probabilistic sensitivity analyses. RESULTS Penicillin allergy testing was cost-saving in all decision models built. For models assessing the performance of both skin tests and drug challenges, allergy testing resulted in average savings (in United States [US] dollars) of $657 for inpatients (US: $1444; Europe: $489) and $2746 for outpatients (US: $256; Europe: $6045). 75% of simulations obtained through probabilistic sensitivity analysis identified testing as the less costly option. CONCLUSIONS Penicillin allergy testing was projected to be cost-saving across different scenarios. These results are devised to inform guidelines, supporting the adoption of policies promoting widespread testing of patients with a penicillin allergy label.
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Affiliation(s)
- Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal.,Basic and Clinical Immunology Unit, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, California, USA
| | - Ana Margarida Pereira
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
| | - Luís Filipe Azevedo
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
| | - Luís Delgado
- Center for Health Technology and Services Research, Porto, Portugal.,Basic and Clinical Immunology Unit, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Almeida Fonseca
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, Porto, Portugal
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27
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Sousa-Pinto B, Blumenthal KG, Courtney L, Mancini CM, Jeffres MN. Assessment of the Frequency of Dual Allergy to Penicillins and Cefazolin: A Systematic Review and Meta-analysis. JAMA Surg 2021; 156:e210021. [PMID: 33729459 PMCID: PMC7970387 DOI: 10.1001/jamasurg.2021.0021] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/17/2020] [Indexed: 12/15/2022]
Abstract
Importance Cefazolin is the preoperative antibiotic of choice because it is safer and more efficacious than second-line alternatives. Surgical patients labeled as having penicillin allergy are less likely to prophylactically receive cefazolin and more likely to receive clindamycin or vancomycin, which results in higher rates of surgical site infections. Objective To examine the incidence of dual allergy to cefazolin and natural penicillins. Data Sources MEDLINE/PubMed, Web of Science, and Embase were searched without language restrictions for relevant articles published from database inception until July 31, 2020. Study Selection In this systematic review and meta-analysis, a search of MEDLINE/PubMed, Web of Science, and Embase was performed for articles published from database inception to July 31, 2020, for studies that included patients who had index allergies to a natural penicillin and were tested for tolerability to cefazolin or that included patients who had index allergies to cefazolin and were tested for tolerability to a natural penicillin. A total of 3228 studies were identified and 2911 were screened for inclusion. Data Extraction and Synthesis Data were independently extracted by 2 authors. Bayesian meta-analysis was used to estimate the frequency of allergic reactions. Main Outcomes and Measures Dual allergy to cefazolin and a natural penicillin. Results Seventy-seven unique studies met the eligibility criteria, yielding 6147 patients. Cefazolin allergy was identified in 44 participants with a history of penicillin allergy, resulting in a dual allergy meta-analytical frequency of 0.7% (95% credible interval [CrI], 0.1%-1.7%; I2 = 74.9%). Such frequency was lower for participants with unconfirmed (0.6%; 95% CrI, 0.1%-1.3%; I2 = 54.3%) than for those with confirmed penicillin allergy (3.0%; 95% CrI, 0.01%-17.0%; I2 = 88.2%). Thirteen studies exclusively assessed surgical patients (n = 3884), among whom 0.7% (95% CrI, 0%-3.3%; I2 = 85.5%) had confirmed allergy to cefazolin. Low heterogeneity was observed for studies of patients with unconfirmed penicillin allergy who had been exposed to perioperative cefazolin (0.1%; 95% CrI, 0.1%-0.3%; I2 = 13.1%). Penicillin allergy was confirmed in 16 participants with a history of cefazolin allergy, resulting in a meta-analytical frequency of 3.7% (95% CrI, 0.03%-13.3%; I2 = 64.4%). The frequency of penicillin allergy was 4.4% (95% CrI, 0%-23.0%; I2 = 75%) for the 8 studies that exclusively assessed surgical patients allergic to cefazolin. Conclusions and Relevance These findings suggest that most patients with a penicillin allergy history may safely receive cefazolin. The exception is patients with confirmed penicillin allergy in whom additional care is warranted.
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Affiliation(s)
- Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Center for Health Technology and Services Research, University of Porto, Porto, Portugal
- Basic and Clinical Immunology Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- The Mongan Institute, Massachusetts General Hospital, Boston
| | - Lindsay Courtney
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
| | - Christian M. Mancini
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| | - Meghan N. Jeffres
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
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28
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Gaudreau S, Bourque G, Côté K, Nutu C, Beauchesne MF, Longpré AA, Beloin-Jubinville B, Legeleux L, Blaquière M, Martin P, Gilbert M. Resources Assessment for Penicillin Allergy Testing Performed by Pharmacists at the Patient's Bedside. Ann Pharmacother 2021; 55:1355-1362. [PMID: 33703922 PMCID: PMC8908455 DOI: 10.1177/10600280211002412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: False penicillin allergies lead to increased antimicrobial resistance, adverse effects, and health care costs by promoting the use of broad-spectrum antibiotics. The Infectious Diseases Society of America recommends the implementation of allergy testing. Objectives: The primary objective of this research was to estimate the number of pharmacist full-time equivalents (FTEs) required for an intervention aimed at determining penicillin allergy in hospitalized patients. Acceptance of pharmacists’ suggestions on antibiotic therapy are described. Methods: A quasi-experimental study was conducted in a 712-bed university hospital involving hospitalized patients with a suspected penicillin allergy and an infection treatable with penicillin. The time required for the intervention, which included a questionnaire, penicillin allergy testing (skin-prick test, intradermal injection, and oral provocation test), and recommendations on antibiotic therapy were measured to calculate the number of pharmacist FTEs. Results: A total of 55 patients were included. Scarification allergy testing was performed on 37, intradermal allergy test on 33, and oral provocation test on 26 patients. The intervention ruled out penicillin allergy in 26 patients, with no serious adverse effects. The intervention was associated with a median weekly pharmacist FTE of 0.15 (interquartile range = 0.12-0.25). The acceptance of pharmacists’ suggestions was high and led to 9 patients being switched to an antibiotic with a narrower spectrum of activity. Conclusions and Relevance: This study describes penicillin allergy testing and the number of median weekly hospital pharmacist FTEs required, which was approximately 0.15. These data may aid in the implementation of this safe intervention that promotes narrower-spectrum antibiotherapy.
