The Cost of Developing and Implementing an Antepartum Referral Program for Penicillin Allergy Evaluation at a Single Academic Tertiary Care Hospital

OBJECTIVE

 Approximately 10% of pregnant individuals report a penicillin allergy, yet most are not truly allergic. Allergy verification during pregnancy is safe and recommended; however, many hospitals lack the infrastructure to execute testing. Our aim was to evaluate the cost of developing and implementing a penicillin allergy referral program for pregnant individuals at an academic institution and to compare costs of care between patients who were referred and not referred through the program.

STUDY DESIGN

 We conducted an economic analysis of our institution's antepartum penicillin allergy referral program. We prospectively collected detailed resource utilization data and conducted the analysis from the program's perspective, accounting for costs related to program development, allergy verification, antibiotic cost, and delivery hospitalization. Costs were compared between patients who were referred for evaluation versus patients who were not referred using bivariate tests as well as quantile regression adjusting for baseline differences. A sensitivity analysis was performed for allergy testing cost. All cost estimates were inflation adjusted to 2021 U.S. dollars.

RESULTS

 The startup cost of program development and educational initiatives was $19,920, or $86 per patient. The median allergy evaluation cost was $397 (interquartile range: $303-$663). There was no significant difference in maternal (median: $13,579 vs. $13,999, p = 0.94) or neonatal (median: $3,565 vs. $3,577, p = 0.55) delivery hospitalization cost or antibiotic cost (median: $1.57 vs. $3.87, p = 0.10) between referred and nonreferred patients. Overall, the total cost per person did not differ significantly between study groups (median: $18,931 vs. $18,314, p = 0.69).

CONCLUSION

 The cost of developing a penicillin allergy referral program in pregnancy was modest and did not significantly alter short-term cost of care with potential for long-term cost benefit. Verification of a reported penicillin allergy is an integral part of antibiotic stewardship, and the pregnancy period should be utilized as an important opportunity to perform this evaluation.

KEY POINTS

· The cost of developing and implementing an antepartum penicillin allergy referral program is modest.. · Program cost did not significantly alter short-term cost with a potential for long-term cost benefit.. · Penicillin allergy verification is an important part of antibiotic stewardship and should be expanded..

Pregnant Patients with a Documented History of Penicillin Allergy and Associated Maternal and Neonatal Outcomes at a Tertiary Care Center

BACKGROUND

Pregnant individuals are likely to need antibiotics during the peripartum period. For pregnant individuals who report a history of penicillin allergy, non-beta-lactam antibiotics are often administered. Compared to first-line beta-lactam antibiotics, alternative antibiotics can be less effective, more toxic, and more costly. It remains unclear if being labelled with a penicillin allergy is associated with adverse maternal and neonatal outcomes.

METHODS

We conducted a retrospective cohort study of all pregnant patients who delivered a viable singleton between 24-42 weeks of gestation at a large academic hospital from 2013-2021. We compared patients who had a documented penicillin allergy history in their electronic medical record versus those who did not and examined whether there were significant differences in maternal outcomes and neonatal outcomes. Bivariable and multivariable analyses were performed.

RESULTS

Of 41,943 eligible deliveries included in the analysis, 4,705 (11.2%) patients had a penicillin allergy history documented in their electronic medical record and 37,238 (88.8%) did not. Even after adjusting for potential confounders, patients with a documented penicillin allergy had a higher risk of postpartum endometritis (aOR 1.46 (95% CI 1.01-2.11) and a higher risk of their neonates having a postnatal hospital stay lasting more than 72 hours (aOR 1.10 (95% CI 1.02-1.18). There were no significant differences seen in the other maternal and neonatal outcomes in both bivariable and multivariable analyses.

CONCLUSION

Pregnant patients who are labelled as having a penicillin allergy are more likely to have postpartum endometritis, and neonates born to mothers who are labelled as having a penicillin allergy are more likely to have a postnatal hospital stay lasting >72 hours. Pregnant individuals with a documented penicillin allergy were significantly more likely to receive alternative non-beta-lactam antibiotics, and may have benefitted from having more details of their allergy history available as well as allergy testing.

Survey of Obstetric Providers to Assess the Knowledge and Management of a Reported Penicillin Allergy in Pregnant Women

OBJECTIVE

Penicillin allergy is the most commonly reported drug allergy in the United States; however, less than 10% of individuals labeled with a penicillin allergy are truly allergic. A reported penicillin allergy in pregnancy is associated with adverse maternal and perinatal outcomes. Despite recommendations for penicillin allergy testing in pregnancy, limited literature regarding obstetric providers' comfort and knowledge in addressing penicillin allergy and referral patterns exists. The objective of this study is to survey obstetric providers to assess their clinical practice patterns and baseline penicillin allergy knowledge, identify potential knowledge gaps in the management of pregnant patients with reported penicillin allergy, and measure the impact of an educational intervention on provider knowledge and practice patterns.

