1
|
Augustino A, Alvarez KS, Kassem L, Roy L, Termulo C, Smartt J, Sparks M, Mercadel C, Chow TG. Patient Perceptions of Penicillin Allergy Testing in a Public Health System. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00834-1. [PMID: 39182907 DOI: 10.1016/j.jaip.2024.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 07/31/2024] [Accepted: 08/06/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Documented penicillin allergies are associated with increased morbidity, increased hospital stay, and an increase in resistant infections. Penicillin allergy evaluations using a direct oral challenge with or without skin testing has been recommended as a delabeling strategy for patients with penicillin reaction histories. Barriers for achieving equitable access, however, exist. Understanding patient perceptions regarding their penicillin allergy across diverse populations is crucial to mitigate potential obstacles to penicillin allergy testing (PAT) and the use of penicillin-like antibiotics after delabeling. OBJECTIVE The objective of this study was to gather perceptions of patients delabeled of their penicillin allergy after testing through a PAT program. METHODS Patients who underwent PAT and had a subsequent allergy removal due to a negative result were interviewed using closed and open-ended questions. RESULTS A total of 100 patient interviews were completed. Awareness of the risks associated with unnecessary penicillin avoidance and PAT was low. Initial concerns regarding PAT were common but were frequently alleviated with targeted education. Most patients undergoing testing reported a positive experience and would recommend PAT to others. A minority of patients continued to have discordant perceptions regarding their penicillin allergy label with mistrust in the negative result being a critical theme identified. CONCLUSIONS Future interventions increasing the awareness of penicillin allergy labels and the risks and benefits of PAT in the general population are needed and must consider health literacy levels, languages, and cultural contexts. Measures to offer PAT within a clinical setting that has built high levels of patient trust will likely achieve the greatest long-term success.
Collapse
Affiliation(s)
| | - Kristin S Alvarez
- Center of Innovation and Value at Parkland, Parkland Health, Dallas, Texas
| | | | - Lonnie Roy
- Office of Research Administration, Parkland Health, Dallas, Texas
| | | | - Jillian Smartt
- Center of Innovation and Value at Parkland, Parkland Health, Dallas, Texas
| | - Madeline Sparks
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Candice Mercadel
- Center of Innovation and Value at Parkland, Parkland Health, Dallas, Texas
| | - Timothy G Chow
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
2
|
Bjørbak Alnæs M, Skodvin B, Anker Jahnsen J, Kalleklev Velure G, Oppegaard O, Reiakvam Kittang B, Storaas T, Aase Schaufel M. "What if the patient has a severe reaction, and it is my fault?" A qualitative study exploring factors for sustainable implementation of penicillin allergy delabelling. Antimicrob Resist Infect Control 2024; 13:97. [PMID: 39218954 PMCID: PMC11368001 DOI: 10.1186/s13756-024-01456-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 08/24/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Penicillin allergy delabelling (PAD), the process of evaluating penicillin allergy labels, is a key target in antibiotic stewardship, but uptake of the procedure outside clinical studies is limited. We aimed to explore factors that need to be addressed to sustainably implement a clinical pathway for PAD. METHODS We conducted a qualitative study based on semi-structured interviews with focus groups consisting of a purposive sample of twenty-five nurses and physicians working in four different hospitals in Western Norway. Systematic text condensation was applied for analysis. RESULTS Psychological safety was reported as crucial for clinicians to perform PAD. A narrative of uncertainty and anticipated negative outcomes were negatively associated with PAD performance. Education, guidelines, and colleague- and leadership support could together create psychological safety and empower health personnel to perform PAD. Key factors for sustainable implementation of PAD were facilitating the informant's profound motivation for providing optimal health care and for reducing antimicrobial resistance. Informants were motivated by the prospect of a simplified PAD procedure. We identified three main needs for implementation of PAD: (1) creating psychological safety; (2) utilising clinicians' inherent motivation and (3) optimal organisational structures. CONCLUSION A planned implementation of PAD must acknowledge clinicians' need for psychological safety and aid reassurance through training, leadership, and guidelines. To implement PAD as an everyday practice it must be minimally disruptive and provide a contextually adaptive logistic chain. Also, the clinician's motivation for providing the best possible healthcare should be utilised to aid implementation. The results of this study will aid sustainable implementation of PAD in Norway. ETHICS The study was approved by the Western Norway Regional Committee for Medical Research Ethics (Study No:199210).
Collapse
Affiliation(s)
- Marie Bjørbak Alnæs
- Section of Clinical Allergy, Department of Occupational Medicine, Haukeland University Hospital, Bergen, 5020, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway.