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Affiliation(s)
- Sophie Gaudreau
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | - Geneviève Bourque
- Centre intégré de santé et de services sociaux de la Montérégie-Centre, Saint-Jean-sur-Richelieu, QC, Canada
| | - Kevin Côté
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | | | - Marie-France Beauchesne
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada.,Centre de recherche du CHUS, Sherbrooke, QC, Canada
| | - Audrey-Anne Longpré
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | - Bianca Beloin-Jubinville
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | - Lorraine Legeleux
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
| | - Martin Blaquière
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Philippe Martin
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Mélanie Gilbert
- Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Université de Montréal, Montréal, QC, Canada
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29
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Pagani NR, Moverman MA, Puzzitiello RN, Menendez ME, Barnes CL, Kavolus JJ. Preoperative Allergy Testing for Patients Reporting Penicillin and Cephalosporin Allergies is Cost-Effective in Preventing Infection after Total Knee and Hip Arthroplasty. J Arthroplasty 2021; 36:700-704. [PMID: 32933797 DOI: 10.1016/j.arth.2020.08.045] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/29/2020] [Accepted: 08/21/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Routine preoperative allergy testing in patients reporting penicillin and cephalosporin allergies increases the number able to receive cefazolin, which should reduce the risk of infection after total knee and hip arthroplasty (TKA/THA), but it remains unclear whether this practice is cost-effective. Using a break-even analysis, we calculated the cost-effectiveness of routine preoperative allergy testing for infection prevention in total joint arthroplasty patients reporting penicillin and cephalosporin allergies. METHODS The cost of a penicillin allergy evaluation, the cost of revision arthroplasty for prosthetic joint infection (PJI), and baseline rates of PJI in patients receiving a noncefazolin antibiotic in the perioperative period were derived from existing literature. A break-even economic model using these variables was constructed to calculate the absolute risk reduction (ARR) in infection rate needed for preoperative allergy testing to be cost-effective. The number needed to treat (NNT) was calculated from the ARR. RESULTS Preoperative allergy testing before TKA and THA in patients reporting penicillin and cephalosporin allergies was cost-effective if the initial infection rate decreased by an ARR of 0.810% (NNT = 123) and 0.655% (NNT = 153) for TKA and THA, respectively. Cost-effectiveness was maintained with varying allergy consultation costs, infection rates, and costs associated with PJI treatment. CONCLUSION Routine preoperative allergy testing and clearance are cost-effective infection prevention strategies among patients reporting penicillin and cephalosporin allergies in the setting of elective joint arthroplasty. Widespread adoption of this practice may considerably reduce the economic and societal burden associated with prosthetic infections.
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Affiliation(s)
| | | | | | | | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Joseph J Kavolus
- Tufts Medical Center, Department of Orthopaedic Surgery, Boston, MA
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30
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Neu DW, Guidry TJ, Gillion AR, Pattanaik DN. Impact of Beta-Lactam Allergies on Selection of Antimicrobials in an Inpatient Setting Among Veteran Population. Mil Med 2021; 187:e567-e571. [DOI: 10.1093/milmed/usab004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/27/2020] [Accepted: 01/27/2021] [Indexed: 01/09/2023] Open
Abstract
ABSTRACT
Purpose
Beta-lactam antibiotics are among the most common and widely used antibiotics. However, reported allergy to this class of antibiotics is also common, leading to the use of alternative broad-spectrum antibiotics by healthcare providers. This has led to the emergence of various negative health outcomes. The purpose of the study is to investigate the impact of using alternative antibiotics secondary to a beta-lactam allergy among U.S. veterans who have otherwise multiple comorbidities.
Methods
This retrospective observational analysis was conducted over a 5-year period (January 1, 2011 to December 31, 2016) at the Memphis Veterans Affairs Medical Center (VAMC). Admitted patients with a documented beta-lactam allergy were categorized to preferred or non-preferred status based on initial antibiotic therapy antibiotic, allergy history, published guidelines, and local antibiogram. Preferred therapy was defined as the optimal antibiotic treatment for a given indication based on patient allergy history, published Infectious Disease Society of America guidelines, and local antibiogram of Memphis VAMC. The therapy was classified as “non-preferred” if it did not satisfy the preferred therapy criteria. Non-preferred treatments were further assessed for appropriateness based on indication and patient-specific factors. Chi-square and Fisher’s exact tests were conducted to find a difference in rates of negative sequelae among patients receiving preferred vs. non-preferred treatments and appropriate vs. inappropriate treatments.
