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Rose M, Holmes N, Eastwood G, Vogrin S, James F, Phung M, Barnes S, Murfin B, Rogers B, Lambros B, Peel T, Gibney G, Slavin M, Trubiano J. Oral challenge vs routine care to assess low-risk penicillin allergy in critically ill hospital patients (ORACLE): a pilot randomised controlled trial. Pilot Feasibility Stud 2023; 9:126. [PMID: 37475038 DOI: 10.1186/s40814-023-01337-8] [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: 01/13/2023] [Accepted: 06/07/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Self-reported penicillin allergies are highly prevalent in hospitalised patients and are associated with poor health and health service outcomes. Critically ill patients have historically been underrepresented in prospective delabelling studies in part due to concerns around clinical stability and reliability of penicillin skin testing. Allergy assessment tools exist to identify low-risk penicillin allergy phenotypes and facilitate direct oral challenge delabelling. PEN-FAST is a clinical decision rule that has been validated to predict true penicillin allergy in a cohort of non-critically ill patients. There is however limited evidence regarding the feasibility, safety and efficacy of direct oral challenges and the use of delabelling clinical decisions rules in the intensive care setting. METHODS Critically ill patients in the intensive care unit (ICU) with low-risk penicillin allergy phenotypes (PEN-FAST score < 3) will be randomised 1:1 to direct oral penicillin challenge (single dose 250 mg oral amoxicillin or implicated penicillin) or routine care, followed by a 2-h observation period. Patients will receive a second oral challenge/observation prior to hospital discharge (with subsequent observation for 2 h). An assessment for antibiotic-associated adverse events will also be undertaken at 24 h and 5 days post each challenge/observation and again at 90 days post-randomisation. The primary outcome measures are feasibility (proportion of eligible patients recruited and protocol compliance) and safety (proportion of patients who experience an antibiotic-associated immune-mediated adverse event or serious adverse event). DISCUSSION We will report the feasibility and safety of point-of-care penicillin direct oral challenge in this first randomised controlled trial of low-risk penicillin allergy in critically ill hospitalised patients. Upon completion of the project, important findings will inform the design of planned large prospective multi-centre clinical trials in Australian and international ICUs, further examining safety and efficacy and exploring antimicrobial prescribing-related outcomes following penicillin oral challenge. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry Registration Number: ACTRN12621000051842 Date registered: 20/01/2021 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379735&isReview=true.
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Affiliation(s)
- Morgan Rose
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia.
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
| | - Natasha Holmes
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- Department of Infectious Diseases, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, Austin Health/University of Melbourne, Heidelberg, VIC, Australia
- Department of Critical Care, The University of Melbourne, Parkville, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Sara Vogrin
- Department of Medicine (St Vincent's Hospital), University of Melbourne, Melbourne, VIC, Australia
| | - Fiona James
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Michelle Phung
- Pharmacy Department, Monash Health, Clayton, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Sara Barnes
- Monash Lung Sleep Allergy and Immunology, Monash Health, Clayton, VIC, Australia
| | - Brendan Murfin
- Intensive Care Unit, Monash Health, Clayton, VIC, Australia
| | - Ben Rogers
- Monash Infectious Diseases, Monash Health, Clayton, VIC, Australia
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Belinda Lambros
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Trisha Peel
- Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Department of Infectious Diseases, Alfred Health, Melbourne, VIC, Australia
| | - Grace Gibney
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Monica Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Immunocompromised Host Infection Service, Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jason Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
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De Luca JF, James F, Vogrin S, Chua K, Fletcher L, Nazareth J, Guha R, Hardidge A, Douglas N, Carruthers J, Stewardson A, Cheng AC, Johnson D, Douglass J, Peel T, Trubiano J. Study protocol for PREPARE: a phase II feasibility/safety randomised controlled trial on PeRiopErative Penicillin AlleRgy TEsting. BMJ Open 2023; 13:e067653. [PMID: 36828661 PMCID: PMC9972415 DOI: 10.1136/bmjopen-2022-067653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/23/2023] [Indexed: 02/26/2023] Open
Abstract
INTRODUCTION Patient-reported antibiotic allergy labels (AALs) are common. These labels have been demonstrated to have a negative impact on use of appropriate antibiotics and patient-related health outcomes. These patients are more likely to receive suboptimal antibiotics, have increased rates of surgical site infections and are more likely to be colonised with multidrug-resistant organisms. Increasing recognition that antibiotic allergy forms a key part of good antimicrobial stewardship has led to calls for greater access to antibiotic allergy assessment.PREPARE is a pilot randomised controlled trial of beta-lactam allergy assessment and point of care delabelling in perioperative patients utilising a validated antibiotic allergy assessment tool that has been repurposed into a smartphone application. The aim of the study is to assess the feasibility and safety of this approach in the perioperative outpatient setting. METHODS AND ANALYSIS Adult participants requiring elective surgery and are likely to require prophylactic intravenous antibiotics will be recruited. During the intervention phase, participants will be randomised to the intervention or control arm, with control patients receiving usual standard of care. Those randomised to intervention undertake a risk assessment via the smartphone application, with those deemed low risk proceeding to direct oral provocation with either a penicillin or cephalosporin. Study outcomes will be evaluated in the postintervention phase, 30 and 90 days after surgery.Feasibility of intervention delivery and recruitment will be reported as proportions with respective 95% CIs. Participants who experience an antibiotic adverse event will be reported by group with respective 95% CIs and compared using modified Poisson regression model with robust SE estimation. ETHICS AND DISSEMINATION This protocol has received approval from the Austin Health human research and ethics committee, Heidelberg, Victoria, Australia (HREC/17/Austin/575). Results will be disseminated via publication in peer-reviewed journals as well as presentation at international conferences. TRIAL REGISTRATION NUMBER ACTRN12620001295932.
