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Ravikumar R, Arora NS, Hanson R, Barhitte L, Nagel J, Aitken SL, Bashaw L, Gandhi T, Spranger E, Marshall VD, Eschenauer GA. A novel 2-step process for the management of inpatient beta-lactam allergy labels. Ann Allergy Asthma Immunol 2024; 132:525-531.e1. [PMID: 38151095 DOI: 10.1016/j.anai.2023.12.028] [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: 10/12/2023] [Revised: 12/22/2023] [Accepted: 12/22/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Inpatient beta-lactam allergy labels may increase the unnecessary use of aztreonam and non-beta-lactam antibiotics, which can then lead to more adverse events and increased health care costs, OBJECTIVE: To assess the impact of a novel 2-step process (medication history review followed by risk stratification) on rates of beta-lactam delabeling, aztreonam use, and desensitizations on pediatric, adult, and obstetrics inpatients at a tertiary academic center. METHODS We prospectively collected data on 700 patients who received inpatient consultation from the Beta-Lactam Allergy Evaluation Service between August 2021 and July 2022. Patients were delabeled either by medication review alone, drug challenge alone if with a low-risk history, or penicillin skin test followed by drug challenge if with a high-risk history. Generalized linear regression modeling was used to compare aztreonam days of therapy in the intervention year with the 2 prior years. Drug desensitizations were assessed by electronic chart review. RESULTS Most of the patients (n = 656 of 700, 94%) had more than or equal to 1 beta-lactam allergy label removed, clarified, or both; 77.9% of these patients (n = 511 of 656) had 587 beta-lactam allergy labels removed. Nearly one-third (n = 149, 27.6%) had 162 allergy labels removed solely by medication history review. All 114 penicillin skin tests performed had negative results, and 98% (8 of 381) of the patients who underwent any drug challenge passed. Only 5.7% of the delabeled patients were relabeled. There was a 27% reduction in aztreonam use (P = .007). Beta-lactam desensitizations were reduced by 80%. CONCLUSION A full-time inpatient beta-lactam allergy service using medication history review and risk stratification can safely and effectively remove inpatient beta-lactam allergy labels, reduce aztreonam use, and decrease beta-lactam desensitizations.
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Affiliation(s)
- Rajan Ravikumar
- Division of Allergy and Clinical Immunology, Michigan Medicine, Ann Arbor, Michigan.
| | - Nonie S Arora
- Department of Internal Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Rebecca Hanson
- Division of Allergy and Clinical Immunology, Michigan Medicine, Ann Arbor, Michigan
| | - Lauren Barhitte
- Division of Allergy and Clinical Immunology, Michigan Medicine, Ann Arbor, Michigan
| | - Jerod Nagel
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan
| | - Samuel L Aitken
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan
| | - Linda Bashaw
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Tejal Gandhi
- Division of Infectious Diseases, Michigan Medicine, Ann Arbor, Michigan
| | | | - Vincent D Marshall
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Gregory A Eschenauer
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan
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2
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Wrenn RH, Trubiano JA. Penicillin Allergy Impact and Management. Infect Dis Clin North Am 2023; 37:793-822. [PMID: 37537003 DOI: 10.1016/j.idc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
There is international evidence that penicillin allergies are associated with inferior prescribing and patient outcomes. A host of tools now exist from assessment (risk assessment tools, clinical decision rules) to delabeling (the removal of a beta-lactam allergy via testing or medical reconciliation) to reduce the impact of these "labels" in the hospital and community setting, as a primary antimicrobial stewardship intervention.
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Affiliation(s)
- Rebekah H Wrenn
- Duke University Medical Center, Durham, NC, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA.
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Melbourne, Australia; Department of Infectious Diseases, University of Melbourne, at The Peter Doherty Institute for Infection and Immunity, Victoria 3000, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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3
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Otani IM, Tang M, Wang L, Anstey KM, Hilts-Horeczko A, Li F, Le VP, Lee M, Bystritsky R, Mulliken JS, Wattier RL, Blumenthal KG, Doernberg SB. Impact of an Inpatient Allergy Guideline on β-Lactam and Alternative Antibiotic Use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2557-2567.e6. [PMID: 37182569 DOI: 10.1016/j.jaip.2023.04.051] [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: 08/17/2022] [Revised: 04/03/2023] [Accepted: 04/26/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND A guideline identifying when inpatients with penicillin or cephalosporin antibiotic allergy labels (PCAAL) can receive β-lactam antibiotics increased β-lactam receipt at a large northeastern US health care system. OBJECTIVE To report outcomes of implementing a similar guideline and electronic order set (OS) at an independent academic health care system. METHODS Penicillin/cephalosporin receipt (percentage of inpatients receiving full doses) and alternative antibiotic use (days of therapy per 1000 patient-days [DOT/1000PD]) were compared over 3 periods before (February 1, 2017, to January 31, 2018) and after guideline implementation (February 1, 2018, to January 31, 2019), and after OS implementation (February 1, 2019, to January 31, 2020) among inpatients with PCAAL admitted on medical services with access to guideline/OS and education (Medical-PCAAL, n = 8721), surgical services with access to guideline/OS without education (Surgical-PCAAL, n = 5069), and obstetrics/gynecology services without interventions (Ob/Gyn-PCAAL, n = 798) and inpatients without PCAAL admitted on the same services (Medical-No-PCAAL, n = 50,840; Surgical-No-PCAAL, n = 29,845; Ob/Gyn-No-PCAAL, n = 6109). χ2 tests were used to compare categorical variables, and analysis of variance was used to compare continuous and interrupted time series analyses (ITSA) to investigate the guideline/OS implementation effect on penicillin/cephalosporin receipt. RESULTS In the Medical-PCAAL group, penicillin/cephalosporin receipt increased (58%-68%, P < .001), specifically for cefazolin (8%-11%, P = .02) and third- to fifth-generation cephalosporins (43%-48%, P = .04), and aztreonam use decreased (12 DOT/1000PD, P = .03). In the Medical-No-PCAAL group, penicillin/cephalosporin receipt increased (88%-90%, P = .004), specifically for penicillin (40%-44%, P < .001), without changes in aztreonam use. Significant changes were not observed in these outcomes on surgical or obstetrics/gynecology services. Per ITSA, guideline/OS implementation was associated with increased penicillin/cephalosporin receipt in the Medical-PCAAL group only. CONCLUSION Guideline and OS implementation was associated with improved antibiotic stewardship on inpatient services that also received allergy education.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of California San Francisco, San Francisco, Calif.
