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Tan JJ, Zhou PY, Chua NGS, Hung KC, Lee HLW, Lee LW, Lim JL, Lim YCS, Liew Y, Loo LW, Koomanan N, Teoh BS, Yii YCD, Thien SY, Cherng PZB, Piotr CM, Kwa LHA, Chung SJ. The Safety of Aztreonam Versus Ceftazidime in Patients Labeled With Penicillin Allergy: A Cohort Study. Clin Ther 2024:S0149-2918(24)00114-0. [PMID: 38942719 DOI: 10.1016/j.clinthera.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/12/2024] [Accepted: 05/16/2024] [Indexed: 06/30/2024]
Abstract
PURPOSE Penicillin allergy is the most common drug allergy among hospitalized patients. Traditionally, aztreonam is recommended for patients labeled with penicillin allergy (PLWPA) in our institutional empirical antibiotic guidelines. Due to a global aztreonam shortage in December 2022, the antimicrobial stewardship unit recommended ceftazidime as a substitute. There is a paucity of real-world data on the safety profile of ceftazidime in PLWPA. Hence, we evaluated tolerability outcomes of ceftazidime use in PLWPA. METHODS This retrospective cohort study compared PLWPA in Singapore General Hospital who received aztreonam (October 2022-December 2022) or ceftazidime (December 2022-February 2023). Patients were stratified according to their risk of allergic reaction (AR) based on history of penicillin allergy. The severity of AR was based on the Delphi study grading system. The primary outcome was development of AR after initiation of aztreonam or ceftazidime. The secondary tolerability outcomes include hepatotoxicity and neurotoxicity. FINDINGS There were 168 patients in the study; 69 were men (41.1%) and the median age was 69 years (interquartile range: 59-76 years). Incidence of AR was statistically similar in both arms: 1 of 102 patients (0.98%) in the aztreonam arm vs 2 of 66 patients (3.03%) in the ceftazidime arm (P = 0.33). The patient in the aztreonam arm was deemed at medium risk of having an AR and developed localized rashes (grade 1). Both patients in the ceftazidime arm were deemed at high risk of AR and developed localized skin reaction (grade 1). Hepatotoxicity was observed in 1 patient prescribed aztreonam. No patients in the ceftazidime arm developed adverse events. IMPLICATIONS Ceftazidime appears to be better tolerated and cheaper compared with aztreonam in PLWPA, and serves as an antimicrobial stewardship strategy to conserve broader-spectrum antibiotics use.
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Affiliation(s)
- Jun Jie Tan
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore.
| | - Peijun Yvonne Zhou
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | | | - Kai Chee Hung
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | | | - Lai Wei Lee
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Jia Le Lim
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Yun Chun Shena Lim
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Yixin Liew
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Li Wen Loo
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Narendran Koomanan
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Boon San Teoh
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | | | - Siew Yee Thien
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
| | | | | | - Lay Hoon Andrea Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore; SingHealth Duke-NUS Medicine Academic Clinical Programme, Singapore, Singapore; Emerging Infectious Diseases Program, Duke-NUS Medical School, Singapore, Singapore
| | - Shimin Jasmine Chung
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
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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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Gray MP, Kellum JA, Kirisci L, Boyce RD, Kane-Gill SL. Long-Term Outcomes Associated With β-Lactam Allergies. JAMA Netw Open 2024; 7:e2412313. [PMID: 38758551 PMCID: PMC11102016 DOI: 10.1001/jamanetworkopen.2024.12313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/19/2024] [Indexed: 05/18/2024] Open
Abstract