Findings
Of the 1806 admissions identified, data were collected on 95 unique patients with 147 different antibiotic regimens. There were 68 (52%) preferred treatment regimens and 64 (48%) non-preferred treatment regimens. Of the 64 non-preferred treatments, 43 (67%) were inappropriate. There was a statistically significant decrease in the number of adverse drug events and in the combined negative sequelae outcome among patients receiving preferred therapy vs. non-preferred therapy (2 vs. 12; P < .01 and 11 vs. 23; P < .01, respectively).
Implications
The receipt of non-preferred antibiotic therapy among veterans with a recorded beta-lactam allergy may be associated with an increased risk of developing negative outcomes. Among military personnel, removing unnecessary beta-lactam allergies would improve readiness with optimal antibiotic choices and avoidance of unnecessary risks, expediting return to full duty.
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Affiliation(s)
- Daniel W Neu
- Pharmacy Department (119), Veterans Affairs Medical Center, Memphis, TN 38104, USA
| | - Tommie Jo Guidry
- Pharmacy Department (119), Veterans Affairs Medical Center, Memphis, TN 38104, USA
| | - Amanda R Gillion
- Pharmacy Department (119), Veterans Affairs Medical Center, Memphis, TN 38104, USA
| | - Debendra N Pattanaik
- Pharmacy Department (119), Veterans Affairs Medical Center, Memphis, TN 38104, USA
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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31
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Gupta A, Tennakoon L, Spain DA, Forrester JD. Outcomes after Surgery among Patients Diagnosed with One or More Multi-Drug-Resistant Organisms. Surg Infect (Larchmt) 2021; 22:722-729. [PMID: 33471591 DOI: 10.1089/sur.2020.400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background: Infections with multi-drug-resistant organisms (MDROs) may be difficult to treat and prolong patient hospitalization and recovery. Multiple MDRO coinfections may increase the complexity of clinical management. However, association between multiple MDROs and outcomes of patients who undergo surgery is unknown. Patients and Methods: We performed a retrospective, cross-sectional analysis of the 2016 National Inpatient Sample for identified by International Classification of Disease, 10th Revision Clinical Modification (ICD-10-CM) diagnosis codes associated with multi-drug-resistant organisms: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), multi-drug-resistant gram-negative bacilli, and Clostridioides difficile infection (CDI). Admitted patients with diagnosis codes for MDROs were cross-matched with codes for common general surgery procedures. Outcomes of interest included length of stay and mortality. Weighted univariable and multivariable analyses accounting for the survey methodology were performed. Results: Of 1,550,224 patients undergoing surgery in 2016, 39,065 (3%) admissions were diagnosed with an MDRO and 1,176 (0.1%) were associated with dual MDROs diagnoses. Patients diagnosed with one MDRO were hospitalized three times longer (17.3 days; 95% confidence interval [CI], 16.8-17.7) and patients diagnosed with two MDROs five times longer (31.6 days; 95% CI, 27.0-36.2; p < 0.0001) than undiagnosed patients (6.1 days; 95% CI, 6.1-6.1; all p < 0.0001). On multivariable analysis, the strongest predictor of mortality was a diagnosis of two MDRO infections (odds ratio [OR], 4.8; 95% CI, 3.16-7.21; p < 0.0001). The second strongest predictor was diagnosis of single MDRO infection (OR, 2.9; 95% CI, 2.64-3.20; p < 0.0001). Conclusion: Presence of an MDRO was associated with increased odds of mortality and length of stay in admitted surgical patients. Interventions to reduce MDRO infection among surgical patients may reduce hospital length of stay and mortality.
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Affiliation(s)
- Anshal Gupta
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
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Lee RU. Penicillin Allergy Delabeling Can Decrease Antibiotic Resistance, Reduce Costs, and Optimize Patient Outcomes. Fed Pract 2020; 37:460-465. [PMID: 33132684 DOI: 10.12788/fp.0040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Antibiotics are one of the most frequently prescribed medications. Among all classes of antibiotics, penicillins are prescribed due to their clinical efficacy, cost-effectiveness, and general safety. Unfortunately, penicillins also are the most common drug allergy listed in patient medical records. Increasing evidence shows that > 90% of patients labeled with a penicillin allergy are not allergic to penicillins and associated β-lactams. The health care consequences of penicillin allergy in the setting of military medicine and readiness are important to consider. Observations In the US, 8 to 10% of the population and up to 15% of hospitalized patients have a documented penicillin allergy, limiting the use of these effective antibiotics. When treating a patient with a penicillin allergy, many clinicians avoid prescribing all β-lactam antibiotics and stay away from cephalosporins due to the concern for potential cross-reactivity. The cost of treating those with a documented penicillin allergy is greater than the cost for those who can receive penicillin, as treatment with broad-spectrum antibiotics often results in longer hospitalizations with increased rates of adverse effects (AEs). Despite preventive programs such as vaccinations, hygiene measures, and prophylactic antibiotics, military personnel are at increased risk for infections due to the military's mobile nature and crowded living situations. Conclusions Many patients report an allergy to penicillin, but only a small portion have a true immune-mediated allergy. Given the clinical, public health, and economic costs associated with a penicillin allergy label, evaluation and clearance of penicillin allergies improves clinical outcomes, decreases AEs from higher risk alternative broad-spectrum antibiotics, and prevents the spread of antibiotic resistance. In military personnel, penicillin delabeling improves readiness with optimal antibiotic options and avoidance of unnecessary risks, expediting return to full duty.
