1
|
Bodega-Azuara J, Belles Medall MD, Edo-Peñarrocha J, Puplá-Bartoll A, Ferrando Piqueres R, Torres-Górriz MC, Germán-Sánchez A, Enrique E. Beta-lactam allergy in patients: an antibiotic stewardship challenge. Eur J Hosp Pharm 2024; 31:307-313. [PMID: 36564160 DOI: 10.1136/ejhpharm-2022-003304] [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: 03/17/2022] [Accepted: 12/12/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patients are commonly reported as being allergic to beta-lactam (BL) antibiotics. However, many patients with this reported allergy are able to receive BL treatments because they do not have true allergies. In many cases these are simply intolerances due to side effects reported as an allergy. Delabelling these patients leads to better clinical outcomes, optimal antibiotic usage, decreased bacterial resistance and reduced healthcare costs. Therefore, the aims of this study were to identify incorrectly labelled BL allergies in hospitalised patients and to assess antibiotic use in delabelled patients in order to establish a quality indicator to optimise antimicrobial treatments. METHODS A prospective study was conducted in which hospitalised patients treated with antimicrobial drugs and labelled as 'BL-allergic' were identified by clinical pharmacists. An allergist assessed whether patients were suitable candidates for a skin test or oral challenge. The Allergy Service removed 'BL-allergic' labels if negative results were obtained. Delabelled patients were followed up by clinical pharmacists to study the use of BL antibiotics as a result of the delabelling programme. RESULTS A total of 176 suspected allergic patients were identified and 91 (51.7%) were tested either by a skin test or oral challenge based on the patient indicators. Seven (16.4%) patients tested were allergic to BL antibiotics, 76 (83.5%) were totally delabelled and eight (0.1%) were partially delabelled. Thirty-two (38.1%) delabelled patients required antibiotic treatment in another inpatient or outpatient setting, of whom 27 (84.3%) patients with a new infectious episode received BL treatments while five (15.7%) continued to receive antimicrobial treatments without BL. CONCLUSION After the implementation of a protocol to detect incorrect BL allergy labels, 83.5% of the patients in this cohort were completely delabelled. This shows that there is a clear opportunity to optimise the use of antibiotics by delabelling 'BL-allergic' patients.
Collapse
Affiliation(s)
- Julia Bodega-Azuara
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | | | - Josep Edo-Peñarrocha
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | - Aarón Puplá-Bartoll
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | - Raul Ferrando Piqueres
- Pharmacy, Hospital General Universitari de Castelló, Castellon de la Plana, Spain, Spain
| | | | - Adrián Germán-Sánchez
- Allergology, Hospital General Universitari de Castello, Castellon de la Plana, Spain
| | - Ernesto Enrique
- Allergology, Hospital General Universitari de Castello, Castellon de la Plana, Spain
| |
Collapse
|
2
|
Zavaleta-Monestel E, Webster K, Rojas-Chinchilla C, Muñoz-Gutierrez G, Díaz-Madriz JP. Management and Implications of Beta-Lactam Allergies. Cureus 2024; 16:e60281. [PMID: 38872647 PMCID: PMC11170240 DOI: 10.7759/cureus.60281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 06/15/2024] Open
Abstract
Beta-lactam antibiotics are essential components in the current antimicrobial treatment strategy, playing a crucial role in ambulatory patients and hospitalized patients. Despite their prominent therapeutic index, the use of beta-lactam can lead to adverse effects, with allergic reactions being the most concerning because of their severity. Additionally, the phenomenon of cross-reactivity may occur among various beta-lactam families, with side chains significantly contributing to immunological recognition, making these structures often responsible for the cross-allergic reactivity of beta-lactams. Tools to assess beta-lactam allergy include taking a patient's medical history, performing skin tests, and conducting provocation tests. This research aims to analyze the relevant aspects related to the safe administration of beta-lactam antibiotics in hospitalized patients as well as provide knowledge on the proper management of patients with such hypersensitivity, by doing systemic research. This research was made using Google Scholar and keywords such as "Beta-lactam allergy," "Hypersensitivity," "Cross-reactivity," "Desensitization," and "Beta-lactam allergy management." In conclusion, substituting a beta-lactam antibiotic with an alternative antibiotic may not always be the best management option for these patients, as it may lead to more adverse effects, be less effective, and prolong hospitalization time. It may also result in higher rates of antibiotic-resistant infections and increased medical costs, as these alternatives are often more expensive. However, an alternative within the beta-lactam family can be sought by conducting the appropriate analyses. Although cross-reactivity does not always occur among all beta-lactams, potential cross-reactivity should always be considered.
Collapse
Affiliation(s)
| | - Keyla Webster
- Pharmacy, Universidad de Ciencias Médicas, San Jose, CRI
| | | | | | | |
Collapse
|
3
|
A novel framework to guide antibiotic stewardship nursing practice. Am J Infect Control 2022; 50:99-104. [PMID: 34492325 DOI: 10.1016/j.ajic.2021.08.029] [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] [Received: 07/12/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND There is a pervasive view among some nurses and health care disciplines that antibiotic stewardship (AS) is solely a physician or pharmacist responsibility. There is an urgent need to alter this view so that nurses can seize every opportunity to prevent patient harm from antibiotics and optimize antibiotic use. One challenge to achieving full nurse engagement as equal members of the AS team is lack of an organizing framework to illustrate relationships of phenomena and concepts inherent to adoption of AS nursing practices. METHODS We sought to create a framework derived from the peer-reviewed literature, systematic and scoping reviews, and professional standards, consensus statements and white papers. The emerging framework went through multiple iterations as it was vetted with nurse clinicians, scholars and educators, physicians, pharmacists, infection preventionists and AS subject matter experts. RESULTS Our evidence-based Antibiotic Stewardship Nursing Practice SCAN-P Framework provides the much-needed context and clarity to help guide local-level nurses to participate in and lead AS nursing practice. CONCLUSIONS Nurses worldwide are ideally situated to provide holistic person-centered care, advocate for judicious use of antibiotics to minimize antibiotic resistance, and be AS educators of their patients, communities and the general public. The Antibiotic Stewardship Nursing Practice SCAN-P Framework provides a tool to do so.