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Affiliation(s)
- Joseph F De Luca
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Fiona James
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Sara Vogrin
- St Vincent's Department of Medicine, The University of Melbourne, Fitzroy, Victoria, Australia
| | - Kyra Chua
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Luke Fletcher
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Justin Nazareth
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Ranjan Guha
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew Hardidge
- Department of Orthopaedic Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Ned Douglas
- Department of Anaesthesia, Melbourne Health, Parkville, Victoria, Australia
| | - John Carruthers
- Department of Anaesthesia, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew Stewardson
- Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
- Infectious Diseases, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine Clinical Trials Centre, Monash University, Melbourne, Victoria, Australia
| | - Douglas Johnson
- Department of General Medicine, Melbourne Health, Parkville, Victoria, Australia
- Department of Medicine RMH, The University of Melbourne, Parkville, Victoria, Australia
| | - Jo Douglass
- Department of Medicine RMH, The University of Melbourne, Parkville, Victoria, Australia
| | - Trisha Peel
- Infectious Diseases, Monash University, Melbourne, Victoria, Australia
- Infectious Diseases, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
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Zhao Y, Wang X, Chen Y, Wang Q, Yao Z, Wang L. Electrochemical synthesis of Co/Ni bimetal-organic frameworks: A high-performance SERS platform for detection of tetracycline. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2023; 285:121843. [PMID: 36099730 DOI: 10.1016/j.saa.2022.121843] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/29/2022] [Accepted: 09/02/2022] [Indexed: 06/15/2023]
Abstract
Surface-enhanced Raman scattering (SERS) enables food contaminants monitoring become facile and efficient. Herein, a facile strategy of integrating three-dimensional Ni form with Co/Ni bimetal-organic frameworks combining Ag nanoparticles via electrochemical synthesis method was proposed to develop a high-performance SERS substrate (CoNi-ZIFs@Ag@NF) for efficient detection of tetracycline. The flexible Ni foam (NF) acted as scaffold which can contribute to dramatically enhancing intrinsic electrical conductivity and endowing prepared substrate with high stability and uniform distribution of Ag nanoparticles. Furthermore, the pre-concentration effect of CoNi-ZIFs@Ag@NF for target molecules enhanced SERS performance dramatically. Besides, tetracycline was sensitively detected using CoNi-ZIFs@Ag@NF with low limit of detection (1.0 × 10-11 M) and wide linear detection range (10-10 - 10-5 M) in aqueous solution. Also, the satisfactory recovery (94.45 - 114.25 %) was realized with less than 6.78 % of RSD in real samples. This method would provide a potential and high-performance substrate for SERS monitoring of tetracycline in food and environment.
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Affiliation(s)
- Yijian Zhao
- College of Food Science and Engineering, Northwest A&F University, Yangling, 712100, Shaanxi, China; Beijing Laboratory of Food Quality and Safety, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing 100083, China
| | - Xin Wang
- College of Food Science and Engineering, Northwest A&F University, Yangling, 712100, Shaanxi, China
| | - Yanqiang Chen
- College of Food Science and Engineering, Northwest A&F University, Yangling, 712100, Shaanxi, China
| | - Qinzhi Wang
- Key Laboratory of Food Processing Technology and Quality Control in Shandong Province, College of Food Science and Engineering, Shandong Agricultural University, Tai'an, 271018, Shandong, China.
| | - Zhiyi Yao
- Beijing Laboratory of Food Quality and Safety, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing 100083, China.
| | - Li Wang
- College of Food Science and Engineering, Northwest A&F University, Yangling, 712100, Shaanxi, China.
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Copaescu AM, James F, Vogrin S, Rose M, Chua K, Holmes NE, Turner NA, Stone C, Phillips E, Trubiano J. Use of a penicillin allergy clinical decision rule to enable direct oral penicillin provocation: an international multicentre randomised control trial in an adult population (PALACE): study protocol. BMJ Open 2022; 12:e063784. [PMID: 35940831 PMCID: PMC9364402 DOI: 10.1136/bmjopen-2022-063784] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Penicillin allergies are highly prevalent in the healthcare setting and associated with the prescription of second-line inferior antibiotics. More than 85% of all penicillin allergy labels can be removed by skin testing and 96%-99% of low-risk penicillin allergy labels can be removed by direct oral challenge. An internally and externally validated clinical assessment tool for penicillin allergy, PEN-FAST, can identify a low-risk penicillin allergy without the need for skin testing; a score of less than 3 has a negative predictive value of 96.3% (95% CI, 94.1 to 97.8) for the presence of a penicillin allergy. It is hypothesised that PEN-FAST is a safe and effective tool for assessing penicillin allergy in an outpatient clinic setting. METHODS AND ANALYSIS This is an international, multicentre randomised control trial using the PEN-FAST tool to risk-stratify penicillin allergy labels in adult outpatients. The study's primary objective is to evaluate the non-inferiority of using PEN-FAST score-guided management with direct oral challenge compared with standard care (defined as prick and intradermal skin testing followed by oral penicillin challenge). Participants will be randomised 1:1 to the intervention arm (direct oral penicillin challenge) or standard of care arm (skin testing followed by oral penicillin challenge, if skin testing is negative). The sample size of 380 randomised patients (190 per treatment arm) is required to demonstrate non-inferiority. ETHICS AND DISSEMINATION The study will be performed according to the guidelines of the Helsinki Declaration and is approved by the Austin Health Human Research Ethics Committee (HREC/62425/Austin-2020) in Melbourne Australia, Vanderbilt University Institutional Review Board (IRB #202174) in Tennessee, USA, Duke University Institutional Review Board (IRB #Pro00108461) in North Carolina, USA and McGill University Health Centre Research Ethics Board in Canada (PALACE/2022-7605). The results of this study will be published and presented in various scientific forums. TRIAL REGISTRATION NUMBER NCT04454229.
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Affiliation(s)
- Ana-Maria Copaescu
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Division of Allergy and Clinical Immunology, McGill University Health Centre (MUHC), Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Fiona James
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Victoria, Australia
| | - Morgan Rose
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Kyra Chua
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Natasha E Holmes
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Nicholas A Turner
- Department of Infectious Diseases, Duke University Medical Center, Durham, Carolina, USA
| | - Cosby Stone
- Department of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth Phillips
- Department of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Jason Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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De-labeling Beta-lactam in Adult Population. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00316-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Liu HH, Mutneja H, Buckley M, Cushinotto L. Trends in Antimicrobial Allergies in Patients Seen in Infectious Disease Consultation During Selected Periods 2007–2016. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Powell N, Kohl D, Ahmed S, Kent B, Sandoe J, Tonkin-Crine S, Owens R, Stephens J, Upton M. Effectiveness of interventions that support penicillin allergy assessment and de-labelling of patients by non-allergy specialists: a systematic review protocol. JBI Evid Synth 2021; 20:624-632. [PMID: 34698707 DOI: 10.11124/jbies-21-00075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE This review will systematically examine and synthesize the evidence evaluating the effectiveness and safety of interventions that enable non-allergy specialist health care workers to assess allergy risk in patients with reported penicillin allergies and subsequently remove erroneous allergy records. INTRODUCTION The potential benefits of removing erroneous penicillin allergy labels (de-labeling) are wide-ranging. Penicillin allergy assessment and de-labeling is an antibiotic stewardship priority. Delivery of such assessment and de-labeling by non-allergy specialists has been reported in several studies, but the effectiveness and safety have not been formally synthesized. This is a necessary step in the upscaling of penicillin allergy assessment services. INCLUSION CRITERIA This review will consider quantitative studies using appropriate designs. The studies will include adults and pediatric patients who have undergone penicillin allergy assessment and de-labeling by non-allergy specialists in any health care setting. METHODS A range of databases will be searched to identify studies published in English, with no date limit. Unpublished studies and gray literature will also be searched. Title and abstract screening, and assessment of selected full texts against the inclusion criteria will be conducted by at least two independent reviewers. Identified studies will be assessed for methodological quality using standardized critical appraisal instruments. Data will be extracted and categorized using the EPOC taxonomy, and the effectiveness and safety of the intervention will be determined. Where possible, data will be pooled to facilitate meta-analysis. Data from heterogeneous studies will be reported narratively. The GRADE approach for grading the certainty of evidence will be followed. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020219044.