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Affiliation(s)
- Rachel U Lee
- is a Staff Allergist and Immunologist in the Division of Allergy, Department of Internal Medicine at the Naval Medical Center in San Diego, California
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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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Powell N, Honeyford K, Sandoe J. Impact of penicillin allergy records on antibiotic costs and length of hospital stay: a single-centre observational retrospective cohort. J Hosp Infect 2020; 106:35-42. [DOI: 10.1016/j.jhin.2020.05.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/27/2020] [Indexed: 12/01/2022]
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Chakravorty A, Binder E, Rawlins M, Trevenen M, Ingram PR, McKeogh A, Murray K, Dyer J, Lucas M. Antibiotic allergy labels and optimal antimicrobial stewardship. Intern Med J 2020; 52:396-402. [PMID: 32743883 DOI: 10.1111/imj.15003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although common, antimicrobial allergy labels (AAL) rarely reflect immunologically-mediated hypersensitivity and can lead to poorer outcomes from alternative antimicrobial agents. Antimicrobial stewardship programs are ideally placed to assess AAL early as a means of improving antimicrobial use. OBJECTIVES To quantify the prevalence of AAL in patients referred for antimicrobial stewardship review and assess their impact on antibiotic prescribing, patient mortality, hospital length of stay, readmission, and rates of multidrug-resistant infections. METHODS We conducted a retrospective analysis of adult patients referred for inpatient antimicrobial prospective audit and feedback rounds (PAFR) via an electronic referral system (eReferrals) over a 12-month period in 2015. Outcome data was collected for a period of 36 months following the initial review. RESULTS Of the 639 patient records reviewed, 630 met inclusion criteria; 103 (16%) had an AAL, of which 82 (13%) had reported allergies to β-lactam antibiotics. Those with AAL were significantly less likely to be receiving guideline-recommended antimicrobial therapy (50% versus 64%, p=0.0311), however there were no significant difference in mortality, hospital length of stay, readmission or increased incidence of multidrug-resistant infections. CONCLUSIONS Our cohort demonstrated that AAL was associated with reduced adherence to antibiotic guidelines. The lack of association with adverse outcomes may reflect limitations within the study including retrospective cohort study numbers and observational nature, further skewed by high rates of poor documentation. A clear opportunity exists for antimicrobial stewardship programs to incorporate allergy assessment, delabelling, challenge and referral into these rounds. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | | | | | - Michelle Trevenen
- Centre for Applied Statistics, The University of Western Australia, Perth, WA, Australia
| | - Paul Robert Ingram
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia.,Department of Pathology and Laboratory Medicine, The University of Western Australia, Perth, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, Australia
| | - Anna McKeogh
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
| | - Kevin Murray
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - John Dyer
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
| | - Michaela Lucas
- Department of Immunology, Sir Charles Gairdner Hospital, Perth, Australia.,Department of Immunology, PathWest Laboratory Medicine, Perth, Australia.,School of Medicine, The University of Western Australia, Perth, Australia
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Molloy L, Barron S, Khan N, Abrass E, Ang J, Abdel-Haq N. Oral β-Lactam Antibiotics for Pediatric Otitis Media, Rhinosinusitis, and Pneumonia. J Pediatr Health Care 2020; 34:291-300. [PMID: 32334748 DOI: 10.1016/j.pedhc.2019.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 10/29/2019] [Accepted: 11/06/2019] [Indexed: 12/14/2022]
Abstract
Acute otitis media, acute bacterial rhinosinusitis, and community-acquired pneumonia are major drivers of pediatric antibiotic consumption. With many available options and the added challenges of navigating antibiotic allergies and de-escalating from intravenous treatment for children requiring hospitalization, prescribing for these relatively simple infections can be a source of confusion and error. The purpose of this article is to evaluate the pharmacokinetic and pharmacodynamic properties of antibiotics commonly prescribed for these disease states, and to specifically compare antipneumococcal activity between oral beta-lactams.
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Cephalosporins' Cross-Reactivity and the High Degree of Required Knowledge. Case Report and Review of the Literature. Antibiotics (Basel) 2020; 9:antibiotics9050209. [PMID: 32344946 PMCID: PMC7277108 DOI: 10.3390/antibiotics9050209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/14/2020] [Accepted: 04/23/2020] [Indexed: 12/30/2022] Open
Abstract
Antibiotic cross-reactivity represents a phenomenon of considerable interest as well as antibiotic resistance. Immediate reactions to cephalosporins are reported in the literature with a prevalence of only 1%-3% of the population, while anaphylactic reactions are rarely described (approximately 0.0001%-0.1%) as well as fatalities. Allergic reaction to cephalosporins may occur because of sensitization to unique cephalosporin haptens or to determinants shared with penicillins. Cross-reactivity between cephalosporins represents, in fact, a well-known threatening event involving cephalosporins with similar or identical R1- or R2-side chains. The present report describes the case of a 79-year-old man who suddenly died after intramuscular administration of ceftriaxone. Serum dosage of mast cell tryptase from a femoral blood sample at 3 and 24 hours detected values of 87.7μg/L and 93.5μg/L, respectively (cut-off value 44.3 μg/L); the serum-specific IgE for penicillins, amoxicillin, cephaclor and also for the most common allergens were also determined. A complete post-mortem examination was performed, including gross, histological and immunohistochemical examination, with an anti-tryptase antibody. The cause of death was identified as anaphylactic shock: past administrations of cefepime sensitized the subject to cephalosporins and a fatal cross-reactivity of ceftriaxone with cefepime occurred due to the identical seven-position side chain structure in both molecules. The reported case offers food for thought regarding the study of cross-reactivity and the need to clarify the predictability and preventability of the phenomenon in fatal events.