| | - Monica Tang
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of California San Francisco, San Francisco, Calif
| | - Lusha Wang
- Department of Quality-Hospital Epidemiology and Infection Prevention, University of California San Francisco, San Francisco, Calif
| | - Karen M Anstey
- Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, Ore
| | - Alexandra Hilts-Horeczko
- Department of Pharmaceutical Services, University of California San Francisco, San Francisco, Calif
| | - Fanny Li
- Department of Pharmaceutical Services, University of California San Francisco, San Francisco, Calif
| | - Vincent P Le
- Health Clinical Systems, University of California San Francisco, San Francisco, Calif
| | - Melissa Lee
- The Center for Nursing Excellence and Innovation, University of California San Francisco, San Francisco, Calif
| | - Rachel Bystritsky
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, Calif
| | - Jennifer S Mulliken
- Infectious Disease Section, Medical Service, San Francisco Veterans' Affairs Medical Center, San Francisco, Calif
| | - Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California San Francisco, San Francisco, Calif
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Sarah B Doernberg
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, Calif
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4
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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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5
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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: 173] [Impact Index Per Article: 86.5] [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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6
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De-labeling Beta-lactam in Adult Population. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00316-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Anstey KM, Tsao L, Otani IM. Drug Allergy Delabeling Programs: Recent Strategies and Targeted Populations. Clin Rev Allergy Immunol 2022; 62:484-504. [PMID: 35031956 DOI: 10.1007/s12016-021-08913-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 12/12/2022]
Abstract
Drug allergy delabeling programs have become an essential element of antibiotic stewardship. Development of delabeling programs involves careful selection of target patient population, thoughtful design of delabeling approach, stakeholder engagement, assembly of key team members, implementation, and evaluation of clinical and safety outcomes. Recent programs have targeted patients thought to be most likely to benefit from removal of inaccurate antibiotic allergy labels, those with β-lactam antibiotic allergies and high-risk populations likely to need β-lactam antibiotics as first-line treatment. This review provides an overview of current risk stratification methods and β-lactam cross-reactivity data and summarizes how different inpatient and outpatient delabeling programs have used these concepts in delabeling algorithms. β-Lactam delabeling programs for inpatients, pediatric patients, and programs utilizing telehealth have been implemented with good outcomes. This review also focuses on delabeling programs for high-risk populations likely to benefit from first-line β-lactam antibiotics. These populations include perioperative, prenatal, and immunocompromised patients. Delabeling programs have been successful in the inpatient and outpatient settings at enabling appropriate antibiotic use. This article reviews delabeling strategies utilized by these programs with a focus on highlighting elements key to their success and future areas for innovation.
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Affiliation(s)
- Karen M Anstey
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code UHN67, Portland, OR, 97239, USA.
| | - Lulu Tsao
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
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9
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Gaberino CL, Chiu AM, Mahatme SS. The effects of beta-lactam allergy relabeling on antibiotic prescribing practices. Ann Allergy Asthma Immunol 2021; 128:307-313. [PMID: 34890777 DOI: 10.1016/j.anai.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/05/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Beta-lactam antibiotic allergy labels are highly prevalent but rarely indicate an allergic intolerance. These patient-reported allergies lead to broad-spectrum antibiotic use, conferred resistance, increased expense, and adverse effects. OBJECTIVE To implement and assess the impact of a history-based clinical guideline that directs antibiotic management and beta-lactam allergy relabeling for patients reporting beta-lactam allergies. METHODS Patients with beta-lactam allergy labels were identified by our trained multidisciplinary team in diverse clinical settings. This quality improvement project was conducted to evaluate the safety and impact of the guideline on antibiotic use by comparing prescribing practices before and after guideline implementation. RESULTS A total of 79 patients with beta-lactam allergies were identified (penicillins-90%, cephalosporins-10%). After guideline implementation, outcomes of allergy relabeling included the following: (1) complete removal, indicating an unlikely true allergy (27%); (2) updated to detail successfully tolerated beta-lactam courses (48%); or (3) no change made to current label (25%). Beta-lactam antibiotic courses before and after guideline implementation compared with total antibiotic courses: allergy removed (44% vs 70%; P < .001), allergy updated (32% vs 68%; P < .001), and no change (27% vs 41%; P = .08). Compared with before guideline implementation, beta-lactam antibiotics were 3 times more likely to be prescribed after allergy assessment (odds ratio, 3.22; 95% confidence interval, 2.4-4.3; P < .05). CONCLUSION The implementation of the beta-lactam allergy clinical guideline resulted in most patients' allergy labels being removed or advantageously updated. These allergy label changes correlated with a substantial increase in the percentage of beta-lactam antibiotics prescribed. After guideline implementation, beta-lactam antibiotics had a 3-fold increased odds of being prescribed independent of allergy label outcome.