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Affiliation(s)
- Neil Powell
- Pharmacy Department, Royal Cornwall Hospital Trust, Truro, Cornwall, UK School of Biomedical Sciences, University of Plymouth, Plymouth, Devon, UK School of Biomedical Sciences, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence, Faculty of Health, University of Plymouth, Plymouth, Devon, UK Leeds Institute of Medical Research, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK Department of Critical Care, Royal Cornwall Hospital Trust, Truro, Cornwall, UK Department of Medicine, Royal Cornwall Hospital Trust, Truro, Cornwall, UK
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Burden of antibiotic allergy labels in Australian aged care residents: Findings from a national point-prevalence survey. Infect Control Hosp Epidemiol 2021; 41:641-644. [PMID: 32188526 DOI: 10.1017/ice.2020.53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the prevalence of antibiotic allergy labels (AALs) in Australian aged care residents and to describe the impact of labels on antibiotic prescribing practices. DESIGN Point-prevalence survey. SETTING Australian residential aged care facilities. PARTICIPANTS We surveyed 1,489 residents in 407 aged care facilities. METHODS Standardized data were collected on a single day between June 1 and August 31, 2018, for residents prescribed an antibiotic. An AAL was reported if it was documented in the resident's health record. Resident-level data were used to calculate overall prevalence, and antibiotic-level data were used to report relative frequency of AALs for individual antibiotics and classes. RESULTS Among 1,489 residents, 356 (24%) had 1 or more documented AALs. The AALs for penicillin (28.3%), amoxicillin or amoxicillin/clavulanic acid (10.5%), cefalexin (7.2%), and trimethoprim (7.0%) were most commonly reported. The presence of an AAL was associated with significantly less prescribing of penicillins (OR, 0.43; 95% CI, 0.31-0.62; P < .001) and significantly more prescribing of lincosamides (OR, 4.81; P < .001), macrolides (OR, 2.03; P = .007), and tetracyclines (OR, 1.54; P = .033). Of residents with AALs, 7 residents (1.9%) were prescribed an antibiotic that was listed on the allergy section of their health record. CONCLUSIONS A high prevalence of AALs was observed among residents of Australian aged care facilities, comparable to the prevalence of AALs in high-risk hospitalized patients. Significant increases in prescribing of lincosamide, macrolide, and tetracycline agents poses a potential risk to aged populations, and future studies must evaluate the benefits of AAL delabelling programs tailored for aged care settings.
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Chua KYL, Vogrin S, Bury S, Douglas A, Holmes NE, Tan N, Brusco NK, Hall R, Lambros B, Lean J, Stevenson W, Devchand M, Garrett K, Thursky K, Grayson ML, Slavin MA, Phillips EJ, Trubiano JA. The Penicillin Allergy Delabeling Program: A Multicenter Whole-of-Hospital Health Services Intervention and Comparative Effectiveness Study. Clin Infect Dis 2021; 73:487-496. [PMID: 32756983 DOI: 10.1093/cid/ciaa653] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/23/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Penicillin allergies are associated with inferior patient and antimicrobial stewardship outcomes. We implemented a whole-of-hospital program to assess the efficacy of inpatient delabeling for low-risk penicillin allergies in hospitalized inpatients. METHODS Patients ≥ 18 years of age with a low-risk penicillin allergy were offered a single-dose oral penicillin challenge or direct label removal based on history (direct delabeling). The primary endpoint was the proportion of patients delabeled. Key secondary endpoints were antibiotic utilization pre- (index admission) and post-delabeling (index admission and 90 days). RESULTS Between 21 January 2019 and 31 August 2019, we assessed 1791 patients reporting 2315 antibiotic allergies, 1225 with a penicillin allergy. Three hundred fifty-five patients were delabeled: 161 by direct delabeling and 194 via oral penicillin challenge. Ninety-seven percent (194/200) of patients were negative upon oral penicillin challenge. In the delabeled patients, we observed an increase in narrow-spectrum penicillin usage (adjusted odds ratio [OR], 10.51 [95% confidence interval {CI}, 5.39-20.48]), improved appropriate antibiotic prescribing (adjusted OR, 2.13 [95% CI, 1.45-3.13]), and a reduction in restricted antibiotic usage (adjusted OR, 0.38 [95% CI, .27-.54]). In the propensity score analysis, there was an increase in narrow-spectrum penicillins (OR, 10.89 [95% CI, 5.09-23.31]) and β-lactam/β-lactamase inhibitors (OR, 6.68 [95% CI, 3.94-11.35]) and a reduction in restricted antibiotic use (OR, 0.52 [95% CI, .36-.74]) and inappropriate prescriptions (relative risk ratio, 0.43 [95% CI, .26-.72]) in the delabeled group compared with the group who retained their allergy label. CONCLUSIONS This health services program using a combination of direct delabeling and oral penicillin challenge resulted in significant impacts on the use of preferred antibiotics and appropriate prescribing.