| | - Brita Skodvin
- The Norwegian Advisory Unit for Antibiotic use in Hospitals, 5020, Bergen, Norway
| | - Jan Anker Jahnsen
- Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway
- Regional Medicines Information and Pharmacovigilance Centre (RELIS Vest), University Hospital, Haukeland, Bergen, Norway
| | - Grete Kalleklev Velure
- Section of Clinical Allergy, Department of Occupational Medicine, Haukeland University Hospital, Bergen, 5020, Norway
| | - Oddvar Oppegaard
- Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, 5020, Norway
| | - Bård Reiakvam Kittang
- Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway
- Haraldsplass Deaconess Hospital, Bergen, 5009, Norway
- Department of Nursing Home Medicine, Fyllingsdalen, 5145, Norway
| | - Torgeir Storaas
- Section of Clinical Allergy, Department of Occupational Medicine, Haukeland University Hospital, Bergen, 5020, Norway
| | - Margrethe Aase Schaufel
- Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, 5020, Norway
| |
Collapse
|
3
|
Mann J, Cox V, Gorman S, Calissi P. Barriers to and Facilitators of Delabelling of Antimicrobial Allergies: A Qualitative Meta-synthesis. Can J Hosp Pharm 2024; 77:e3490. [PMID: 38357298 PMCID: PMC10846797 DOI: 10.4212/cjhp.3490] [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: 04/23/2023] [Accepted: 08/11/2023] [Indexed: 02/16/2024]
Abstract
Background Patients who report penicillin allergies may receive alternative antibiotics. Such substitution contributes to antimicrobial resistance, lower treatment efficacy, increased frequency of adverse events, and increased costs. Approximately 90% of individuals who report a penicillin allergy can tolerate a penicillin. Objective To identify the barriers to and facilitators of removal by health care workers of inaccurate antimicrobial allergies from patient records, known as delabelling. Data Sources The MEDLINE database was searched from inception to December 29, 2020. Study Selection and Data Extraction Qualitative studies evaluating health care professionals' perceptions of barriers to and/or facilitators of the act of delabelling a patient's antimicrobial allergies were included in the meta-synthesis. Data Synthesis The Theoretical Domains Framework was used to code and group individual utterances from the included studies, which were mapped to the Behaviour Change Wheel and corresponding intervention function and policy categories. Results Four studies met the inclusion criteria. Eight themes were identified as representing barriers to delabelling: delabelling skills, patient education skills, knowledge, electronic health records (EHRs), communication frameworks, time, fear about allergic reactions, and professional roles. Behaviour change interventions that may overcome these barriers include education, training, algorithms and toolkits, changes to EHRs, use of dedicated personnel, policies, incentivization of correct labelling, and an audit system. Conclusions Eight themes were identified as barriers to delabelling of antimicrobial allergies. Future behaviour change interventions to address these barriers were proposed. Confidence in the findings of this study was judged to be moderate, according to the GRADE CERQual approach.
Collapse
Affiliation(s)
- Juliana Mann
- , BSc(Pharm), ACPR, is a Clinical Pharmacist with the East Kootenay Regional Hospital, Cranbrook, British Columbia
| | - Victoria Cox
- , BSc(Pharm), ACPR, PharmD, is a Clinical Pharmacy Specialist, Infectious Diseases, Kelowna General Hospital, Kelowna, British Columbia
| | - Sean Gorman
- , BSc(Pharm), PharmD, is Pharmacy Director, East and South Interior Health Pharmacy Services, Kelowna, British Columbia
| | - Piera Calissi
- , BSc(Pharm), PharmD, FSCHP, is Coordinator, Antimicrobial Stewardship Program, Interior Health, Kelowna, British Columbia
| |
Collapse
|
4
|
Xiang YY, Heriot GS, Jamrozik E. Ethics of antibiotic allergy. JOURNAL OF MEDICAL ETHICS 2023; 50:39-44. [PMID: 37286334 PMCID: PMC7615378 DOI: 10.1136/jme-2022-108648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 04/01/2023] [Indexed: 06/09/2023]
Abstract
Antibiotic allergies are commonly reported among patients, but most do not experience reactions on rechallenge with the same agents. These reported allergies complicate management of infections in patients labelled as having penicillin allergy, including serious infections where penicillin-based antibiotics are the first-line (most effective and least toxic) treatment option. Allergy labels are rarely questioned in clinical practice, with many clinicians opting for inferior second-line antibiotics to avoid a perceived risk of allergy. Reported allergies thereby can have significant impacts on patients and public health, and present major ethical challenges. Antibiotic allergy testing has been described as a strategy to circumvent this dilemma, but it carries limitations that often make it less feasible in patients with acute infections or in community settings that lack access to allergy testing. This article provides an empirically informed ethical analysis of key considerations in this clinical dilemma, using Staphylococcus aureus bacteraemia in patients with penicillin allergies as a case study. We argue that prescribing first-line penicillin-based antibiotics to patients with reported allergies may often present a more favourable ratio of benefits to risks, and may therefore be more ethically appropriate than using second-line drugs. We recommend changes to policy-making, clinical research and medical education, in order to promote more ethically acceptable responses to antibiotic allergies than the status quo.
Collapse
Affiliation(s)
- Yu Yi Xiang
- Western Health, Footscray, Victoria, Australia
| | - George S Heriot
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Euzebiusz Jamrozik
- Ethox and Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
- Royal Melbourne Hospital Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Monash Bioethics Centre, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
5
|
Gillespie C, Sitter K, McConeghy KW, Strymish J, Gupta K, Hartmann CW, Borzecki AM. Facilitators and Barriers to Verifying Penicillin Allergies in a Veteran Nursing Home Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2848-2854.e3. [PMID: 37352930 DOI: 10.1016/j.jaip.2023.06.023] [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: 02/13/2023] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Unconfirmed penicillin allergies are common and may contribute to adverse outcomes, especially in frail older patients. Evidence-based clinical pathways for evaluating penicillin allergies have been effectively and safely applied in selected settings, but not in nursing home populations. OBJECTIVE To identify potential facilitators and barriers to implementing a strategy to verify penicillin allergies in Veterans Health Administration nursing homes, known as Community Living Centers (CLCs). METHODS We conducted semistructured interviews with staff, patients, and family members at 1 CLC to assess their understanding of penicillin allergies and receptiveness to verifying the allergy. We also asked staff about the proposed allergy assessment strategy, including willingness to delabel by history and feasibility of performing oral challenges or skin testing on their unit. RESULTS From 24 interviews (11 front-line staff, 4 leadership, 3 patients, 6 family members), we identified several facilitators or barriers. Staff recognized the importance of allergy verification and were willing to support and assist in implementing verification strategies. The CLC residents were willing to have their allergy status verified. However, some family members expressed reluctance to verifying their relative's allergy status owing to safety concerns. Front-line staff also expressed concern over having the necessary resources, including time and expertise, to implement the strategy. Staff suggested involving clinical pharmacists and educating staff, patients, and family members as ways to overcome these barriers. CONCLUSIONS Concerns about safety and staff resources are important potential barriers to implementing verification strategies. Involvement of pharmacists and education of both staff and patients and family members will be important components of any successful intervention.