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Affiliation(s)
- Courtney L Gaberino
- Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Asriani M Chiu
- Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; Division of Asthma, Allergy, and Clinical Immunology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sheran S Mahatme
- Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
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10
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Penicillin Allergy Delabeling: A Multidisciplinary Opportunity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2858-2868.e16. [PMID: 33039010 DOI: 10.1016/j.jaip.2020.04.059] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022]
Abstract
The penicillin allergy label has been consistently linked with deleterious effects that span the health care spectrum, including suboptimal clinical outcomes, the emergence of bacterial resistance, and increased health care expenditures. These risks have recently motivated professional organizations and public health institutes to advocate for the implementation of penicillin allergy delabeling initiatives; however, the burden of delabeling millions of patients is too expansive for any one discipline to bear alone. This review presents the unique perspectives and roles of various stakeholder groups involved in penicillin allergy diagnosis, assessment, and delabeling; we emphasize opportunities, barriers, and promising areas of innovation. We summarize penicillin allergy methods and tools that have proven successful in delabeling efforts. A multidisciplinary approach to delabeling patients with reported penicillin allergy, bolstered by evidence-based clinical practices, is recommended to reduce the risks that associate with the penicillin allergy label.
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11
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Turner NA, Wrenn R, Sarubbi C, Kleris R, Lugar PL, Radojicic C, Moehring RW, Anderson DJ. Evaluation of a Pharmacist-Led Penicillin Allergy Assessment Program and Allergy Delabeling in a Tertiary Care Hospital. JAMA Netw Open 2021; 4:e219820. [PMID: 33983399 PMCID: PMC8120333 DOI: 10.1001/jamanetworkopen.2021.9820] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Penicillin allergies are frequently mislabeled, which may contribute to use of less-preferred alternative antibiotics. OBJECTIVE To evaluate a pharmacist-led allergy assessment program's association with antimicrobial use and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS A pharmacist-led allergy assessment program was launched in 2 phases (June 1, 2015, and November 2, 2016) at a single-center tertiary referral hospital. The longitudinal cross-sectional study included all study period adult admissions; hospitalwide outcomes were assessed by segmented regression. Individual outcomes were assessed within an embedded propensity score-matched case-control study of inpatients undergoing comprehensive allergy assessment following self-report of penicillin allergy. Analysis occurred from March 1, 2020, to February 29, 2020. EXPOSURES The longitudinal study analyzed hospital-level outcomes over 3 periods: preintervention (15 months), phase 1 (structured allergy history alone, 16 months), and phase 2 (comprehensive assessment including penicillin skin testing, 52 months). The case-control study defined cases as individuals undergoing comprehensive allergy assessment. MAIN OUTCOMES AND MEASURES Hospital-level outcomes included antibiotic days of therapy per 1000 patient-days and hospital-acquired Clostridioides difficile infection (CDI) incidence per 10 000 patient-days. Individual outcomes included antibiotic selection, overall survival, and CDI-free survival. RESULTS Longitudinal analysis spanned 2014-2020 (median admissions, 46 416 per year; interquartile range [IQR], 46 001-50 091 per year). Hospitalwide, allergy histories were temporally associated with decreased use of nonpenicillin alternative antibiotics (rate ratio, 0.87; 95% CI, 0.79-0.97) and high-CDI-risk antibiotics (rate ratio, 0.91; 95% CI, 0.85-0.98). Penicillin skin testing was temporally associated with lower hospital-acquired CDI rates (rate ratio, 0.61; 95% CI, 0.43-0.86). The embedded case-control study included 272 cases and 819 controls. Median age was 63 years (interquartile range, 51-73 years), 553 (50.7%) patients were women, and 229 (21.0%) patients were Black. Allergy-assessed patients were less likely to receive high-CDI-risk antibiotics at discharge (odds ratio, 0.66; 95% CI, 0.44-0.98). Estimated reductions in mortality (hazard ratio, 0.77; 95% CI, 0.55-1.07) and hospital-acquired CDI risk (hazard ratio, 0.53; 95% CI, 0.18-1.55) were not statistically significant. CONCLUSIONS AND RELEVANCE Pharmacist-led allergy assessments may be associated with reduced high-CDI-risk antibiotic use at both hospitalwide and individual levels. Although individual reductions in mortality and CDI risk did not achieve significance, divergence of survival curves suggest longer-term benefits of allergy delabeling warrant future study.