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Affiliation(s)
- Kyra Y L Chua
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Australia
| | - Susan Bury
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Pharmacy, Austin Health, Heidelberg, Australia
| | - Abby Douglas
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Natasha E Holmes
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Nixon Tan
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Natasha K Brusco
- Alpha Crucis Group, Health Economics, Langwarrin, Australia.,Rehabilitation, Ageing and Independent Living Research Centre, Monash University, Frankston, Australia
| | - Rebecca Hall
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Belinda Lambros
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Jacinta Lean
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia
| | - Wendy Stevenson
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Misha Devchand
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Pharmacy, Austin Health, Heidelberg, Australia
| | - Kent Garrett
- Department of Pharmacy, Austin Health, Heidelberg, Australia
| | - Karin Thursky
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia.,National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Melbourne, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Parkville, Australia
| | - M Lindsay Grayson
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia
| | - Monica A Slavin
- Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Parkville, Australia
| | - Elizabeth J Phillips
- Department of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia.,Department of Infectious Diseases and the National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia
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Hills T, Arroll N, Duffy E, Capstick J, Jordan A, Fitzharris P. Penicillin Allergy De-labeling Results in Significant Changes in Outpatient Antibiotic Prescribing Patterns. FRONTIERS IN ALLERGY 2020; 1:586301. [PMID: 35386932 PMCID: PMC8974713 DOI: 10.3389/falgy.2020.586301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/14/2020] [Indexed: 11/13/2022] Open
Abstract
Unverified penicillin allergies are common but most patients with a penicillin allergy label can safely use penicillin antibiotics. Penicillin allergy labels are associated with poor clinical outcomes and overuse of second-line antibiotics. There is increasing focus on penicillin allergy "de-labeling" as a tool to improve antibiotic prescribing and antimicrobial stewardship. The effect of outpatient penicillin allergy de-labeling on long-term antibiotic use is uncertain. We performed a retrospective pre- and post- study of antibiotic dispensing patterns, from an electronic dispensing data repository, in patients undergoing penicillin allergy assessment at Auckland City Hospital, New Zealand. Over a mean follow-up of 4.55 years, 215/304 (70.7%) of de-labeled patients were dispensed a penicillin antibiotic. Rates of penicillin antibiotic dispensing were 0.24 (0.18-0.30) penicillin courses per year before de-labeling and 0.80 (0.67-0.93) following de-labeling with a reduction in total antibiotic use from 2.30 (2.06-2.54) to 1.79 (1.59-1.99) antibiotic courses per year. In de-labeled patients, the proportion of antibiotic courses that were penicillin antibiotics increased from 12.81 to 39.62%. Rates of macrolide, cephalosporin, trimethoprim/co-trimoxazole, fluoroquinolone, "other" non-penicillin antibiotic use, and broad-spectrum antibiotic use were all lower following de-labeling. Further, antibiotic costs were lower following de-labeling. In this study, penicillin allergy de-labeling was associated with significant changes in antibiotic dispensing patterns.
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Affiliation(s)
- Thomas Hills
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Nicola Arroll
- Health Information and Technology Service, Auckland District Health Board, Auckland, New Zealand
| | - Eamon Duffy
- Depatment of Infectious Diseases, Auckland District Health Board, Auckland, New Zealand
| | - Janice Capstick
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
| | - Anthony Jordan
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
| | - Penny Fitzharris
- Department of Immunology, Auckland District Health Board, Auckland, New Zealand
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11
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The impact of antibiotic allergy labels on antibiotic exposure, clinical outcomes, and healthcare costs: A systematic review. Infect Control Hosp Epidemiol 2020; 42:530-548. [PMID: 33059777 DOI: 10.1017/ice.2020.1229] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE A growing body of evidence suggests that antibiotic allergy labels as documented in medical records are a risk factor for poor clinical outcomes. In this systematic review, we aimed to determine how antibiotic allergy labels influence 3 domains: antibiotic use and exposure, clinical outcomes, and healthcare-related costs. DESIGN We performed a systematic review to identify studies reporting outcomes in patients with antibiotic allergy labels compared to nonallergic counterparts. The search included PubMed, EMBASE, Cochrane CENTRAL, EBSCO, Cochrane Database of Abstracts of Reviews of Effects and Web of Science. Two reviewers independently screened studies for inclusion and abstracted data. Studies were graded using the Newcastle-Ottawa quality assessment scale. Study outcomes included antibiotic use, clinical outcomes, and economic outcomes. RESULTS In total, 41 studies met our criteria for inclusion. These studies varied in medical specialty, patient population, healthcare delivery system, and design, but most were conducted among adults age >18 years (85%) in the inpatient setting (82.5%). Among 34 studies examining antibiotic exposure, 32 (94%) found that patients with antibiotic allergy labels received more broad-spectrum antibiotics. Moreover, 31 studies examined clinical outcomes such as length of hospitalization, ICU admission, hospital readmission, multidrug-resistant or opportunistic infection, or mortality, and 27 (87%) found that allergy-labeled patients had at least 1 negative outcome. Of 9 studies examining healthcare costs, 7 (78%) found that allergy-labeled patients incurred significantly higher drug or hospital-related costs. CONCLUSIONS Antibiotic allergy labels have negative effects on antibiotic use, clinical outcomes, and economic outcomes in a variety of clinical settings and populations.
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12
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Devchand M, Kirkpatrick CMJ, Stevenson W, Garrett K, Perera D, Khumra S, Urbancic K, Grayson ML, Trubiano JA. Evaluation of a pharmacist-led penicillin allergy de-labelling ward round: a novel antimicrobial stewardship intervention. J Antimicrob Chemother 2020; 74:1725-1730. [PMID: 30869124 DOI: 10.1093/jac/dkz082] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/15/2019] [Accepted: 02/04/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Antibiotic allergy labels (AALs), reported by up to 25% of hospitalized patients, are a significant barrier to appropriate prescribing and a focus of antimicrobial stewardship (AMS) programmes. METHODS A prospective audit of a pharmacist-led AMS penicillin allergy de-labelling ward round at Austin Health (Melbourne, Australia) was evaluated. Eligible inpatients with a documented penicillin allergy receiving an antibiotic were identified via an electronic medical report and then reviewed by a pharmacist-led AMS team. The audit outcomes evaluated were: (i) AMS post-prescription review recommendations; (ii) direct de-labelling; (iii) inpatient oral rechallenge referral; (iv) skin prick testing/intradermal testing referral; and (v) outpatient antibiotic allergy clinic assessment. RESULTS Across a 5 month period, 106 patients were identified from a real-time electronic prescribing antibiotic allergy report. The highest rate of penicillin allergy de-labelling was demonstrated in patients who were referred for an inpatient oral rechallenge with 95.2% (n = 21) successfully having their penicillin AAL removed. From the 22 patients with Type A reactions, 63.6% had their penicillin AAL removed. We demonstrated a significant decrease in the prescribing of restricted antibiotics (defined as third- or fourth-generation cephalosporins, fluoroquinolones, glycopeptides, carbapenems, piperacillin/tazobactam, lincosamides, linezolid or daptomycin) in patients reviewed (pre 42.5% versus post 17.9%, P = 0.0002). CONCLUSIONS A pharmacist-led AMS penicillin allergy de-labelling ward round reduced penicillin AALs and the prescribing of restricted antibiotics. This model could be implemented at other hospitals with existing AMS programmes.
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Affiliation(s)
- M Devchand
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia.,Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - C M J Kirkpatrick
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - W Stevenson
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia
| | - K Garrett
- Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia
| | - D Perera
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia.,Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia
| | - S Khumra
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia.,Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - K Urbancic
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia.,Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Victoria, Australia
| | - M L Grayson
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Parkville, Victoria, Australia
| | - J A Trubiano
- Infectious Diseases Department and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Parkville, Victoria, Australia
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Rose MT, Slavin M, Trubiano J. The democratization of de-labeling: a review of direct oral challenge in adults with low-risk penicillin allergy. Expert Rev Anti Infect Ther 2020; 18:1143-1153. [PMID: 32662696 DOI: 10.1080/14787210.2020.1792775] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Penicillin antibiotic allergy labels (AALs) are common and lead to significant negative health and health system outcomes. Direct oral challenge offers a rapid and cost-effective way of removing inaccurate AALs and improving outcomes. AREAS COVERED A narrative review (Medline, May 2020) of direct oral challenge in low-risk penicillin allergy in adults is described, and the evidence for the safety and efficacy of this approach in inpatients, outpatients, and special patient groups is presented. EXPERT OPINION Whilst the current literature demonstrates the safety and efficacy of direct oral challenge in de-labeling low-risk penicillin allergy in adults, novel approaches are needed to improve access to antibiotic allergy assessment and address the growing global need.