Collapse
|
4
|
Johnson JL, Hawthorne A, Bounds M, Weldon DJ. New perspectives on propofol allergy. Am J Health Syst Pharm 2021; 78:2195-2203. [PMID: 34309659 DOI: 10.1093/ajhp/zxab298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Propofol is an intravenous sedative used in many patient populations and care settings. Although generally considered safe and effective, the drug has historically been avoided in patients with reported allergies to egg, soy, and/or peanut on the basis of the manufacturer's prescribing information. Concerns exist for potential adverse events, increased medication costs, reduced efficacy, and risk of medication errors when using alternative agents. Here we present a critical examination of the literature concerning cross-reactivity of food allergies with propofol to provide evidence-based recommendations for the evaluation and management of potential allergic reactions. SUMMARY Literature regarding the history of propofol allergy warnings and clinical trial data were assessed to provide an alternative perspective on avoidance of propofol in patients with food allergies. Suspected trigger molecules are discussed with evaluation of the antigenic potential of excipient ingredients used in the manufacture of multiple propofol formulations. Evidence-based recommendations are provided for pharmacist-led screening of adult patients with reported food allergies to support selection of propofol or alternative therapy. CONCLUSION There is a lack of definitive evidence that propofol must be routinely avoided in patients with reported allergies to egg, soy, and/or peanut products. Data from clinical trials suggest that propofol is safe for patients with nonanaphylactic food allergies. Patients who do experience allergic reactions following administration of propofol should undergo further testing to definitively identify the specific trigger and prevent future unnecessary avoidance of preferred medication regimens. Pharmacists can play an important role in interviewing patients with reported food allergies to better determine the risk vs benefit of propofol avoidance.
Collapse
Affiliation(s)
| | | | - Michael Bounds
- William Carey University School of Pharmacy, Biloxi, MS, USA
| | - David J Weldon
- William Carey University School of Pharmacy, Biloxi, MS, USA
| |
Collapse
|
5
|
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
|
6
|
Lee AYS, Hudson P, Smith AJF. Audit of medication allergy referrals to an allergy outpatient service at a tertiary hospital. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2020. [DOI: 10.1002/jppr.1646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Adrian Y. S. Lee
- Allergy/Clinical Immunology Department Flinders Medical Centre Bedford Park Australia
- Department of Immunology SA Pathology Flinders Medical Centre Bedford Park Australia
- College of Medicine and Public Health Flinders University Bedford Park Australia
| | - Pamela Hudson
- Allergy/Clinical Immunology Department Flinders Medical Centre Bedford Park Australia
| | - Anthony J. F. Smith
- Allergy/Clinical Immunology Department Flinders Medical Centre Bedford Park Australia
- College of Medicine and Public Health Flinders University Bedford Park Australia
| |
Collapse
|
7
|
Kufel WD, Justo JA, Bookstaver PB, Avery LM. Penicillin Allergy Assessment and Skin Testing in the Outpatient Setting. PHARMACY 2019; 7:pharmacy7030136. [PMID: 31546887 PMCID: PMC6789533 DOI: 10.3390/pharmacy7030136] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/05/2019] [Accepted: 09/12/2019] [Indexed: 01/09/2023] Open
Abstract
Penicillin allergies are among of the most commonly reported allergies, yet only 10% of these patients are truly allergic. This leads to potential inadvertent negative consequences for patients and makes treatment decisions challenging for clinicians. Thus, allergy assessment and penicillin skin testing (PST) are important management strategies to reconcile and clarify labeled penicillin allergies. While PST is more common in the inpatient setting where the results will immediately impact antibiotic management, this process is becoming of increasing importance in the outpatient setting. PST in the outpatient setting allows clinicians to proactively de-label and educate patients accordingly so beta-lactam antibiotics may be appropriately prescribed when necessary for future infections. While allergists have primarily been responsible for PST in the outpatient setting, there is an increasing role for pharmacist involvement in the process. This review highlights the importance of penicillin allergy assessments, considerations for PST in the outpatient setting, education and advocacy for patients and clinicians, and the pharmacist’s role in outpatient PST.
Collapse
Affiliation(s)
- Wesley D Kufel
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY 13902, USA.
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY 13210, USA.
- Department of Pharmacy, State University of New York Upstate University Hospital, Syracuse, NY 13210, USA.
| | - Julie Ann Justo
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia, SC 29208, USA.
- Department of Pharmacy, Prisma Health Richland Hospital, Columbia, SC 29203, USA.
| | - P Brandon Bookstaver
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia, SC 29208, USA.
- Department of Pharmacy, Prisma Health Richland Hospital, Columbia, SC 29203, USA.
| | - Lisa M Avery
- Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY 14618, USA.
- Department of Pharmacy, St. Josephs Health, Syracuse, NY 13203, USA.
| |
Collapse
|