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Affiliation(s)
- Nicholas A. Turner
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Rebekah Wrenn
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | | | - Renee Kleris
- Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Patricia L. Lugar
- Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Christine Radojicic
- Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - Rebekah W. Moehring
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Deverick J. Anderson
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
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12
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Powell N, West R, Sandoe JAT. The impact of penicillin allergy de-labelling on the WHO AWaRe antibiotic categories: a retrospective cohort study. J Hosp Infect 2021; 115:10-16. [PMID: 33895164 DOI: 10.1016/j.jhin.2021.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/07/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The WHO's AWaRe classification categorizes antibiotics into three stewardship groups: Access, Watch and Reserve. The Access group includes antibiotics with lower resistance potential than antibiotics in the other two groups. The UK five-year AMR strategy has set targets for reducing non-Access antibiotic use. The majority of penicillins are in the Access group and therefore patients with a penicillin allergy record are likely to receive more non-Access antibiotics. This study aimed to quantify the impact of penicillin allergy records on non-Access antibiotic prescribing and to estimate potential reductions in non-Access antibiotic use through penicillin allergy de-labelling. METHODS Inpatients of a 750-patient-bed UK district general hospital in England prescribed antibiotics between 1st April 2018 and 31st March 2019 were included. Variables included: age, sex, co-morbidity, infection treated, antibiotic usage, hospital length of stay, penicillin allergy status. Multivariable logistic regression was used to explore the association between patient characteristics and their receipt of antibiotics in the Access and non-Access groups. RESULTS A total of 67,059 antibiotic prescriptions for 23,356 inpatients were analysed. Penicillin allergy records were present in 14.3% of hospital admissions. Patients with a penicillin allergy record were around four times more likely (odds ratio = 4.7) to receive an antibiotic from the non-Access groups (i.e. Reserve and Watch groups). We estimate de-labelling 50% of hospital inpatients with a penicillin allergy record could reduce non-Access antibiotic use by 5.8% and total antibiotic use by 0.86%. CONCLUSION Penicillin allergy records are associated with non-Access antibiotic prescribing. Penicillin allergy de-labelling has potential to reduce non-Access antibiotic use.
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Affiliation(s)
- N Powell
- Royal Cornwall Hospitals NHS Trust, Truro, UK; National Institute for Health Research Health Protection Research Unit, Healthcare-associated Infections and Antimicrobial Resistance, Imperial College London, Public Health England, London, UK.
| | - R West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - J A T Sandoe
- Leeds Institute of Medical Research, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
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13
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Abstract
BACKGROUND Aztreonam is not a preferred empiric antibiotic because of variable susceptibilities compared with alternative agents. In addition, it has no Gram-positive activity, necessitating coadministration with vancomycin when used empirically, and is more costly when compared with other Gram-negative active agents. Aztreonam is often given to patients with a reported penicillin allergy without further investigation into the reaction or other relevant allergy information. STUDY QUESTION How frequently is aztreonam being used inappropriately? STUDY DESIGN We conducted a retrospective chart review at an academic medical center to assess the appropriateness of our aztreonam use. MEASURES AND OUTCOMES Our primary outcome was frequency of appropriate aztreonam use, based on a true IgE-mediated allergy reported for each patient. We evaluated whether the patients had tolerated a beta-lactam in the past, and what the reported allergic reaction was. RESULTS We included 165 patients and found that 46.7% of our aztreonam use was inappropriate, based on previous use of a beta-lactam, or no documentation of an IgE-mediated response. Of the patients with a documented beta-lactam allergy, 63 (38.2%) patients had no allergy manifestation listed, and 37 (22.4%) patients had a non-IgE-mediated allergy manifestation. Of the total population, 61 (37%) patients had tolerated a beta-lactam in the past. CONCLUSIONS Aztreonam should be avoided, except in the case of a true IgE-mediated allergic reaction. Our goal was to reduce the inappropriate use of aztreonam at our institution by one or more of the following: educating providers, reviewing aztreonam orders, requiring answering of order questions, or requiring an indication for use. Penicillin skin testing and desensitization are options as well.
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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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15
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Mann KL, Wu JY, Shah SS. Implementation of a Pharmacist-Driven Detailed Penicillin Allergy Interview. Ann Pharmacother 2019; 54:364-370. [PMID: 31701755 DOI: 10.1177/1060028019884874] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Self-reported penicillin allergies may be outdated or inaccurate, leading to the use of alternative antimicrobials that may be less effective, more toxic, and/or more expensive. Although penicillin skin tests can provide accurate assessments of penicillin allergies, these procedures are not feasible at all institutions. Another solution is to conduct a detailed penicillin allergy interview (DPAI), which can potentially lead to optimization of antimicrobial therapy. Objective: The purpose of this study was to assess the impact of a pharmacist-driven DPAI protocol. The primary objective was to measure the number of patients requiring a change to their allergy profile following DPAI. Secondary objectives included characterizing allergy profile updates and measuring the number of recommendations to switch to a β-lactam agent, provider acceptance rate, and patient tolerance. Methods: Standardized pharmacist-driven DPAIs were conducted prospectively on adult patients admitted with a documented penicillin allergy. The allergy profile within the electronic health record (EHR) was updated and a recommendation to switch to noncarbapenem β-lactam therapy was made when indicated by a decision algorithm. Results: A total of 175 (37.5%) patients received a DPAI. Of these, 133 (76.0%) required a change to their allergy profile. Additionally, 135 (77.1%) patients interviewed were on antimicrobial therapy, with 42 (31.1%) meeting criteria to switch to noncarbapenem β-lactam therapy; of which 31 (73.8%) patients were successfully transitioned, with no signs or symptoms of intolerance. Conclusions and Relevance: Implementation of pharmacist-driven DPAIs can provide updated and corrected allergy information within the EHR, allowing for de-escalation and/or optimization of antimicrobial therapy.