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Affiliation(s)
- Morgan Thomas Rose
- Department of Infectious Diseases, Austin Health , Melbourne, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Parkville, Australia.,Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre , Melbourne, Australia
| | - Monica Slavin
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Parkville, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne , Parkville, Australia
| | - Jason Trubiano
- Department of Infectious Diseases, Austin Health , Melbourne, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Parkville, Australia.,Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre , Melbourne, Australia.,Department of Medicine (Austin Health), University of Melbourne , Parkville, Australia
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14
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Tan N, Holmes NE, Chua KY, Stewardson AJ, Trubiano JA. Long-term impacts of antibiotic allergy testing on patient perceptions and antibiotic utilization. JAC Antimicrob Resist 2019; 1:dlz058. [PMID: 34222932 PMCID: PMC8210220 DOI: 10.1093/jacamr/dlz058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/14/2019] [Accepted: 09/01/2019] [Indexed: 12/17/2022] Open
Abstract
Objectives To define the long-term impacts of antibiotic allergy testing (AAT) on patient allergy perception and antibiotic utilization. Methods Patients were identified from a prospective AAT database as having completed testing during a 15 month period beginning January 2017. Patients were contacted for a follow-up survey at least 12 months post-AAT. For those contacted, baseline demographics, antibiotic allergy label (AAL) history, age-adjusted Charlson comorbidity index, infection history, antibiotic de-labelling (≥1 AAL removed following AAT) and antibiotic usage for 12 months prior to testing (pre-AAT) and 12 months following testing (post-AAT) were recorded for each patient. Results From the follow-up survey of 112 patients post-AAT, 95.2% (59/62) of patients with complete AAL removal expressed willingness to use ‘de-labelled’ antibiotics and 91.9% (57/62) were adherent to allergy label modification. Comparing antibiotic utilization 12 months pre-AAT versus 12 months post-AAT, AAT was associated with a significant increase in preferred antibiotic therapy [adjusted odds ratio (aOR) 3.29, 95% CI 1.56–6.92] and reduction in restricted antibiotic utilization (aOR 0.42, 95% CI 0.19–0.93). Conclusions An antimicrobial stewardship (AMS)-led AAT programme was safe and effective in the long term in the promotion of preferred and narrow-spectrum antibiotic usage, and favourable patient perception towards the AAT testing results was identified. This study further supports the routine incorporation of AAT into AMS programmes, confirming safety and durability of testing impacts on patients as well as increasing preferred antibiotic utilization.
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Affiliation(s)
- N Tan
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Hospital, VIC, Melbourne, Australia
| | - N E Holmes
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Hospital, VIC, Melbourne, Australia
| | - K Y Chua
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Hospital, VIC, Melbourne, Australia
| | - A J Stewardson
- Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, VIC, Melbourne, Australia
| | - J A Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Hospital, VIC, Melbourne, Australia.,Department of Medicine, University of Melbourne, VIC, Melbourne, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, VIC, Melbourne, Australia
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16
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Reply. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2095-2096. [PMID: 31279472 DOI: 10.1016/j.jaip.2019.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 02/28/2019] [Indexed: 11/20/2022]
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17
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Trubiano JA, Grayson ML, Thursky KA, Phillips EJ, Slavin MA. How antibiotic allergy labels may be harming our most vulnerable patients. Med J Aust 2019; 208:469-470. [PMID: 29902399 DOI: 10.5694/mja17.00487] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/15/2017] [Indexed: 01/17/2023]
Affiliation(s)
| | | | - Karin A Thursky
- Peter MacCallum Cancer Centre and National Centre for Infections in Cancer, Melbourne, VIC
| | | | - Monica A Slavin
- Peter MacCallum Cancer Centre and National Centre for Infections in Cancer, Melbourne, VIC
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18
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Lucas M, Arnold A, Sommerfield A, Trevenen M, Braconnier L, Schilling A, Abass F, Slevin L, Knezevic B, Blyth C, Murray K, von Ungern-Sternberg B, Rueter K. Antibiotic Allergy Labels in Children Are Associated with Adverse Clinical Outcomes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:975-982. [DOI: 10.1016/j.jaip.2018.09.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 08/21/2018] [Accepted: 09/02/2018] [Indexed: 11/17/2022]
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Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Antibiotic allergy. Lancet 2019; 393:183-198. [PMID: 30558872 PMCID: PMC6563335 DOI: 10.1016/s0140-6736(18)32218-9] [Citation(s) in RCA: 312] [Impact Index Per Article: 62.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/25/2018] [Accepted: 09/04/2018] [Indexed: 02/07/2023]
Abstract
Antibiotics are the commonest cause of life-threatening immune-mediated drug reactions that are considered off-target, including anaphylaxis, and organ-specific and severe cutaneous adverse reactions. However, many antibiotic reactions documented as allergies were unknown or not remembered by the patient, cutaneous reactions unrelated to drug hypersensitivity, drug-infection interactions, or drug intolerances. Although such reactions pose negligible risk to patients, they currently represent a global threat to public health. Antibiotic allergy labels result in displacement of first-line therapies for antibiotic prophylaxis and treatment. A penicillin allergy label, in particular, is associated with increased use of broad-spectrum and non-β-lactam antibiotics, which results in increased adverse events and antibiotic resistance. Most patients labelled as allergic to penicillins are not allergic when appropriately stratified for risk, tested, and re-challenged. Given the public health importance of penicillin allergy, this Review provides a global update on antibiotic allergy epidemiology, classification, mechanisms, and management.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jonny G Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; The National Centre for Infections in Cancer, Peter McCallum Cancer Centre, Melbourne, VIC, Australia
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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20
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Moran R, Devchand M, Smibert O, Trubiano JA. Antibiotic allergy labels in hospitalized and critically ill adults: A review of current impacts of inaccurate labelling. Br J Clin Pharmacol 2019; 85:492-500. [PMID: 30521088 DOI: 10.1111/bcp.13830] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 11/04/2018] [Accepted: 11/19/2018] [Indexed: 11/29/2022] Open
Abstract
Antibiotic allergy labels (AALs) are reported by approximately 20% of hospitalized patients, yet over 85% will be negative on formal allergy testing. Hospitalized patients with an AAL have inferior patient outcomes, increased colonization with multidrug-resistant organisms and frequently receive inappropriate antimicrobials. Hospitalized populations have been well studied but, to date, the impact of AALs on patients with critical illness remains less well defined. We review the prevalence and impact of AALs on hospitalized patients, including those in in critical care.