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Lee RU, Banks TA, Waibel KH, Rodriguez RG. Penicillin Allergy…Maybe Not? The Military Relevance for Penicillin Testing and De-labeling. Mil Med 2020; 184:e163-e168. [PMID: 30137597 DOI: 10.1093/milmed/usy194] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/28/2018] [Accepted: 07/19/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Penicillin allergy is the most common drug allergy reported. About 8-10% of individuals in the USA have a documented penicillin allergy, yet 90% are not truly allergic to penicillin. A penicillin allergy "label" results in increased antibiotic-related adverse reactions and increased health care costs, thus impacting the overall "readiness" of the military. MATERIALS AND METHODS A review of the current literature and approaches to penicillin allergy and "de-labeling" a patient who reports penicillin allergy was conducted and future strategies to identify and assess military beneficiaries were outlined. Military allergists had a formal discussion at the Tri-service Military Allergy Immunology Assembly regarding the state of penicillin allergy testing in military allergy clinics. RESULTS A PubMed search yielded 5,775 results for "penicillin allergy" and 484 results for "penicillin allergy testing." There were two formalized penicillin testing programs in the military treatment facilities. In 2017, the military trained nearly 165,000 new recruits. If 5-10% reported a penicillin allergy and 90% were de-labeled, that would yield a $15-30 million cost savings annually. Further, de-labeling of the 9.4 million active duty, beneficiaries and retirees with a 90% success rate could result in even greater savings for the military health care system. CONCLUSION A penicillin allergy label is a risk to military readiness secondary to associated increases in the length of hospitalizations and emergency department and medical visits. Penicillin de-labeling is a simple intervention that can improve readiness, significantly decrease health care costs and prevent antibiotic resistance, as well as antibiotic-associated adverse events. The military allergist should be "front and center" providing expertise guidance and leadership for clinic and hospital-based penicillin de-labeling efforts which are nested within the antibiotic stewardship programs.
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Affiliation(s)
- Rachel U Lee
- Naval Medical Center San Diego, Division of Allergy/Immunology, NTC Branch Health Clinic, 2051 Cushing Rd. San Diego, CA
| | - Taylor A Banks
- Walter Reed National Military Medical Center, Division of Allergy/Immunology, 8901 Rockville Pike, Bethesda, MD
| | - Kirk H Waibel
- Landstuhl Regional Medical Center, Allergy Service, Division of Medicine, Dr. Hitzelberger Strasse, Landstuhl, Germany
| | - Rechell G Rodriguez
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
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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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40
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Sakoulas G, Geriak M, Nizet V. Is a Reported Penicillin Allergy Sufficient Grounds to Forgo the Multidimensional Antimicrobial Benefits of β-Lactam Antibiotics? Clin Infect Dis 2020; 68:157-164. [PMID: 29986019 DOI: 10.1093/cid/ciy557] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/07/2018] [Indexed: 12/18/2022] Open
Abstract
The majority of patients with reported penicillin allergy are not allergic when tested or challenged. Penicillin allergy testing has been shown to significantly reduce annual healthcare expenditures. Data have emerged showing β-lactams have multidimensional antibacterial effects in vivo, far beyond what is appreciated in standard bacteriological susceptibility testing media. These include enhancing bacterial killing by the innate immune system. Supporting the clinical relevance of these secondary underappreciated effects are recent clinical and pharmacoeconomic analyses that show worse outcomes in patients with reported penicillin allergies who receive non-β-lactam antibiotics when compared to their non-penicillin-allergic counterparts. This is particularly relevant in the treatment of Staphylococcus aureus bacteremia. This article reviews the tremendous advantages offered by β-lactam therapy and makes a strong case that the debunking of false penicillin allergies through a detailed allergy history and penicillin allergy testing should be a vital component of antimicrobial stewardship practices.
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Affiliation(s)
- George Sakoulas
- Sharp Memorial Hospital, San Diego, La Jolla.,School of Medicine, University of California, San Diego, La Jolla
| | | | - Victor Nizet
- School of Medicine, University of California, San Diego, La Jolla.,Skaggs School of Pharmacy, University of California, San Diego, La Jolla
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41
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Bermingham WH, Hussain A, Bhogal R, Balaji A, Krishna MT. The adverse impact of penicillin allergy labels on antimicrobial stewardship in sepsis and associated pharmacoeconomics: An observational cohort study (IMPALAS study). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1747-1749.e4. [PMID: 31917368 DOI: 10.1016/j.jaip.2019.12.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/21/2019] [Accepted: 12/22/2019] [Indexed: 12/25/2022]
Affiliation(s)
- William Hywel Bermingham
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
| | - Abid Hussain
- Department of Microbiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Rashmeet Bhogal
- Department of Pharmacy, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ariyur Balaji
- Department of Acute Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Mamidipudi Thirumala Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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42
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Menéndez R, Cantón R, García-Caballero A, Barberán J. [Three keys to the appropriate choice of oral antibiotic treatment in the respiratory tract infections]. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2019; 32:497-515. [PMID: 31795630 PMCID: PMC6913073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 11/25/2019] [Indexed: 11/18/2022]
Abstract
Exacerbation of chronic obstructive pulmonary disease and community-acquired pneumonia are the most frequent infections of the lower respiratory tract in daily clinical practice. Antibiotic selection is a crucial component in its treatment and, in most cases, it is performed empirically. Scientific societies make therapeutic recommendations based on scientific evidence and / or expert recommendations that are of great help to clinicians. Beta-lactams, fluoroquinolones and macrolides are the most commonly used drugs for oral administration. From a practical point of view, there are three keys to the appropriate choice of oral antibiotic treatment, which are the effectiveness, safety and the ecological impact on the patient's microbiota, including the development of resistance, which will be assessed in depth in this review.