Importance β-lactam (BL) allergies are the most common drug allergy worldwide, but most are reported in error. BL allergies are also well-established risk factors for adverse drug events and antibiotic-resistant infections during inpatient health care encounters, but the understanding of the long-term outcomes of patients with BL allergies remains limited. Objective To evaluate the long-term clinical outcomes of patients with BL allergies. Design, Setting, and Participants This longitudinal retrospective cohort study was conducted at a single regional health care system in western Pennsylvania. Electronic health records were analyzed for patients who had an index encounter with a diagnosis of sepsis, pneumonia, or urinary tract infection between 2007 and 2008. Patients were followed-up until death or the end of 2018. Data analysis was performed from January 2022 to January 2024. Exposure The presence of any BL class antibiotic in the allergy section of a patient's electronic health record, evaluated at the earliest occurring observed health care encounter. Main Outcomes and Measures The primary outcome was all-cause mortality, derived from the Social Security Death Index. Secondary outcomes were defined using laboratory and microbiology results and included infection with methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, or vancomycin-resistant Enterococcus (VRE) and severity and occurrence of acute kidney injury (AKI). Generalized estimating equations with a patient-level panel variable and time exposure offset were used to evaluate the odds of occurrence of each outcome between allergy groups. Results A total of 20 092 patients (mean [SD] age, 62.9 [19.7] years; 12 231 female [60.9%]), of whom 4211 (21.0%) had BL documented allergy and 15 881 (79.0%) did not, met the inclusion criteria. A total of 3513 patients (17.5%) were Black, 15 358 (76.4%) were White, and 1221 (6.0%) were another race. Using generalized estimating equations, documented BL allergies were not significantly associated with the odds of mortality (odds ratio [OR], 1.02; 95% CI, 0.96-1.09). BL allergies were associated with increased odds of MRSA infection (OR, 1.44; 95% CI, 1.36-1.53), VRE infection (OR, 1.18; 95% CI, 1.05-1.32), and the pooled rate of the 3 evaluated antibiotic-resistant infections (OR, 1.33; 95% CI, 1.30-1.36) but were not associated with C difficile infection (OR, 1.04; 95% CI, 0.94-1.16), stage 2 and 3 AKI (OR, 1.02; 95% CI, 0.96-1.10), or stage 3 AKI (OR, 1.06; 95% CI, 0.98-1.14). Conclusions and Relevance Documented BL allergies were not associated with the long-term odds of mortality but were associated with antibiotic-resistant infections. Health systems should emphasize accurate allergy documentation and reduce unnecessary BL avoidance.
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Affiliation(s)
- Matthew P. Gray
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - John A. Kellum
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Levent Kirisci
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Richard D. Boyce
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sandra L. Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
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Leventoğlu E, Uzun Kenan B, Büyükkaragöz B, Bakkaloğlu SA. Clinical Characteristics of Children With Acute Tubulointerstitial Nephritis: A Single-Center Experience. Cureus 2023; 15:e36379. [PMID: 37090263 PMCID: PMC10115660 DOI: 10.7759/cureus.36379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 03/22/2023] Open
Abstract
OBJECTIVE Acute tubulointerstitial nephritis (ATIN) is an infiltration of the kidney interstitium with inflammatory cells. Medications are most frequently blamed for the etiology. Patients may present with non-specific signs and symptoms. Therefore, the diagnosis of ATIN is often delayed. In this study, clinical characteristics, treatment protocols, and outcomes of children diagnosed with ATIN were presented. METHODS This is a retrospective study based on the data of 18 patients diagnosed with ATIN between 2017 and 2022 at Gazi University. Patients were divided into two groups: steroid-treated (n=13) and non-steroid-treated (n=5). Clinical features and laboratory evaluations were compared between the groups. RESULTS The mean age of the patients was 14.4±2.6 years, and the great majority were girls (88.9%, n=16). ATIN was mostly medication-related (n=17, 94.4%). Steroids were started in one-third of patients using non-steroidal anti-inflammatory drugs. Steroids were started in 45.4% of the patients with eosinophilia, 75% of those with pyuria, 66.6% of those with hematuria, and half of the patients with increased kidney echogenicity. The kidney functions returned to normal ranges in all patients. In steroid-treated patients, although recovery times for serum creatinine were longer (7.2±2.5 vs. 71.2±100.7 days), blood eosinophil count reached normal values more rapidly (5.4±2.3 vs. 3.1±1.0 days). CONCLUSION ATIN can be associated with diverse clinical presentations. The first and most important step of treatment is to discontinue the medication responsible for the etiology. Steroid treatment improves eosinophilia more rapidly. However, randomized controlled studies are needed to determine further treatment steps and establish a more definite treatment protocol.
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