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Affiliation(s)
- Rebekah Moran
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Misha Devchand
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of Pharmacy, Austin Health, Heidelberg, VIC, Australia
| | - Olivia Smibert
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Lachover-Roth I, Sharon S, Rosman Y, Meir-Shafrir K, Confino-Cohen R. Long-Term Follow-Up After Penicillin Allergy Delabeling in Ambulatory Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:231-235.e1. [DOI: 10.1016/j.jaip.2018.04.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/22/2018] [Accepted: 04/27/2018] [Indexed: 12/21/2022]
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22
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Lucas M, Loh RKS, Smith WB. Improving drug allergy management in Australia: education, communication and accurate information. Med J Aust 2018; 210:62-64. [DOI: 10.5694/mja18.00467] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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23
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Trubiano JA, Smibert O, Douglas A, Devchand M, Lambros B, Holmes NE, Chua KY, Phillips EJ, Slavin MA. The Safety and Efficacy of an Oral Penicillin Challenge Program in Cancer Patients: A Multicenter Pilot Study. Open Forum Infect Dis 2018; 5:ofy306. [PMID: 30547046 PMCID: PMC6287673 DOI: 10.1093/ofid/ofy306] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 11/13/2018] [Indexed: 11/21/2022] Open
Abstract
Antibiotic allergies are reported by up to 1 in 4 cancer patients, almost 50% of which are considered low risk and precede the cancer diagnosis. We demonstrate the successful and safe implementation of a pilot oral penicillin challenge program for cancer patients with low-risk penicillin allergies, increasing the use of penicillin and narrow-spectrum beta-lactams post-testing.
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Affiliation(s)
- Jason A Trubiano
- The National Centre for Infections in Cancer, Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Melbourne, Australia.,Department of Medicine (Austin Health), University of Melbourne, Melbourne, Australia
| | - Olivia Smibert
- The National Centre for Infections in Cancer, Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Abby Douglas
- The National Centre for Infections in Cancer, Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Misha Devchand
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Melbourne, Australia
| | - Belinda Lambros
- The National Centre for Infections in Cancer, Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Natasha E Holmes
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Melbourne, Australia
| | - Kyra Y Chua
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Melbourne, Australia
| | - Elizabeth J Phillips
- Department of Infectious Diseases, Vanderbilt University Medical Centre, Nashville, Tennessee
| | - Monica A Slavin
- The National Centre for Infections in Cancer, Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Torda A, Chan V. Antibiotic allergy labels-the impact of taking a clinical history. Int J Clin Pract 2018; 72:e13058. [PMID: 29341373 DOI: 10.1111/ijcp.13058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 12/20/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Many patients admitted to hospital have an antibiotic allergy (AAL) documented in their medical record. In many of these, the reaction is not a hypersensitivity reaction or may no longer be relevant. Despite this, the label adversely affects patient care directly in terms of antibiotic selection, and indirectly in terms of patient costs and the development of antimicrobial resistance. AIMS To estimate the prevalence of AALs in a cohort of hospitalised patients, to investigate the feasibility of de-labelling through re-challenge based solely upon clinical grounds. DESIGN This is a cross-sectional study conducted over a 6-month period on adult inpatients. An allergy history was taken from each patient and compared with medical record data regarding allergy. Antibiotic selection data were collected (if relevant). It was then determined whether immediate de-labelling was appropriate, if direct provocation test (DPT) could be relatively safely performed, and if antibiotic selection was appropriate. RESULTS Three thousand eight hundred and fifty five patients were screened, 553 (14.35%) had an AAL, and 352 were interviewed. There were 426 AALs; 276 (64.8%) towards a penicillin. After taking a detailed clinical history of the type of reaction, approximately 20% could be immediately de-labelled and educated (non-allergic, non-severe reactions) and another 38% with either a definite or vague history of mild cutaneous reaction would be suitable for an attempt at clinical de-labelling DPT. CONCLUSIONS These simple measures to 'de-label' patients appropriately, would increase the quality of care of this group known to have higher costs, infection with more resistant bacteria and worse health outcomes that 'non-labelled' patients.
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Affiliation(s)
- Adrienne Torda
- Prince of Wales Clinical School, University of New South Wales, Randwick, NSW, Australia
- Prince of Wales Hospital, Randwick, NSW, Australia
| | - Victor Chan
- Prince of Wales Clinical School, University of New South Wales, Randwick, NSW, Australia
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Inglis JM, Caughey GE, Smith W, Shakib S. Documentation of penicillin adverse drug reactions in electronic health records: inconsistent use of allergy and intolerance labels. Intern Med J 2017; 47:1292-1297. [DOI: 10.1111/imj.13558] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 06/19/2017] [Accepted: 07/18/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Joshua M. Inglis
- Department of Clinical Pharmacology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Gillian E. Caughey
- Department of Clinical Pharmacology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - William Smith
- Department of Clinical Immunology and Allergy; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Sepehr Shakib
- Department of Clinical Pharmacology; Royal Adelaide Hospital; Adelaide South Australia Australia
- Discipline of Clinical Pharmacology, School of Medicine; University of Adelaide; Adelaide South Australia Australia
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Trubiano JA, Stone CA, Grayson ML, Urbancic K, Slavin MA, Thursky KA, Phillips EJ. The 3 Cs of Antibiotic Allergy-Classification, Cross-Reactivity, and Collaboration. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:1532-1542. [PMID: 28843343 PMCID: PMC5681410 DOI: 10.1016/j.jaip.2017.06.017] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/08/2017] [Accepted: 06/16/2017] [Indexed: 12/22/2022]
Abstract
Antibiotic allergy labeling is highly prevalent and negatively impacts patient outcomes and antibiotic appropriateness. Reducing the prevalence and burden of antibiotic allergies requires the engagement of key stakeholders such as allergists, immunologists, pharmacists, and infectious diseases physicians. To help address this burden of antibiotic allergy overlabeling, we review 3 key antibiotic allergy domains: (1) antibiotic allergy classification, (2) antibiotic cross-reactivity, and (3) multidisciplinary collaboration. We review the available evidence and research gaps of currently used adverse drug reaction classification systems, antibiotic allergy cross-reactivity, and current and future models of antibiotic allergy care.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Karen Urbancic
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia; Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia; National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Elizabeth J Phillips
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Pathology, Microbiology, Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University Medical School, Nashville, Tenn
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Knezevic B, Sprigg D, Seet J, Trevenen M, Trubiano J, Smith W, Jeelall Y, Vale S, Loh R, McLean-Tooke A, Lucas M. The revolving door: antibiotic allergy labelling in a tertiary care centre. Intern Med J 2017; 46:1276-1283. [PMID: 27530619 DOI: 10.1111/imj.13223] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 06/13/2016] [Accepted: 07/18/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients frequently report antibiotic allergies; however, only 10% of labelled patients have a true allergy. AIM We investigated the documentation of antibiotic 'allergy' labels (AAL) and the effect of labelling on clinical outcomes, in a West Australian adult tertiary hospital. METHODS Retrospective cross-sectional analysis of patients captured in the 2013 and 2014 National Antimicrobial Prescribing Surveys was carried out. Data were collected on documented antibiotic adverse drug reactions, antibiotic cost, prescribing appropriateness, prevalence of multi-drug resistant organisms, length of stay, intensive care admission and readmissions. RESULTS Of the 687 patients surveyed, 278 (40%) were aged 70 or above, 365 (53%) were male and 279 (41%) were prescribed antibiotics. AAL were recorded in 122 (18%) patients and the majority were penicillin labels (n = 87; 71%). Details of AAL were documented for 80 of 141 (57%) individual allergy labels, with 61 describing allergic symptoms. Patients with beta-lactam allergy labels received fewer penicillins (P = 0.0002) and more aminoglycosides (P = 0.043) and metronidazole (P = 0.021) than patients without beta-lactam labels. Five patients received an antibiotic that was contraindicated according to their allergy status. Patients with AAL had significantly more hospital readmissions within 4 weeks (P = 0.001) and 6 months (P = 0.025) of discharge, compared with unlabelled patients. The majority (81%) of readmitted labelled patients had major infections. CONCLUSIONS AAL are common, but poorly documented in hospital records. Patients with AAL are significantly more likely to require alternative antibiotics and hospital readmissions. There may be a role for antibiotic allergy delabelling to mitigate the clinical and economic burdens for patients with invalid allergy labels.