Collapse
Affiliation(s)
- Chris Gillespie
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass.
| | - Kailyn Sitter
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass
| | - Kevin W McConeghy
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, RI; Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI
| | - Judith Strymish
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Infectious Diseases, VA Boston Healthcare System, Boston, Mass
| | - Kalpana Gupta
- Division of Infectious Diseases, VA Boston Healthcare System, Boston, Mass; Center for Healthcare Organization and Implementation Research (CHOIR), Boston Campus, VA Boston Healthcare System, Boston, Mass; Department of General Internal Medicine, Boston University School of Medicine, Boston, Mass
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass; Zuckerberg College of Health Sciences, Department of Public Health, University of Massachusetts Lowell, Lowell, Mass
| | - Ann M Borzecki
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass; Department of General Internal Medicine, Boston University School of Medicine, Boston, Mass; School of Public Health, Department of Health Law, Policy and Management, Boston University School of Public Health, Boston University, Boston, Mass
| |
Collapse
|
6
|
Fransson S, Damving CM, Boel JB, Arpi M, Skinhøj IG, Jarløv JO, Mosbech HF, Poulsen LK, Garvey LH. Delabeling of Penicillin Allergy: Room for Improvement. Int Arch Allergy Immunol 2023; 184:870-874. [PMID: 37321191 DOI: 10.1159/000530770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/11/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Penicillin allergy labels have been shown to be associated with suboptimal treatment, negative health outcomes, and increased antibiotic resistance. Many inpatients claim to have penicillin allergy, but studies show that allergy can be disproved and the label removed in up to 90% of cases. OBJECTIVES The purpose of the study was to investigate the proportion of patients with a penicillin allergy label in a Danish hospital and to classify patients according to the risk of having penicillin allergy in "no risk," low, and high risk. METHODS For 22 days, inpatients with penicillin allergy labels were interviewed, had their dispensed penicillin prescriptions examined, and were subsequently categorized into risk groups based on the risk evaluation criteria in national guidelines. RESULTS In total, 260 patients had a penicillin allergy label (10% of the inpatients). Out of 151 included patients, 25 were "no risk" patients (17%), who could potentially have their penicillin allergy label removed without testing. 42 were low-risk patients (28%). 10 "no risk" patients and 20 low-risk patients had been prescribed and dispensed one or more penicillins despite an allergy label. CONCLUSION Ten percent of inpatients have a penicillin allergy label in a Danish hospital. 17% of these could potentially have their penicillin allergy label removed without allergy testing.
Collapse
Affiliation(s)
- Sara Fransson
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Christina Monnerup Damving
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Jonas Bredtoft Boel
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Magnus Arpi
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Ida Gjørup Skinhøj
- Department of Infectious Disease, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Jens Otto Jarløv
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Holger F Mosbech
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Lars K Poulsen
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Lene H Garvey
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
7
|
Achar RK, Madapoosi S, Devlin D, Smiley J, Ravikumar R, Baptist AP, Walford E. Comparison of 2 penicillin allergy skin test referral strategies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1957-1959.e2. [PMID: 36990431 DOI: 10.1016/j.jaip.2023.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 03/08/2023] [Accepted: 03/18/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Rohan K Achar
- Department of Internal Medicine, University of Michigan, Ann Arbor, Mich.
| | | | - Danielle Devlin
- Department of Internal Medicine, University of Michigan, Ann Arbor, Mich
| | - Josiah Smiley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Mich
| | - Rajan Ravikumar
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan, Ann Arbor, Mich
| | - Alan P Baptist
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan, Ann Arbor, Mich
| | - Eric Walford
- Department of Internal Medicine, University of Michigan, Ann Arbor, Mich
| |
Collapse
|
8
|
Mabilat C, Gros MF, Van Belkum A, Trubiano JA, Blumenthal KG, Romano A, Timbrook TT. Improving antimicrobial stewardship with penicillin allergy testing: a review of current practices and unmet needs. JAC Antimicrob Resist 2022; 4:dlac116. [PMID: 36415507 PMCID: PMC9675589 DOI: 10.1093/jacamr/dlac116] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Penicillin allergy, the most frequently reported drug allergy, has been associated with suboptimal antibiotic therapy, increased antimicrobial resistance, increased rates of Clostridioides difficile colonization and infection, as well as extended hospital length of stay and increased cost. Although up to 10% of all patients may report penicillin allergy, most penicillin allergies are not confirmed. As such, most patients with a penicillin allergy can still safely use penicillin and related drugs following a more precise assessment. Herein, we review the current practices and unmet needs in penicillin allergy testing. The diagnostic algorithm is mostly based on a clinical history assessment followed by in vivo testing, i.e. skin test and/or drug challenge. As these tests are labour and resource intensive, there is increased interest in point-of-care penicillin allergy de-labelling solutions incorporated into Antimicrobial Stewardship Programmes including digital assessment tools. These can be locally parameterized on the basis of characteristics of target populations, incidence of specific allergies and local antibiotic usage to perform clinical risk stratification. Safely ruling out any residual risk remains essential and in vivo drug challenge and/or skin testing should be systematically encouraged. Gradual understanding and convergence of the risk stratification of the clinical presentation of penicillin allergy is enabling a wider implementation of this essential aspect of antimicrobial stewardship through digitalized decision tools and in vivo testing. More research is needed to deliver point of care in vitro diagnostic tools to democratize this de-labelling practice, which would be highly beneficial to patient care. This progress, together with better education of patients and clinicians about the availability, efficacy and safety of penicillin allergy testing, will increase the dissemination of penicillin allergy assessment as an important component of Antimicrobial Stewardship Programmes.