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Affiliation(s)
| | | | | | - J Barberán
- José Barberán, Servicio de Medicina Interna y Enfermedades infecciosas, Hospital Universitario HM Montepríncipe, Universidad San Pablo CEU. Madrid, Spain.
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43
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Chaudhry SB, Veve MP, Wagner JL. Cephalosporins: A Focus on Side Chains and β-Lactam Cross-Reactivity. PHARMACY 2019; 7:E103. [PMID: 31362351 PMCID: PMC6789778 DOI: 10.3390/pharmacy7030103] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/24/2019] [Accepted: 07/26/2019] [Indexed: 12/13/2022] Open
Abstract
Cephalosporins are among the most commonly prescribed antibiotic classes due to their wide clinical utility and general tolerability, with approximately 1-3% of the population reporting a cephalosporin allergy. However, clinicians may avoid the use of cephalosporins in patients with reported penicillin allergies despite the low potential for cross-reactivity. The misdiagnosis of β-lactam allergies and misunderstanding of cross-reactivity among β-lactams, including within the cephalosporin class, often leads to use of broader spectrum antibiotics with poor safety and efficacy profiles and represents a serious obstacle for antimicrobial stewardship. Risk factors for cephalosporin allergies are broad and include female sex, advanced age, and a history of another antibiotic or penicillin allergy; however, cephalosporins are readily tolerated even among individuals with true immediate-type allergies to penicillins. Cephalosporin cross-reactivity potential is related to the structural R1 side chain, and clinicians should be cognizant of R1 side chain similarities when prescribing alternate β-lactams in allergic individuals or when new cephalosporins are brought to market. Clinicians should consider the low likelihood of true cephalosporin allergy when clinically indicated. The purpose of this review is to provide an overview of the role of cephalosporins in clinical practice, and to highlight the incidence of, risk factors for, and cross-reactivity of cephalosporins with other antibiotics.
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Affiliation(s)
- Saira B Chaudhry
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ 08854, USA
- Department of Infectious Diseases, Jersey Shore University Medical Center, Neptune, NJ 07753, USA
| | - Michael P Veve
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Knoxville, TN 37920, USA.
| | - Jamie L Wagner
- Department of Pharmacy Practice, School of Pharmacy, University of Mississippi, Jackson, MS 39216, USA
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Leis JA, Palmay L, Ho G, Raybardhan S, Gill S, Kan T, Campbell J, Kiss A, McCready JB, Das P, Minnema B, Powis JE, Walker SAN, Ferguson H, Wong B, Weber E. Point-of-Care β-Lactam Allergy Skin Testing by Antimicrobial Stewardship Programs: A Pragmatic Multicenter Prospective Evaluation. Clin Infect Dis 2019; 65:1059-1065. [PMID: 28575226 DOI: 10.1093/cid/cix512] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/26/2017] [Indexed: 02/06/2023] Open
Abstract
Background β-lactam allergy skin testing (BLAST) is recommended by antimicrobial stewardship program (ASP) guidelines, yet few studies have systematically evaluated its impact when delivered at point of care. Methods We conducted a pragmatic multicenter prospective evaluation of the use of point-of-care BLAST by ASPs. In staggered 3-month intervals, ASP teams at 3 hospitals received training by allergists to offer BLAST for eligible patients with infectious diseases receiving nonpreferred therapy due to severity of their reported allergy. The primary outcome was the proportion of patients receiving the preferred β-lactam therapy. Results Of 827 patients with reported β-lactam allergy over 15 months, β-lactam therapy was preferred among 632 (76%). During baseline periods, 50% (124/246) received preferred β-lactam therapy based on history, compared with 60% (232/386) during the intervention periods (P = .02), which improved further to 81% (313/386) upon provision of BLAST (P < .001) without any increase in incidence of adverse drug reactions (4% vs 3%; P = .4). After adjusting for patient variables and the correlation between hospitals, the intervention period was associated with a 4.5-fold greater odds of receiving preferred β-lactam therapy (95% confidence interval, 2.4-8.2; P < .0001). Conclusions The use of BLAST at the point of care across 3 hospital ASPs resulted in greater use of preferred β-lactam therapy without increasing the risk of adverse drug reactions. Longer-term studies are needed to better assess the safety and clinical impact of this ASP intervention.