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Affiliation(s)
- B Knezevic
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia.
| | - D Sprigg
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - J Seet
- Department of Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - M Trevenen
- Department of Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Centre for Applied Statistics, University of Western Australia, Perth, Western Australia, Australia
| | - J Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
| | - W Smith
- Department of Immunology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Y Jeelall
- School of Medicine and Pharmacology, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - S Vale
- Drug Allergy Working Party, Australasian Society of Clinical Immunology and Allergy, Sydney, New South Wales, Australia
| | - R Loh
- Department of Clinical Immunology, Princess Margaret Hospital, Perth, Western Australia, Australia.,Pathwest Laboratory, Queen Elizabeth II Campus, Perth, Western Australia, Australia
| | - A McLean-Tooke
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia.,Pathwest Laboratory, Queen Elizabeth II Campus, Perth, Western Australia, Australia
| | - M Lucas
- Department of Clinical Immunology, Royal Perth Hospital, Perth, Western Australia, Australia.,Pathwest Laboratory, Queen Elizabeth II Campus, Perth, Western Australia, Australia.,Department of Clinical Immunology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
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Trubiano JA, Thursky KA, Stewardson AJ, Urbancic K, Worth LJ, Jackson C, Stevenson W, Sutherland M, Slavin MA, Grayson ML, Phillips EJ. Impact of an Integrated Antibiotic Allergy Testing Program on Antimicrobial Stewardship: A Multicenter Evaluation. Clin Infect Dis 2017; 65:166-174. [PMID: 28520865 PMCID: PMC5849110 DOI: 10.1093/cid/cix244] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 05/12/2017] [Indexed: 01/03/2023] Open
Abstract
Background Despite the high prevalence of patient-reported antibiotic allergy (so-called antibiotic allergy labels [AALs]) and their impact on antibiotic prescribing, incorporation of antibiotic allergy testing (AAT) into antimicrobial stewardship (AMS) programs (AAT-AMS) is not widespread. We aimed to evaluate the impact of an AAT-AMS program on AAL prevalence, antibiotic usage, and appropriateness of prescribing. Methods AAT-AMS was implemented at two large Australian hospitals during a 14-month period beginning May 2015. Baseline demographics, AAL history, age-adjusted Charlson comorbidity index, infection history, and antibiotic usage for 12 months prior to testing (pre-AAT-AMS) and 3 months following testing (post-AAT-AMS) were recorded for each participant. Study outcomes included the proportion of patients who were "de-labeled" of their AAL, spectrum of antibiotic courses pre- and post-AAT-AMS, and antibiotic appropriateness (using standard definitions). Results From the 118 antibiotic allergy-tested patients, 226 AALs were reported (mean, 1.91/patient), with 53.6% involving 1 or more penicillin class drug. AAT-AMS allowed AAL de-labeling in 98 (83%) patients-56% (55/98) with all AALs removed. Post-AAT, prescribing of narrow-spectrum penicillins was more likely (adjusted odds ratio [aOR], 2.81, 95% confidence interval [CI], 1.45-5.42), as was narrow-spectrum β-lactams (aOR, 3.54; 95% CI, 1.98-6.33), and appropriate antibiotics (aOR, 12.27; 95% CI, 5.00-30.09); and less likely for restricted antibiotics (aOR, 0.16; 95% CI, .09-.29), after adjusting for indication, Charlson comorbidity index, and care setting. Conclusions An integrated AAT-AMS program was effective in both de-labeling of AALs and promotion of improved antibiotic usage and appropriateness, supporting the routine incorporation of AAT into AMS programs.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- Department of Medicine, University of Melbourne, Parkville
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
| | | | - Karen Urbancic
- Department of Infectious Diseases, Austin Health, Heidelberg
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
- Department of Pharmacy, Austin Health, Heidelberg
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
| | - Cheryl Jackson
- Department of Pharmacy, Peter MacCallum Cancer Centre, VCCC, Parkville, and
| | - Wendy Stevenson
- Department of Infectious Diseases, Austin Health, Heidelberg
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, and
| | - Michael Sutherland
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, and
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria Comprehensive Cancer Centre (VCCC)
- Centre for Improving Cancer Outcomes Through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, Sir Peter MacCallum Department of Oncology, University of Melbourne
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg
- Department of Medicine, University of Melbourne, Parkville
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia; and
- Departments of Medicine and Pharmacology, Vanderbilt University Medical Centre, Nashville, Tennessee
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Gomes ER, Kuyucu S. Epidemiology and Risk Factors in Drug Hypersensitivity Reactions. CURRENT TREATMENT OPTIONS IN ALLERGY 2017. [DOI: 10.1007/s40521-017-0128-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Graudins LV, Dooley MJ. Medication Safety: Experiential Learning for Pharmacy Students and Staff in a Hospital Setting. PHARMACY 2016; 4:E38. [PMID: 28970411 PMCID: PMC5419372 DOI: 10.3390/pharmacy4040038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/01/2016] [Accepted: 11/05/2016] [Indexed: 01/26/2023] Open
Abstract
Medication Safety has been an established pharmacy specialty in Australian hospitals since the early 2000s and is now one of the ten Australian hospital accreditation standards. Although advances have occurred, medication-related patient harm has not been eradicated. Victorian undergraduate pharmacy programs include some aspects of medication safety, however clinical pharmacy experience, along with interpersonal and project management skills, are required to prepare pharmacists to be confident medication safety practitioners. This article outlines the range of medication safety-related training offered at an Australian tertiary teaching hospital, including; on-site tutorial for undergraduate students, experiential placement for pharmacy interns, orientation for pharmacy staff and resources for credentialing pharmacists for extended roles. Improvements continue to be made, such as electronic medication management systems, which increase the safe use of medications and facilitate patient care. Implementation and evaluation of these systems require medication safety expertise. Patients' engaging in their own care is an acknowledged safety improvement strategy and is enhanced by pharmacist facilitation. Building educator skills and integrating experiential teaching with university curricula should ensure pharmacists have both the knowledge and experience early in their careers, in order to have a leading role in future medication management.