Collapse
Affiliation(s)
| | - Marie-Françoise Gros
- bioMérieux, Medical Affairs, 100 Rue Louis Pasteur, F-69280 Marcy l'Etoile, France
| | - Alex Van Belkum
- Current address:BaseClear, Sylviusweg 74, 2333 BE Leiden, The Netherlands
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, 145 Studley Road, Heidelberg, Victoria, 3084Australia
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | | | - Tristan T Timbrook
- bioMérieux, BioFire Diagnostics, Global Medical Affairs, 515 Colorow Drive, Salt Lake City, UT 84108, USA
| |
Collapse
|
9
|
Guarnieri KM, Xie SS, Courter JD, Liu C, Ruddy RM, Risma KA. Distinct Characteristics and Chronology of Amoxicillin-Associated Reactions in Pediatric Acute Care Settings. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2951-2957.e3. [PMID: 35872212 DOI: 10.1016/j.jaip.2022.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Amoxicillin-associated reactions (AARs) in children presenting as rashes are common, and recent data suggest that >90% tolerate amoxicillin on re-exposure. However, additional data would help pediatricians and allergists gain confidence in referring and testing children who experienced systemic symptoms perceived as "worrisome," thus leading to urgent medical evaluations. By characterizing the entire spectrum of AAR symptoms in pediatric patients presenting to emergency department (ED)/urgent care (UC) settings, we sought to increase our diagnostic acumen to guide subsequent allergy evaluations. OBJECTIVE To fully characterize clinical features of rash and systemic symptoms in children presenting to the ED/UC with AARs. METHODS A retrospective chart review of children seen in the ED/UC from July 1, 2015, to June 30, 2017, was conducted. Clinical features, chronology, and seasonality were detailed, and cases were classified into 3 previously described AAR phenotypes: maculopapular exanthem (MPE), urticaria, and serum sickness-like reactions (SSLRs), if they experienced joint symptoms. RESULTS Children (n = 668; median age: 1.8 years) presented to the ED/UC with urticaria (44%), MPE (36%), and SSLRs (11%) typically on days 7 to 10 of amoxicillin. Although children with SSLRs were more frequently treated with corticosteroids (28%, P < .0001) and exhibited higher rates of "worrisome" features (fever, angioedema, or gastrointestinal symptoms; 73%, P < .0001), delayed-onset systemic symptoms were identified frequently in all 3 groups. ED/UC reutilization was unexpectedly high with 66 children (10%) returning to the ED/UC for re-evaluation. CONCLUSION "Worrisome" symptoms are common in children presenting to the ED/UC with AARs. Future studies are needed to determine the impact on subsequent referral and allergy testing.
Collapse
Affiliation(s)
- Katharine M Guarnieri
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Susan S Xie
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joshua D Courter
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Richard M Ruddy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kimberly A Risma
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| |
Collapse
|
10
|
Wanat M, Santillo M, Galal U, Davoudianfar M, Bongard E, Savic S, Savic L, Porter C, Fielding J, Butler CC, Pavitt S, Sandoe J, Tonkin-Crine S. Mixed-methods evaluation of a behavioural intervention package to identify and amend incorrect penicillin allergy records in UK general practice. BMJ Open 2022; 12:e057471. [PMID: 36691248 PMCID: PMC9171226 DOI: 10.1136/bmjopen-2021-057471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 05/11/2022] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES About 6% of the UK general practice population has a record of a penicillin allergy but fewer than 10% of these are likely to be truly allergic. In the ALABAMA (Allergy Antibiotics and Microbial resistance) feasibility trial, primary care patients with penicillin allergy were randomised to penicillin allergy assessment pathway or usual care to assess the effect on health outcomes. A behavioural intervention package was developed to aid delabelling. This study aimed to investigate patients' and clinicians' views of penicillin allergy testing (PAT). DESIGN We conducted a mixed-methods process evaluation embedded within the ALABAMA trial, which included a clinician survey, a patient survey (at baseline and follow-up) and semistructured interviews with patients and clinicians. SETTINGS The study was conducted in primary care, as part of the feasibility stage of the ALABAMA trial. PARTICIPANTS Patients and primary care clinicians. RESULTS Clinicians (N=53; 52.2%) were positive about PAT and its potential value but did not have previous experience of referring patients for a PAT and were unsure whether patients would take penicillin after a negative allergy test. Patients (N=36; 46%) were unsure whether they were severely allergic to penicillin and did not fear a severe allergic reaction to penicillin. Clinician interviews showed that they were already aware of the benefit of PAT. Interviews with patients suggested the importance of safety as patients valued having numerous opportunities to address their concerns about safety of the test. CONCLUSIONS This study highlights the positive effects of the ALABAMA behavioural intervention for both patients and clinicians. TRIAL REGISTRATION NUMBER NCT04108637; ISRCTN20579216; Pre-results.