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16
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Ramsey A, Sheikh A. Innovations in Health Care Delivery: Drug Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2143-2150. [DOI: 10.1016/j.jaip.2019.04.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/18/2019] [Accepted: 04/23/2019] [Indexed: 01/03/2023]
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17
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Beta-lactam Allergy Review: Implications for Antimicrobial Stewardship Programs. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-00186-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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18
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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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19
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Silva ML, Cargnello C, Aulois-Griot M, Dumartin C. Antibiotic misuse: How to evaluate the costs? Med Mal Infect 2019; 49:485-494. [PMID: 30954321 DOI: 10.1016/j.medmal.2019.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/08/2018] [Accepted: 03/13/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Few studies have assessed the costs associated with the misuse of antibiotics in hospitals in France, despite the value of health economic data to inform antibiotic stewardship activities. We aimed to identify the methodological tools used to assess the cost of antibiotic misuse in hospitals. METHODS We performed a literature review using the major electronic medical databases. An index of relevance was developed to assess the intrinsic quality of selected articles. RESULTS Four hundred and three articles were retrieved, but 35 were selected for analysis. Most studies investigated the inadequate choice of the antibiotic molecule (n=17), the incorrect treatment duration (n=9), and the administration of an inappropriate dosage (n=7). Only three studies were medical/economic evaluations of specific interventions, such as prescription control by pharmacists or the implementation of a new diagnostic test. Considering our aim, the relevance of the studies was limited: few had defined the economic assessment as the primary objective or had detailed the method for calculating costs. Nevertheless, the misuse evaluation was usually better described. CONCLUSIONS Despite these limits, key factors for measuring antibiotic misuse (i.e., molecule choice, dosage) in relation to the costs (i.e., over/under prescription, hospital stay, staff remuneration) might serve as the basis for the development of a reference methodology to value the costs of misuse. The application of this methodology on identified situations of antibiotic misuse would help hospital decision-makers to justify resource allocation for implementing antimicrobial stewardship activities.
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Affiliation(s)
- M L Silva
- Unité Inserm 1219, UFR sciences pharmaceutiques- laboratoire de droit et économie pharmaceutiques, université de Bordeaux, 146, rue Léo-Saignat, case postale 81, 33076 Bordeaux, France.
| | - C Cargnello
- Unité Inserm 1219, UFR sciences pharmaceutiques- laboratoire de droit et économie pharmaceutiques, université de Bordeaux, 146, rue Léo-Saignat, case postale 81, 33076 Bordeaux, France
| | - M Aulois-Griot
- Unité Inserm 1219, UFR sciences pharmaceutiques- laboratoire de droit et économie pharmaceutiques, université de Bordeaux, 146, rue Léo-Saignat, case postale 81, 33076 Bordeaux, France
| | - C Dumartin
- Unité Inserm 1219, UFR sciences pharmaceutiques- laboratoire de droit et économie pharmaceutiques, université de Bordeaux, 146, rue Léo-Saignat, case postale 81, 33076 Bordeaux, France; CHU Bordeaux, CPIAS Nouvelle Aquitaine, hôpital Pellegrin - bâtiment Le Tondu, 33076 Bordeaux, France
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20
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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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21
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Bland CM, Bookstaver PB, Griffith NC, Heil EL, Jones BM, Ann Justo J, Staicu ML, Torney NP, Wall GC. A practical guide for pharmacists to successfully implement penicillin allergy skin testing. Am J Health Syst Pharm 2019; 76:136-147. [DOI: 10.1093/ajhp/zxy043] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
| | - P Brandon Bookstaver
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Palmetto Health Richland Department of Pharmacy, Columbia, SC
| | | | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
| | - Bruce M Jones
- St. Joseph’s/Candler Health System, Inc., Savannah, GA
| | - Julie Ann Justo
- Department of Clinical Pharmacy & Outcomes Sciences, University of South Carolina College of Pharmacy, Palmetto Health Richland Department of Pharmacy Columbia, SC
| | | | - Nicholas P Torney
- Department of Pharmacy and Infectious Diseases, Munson Medical Center, Traverse City, MI
| | - Geoffrey C Wall
- Drake University College of Pharmacy and Health Sciences, Iowa Methodist Medical Center, Des Moines, IA
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22
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Controversies in Drug Allergy: Drug Allergy Pathways. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:46-60.e4. [PMID: 30573422 DOI: 10.1016/j.jaip.2018.07.037] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 12/16/2022]
Abstract
Drug allergy pathways are standardized approaches for patients reporting prior drug allergies with the aim of quality improvement and promotion of antibiotic stewardship. At the International Drug Allergy Symposium during the 2018 American Academy of Allergy, Asthma, and Immunology/World Allergy Organization Joint Congress in Orlando, Florida, drug allergy pathways were discussed from international perspectives with a focus on beta-lactam allergy pathways and pragmatic approaches for acute care hospitals. In this expert consensus document, we review current pathways, and detail important considerations in devising, implementing, and evaluating beta-lactam allergy pathways for hospitalized patients. We describe the key patient and institutional factors that must be considered in risk stratification, the central feature of pathway design. We detail shared obstacles to widespread beta-lactam allergy pathway implementation and identify potential solutions to address these challenges.