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Affiliation(s)
- Linda V Graudins
- Pharmacy Department, Alfred Health, Melbourne 3004, Victoria, Australia.
| | - Michael J Dooley
- Pharmacy Department, Alfred Health, Melbourne 3004, Victoria, Australia.
- Centre for Medicine Use and Safety, Monash University, Melbourne 3052, Victoria, Australia.
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Trubiano JA, Worth LJ, Urbancic K, Brown TM, Paterson DL, Lucas M, Phillips E. Return to sender: the need to re-address patient antibiotic allergy labels in Australia and New Zealand. Intern Med J 2016; 46:1311-1317. [PMID: 27527526 PMCID: PMC5096978 DOI: 10.1111/imj.13221] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/04/2016] [Accepted: 08/08/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND/AIM Antibiotic allergies are frequently reported and have significant impacts upon appropriate prescribing and clinical outcomes. We surveyed infectious diseases physicians, allergists, clinical immunologists and hospital pharmacists to evaluate antibiotic allergy knowledge and service delivery in Australia and New Zealand. METHODS An online multi-choice questionnaire was developed and endorsed by representatives of the Australasian Society of Clinical Immunology and Allergy (ASCIA) and the Australasian Society of Infectious Diseases (ASID). The 37-item survey was distributed in April 2015 to members of ASCIA, ASID, the Society of Hospital Pharmacists of Australia and the Royal Australasian College of Physicians. RESULTS Of 277 respondents, 94% currently use or would utilise antibiotic allergy testing (AAT) and reported seeing up to 10 patients/week labelled as antibiotic-allergic. Forty-two per cent were not aware of or did not have AAT available. Most felt that AAT would aid antibiotic selection, antibiotic appropriateness and antimicrobial stewardship (79, 69 and 61% respectively). Patients with the histories of immediate hypersensitivity were more likely to be referred than those with delayed hypersensitivities (76 vs 41%, P = 0.0001). Lack of specialist physicians (20%) and personal experience (17%) were barriers to service delivery. A multidisciplinary approach was a preferred AAT model (53%). Knowledge gaps were identified, with the majority overestimating rates of penicillin/cephalosporin (78%), penicillin/carbapenem (57%) and penicillin/monobactam (39%) cross-reactivity. CONCLUSIONS A high burden of antibiotic allergy labelling and demand for AAT is complicated by a relative lack availability or awareness of AAT services in Australia and New Zealand. Antibiotic allergy education and deployment of AAT, accessible to community and hospital-based clinicians, may improve clinical decisions and reduce antibiotic allergy impacts. A collaborative approach involving infectious diseases physicians, pharmacists and allergists/immunologists is required.
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Affiliation(s)
- J A Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.
| | - L J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - K Urbancic
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
- Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia
| | - T M Brown
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - D L Paterson
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - M Lucas
- Department of Clinical Immunology, Pathwest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - E Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
- Department of Medicine, Vanderbilt Medical Center, Nashville, Tennessee, USA
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32
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Jones CA, Davis JS, Looke DFM. The ASID test. Med J Aust 2016; 204:250-1. [PMID: 27078588 DOI: 10.5694/mja16.00284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Cheryl A Jones
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW
| | | | - David F M Looke
- Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD
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Graudins LV, Ly J, Trubiano J, Aung AK. More than skin deep. Ten year follow-up of delayed cutaneous adverse drug reactions (CADR). Br J Clin Pharmacol 2016; 82:1040-7. [PMID: 27265387 DOI: 10.1111/bcp.13030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 05/09/2016] [Accepted: 06/02/2016] [Indexed: 12/17/2022] Open
Abstract
AIMS To determine the gaps in practice regarding appropriate ADR documentation and risk communication for patients diagnosed with severe cutaneous adverse drug reactions (CADR). METHODS This was a retrospective observational cohort study conducted using hospital coding and databases to identify inpatients diagnosed with CADR from January 2004 to August 2014. Hospital discharge summaries, ADR reports and pharmacy dispensing records were reviewed for ADR documentation. Patients still living in Australia and who did not opt out of being contacted were invited to be surveyed by telephone to determine their understanding of recommendations, re-exposure rates and long-term effects. RESULTS Of 85 patients identified, median age was 59 (IQR 44-72) years and 47.1% were male. The most common diagnosis was TENS (49.4%). Ten patients (11.8%) died as inpatients. Of the 81 patients with a drug-related causality, 47 (58%) had appropriate documentation in all three required medical record platforms. Of the 56 eligible patients, 38 (67.9%) were surveyed; 13% had no information provided upon discharge and 26.3% patients had a mismatch in knowledge of implicated medications. No surveyed patient had a relapse of CADR, but 23.7% had a subsequent unrelated allergic reaction. Thirteen patients (34.2%) reported long-term effects. CONCLUSIONS We found gaps in the accuracy of ADR documentation and communication of risk at discharge, which indicated risks to patient safety. Electronic systems are being developed to improve documentation. Written information about CADR is being provided at discharge to improve patient understanding and knowledge.
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Affiliation(s)
- Linda Velta Graudins
- Pharmacy Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.
| | - Jenny Ly
- Pharmacy Department, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia
| | - Jason Trubiano
- Department of Infectious Diseases, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria, Australia.,Department of Infectious Diseases, Austin Health, 145 Studley Road, Heidelberg, 3184, Victoria, Australia.,Department of Medicine, University of Melbourne, Victoria, Australia
| | - Ar Kar Aung
- Department of Infectious Diseases, Alfred Health, 55 Commercial Road, Melbourne, 3004, Victoria, Australia.,Department of General Medicine, Alfred Health and Monash University, Victoria, Australia
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