Collapse
Affiliation(s)
- Marta Wanat
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Ushma Galal
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sinisa Savic
- University of Leeds and Leeds Teaching Hospitals NHS Trust, Faculty of Medicine and Health, Leeds, UK
| | - Louise Savic
- University of Leeds and Leeds Teaching Hospitals NHS Trust, Faculty of Medicine and Health, Leeds, UK
| | - Catherine Porter
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joanne Fielding
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sue Pavitt
- Dental Translational and Clinical Research Unit, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Jonathan Sandoe
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| |
Collapse
|
11
|
Borek AJ, Santillo M, Wanat M, Butler CC, Tonkin-Crine S. How can behavioural science contribute to qualitative research on antimicrobial stewardship in primary care? JAC Antimicrob Resist 2022; 4:dlac007. [PMID: 35156031 PMCID: PMC8826758 DOI: 10.1093/jacamr/dlac007] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Antibiotic use (and misuse) accelerates antimicrobial resistance (AMR), and addressing this complex problem necessitates behaviour change related to infection prevention and management and to antibiotic prescribing and use. As most antibiotic courses are prescribed in primary care, a key focus of antimicrobial stewardship (AMS) is on changing behaviours outside of hospital. Behavioural science draws on behaviour change theories, techniques and methods developed in health psychology, and can be used to help understand and change behaviours related to AMR/AMS. Qualitative methodologies can be used together with a behavioural science approach to explore influences on behaviour and develop and evaluate behavioural interventions. This paper provides an overview of how the behavioural science approach, together with qualitative methods, can contribute and add value to AMS projects. First, it introduces and explains the relevance of the behavioural science approach to AMR/AMS. Second, it provides an overview of behaviour change 'tools': behaviour change theories/models, behavioural determinants and behaviour change techniques. Third, it explains how behavioural methods can be used to: (i) define a clinical problem in behavioural terms and identify behavioural influences; (ii) develop and implement behavioural AMS interventions; and (iii) evaluate them. These are illustrated with examples of using qualitative methods in AMS studies in primary care. Finally, the paper concludes by summarizing the main contributions of taking the behavioural science approach to qualitative AMS research in primary care and discussing the key implications and future directions for research and practice.
Collapse
Affiliation(s)
- Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| |
Collapse
|
12
|
Boesch TS, Eischen E, M AR, Quinn A, Dave A, Beezhold DW. Promoting β-lactam utilization through suppression of electronic medical record cross-allergy alerts. Am J Health Syst Pharm 2022; 79:S43-S52. [PMID: 35136927 DOI: 10.1093/ajhp/zxac040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Current literature surrounding management of patients with reported β-lactam allergies focuses on allergy delabeling. Standard clinical decision support tools have not been optimized to be compatible with the currently accepted cross-reaction rate of 1% to 2%. This potentially promotes use of non-β-lactam antibiotics, which are often not first-line therapy and may carry increased risks. The impact of electronic medical record (EMR) clinical decision support tool optimization on utilization of β-lactam antibiotics in β-lactam-allergic patients was evaluated. METHODS A retrospective pre-post β-lactam cross-allergy EMR alert suppression quality improvement intervention cohort study of β-lactam-allergic adult inpatients prescribed antibiotics was conducted. Preintervention baseline data were collected for an initial cohort admitted during September 2018. The intervention, in which clinical decision support rules were updated to display β-lactam cross-sensitivity allergy alerts only for β-lactam-allergic patients with documentation of organization-defined high-severity reactions of anaphylaxis, hives, and shortness of breath, was implemented August 20, 2019. The postintervention cohort included patients admitted during September 2019. RESULTS A 91% increase in the percentage of β-lactam-allergic patients who received a β-lactam agent at any time during their admission was noted after the intervention (26.6% vs 51%, P < 0.001). Statistically significant decreases in prescribing of alternative antibiotic classes were seen for fluoroquinolones (decrease from 45.3% to 26%, P < 0.001), aminoglycosides (decrease from 9.4% to 2.9%, P = 0.002), and aztreonam (decrease from 30% to 16.7%, P < 0.001). CONCLUSION EMR β-lactam cross-allergy alert optimization consistent with current literature significantly improved the utilization of alternative β-lactam subclasses, mostly through β-lactam prescribing as initial therapy in β-lactam-allergic patients.
Collapse
Affiliation(s)
- Teryl S Boesch
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Edward Eischen
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Amanda Ries M
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Andrea Quinn
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | - Ankur Dave
- Northwestern Medicine Palos Hospital, Palos Heights, IL, USA
| | | |
Collapse
|
13
|
Risk of Multidrug Resistant Bacteria Acquisition in Patients with Declared β-Lactam Allergy during Hospitalization in Intensive Care Unit: A Retrospective Cohort Study (2007-2018). J Immunol Res 2022; 2022:8906316. [PMID: 35071608 PMCID: PMC8769862 DOI: 10.1155/2022/8906316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 12/22/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction The risk of extended spectrum β-lactamase (ESBL) bacterial acquisition in patients with β-lactam allergy has been poorly investigated. In a previous study conducted over a 6-year long period (2007-2012), we found that patients with declared β-lactam allergy had a higher risk of ESBL bacterial carriage at admission in intensive care unit (ICU), but they had not a higher risk of ESBL bacterial acquisition. We present the final results of the study which was eventually conducted over a 12-year long period (2007-2018). Materials and Methods The study included all patients admitted in ICU and receiving antibiotic treatment from January 2007 to December 2018. ESBL bacterial acquisition was the main clinical outcome. Mortality in ICU, multidrug resistant bacterial carriage at admission and discharge were the secondary outcomes. Results Overall, 3332 patients were included, 132/3332 (3.9%) were labelled β-lactam allergic, while 3200/3332 (96.1%) did not presented β-lactam allergy. No significant difference in rates of ESBL acquisition was detected (4/132, 3% vs. 78/3200, 2.4%; p = 0.17). Patients with β-lactam allergy had higher rates of ESBL bacterial carriage at admission (19/132, 14.4% vs. 248/3200, 7.8%, p = 0.01) and at discharge (22/132, 16.7% vs. 351/3200, 11%, p = 0.04) than nonallergic patients. No differences in mortality, duration of hospitalization, and carriage of methicillin resistant Staphylococcus aureus were reported. Female gender was the only factor associated with β-lactam allergy at the multivariate analysis. Conclusions This study confirms that patients with declared β-lactam allergy had not a higher risk of ESBL bacterial acquisition during hospitalization in ICU. However, they had a higher ESBL bacterial carriage at admission.