STUDY DESIGN

An anonymous, electronic 23-question survey administered to all obstetric providers at a single academic medical center assessed obstetric provider characteristics, self-reported antibiotic practice patterns, and antibiotic allergy knowledge before (June 19, 2020) and after (September 16, 2020) a penicillin allergy educational intervention, which consisted of multiple small-group educational sessions and a culminating departmental educational session. Discrete knowledge comparison by provider type and experience level of pre- and postintervention was performed using chi-square tests.

RESULTS

Of 277 obstetric providers invited, 124 (45%) responded preintervention and 62 (22%) postintervention. In total, 27% correctly identified the percentage of patients labeled penicillin allergic who would tolerate penicillins, 45% identified cephalosporin cross-reactivity, 59% understood penicillin allergies can wane, and 54% identified penicillin skin testing (PST) as a valid allergy verification tool. Among 48 respondents who attended educational sessions and responded postintervention, their knowledge of penicillin allergy waning (79% preeducation vs. 98% posteducation, p < 0.01) and PST as a valid tool for penicillin allergy verification (50% preeducation vs. 83% posteducation, p < 0.01) improved.

CONCLUSION

Knowledge gaps related to penicillin allergy exist among obstetric providers. Educational initiatives may improve provider knowledge, help in the identification of patients requiring penicillin allergy evaluation, and reduce referral barriers.

KEY POINTS

· Obstetric providers lack adequate knowledge of penicillin allergy.. · Educational interventions can improve discrete knowledge.. · Limited knowledge is a barrier to allergy referral for penicillin allergy delabeling..

Defining Clinical and Immunological Predictors of Poor Immune Responses to COVID-19 mRNA Vaccines in Patients with Primary Antibody Deficiency

Immune responses to coronavirus disease 2019 (COVID-19) mRNA vaccines in primary antibody deficiencies (PADs) are largely unknown. We investigated antibody and CD4+ T-cell responses specific for SARS-CoV-2 spike protein (S) before and after vaccination and associations between vaccine response and patients' clinical and immunological characteristics in PADs. The PAD cohort consisted of common variable immune deficiency (CVID) and other PADs, not meeting the criteria for CVID diagnosis (oPADs). Anti-S IgG, IgA, and IgG subclasses 1 and 3 increased after vaccination and correlated with neutralization activity in HCs and patients with oPADs. However, 42% of CVID patients developed such responses after the 2nd dose. A similar pattern was also observed with S-specific CD4+ T-cells as determined by OX40 and 4-1BB expression. Patients with poor anti-S IgG response had significantly lower levels of baseline IgG, IgA, CD19+ B-cells, switched memory B-cells, naïve CD8+ T-cells, and a higher frequency of EM CD8+ T-cells and autoimmunity compared to patients with adequate anti-S IgG responses. Patients with oPADs can develop humoral and cellular immune responses to vaccines similar to HCs. However, a subset of CVID patients exhibit impairment in developing such responses, which can be predicted by the baseline immune profile and history of autoimmunity.

The Effect of Burnout on Medical Errors and Professionalism in First-Year Internal Medicine Residents

BACKGROUND

Burnout is a common issue in internal medicine residents, and its impact on medical errors and professionalism is an important subject of investigation.

OBJECTIVE

To evaluate differences in medical errors and professionalism in internal medicine residents with and without burnout.

METHODS

A single institution observational cohort study was conducted between June 2011 and July 2012. Burnout was measured using the Maslach Burnout Inventory to generate subscores for the following 3 domains: emotional exhaustion, depersonalization, and sense of personal accomplishment. By convention, burnout was defined as a high emotional exhaustion or depersonalization subscore. Medication prescription error rate was the chosen measure of medical errors. Professionalism was measured cumulatively through examining discharge summaries completed within 48 hours, outpatient charts completed within 72 hours, and the average time to review outpatient laboratory tests.

RESULTS

Of a total of 54 eligible first-year residents, 53 (98%) and 32 (59%) completed the initial and follow-up surveys, respectively. Residents with year-end burnout had a lower rate of medication prescription errors (0.553 versus 0.780, P = .007). Discharge summaries completed within 48 hours of discharge (83.8% versus 84.0%, P = .93), outpatient charts completed within 72 hours of encounter (93.7% versus 94.3%, P = .31), and time (minutes) to review outpatient laboratory test results (72.3 versus 26.9, P = .28) were similar between residents with and without year-end burnout.

CONCLUSIONS

This study found a small decrease in medical errors in residents with year-end burnout compared to burnout-free residents and no difference in selected measures of professionalism.