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23
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Phan A, Allen B, Epps K, Alikhil M, Kamataris K, Tucker C. Initiative to reduce aztreonam use in patients with self-reported penicillin allergy: Effects on clinical outcomes and antibiotic prescribing patterns. Am J Health Syst Pharm 2018; 75:S58-S62. [DOI: 10.2146/ajhp170400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Anthony Phan
- Department of Pharmacy, St. Vincent˴s HealthCare, Jacksonville, FL
| | - Bryan Allen
- Department of Pharmacy, St. Vincent˴s HealthCare, Jacksonville, FL
| | - Kevin Epps
- Department of Pharmacy, St. Vincent˴s HealthCare, Jacksonville, FL
| | - Maryam Alikhil
- Department of Pharmacy, St. Vincent˴s HealthCare, Jacksonville, FL
| | | | - Calvin Tucker
- Department of Pharmacy, St. Vincent˴s HealthCare, Jacksonville, FL
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24
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Use of a Penicillin Allergy Screening Algorithm and Penicillin Skin Testing for Transitioning Hospitalized Patients to First-Line Antibiotic Therapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1349-1355. [DOI: 10.1016/j.jaip.2017.11.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 10/13/2017] [Accepted: 11/07/2017] [Indexed: 12/13/2022]
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25
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Chen JR, Tarver SA, Alvarez KS, Wei W, Khan DA. Improving Aztreonam Stewardship and Cost Through a Penicillin Allergy Testing Clinical Guideline. Open Forum Infect Dis 2018; 5:ofy106. [PMID: 29977963 PMCID: PMC6016425 DOI: 10.1093/ofid/ofy106] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/03/2018] [Indexed: 11/12/2022] Open
Abstract
Background Patients reporting penicillin allergy often receive unnecessary and costly broad-spectrum alternatives such as aztreonam with negative consequences. Penicillin allergy testing improves antimicrobial therapy but is not broadly used in hospitals due to insufficient testing resources and short-term expenses. We describe a clinical decision support (CDS) tool promoting pharmacist-administered penicillin allergy testing in patients receiving aztreonam and its benefits toward antimicrobial stewardship and costs. Methods A CDS tool was incorporated into the electronic medical record, directing providers to order penicillin allergy testing for patients receiving aztreonam. An allergy-trained pharmacist reviewed orders placed through this new guideline and performed skin testing and oral challenges to determine whether these patients could safely take penicillin. Data on tests performed, antibiotic utilization, and cost-savings were compared with patients tested outside the new guideline as part of our institution's standard stewardship program. Results The guideline significantly increased penicillin allergy testing among patients receiving aztreonam from 24% to 85% (P < .001) while reducing the median delay between admission and testing completion from 3.31 to 1.05 days (P = 0.008). Patients tested under the guideline saw a 58% increase in penicillin exposure (P = .046). Institutional aztreonam administration declined from 2.54 to 1.47 administrations per 1000 patient-days (P = .016). Average antibiotic costs per patient tested before and after CDS decreased from $1265.81 to $592.08 USD, a 53% savings. Conclusions Targeting penicillin allergy testing to patients on aztreonam yields therapeutic and economic benefits during a single admission. This provides a cost-effective model for inpatient testing.
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Affiliation(s)
- Justin R Chen
- Department of Internal Medicine, Division of Allergy and Immunology, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Scott A Tarver
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas
| | - Kristin S Alvarez
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas
| | - Wenjing Wei
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas
| | - David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, The University of Texas Southwestern Medical Center, Dallas, Texas
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26
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Clark KE, Briand ME, Kapoor O, Pirasteh A. Impact of a Standardized Beta-Lactam Allergy Questionnaire on Aztreonam Use. J Pharm Pract 2018; 32:399-403. [PMID: 29466923 DOI: 10.1177/0897190018758557] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
METHODS This quasi-experimental study compared the aztreonam utilization in patients with self-reported beta-lactam allergies admitted to an inpatient service between two study periods (pre- and post-implementation). Post-implementation followed the initiation of a standardized beta-lactam allergy questionnaire, a student pharmacist-driven performance improvement project for beta-lactam allergy documentation. Interviews clarified the allergy, reaction history, and any previous tolerance of beta-lactams. If receiving aztreonam at the time of the questionnaire, recommendations were made for changes in therapy if deemed appropriate by the pharmacist. RESULTS A total of 95 patients were included in the pre-implementation group versus 65 patients in the post-implementation group. Baseline characteristics were similar. The average number of aztreonam doses per 1000 patient-days in the post-implementation group was decreased (21.23 vs 9.05, P = .003). The average number of days of therapy per 1000 patient-days in the post-implementation group was decreased (8.79-4.24, P = .016). An increase in the number of aztreonam de-escalations was observed post-implementation (P = .003). A total of 122 questionnaires were completed with 114 allergy documentation updates. There were no reported instances of adverse events. CONCLUSION Utilization of a standardized beta-lactam allergy questionnaire as a pharmacy education tool resulted in a statistically significant decrease in aztreonam utilization, based on doses, days of therapy, and de-escalations.