Collapse
|
14
|
Wanat M, Anthierens S, Butler CC, Savic L, Savic S, Pavitt SH, Sandoe JAT, Tonkin-Crine S. Management of penicillin allergy in primary care: a qualitative study with patients and primary care physicians. BMC FAMILY PRACTICE 2021; 22:112. [PMID: 34116641 PMCID: PMC8194168 DOI: 10.1186/s12875-021-01465-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 05/20/2021] [Indexed: 12/02/2022]
Abstract
Background Six percent of patients are allergic to penicillin according to their medical records. While this designation protects a small number of truly allergic patients from serious reactions, those who are incorrectly labelled may be denied access to recommended first line treatment for many infections. Removal of incorrect penicillin allergy may have positive health consequences for the individual and the general population. We aimed to explore primary care physicians’ (PCPs) and patients’ views and understanding of penicillin allergy with a focus on clinical management of infections in the face of a penicillin allergy record. Methods We conducted an interview study with 31 patients with a penicillin allergy record, and 19 PCPs in the North of England. Data were analysed thematically. Results Patients made sense of their allergy status by considering the timing and severity of symptoms. Diagnosis of penicillin allergy was reported to be ‘imperfect’ with PCPs relying on patient reports and incomplete medical records. PCPs and patients often suspected that an allergy record was incorrect, but PCPs were reluctant to change records. PCPs had limited knowledge of allergy services. PCPs often prescribed alternative antibiotics which were easy to identify. Both patients and PCPs differed in the extent to which they were aware of the negative consequences of incorrect penicillin allergy records, their relevance and importance to their lives, and management of penicillin allergy. Conclusions PCPs and patients appear insufficiently aware of potential harms associated with incorrect penicillin allergy records. Some of the problems experienced by PCPs could be reduced by ensuring the details of newly diagnosed reactions to antibiotics are clearly documented. In order for PCPs to overturn more incorrect penicillin records through appropriate use of allergy services, more information and training about these services will be needed. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01465-1.
Collapse
Affiliation(s)
- Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK.
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK
| | - Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sinisa Savic
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sue H Pavitt
- Dental Translational and Clinical Research Unit, Faculty of Medicine and Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
| | - Jonathan A T Sandoe
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| |
Collapse
|
15
|
Lutfeali S, DiLoreto FF, Alvarez KS, Patel SV, Joshi SR, Tarver SA, Khan DA. Maintaining penicillin allergy delabeling: A quality improvement initiative. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2104-2106.e2. [PMID: 33482418 DOI: 10.1016/j.jaip.2021.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/30/2022]
Affiliation(s)
- Shazia Lutfeali
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Felicia F DiLoreto
- 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; Division of Hospital Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Shyam R Joshi
- Division of Allergy and Immunology, Department of Internal Medicine, Oregon Health and Science University, Portland, Ore
| | - Scott A Tarver
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
| |
Collapse
|
16
|
Schwiebert R, Sandoe J. Is there a role of penicillin allergy in developing Clostridioides difficile infection? Curr Opin Gastroenterol 2021; 37:1-3. [PMID: 33060397 DOI: 10.1097/mog.0000000000000690] [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] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW To explore the evidence for an association between penicillin allergy, antibiotic prescribing and Clostridioides difficile (CDI) infection. RECENT FINDINGS Several studies have highlighted the differences in antibiotic prescribing in penicillin allergic patients and the impact on rates of C. difficile infection. SUMMARY Penicillin allergy leads to higher incidences of prescriptions for antibiotics that are known to predispose to CDI. In turn CDI is more common in patients with penicillin allergy. Penicillin allergy is often erroneously ascribed to patients and should be challenged.
Collapse
Affiliation(s)
- Ralph Schwiebert
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, West Yorkshire, England
| | | |
Collapse
|
17
|
Santillo M, Wanat M, Davoudianfar M, Bongard E, Savic S, Savic L, Porter C, Fielding J, Butler CC, Pavitt S, Sandoe J, Tonkin-Crine S. Developing a behavioural intervention package to identify and amend incorrect penicillin allergy records in UK general practice and subsequently change antibiotic use. BMJ Open 2020; 10:e035793. [PMID: 33004384 PMCID: PMC7534681 DOI: 10.1136/bmjopen-2019-035793] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 07/29/2020] [Accepted: 08/14/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To develop a behavioural intervention package to support clinicians and patients to amend incorrect penicillin allergy records in general practice. The intervention aimed to: (1) support clinicians to refer patients for penicillin allergy testing (PAT), (2) support patients to attend for PAT and (3) support clinicians and patients to prescribe or consume penicillin, when indicated, following a negative PAT result. METHODS Theory-based, evidence-based and person-based approaches were used in the intervention development. We used evidence from a rapid review, two qualitative studies, and expert consultations with the clinical research team to identify the intervention 'guiding principles' and develop an intervention plan. Barriers and facilitators to the target behaviours were mapped to behaviour change theory in order to describe the proposed mechanisms of change. In the final stage, think-aloud interviews were conducted to optimise intervention materials. RESULTS The collated evidence showed that the key barriers to referral of patients by clinicians were limited experience of referral and limited knowledge of referral criteria and PAT. Barriers for patients attending PAT were lack of knowledge of the benefits of testing and lack of motivation to get tested. The key barriers to the prescription and consumption of first-line penicillin following a negative test result were patient and clinician beliefs about the accuracy of PAT and whether taking penicillin was safe. Intervention materials were designed and developed to address these barriers. CONCLUSIONS We present a novel behavioural intervention package designed to address the multiple barriers to uptake of PAT in general practice by clinicians and patients. The intervention development details how behaviour change techniques have been incorporated to hypothesise how the intervention is likely to work to help amend incorrect penicillin allergy records. The intervention will go on to be tested in a feasibility trial and randomised controlled trial in England.