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Affiliation(s)
- Jerome A Leis
- Division of Infectious Diseases, Department of Medicine.,Sunnybrook Research Institute and Institute of Health Policy, Management and Evaluation.,Centre for Quality Improvement and Patient Safety, and
| | - Lesley Palmay
- Department of Pharmacy, Sunnybrook Health Sciences Centre, and Lesley Dan Faculty of Pharmacy, University of Toronto
| | | | | | | | | | - Jackie Campbell
- Department of Pharmacy, Sunnybrook Health Sciences Centre, and Lesley Dan Faculty of Pharmacy, University of Toronto.,Drug Safety Clinic, Sunnybrook Health Sciences Centre ; and
| | - Alex Kiss
- Sunnybrook Research Institute and Institute of Health Policy, Management and Evaluation
| | - Janine B McCready
- Division of Infectious Diseases, Department of Medicine.,Michael Garron Hospital
| | - Pavani Das
- Division of Infectious Diseases, Department of Medicine.,North York General Hospital
| | - Brian Minnema
- Division of Infectious Diseases, Department of Medicine.,North York General Hospital
| | - Jeff E Powis
- Division of Infectious Diseases, Department of Medicine.,Centre for Quality Improvement and Patient Safety, and.,Michael Garron Hospital
| | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, and Lesley Dan Faculty of Pharmacy, University of Toronto
| | | | - Benny Wong
- North York General Hospital.,Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Ontario, Canada
| | - Elizabeth Weber
- Drug Safety Clinic, Sunnybrook Health Sciences Centre ; and.,Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Ontario, Canada
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45
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Vyles D, Macy E. Self-reported beta-lactam intolerance: not a class effect, dangerous to patients, and rarely allergy. Expert Rev Anti Infect Ther 2019; 17:429-435. [PMID: 31067139 DOI: 10.1080/14787210.2019.1617132] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: About 8% of the United States population carries an unconfirmed penicillin 'allergy' in their medical record. Many physicians needlessly avoid other beta-lactam use in individuals with unconfirmed penicillin allergies. There is a significantly increased risk of developing serious antibiotic-resistant infections, and increased morbidity and mortality in those who report penicillin allergy. Areas covered: Within this study, we reviewed the relevant literature on self-reported beta-lactam allergy. We discuss how the myth of serious allergy to penicillin developed and then discuss and in detail clinically significant immunologically mediated hypersensitivity reactions. Following this discussion, we delineate the risks of not using a beta-lactam when it is the drug of choice and then discuss the epidemiology of beta-lactam-associated anaphylaxis, serious cutaneous adverse reactions, and serious systemic immunologically mediated reactions. Following these topics, we further discuss the consensus current best practices to de-label patients with reported penicillin allergy. Expert opinion: An unconfirmed allergy to penicillin offers considerable harm to patients. Many patients have low-risk allergy symptoms to penicillin who could likely tolerate the medication without having an allergic reaction. The current best practices to de-label reported penicillin allergy is the utilization of a single dose oral challenge, with 1 h of observation, in low-risk patients.
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Affiliation(s)
- David Vyles
- a Pediatric Emergency Medicine , Medical College of Wisconsin , Milwaukee , WI , USA
| | - Eric Macy
- b Department of Allergy , Southern California Permanente Medical Group, San Diego Medical Center , San Diego , CA , USA
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Wolfson AR, Huebner EM, Blumenthal KG. Acute care beta-lactam allergy pathways: approaches and outcomes. Ann Allergy Asthma Immunol 2019; 123:16-34. [PMID: 31009700 DOI: 10.1016/j.anai.2019.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Anna R Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Emily M Huebner
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Medical Practice Evaluation Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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Veve MP, January SE, Kenney RM, Zoratti EM, Zervos MJ, Davis SL. Impact of Reported β-Lactam Allergy on Management of Methicillin-Sensitive Staphylococcus aureus Bloodstream Infections. J Pharm Pract 2019; 33:809-814. [PMID: 30991876 DOI: 10.1177/0897190019841737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antistaphylococcal β-lactams antibiotics are the preferred treatment for methicillin-sensitive Staphylococcus aureus (MSSA) infections. Patient-reported β-lactam allergies may complicate antibiotic decision-making and delay optimal therapy, with potential implications on patient outcomes. OBJECTIVE To determine the impact of reported β-lactam allergies on the receipt of optimal therapy and outcomes for MSSA bloodstream infections (BSI). METHODS Retrospective, matched cohort of MSSA BSI patients with and without a reported β-lactam allergy. The primary end point was receipt of optimal therapy, defined as an antistaphylococcal β-lactam. RESULTS Two hundred twelve patients were included: 53 with reported β-lactam allergy and 159 without β-lactam allergy. Commonly reported β-lactam allergies were 26 (49%) immune-mediated reaction and 8 (15%) intolerance, with 19 (36%) having no documented reaction. Optimal antibiotics were given to 135 patients without a β-lactam allergy and 37 patients with a reported β-lactam allergy (85% vs 70%, P = .015). Among reported β-lactam allergy patients, those without a documented reaction were less likely to receive optimal therapy (47% vs 79%, P = .042). Reported β-lactam allergy was not associated with clinical response (P = .61) or MSSA-related mortality (P = .83). When adjusting for immunosuppression, variables independently associated with optimal therapy were β-lactam allergy (adjusted odds ratio [adjOR], 0.3; 95% confidence interval [CI], 0.1-0.6) and infectious diseases consultation (adjOR, 6.1; 95%CI, 2.7-13.9). Optimal antibiotic use was associated with decreased all-cause 90-day mortality (adjOR, 0.23; 95%CI, 0.09-0.54). CONCLUSIONS Patients with reported β-lactam allergies, particularly those without a documented reaction, were less likely to receive optimal antibiotics for MSSA BSI. Patient outcomes may be improved with enhanced quality of allergy history and routine infectious disease consultation.