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Affiliation(s)
- Kacie E Clark
- 1 Department of Pharmacy, Baptist Medical Center Jacksonville, Jacksonville, FL, USA
| | - Mary E Briand
- 1 Department of Pharmacy, Baptist Medical Center Jacksonville, Jacksonville, FL, USA
| | - Om Kapoor
- 2 Department of Infectious Disease, Baptist Medical Center Jacksonville, Jacksonville, FL, USA
| | - Ameen Pirasteh
- 1 Department of Pharmacy, Baptist Medical Center Jacksonville, Jacksonville, FL, USA
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27
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Mattingly TJ, Fulton A, Lumish RA, Williams AMC, Yoon S, Yuen M, Heil EL. The Cost of Self-Reported Penicillin Allergy: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1649-1654.e4. [PMID: 29355644 DOI: 10.1016/j.jaip.2017.12.033] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/11/2017] [Accepted: 12/28/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients who report a penicillin (PCN) allergy receive suboptimal antibiotic therapy compared with patients not reporting an allergy. However, a majority of patients who report PCN allergy are not truly allergic on confirmatory testing. Ruling out PCN allergy by testing may improve clinical and economic outcomes for patients with reported allergies requiring antibiotic therapy. OBJECTIVE The objective of this study was to summarize clinical and economic outcomes associated with PCN allergy and provide recommendations for future cost-effectiveness analyses for PCN allergy testing. METHODS A literature search was conducted using SCOPUS, EMBASE, and PubMed, including all articles published any date through April 25, 2017 (PROSPERO Registration number 42017064112). A total of 1518 abstracts were found during the initial search with 96 duplicates, for a total of 1422 articles for screening. Thirty articles were included for qualitative synthesis and full data extraction. RESULTS The majority of the studies included had an observational design focusing on inpatient admissions. The most frequently measured outcome in the context of PCN allergy was optimizing antibiotic therapy. Patients with PCN allergy were found to have direct drug costs during inpatient admission ranging from no difference to an additional $609/patient compared with patients without PCN allergy. Outpatient prescription costs were estimated from $14 to $193/patient higher for PCN allergic patients. Total inpatient costs were less for patients without PCN allergy with average savings from $1145 to $4254/patient. CONCLUSIONS Evaluations of clinical and economic outcomes of PCN allergy are primarily observational and focus on inpatient populations. Long-term relationships between PCN allergy and clinical and economic outcomes are unknown.
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Affiliation(s)
- T Joseph Mattingly
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md.
| | - Anne Fulton
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - Rachel A Lumish
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - Anne M C Williams
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - SeJeong Yoon
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - Melissa Yuen
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
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28
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Krey SC, Waise J, Skrupky LP. Confronting the Challenge of Beta-Lactam Allergies: A Quasi-Experimental Study Assessing Impact of Pharmacy-Led Interventions. J Pharm Pract 2017; 32:139-146. [PMID: 29162022 DOI: 10.1177/0897190017743154] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To improve allergy history documentation and increase the use of beta-lactams when appropriate in patients with a reported beta-lactam allergy. METHODS This pre-post study was conducted at a 167-bed tertiary care community hospital and evaluated multidisciplinary interventions on allergy documentation and antibiotic selection. Interventions included education, creation of local practice guidelines, and modified practices for pharmacists and pharmacy technicians. Inpatients with a reported beta-lactam allergy receiving at least 1 antibiotic for >24 hours were included; first admissions were assessed. Primary outcomes were documentation of reaction type and percentage of patients receiving non-beta-lactam therapy. Secondary outcomes included documentation of previously tolerated beta-lactams, modification of non-beta-lactam therapy, discharge antibiotics, and adverse reactions. RESULTS A total of 179 patients were included, 91 preintervention and 88 postintervention. No significant differences were observed between the before versus after groups in the percentage of patients with documentation of reaction type (90.1% vs 89.8%, P = .940) or the overall percentage of patients receiving non-beta-lactams (86.8% vs 84.1%, P = .605). However, significantly more patients in the after phase had documentation of previously tolerated beta-lactams (8.8% vs 28.4%, P = .001), and among patients receiving a non-beta-lactam, a greater percentage was subsequently switched to a beta-lactam (11.4% vs 25.7%, P = .022). One allergic reaction was documented during the study, which occurred in the before phase. CONCLUSION Multidisciplinary education and local guideline implementation led by pharmacists may improve allergy documentation and antibiotic selection in patients with reported beta-lactam allergies.
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Affiliation(s)
- Steven C Krey
- 1 Department of Pharmacy, Aurora Medical Center-Grafton, Grafton, WI, USA
| | - Jeff Waise
- 2 Department of Pharmacy, Aurora BayCare Medical Center, Green Bay, WI, USA
| | - Lee P Skrupky
- 2 Department of Pharmacy, Aurora BayCare Medical Center, Green Bay, WI, USA
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29
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Trubiano JA, Stone CA, Grayson ML, Urbancic K, Slavin MA, Thursky KA, Phillips EJ. The 3 Cs of Antibiotic Allergy-Classification, Cross-Reactivity, and Collaboration. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:1532-1542. [PMID: 28843343 PMCID: PMC5681410 DOI: 10.1016/j.jaip.2017.06.017] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/08/2017] [Accepted: 06/16/2017] [Indexed: 12/22/2022]
Abstract
Antibiotic allergy labeling is highly prevalent and negatively impacts patient outcomes and antibiotic appropriateness. Reducing the prevalence and burden of antibiotic allergies requires the engagement of key stakeholders such as allergists, immunologists, pharmacists, and infectious diseases physicians. To help address this burden of antibiotic allergy overlabeling, we review 3 key antibiotic allergy domains: (1) antibiotic allergy classification, (2) antibiotic cross-reactivity, and (3) multidisciplinary collaboration. We review the available evidence and research gaps of currently used adverse drug reaction classification systems, antibiotic allergy cross-reactivity, and current and future models of antibiotic allergy care.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Karen Urbancic