Collapse
Affiliation(s)
- Marta Santillo
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sinisa Savic
- Faculty of Medicine and Health, University of Leeds, Leeds, Leeds, UK
| | - Louise Savic
- Faculty of Medicine and Health, University of Leeds, Leeds, Leeds, UK
| | - Catherine Porter
- Healthcare Associated Infection Group, University of Leeds, Leeds, West Yorkshire, UK
| | - Joanne Fielding
- Healthcare Associated Infection Group, University of Leeds, Leeds, West Yorkshire, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | | | - Jonathan Sandoe
- Healthcare Associated Infection Group, University of Leeds, Leeds, West Yorkshire, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| |
Collapse
|
18
|
Garritty C, Hamel C, Hersi M, Butler C, Monfaredi Z, Stevens A, Nussbaumer-Streit B, Cheng W, Moher D. Assessing how information is packaged in rapid reviews for policy-makers and other stakeholders: a cross-sectional study. Health Res Policy Syst 2020; 18:112. [PMID: 32993657 PMCID: PMC7523380 DOI: 10.1186/s12961-020-00624-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 08/30/2020] [Indexed: 01/08/2023] Open
Abstract
Background Rapid reviews (RRs) are useful products to healthcare policy-makers and other stakeholders, who require timely evidence. Therefore, it is important to assess how well RRs convey useful information in a format that is easy to understand so that decision-makers can make best use of evidence to inform policy and practice. Methods We assessed a diverse sample of 103 RRs against the BRIDGE criteria, originally developed for communicating clearly to support healthcare policy-making. We modified the criteria to increase assessability and to align with RRs. We identified RRs from key database searches and through searching organisations known to produce RRs. We assessed each RR on 26 factors (e.g. organisation of information, lay language use). Results were descriptively analysed. Further, we explored differences between RRs published in journals and those published elsewhere. Results Certain criteria were well covered across the RRs (e.g. all aimed to synthesise research evidence and all provided references of included studies). Further, most RRs provided detail on the problem or issue (96%; n = 99) and described methods to conduct the RR (91%; n = 94), while several addressed political or health systems contexts (61%; n = 63). Many RRs targeted policy-makers and key stakeholders as the intended audience (66%; n = 68), yet only 32% (n = 33) involved their tacit knowledge, while fewer (27%; n = 28) directly involved them reviewing the content of the RR. Only six RRs involved patient partners in the process. Only 23% (n = 24) of RRs were prepared in a format considered to make information easy to absorb (i.e. graded entry) and 25% (n = 26) provided specific key messages. Readability assessment indicated that the text of key RR sections would be hard to understand for an average reader (i.e. would require post-secondary education) and would take 42 (± 36) minutes to read. Conclusions Overall, conformity of the RRs with the modified BRIDGE criteria was modest. By assessing RRs against these criteria, we now understand possible ways in which they could be improved to better meet the information needs of healthcare decision-makers and their potential for innovation as an information-packaging mechanism. The utility and validity of these items should be further explored. Protocol availability The protocol, published on the Open Science Framework, is available at: osf.io/68tj7
Collapse
Affiliation(s)
- Chantelle Garritty
- Knowledge Synthesis Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, CPCR Building, 501 Smyth Rd, Box 201B, Ottawa, ON, K1H 8L6, Canada. .,TRIBE Graduate Program, University of Split School of Medicine, Split, Croatia.
| | - Candyce Hamel
- Knowledge Synthesis Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, CPCR Building, 501 Smyth Rd, Box 201B, Ottawa, ON, K1H 8L6, Canada.,TRIBE Graduate Program, University of Split School of Medicine, Split, Croatia
| | - Mona Hersi
- Knowledge Synthesis Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, CPCR Building, 501 Smyth Rd, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - Claire Butler
- Knowledge Synthesis Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, CPCR Building, 501 Smyth Rd, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - Zarah Monfaredi
- Knowledge Synthesis Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, CPCR Building, 501 Smyth Rd, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - Adrienne Stevens
- Knowledge Synthesis Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, CPCR Building, 501 Smyth Rd, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | | | - Wei Cheng
- Knowledge Synthesis Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, CPCR Building, 501 Smyth Rd, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - David Moher
- Knowledge Synthesis Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, CPCR Building, 501 Smyth Rd, Box 201B, Ottawa, ON, K1H 8L6, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| |
Collapse
|
19
|
West RM, Smith CJ, Pavitt SH, Butler CC, Howard P, Bates C, Savic S, Wright JM, Hewison J, Sandoe JAT. 'Warning: allergic to penicillin': association between penicillin allergy status in 2.3 million NHS general practice electronic health records, antibiotic prescribing and health outcomes. J Antimicrob Chemother 2020; 74:2075-2082. [PMID: 31225607 DOI: 10.1093/jac/dkz127] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The prevalence of reported penicillin allergy (PenA) and the impact these records have on health outcomes in the UK general population are unknown. Without such data, justifying and planning enhanced allergy services is challenging. OBJECTIVES To determine: (i) prevalence of PenA records; (ii) patient characteristics associated with PenA records; and (iii) impact of PenA records on antibiotic prescribing/health outcomes in primary care. METHODS We carried out cross-sectional/retrospective cohort studies using patient-level data from electronic health records. Cohort study: exact matching across confounders identified as affecting PenA records. Setting: English NHS general practices between 1 April 2013 and 31 March 2014. Participants: 2.3 million adult patients. Outcome measures: prevalence of PenA, antibiotic prescribing, mortality, MRSA infection/colonization and Clostridioides difficile infection. RESULTS PenA prevalence was 5.9% (IQR = 3.8%-8.2%). PenA records were more common in older people, females and those with a comorbidity, and were affected by GP practice. Antibiotic prescribing varied significantly: penicillins were prescribed less frequently in those with a PenA record [relative risk (RR) = 0.15], and macrolides (RR = 4.03), tetracyclines (RR = 1.91) nitrofurantoin (RR = 1.09), trimethoprim (RR = 1.04), cephalosporins (RR = 2.05), quinolones (RR = 2.10), clindamycin (RR = 5.47) and total number of prescriptions were increased in patients with a PenA record. Risk of re-prescription of a new antibiotic class within 28 days (RR = 1.32), MRSA infection/colonization (RR = 1.90) and death during the year subsequent to 1 April 2013 (RR = 1.08) increased in those with PenA records. CONCLUSIONS PenA records are common in the general population and associated with increased/altered antibiotic prescribing and worse health outcomes. We estimate that incorrect PenA records affect 2.7 million people in England. Establishing true PenA status (e.g. oral challenge testing) would allow more people to be prescribed first-line antibiotics, potentially improving health outcomes.