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Affiliation(s)
- Michael P Veve
- 2971Henry Ford Hospital, Detroit, MI, USA.,Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA.,The author is now with the Department of Clinical Pharmacy and Translational Science, 4285University of Tennessee Health Science Center, Knoxville, TN, USA
| | - Spenser E January
- 2971Henry Ford Hospital, Detroit, MI, USA.,The author is now with 21737Barnes-Jewish Hospital, St Louis, MO, USA
| | | | | | | | - Susan L Davis
- 2971Henry Ford Hospital, Detroit, MI, USA.,Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
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Outcomes from an inpatient beta-lactam allergy guideline across a large US health system. Infect Control Hosp Epidemiol 2019; 40:528-535. [PMID: 30915929 PMCID: PMC6536839 DOI: 10.1017/ice.2019.50] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: To assess the safety of, and subsequent allergy documentation associated with, an antimicrobial stewardship intervention consisting of test-dose challenge procedures prompted by an electronic guideline for hospitalized patients with reported β-lactam allergies. Design: Retrospective cohort study. Setting: Large healthcare system consisting of 2 academic and 3 community acute-care hospitals between April 2016 and December 2017. Methods: We evaluated β-lactam antibiotic test-dose outcomes, including adverse drug reactions (ADRs), hypersensitivity reactions (HSRs), and electronic health record (EHR) allergy record updates. HSR predictors were examined using a multivariable logistic regression model. Modification of the EHR allergy record after test doses considered relevant allergy entries added, deleted, and/or specified. Results: We identified 1,046 test-doses: 809 (77%) to cephalosporins, 148 (14%) to penicillins, and 89 (9%) to carbapenems. Overall, 78 patients (7.5%; 95% confidence interval [CI], 5.9%–9.2%) had signs or symptoms of an ADR, and 40 (3.8%; 95% CI, 2.8%–5.2%) had confirmed HSRs. Most HSRs occurred at the second (ie, full-dose) step (68%) and required no treatment beyond drug discontinuation (58%); 3 HSR patients were treated with intramuscular epinephrine. Reported cephalosporin allergy history was associated with an increased odds of HSR (odds ratio [OR], 2.96; 95% CI, 1.34–6.58). Allergies were updated for 474 patients (45%), with records specified (82%), deleted (16%), and added (8%). Conclusion: This antimicrobial stewardship intervention using β-lactam test-dose procedures was safe. Overall, 3.8% of patients with β-lactam allergy histories had an HSR; cephalosporin allergy histories conferred a 3-fold increased risk. Encouraging EHR documentation might improve this safe, effective, and practical acute-care antibiotic stewardship tool.
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Abstract
IMPORTANCE β-Lactam antibiotics are among the safest and most effective antibiotics. Many patients report allergies to these drugs that limit their use, resulting in the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance and adverse events. OBSERVATIONS Approximately 10% of the US population has reported allergies to the β-lactam agent penicillin, with higher rates reported by older and hospitalized patients. Although many patients report that they are allergic to penicillin, clinically significant IgE-mediated or T lymphocyte-mediated penicillin hypersensitivity is uncommon (<5%). Currently, the rate of IgE-mediated penicillin allergies is decreasing, potentially due to a decreased use of parenteral penicillins, and because severe anaphylactic reactions to oral amoxicillin are rare. IgE-mediated penicillin allergy wanes over time, with 80% of patients becoming tolerant after a decade. Cross-reactivity between penicillin and cephalosporin drugs occurs in about 2% of cases, less than the 8% reported previously. Some patients have a medical history that suggests they are at a low risk for developing an allergic reaction to penicillin. Low-risk histories include patients having isolated nonallergic symptoms, such as gastrointestinal symptoms, or patients solely with a family history of a penicillin allergy, symptoms of pruritus without rash, or remote (>10 years) unknown reactions without features suggestive of an IgE-mediated reaction. A moderate-risk history includes urticaria or other pruritic rashes and reactions with features of IgE-mediated reactions. A high-risk history includes patients who have had anaphylaxis, positive penicillin skin testing, recurrent penicillin reactions, or hypersensitivities to multiple β-lactam antibiotics. The goals of antimicrobial stewardship are undermined when reported allergy to penicillin leads to the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance, including increased risk of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Broad-spectrum antimicrobial agents also increase the risk of developing Clostridium difficile (also known as Clostridioides difficile) infection. Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories. Moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95% and approaches 100% when combined with amoxicillin challenge. Clinicians performing penicillin allergy evaluation need to identify what methods are supported by their available resources. CONCLUSIONS AND RELEVANCE Many patients report they are allergic to penicillin but few have clinically significant reactions. Evaluation of penicillin allergy before deciding not to use penicillin or other β-lactam antibiotics is an important tool for antimicrobial stewardship.
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Affiliation(s)
- Erica S Shenoy
- Harvard Medical School, Boston, Massachusetts
- Infection Control Unit, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
| | - Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center
| | - Theresa Rowe
- General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kimberly G Blumenthal
- Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston
- Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston
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Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Antibiotic allergy. Lancet 2019; 393:183-198. [PMID: 30558872 PMCID: PMC6563335 DOI: 10.1016/s0140-6736(18)32218-9] [Citation(s) in RCA: 320] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/25/2018] [Accepted: 09/04/2018] [Indexed: 02/07/2023]
Abstract
Antibiotics are the commonest cause of life-threatening immune-mediated drug reactions that are considered off-target, including anaphylaxis, and organ-specific and severe cutaneous adverse reactions. However, many antibiotic reactions documented as allergies were unknown or not remembered by the patient, cutaneous reactions unrelated to drug hypersensitivity, drug-infection interactions, or drug intolerances. Although such reactions pose negligible risk to patients, they currently represent a global threat to public health. Antibiotic allergy labels result in displacement of first-line therapies for antibiotic prophylaxis and treatment. A penicillin allergy label, in particular, is associated with increased use of broad-spectrum and non-β-lactam antibiotics, which results in increased adverse events and antibiotic resistance. Most patients labelled as allergic to penicillins are not allergic when appropriately stratified for risk, tested, and re-challenged. Given the public health importance of penicillin allergy, this Review provides a global update on antibiotic allergy epidemiology, classification, mechanisms, and management.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jonny G Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; The National Centre for Infections in Cancer, Peter McCallum Cancer Centre, Melbourne, VIC, Australia
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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