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia; Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia; National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Elizabeth J Phillips
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Pathology, Microbiology, Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University Medical School, Nashville, Tenn
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Curtis CE, Al Bahar F, Marriott JF. The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review. PLoS One 2017; 12:e0183062. [PMID: 28837665 PMCID: PMC5570266 DOI: 10.1371/journal.pone.0183062] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/28/2017] [Indexed: 12/18/2022] Open
Abstract
Background Inappropriate antimicrobial use has been shown to be an important determinant of the emergence of antimicrobial resistance (AMR). Health information technology (HIT) in the form of Computerised Decision Support (CDS) represents an option for improving antimicrobial prescribing and containing AMR. Objectives To evaluate the evidence for CDS in improving quantitative and qualitative measures of antibiotic prescribing in inpatient hospital settings. Methods A systematic literature search was conducted of articles published from inception to 20th December 2014 using eight electronic databases: MEDLINE, EMBASE, PUBMED, Web of Science, CINAHL, Cochrane Library, HMIC and PsychINFo. An updated systematic literature search was conducted from January 1st 2015 to October 1st 2016 using PUBMED. The search strategy used combinations of the following terms: (electronic prescribing) OR (clinical decision support) AND (antibiotic or antibacterial or antimicrobial) AND (hospital or secondary care or inpatient). Studies were evaluated for quality using a 10-point rating scale. Results Eighty-one studies were identified matching the inclusion criteria. Seven outcome measures were evaluated: adequacy of antibiotic coverage, mortality, volume of antibiotic usage, length of stay, antibiotic cost, compliance with guidelines, antimicrobial resistance, and CDS implementation and uptake. Meta-analysis of pooled outcomes showed CDS significantly improved the adequacy of antibiotic coverage (n = 13; odds ratio [OR], 2.11 [95% CI, 1.67 to 2.66, p ≤ 0.00001]). Also, CDS was associated with marginally lowered mortality (n = 20; OR, 0.85 [CI, 0.75 to 0.96, p = 0.01]). CDS was associated with lower antibiotic utilisation, increased compliance with antibiotic guidelines and reductions in antimicrobial resistance. Conflicting effects of CDS on length of stay, antibiotic costs and system uptake were also noted. Conclusions CDS has the potential to improve the adequacy of antibiotic coverage and marginally decrease mortality in hospital-related settings.
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Affiliation(s)
- Christopher E. Curtis
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
| | - Fares Al Bahar
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - John F. Marriott
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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Trubiano JA, Thursky KA, Stewardson AJ, Urbancic K, Worth LJ, Jackson C, Stevenson W, Sutherland M, Slavin MA, Grayson ML, Phillips EJ. Impact of an Integrated Antibiotic Allergy Testing Program on Antimicrobial Stewardship: A Multicenter Evaluation. Clin Infect Dis 2017; 65:166-174. [PMID: 28520865 PMCID: PMC5849110 DOI: 10.1093/cid/cix244] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 05/12/2017] [Indexed: 01/03/2023] Open
Abstract
Background Despite the high prevalence of patient-reported antibiotic allergy (so-called antibiotic allergy labels [AALs]) and their impact on antibiotic prescribing, incorporation of antibiotic allergy testing (AAT) into antimicrobial stewardship (AMS) programs (AAT-AMS) is not widespread. We aimed to evaluate the impact of an AAT-AMS program on AAL prevalence, antibiotic usage, and appropriateness of prescribing. Methods AAT-AMS was implemented at two large Australian hospitals during a 14-month period beginning May 2015. Baseline demographics, AAL history, age-adjusted Charlson comorbidity index, infection history, and antibiotic usage for 12 months prior to testing (pre-AAT-AMS) and 3 months following testing (post-AAT-AMS) were recorded for each participant. Study outcomes included the proportion of patients who were "de-labeled" of their AAL, spectrum of antibiotic courses pre- and post-AAT-AMS, and antibiotic appropriateness (using standard definitions). Results From the 118 antibiotic allergy-tested patients, 226 AALs were reported (mean, 1.91/patient), with 53.6% involving 1 or more penicillin class drug. AAT-AMS allowed AAL de-labeling in 98 (83%) patients-56% (55/98) with all AALs removed. Post-AAT, prescribing of narrow-spectrum penicillins was more likely (adjusted odds ratio [aOR], 2.81, 95% confidence interval [CI], 1.45-5.42), as was narrow-spectrum β-lactams (aOR, 3.54; 95% CI, 1.98-6.33), and appropriate antibiotics (aOR, 12.27; 95% CI, 5.00-30.09); and less likely for restricted antibiotics (aOR, 0.16; 95% CI, .09-.29), after adjusting for indication, Charlson comorbidity index, and care setting. Conclusions An integrated AAT-AMS program was effective in both de-labeling of AALs and promotion of improved antibiotic usage and appropriateness, supporting the routine incorporation of AAT into AMS programs.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- Department of Medicine, University of Melbourne, Parkville
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
| | | | - Karen Urbancic
- Department of Infectious Diseases, Austin Health, Heidelberg
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
- Department of Pharmacy, Austin Health, Heidelberg
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
| | - Cheryl Jackson
- Department of Pharmacy, Peter MacCallum Cancer Centre, VCCC, Parkville, and
| | - Wendy Stevenson
- Department of Infectious Diseases, Austin Health, Heidelberg
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, and
| | - Michael Sutherland
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, and
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg
- Department of Medicine, University of Melbourne, Parkville
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia; and
- Departments of Medicine and Pharmacology, Vanderbilt University Medical Centre, Nashville, Tennessee
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Staicu ML, Plakosh M, Ramsey A. Prospective evaluation of electronic medical record penicillin allergy documentation at a tertiary community teaching hospital. Ann Allergy Asthma Immunol 2017; 119:94-95. [PMID: 28578908 DOI: 10.1016/j.anai.2017.05.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/08/2017] [Accepted: 05/12/2017] [Indexed: 12/27/2022]
Affiliation(s)
| | - Matthew Plakosh
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York
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