Collapse
Affiliation(s)
- R M West
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - C J Smith
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - S H Pavitt
- School of Dentistry, University of Leeds, Leeds, UK
| | - C C Butler
- University of Oxford Primary Care Clinical Trials Unit, Oxford, UK
| | - P Howard
- Faculty of Medicine and Health, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - S Savic
- Faculty of Medicine and Health, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - J M Wright
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - J Hewison
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - J A T Sandoe
- Faculty of Medicine and Health, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
20
|
Powell N, Wilcock M, Roberts N, Sandoe J, Tonkin-Crine S. Focus group study exploring the issues and the solutions to incorrect penicillin allergy-labelled patients: an antibiotic stewardship patient safety initiative. Eur J Hosp Pharm 2019; 28:71-75. [PMID: 33608433 DOI: 10.1136/ejhpharm-2019-001863] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/17/2019] [Accepted: 04/30/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Approximately 10% of the general population are reported to have a penicillin allergy, but more than 90% of these patients are able to tolerate penicillins after formal assessment. Patients with penicillin allergy labels have poorer health outcomes and incorrect labels impact negatively on healthcare systems. Identifying patients with incorrect penicillin allergy labels (those who can safely take penicillin) has the potential to benefit patients and healthcare systems. This study explores barriers and enablers towards identifying and removing incorrect penicillin allergy labels in inpatients ('delabelling'). METHODS Two focus groups were completed with a total of 17 doctors, nurses and pharmacists at a 750-bed district general hospital in England. RESULTS Thematic analysis identified four main themes: managing penicillin allergic patients, environmental barriers, education for patients and staff and a future delabelling process. Staff reported that identifying and delabelling incorrect penicillin allergy records was a complex task and not a priority during the acute presentation. Participants felt confident removing erroneous allergy records if the patient was able to describe the reaction. Balancing time to confirm and delabel with competing duties was felt to be a challenge. Revisiting the discussion with the patient when time was less pressured was offered as a solution to the problem. The lack of provision to translate uncertainty about allergy status in the electronic health record was mentioned as a barrier to accurate documentation of allergy history. Ensuring all patient records were amended to reflect the new allergy status was identified as a challenge. A delabelling process involving nurses, doctors and pharmacist was discussed. CONCLUSIONS Delabelling patients with erroneous penicillin allergy labels was recognised as a complex problem. A patient pathway involving nurses, doctors and pharmacist is likely to be the optimal method to safely delabel patients.
Collapse
Affiliation(s)
- Neil Powell
- Pharmacy Department, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Michael Wilcock
- Pharmacy Department, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Neil Roberts
- Pharmacy Department, University Hositals Plymouth NHS Trust, Plymouth, UK
| | | | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
21
|
Wanat M, Anthierens S, Butler CC, Savic L, Savic S, Pavitt SH, Sandoe JAT, Tonkin-Crine S. Patient and Primary Care Physician Perceptions of Penicillin Allergy Testing and Subsequent Use of Penicillin-Containing Antibiotics: A Qualitative Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1888-1893.e1. [PMID: 30877074 DOI: 10.1016/j.jaip.2019.02.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/08/2019] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Removal of an inaccurate penicillin allergy record following testing allows patients to access first-line treatment for infections, and reduce the use of broad-spectrum antibiotics, which contribute to antibiotic resistance. However, it is seldom undertaken. OBJECTIVES To identify clinicians' working in primary care and patients' views on barriers and enablers for penicillin allergy testing and subsequent antibiotic use. METHODS Fifty interviews with patients and clinicians, including 31 patients with a record of penicillin allergy, 16 with experience of testing, and 19 clinicians. Interviews were analyzed thematically. RESULTS Patients were often unaware of the benefits of penicillin allergy testing and only those patients who had experienced negative consequences of having a penicillin allergy label were motivated to get tested. Clinicians were reluctant to change patient records on the basis of their clinical judgment alone but had limited experience of referring patients with suspected penicillin allergy and were often uncertain about referral criteria and what the testing involved. Clinicians felt that allergy testing could be beneficial and patients who had attended testing reported benefits of the test. Clinicians expressed uncertainty related to whose responsibility it was to make sure that the patient understood allergy test results. CONCLUSIONS Clinicians would benefit from information about penicillin allergy testing to be able to use these services appropriately, and to discuss referral with patients. Patients might be more motivated to seek testing if they were more informed regarding its benefits. Good communication between primary and secondary care would facilitate the updating of medical records, and promote better patient education.
Collapse
Affiliation(s)
- Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, United Kingdom.
| | - Sibyl Anthierens
- Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | - Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Sinisa Savic
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Sue H Pavitt
- Dental Translational and Clinical Research Unit, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Jonathan A T Sandoe
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, United Kingdom; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
| |
Collapse
|