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Lam L, Jiang M, Bacchi S, Kovoor J, Inglis JM, Shakib S, Yuson C, Smith W. Prevalence of Trimethoprim-Sulfamethoxazole Adverse Reaction Mislabelling in Australia. Int Arch Allergy Immunol 2023; 184:1225-1229. [PMID: 37673046 DOI: 10.1159/000531975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/02/2023] [Indexed: 09/08/2023] Open
Abstract
INTRODUCTION Trimethoprim-sulfamethoxazole (TMP-SMX) is an important antibiotic, with the most compelling indications for Pneumocystis jirovecii pneumonia prophylaxis and methicillin-resistant Staphylococcus aureus treatment. Previous adverse reactions (AR) to TMP-SMX may limit the usability of TMP-SMX. Electronic medical record (EMR) of AR for other antibiotics has previously been shown to be inaccurate; however, the extent to which this occurs for TMP-SMX is unknown. METHODS A multi-centre retrospective observational study was conducted for consecutive inpatient admissions over a 2.5-year period commencing 2020. Adverse reactions to TMP-SMX recorded in the EMR were collected and reviewed by two independent medical officers using pre-defined expert criteria for the classification of allergies and intolerances. RESULTS TMP-SMX AR were present in the EMR of 759 individuals (prevalence 0.6%). The majority were labelled as allergy (725, 95.5%) rather than intolerance (34, 4.5%). Most common AR were rash, vomiting, and swelling. When classified against the gold-standard expert criteria, there were 437 allergies (57.6%) and 159 intolerances (21.0%). Overall, the number of incorrect EMR AR labels was 133/759 (17.5%). Both medical and surgical specialties had significant numbers of patients with TMP-SMX AR labels and incorrectly classified EMR AR labels. CONCLUSION TMP-SMX AR labels affect inpatients admitted under multiple specialty units. The user-entered categorization as allergy or intolerance labels in EMRs are frequently used incorrectly. These incorrect labels may inappropriately contraindicate the use of TMP-SMX, and formal evaluation of TMP-SMX ARs with immunological assessment and relabelling where appropriate may increase the use of this agent.
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Affiliation(s)
- Lydia Lam
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Melinda Jiang
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Immunology and Allergy Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Flinders Medical Centre and Flinders University, Bedford Park, South Australia, Australia
| | - Joshua Kovoor
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Discipline of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua M Inglis
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Flinders Medical Centre and Flinders University, Bedford Park, South Australia, Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Sepehr Shakib
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Carlo Yuson
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - William Smith
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Immunology and Allergy Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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van der Worp C, Middeldorp T, Kuijpers L, Bank J, Dol L, van der Beek M, van Zuuren EJ, Hendriks B, Visser L, de Boer M, Lambregts M. Guideline-based intervention improves the quality of antibiotic allergy registration in a hospital setting. Clin Microbiol Infect 2023; 29:947-949. [PMID: 37030537 DOI: 10.1016/j.cmi.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/18/2023] [Accepted: 03/25/2023] [Indexed: 04/10/2023]
Affiliation(s)
- Chiara van der Worp
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Tara Middeldorp
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Laura Kuijpers
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Jonna Bank
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Lisa Dol
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Martha van der Beek
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Esther J van Zuuren
- Department of Dermatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart Hendriks
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Leo Visser
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Merel Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands.
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