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Gonzalez-Estrada A, Park MA, Accarino JJO, Banerji A, Carrillo-Martin I, D'Netto ME, Garzon-Siatoya WT, Hardway HD, Joundi H, Kinate S, Plager JH, Rank MA, Rukasin CRF, Samarakoon U, Volcheck GW, Weston AD, Wolfson AR, Blumenthal KG. Predicting Penicillin Allergy: A United States Multicenter Retrospective Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1181-1191.e10. [PMID: 38242531 DOI: 10.1016/j.jaip.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 12/29/2023] [Accepted: 01/07/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND Using the reaction history in logistic regression and machine learning (ML) models to predict penicillin allergy has been reported based on non-US data. OBJECTIVE We developed ML positive penicillin allergy testing prediction models from multisite US data. METHODS Retrospective data from 4 US-based hospitals were grouped into 4 datasets: enriched training (1:3 case-control matched cohort), enriched testing, nonenriched internal testing, and nonenriched external testing. ML algorithms were used for model development. We determined area under the curve (AUC) and applied the Shapley Additive exPlanations (SHAP) framework to interpret risk drivers. RESULTS Of 4777 patients (mean age 60 [standard deviation: 17] years; 68% women, 91% White, and 86% non-Hispanic) evaluated for penicillin allergy labels, 513 (11%) had positive penicillin allergy testing. Model input variables were frequently missing: immediate or delayed onset (71%), signs or symptoms (13%), and treatment (31%). The gradient-boosted model was the strongest model with an AUC of 0.67 (95% confidence interval [CI]: 0.57-0.77), which improved to 0.87 (95% CI: 0.73-1) when only cases with complete data were used. Top SHAP drivers for positive testing were reactions within the last year and reactions requiring medical attention; female sex and reaction of hives/urticaria were also positive drivers. CONCLUSIONS An ML prediction model for positive penicillin allergy skin testing using US-based retrospective data did not achieve performance strong enough for acceptance and adoption. The optimal ML prediction model for positive penicillin allergy testing was driven by time since reaction, seek medical attention, female sex, and hives/urticaria.
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Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Miguel A Park
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - John J O Accarino
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Michael E D'Netto
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - W Tatiana Garzon-Siatoya
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Heather D Hardway
- Digital Innovation Lab, Department of Health Sciences Research, Mayo Clinic, Jacksonville, Fla
| | - Hajara Joundi
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Susan Kinate
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz
| | - Jessica H Plager
- Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Section of Allergy, Immunology, Division of Pulmonary, Phoenix Children's Hospital, Phoenix, Ariz
| | - Christine R F Rukasin
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Section of Allergy, Immunology, Division of Pulmonary, Phoenix Children's Hospital, Phoenix, Ariz
| | - Upeka Samarakoon
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - Alexander D Weston
- Digital Innovation Lab, Department of Health Sciences Research, Mayo Clinic, Jacksonville, Fla
| | - Anna R Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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Epstein-Rigbi N, Ziv S, Bulanenkova M, Bouganim R, Tal-Jasper R, Marchaim D. Beta-lactam antibiotics administration among adult inpatients with a beta-lactam allergy label: incidence, predictors, and outcomes. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e68. [PMID: 38698943 PMCID: PMC11062790 DOI: 10.1017/ash.2024.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/31/2024] [Accepted: 04/04/2024] [Indexed: 05/05/2024]
Abstract
Background A beta-lactam antibiotics (BLA) allergy label is common, resulting in disadvantageous outcomes due to the usage of second-line antimicrobial agents. Noncontrolled case-series analyses report low rates of hypersensitivity reactions, following intentional/non-intentional BLA challenges among labeled inpatients. The study aims were to explore predictors and outcomes associated with hypersensitivity reactions following BLA challenge among BLA-allergic labeled inpatients. Methods Retrospective cohort study (2019-2020) of adult (≥18 years) inpatients (Shamir Medical Center, Israel), labeled as allergic to ≥1 BLA, who received ≥1 dose/s of BLA during their stay. Independent predictors to develop allergic reactions and the independent associations of allergic reactions with clinical outcomes were queried by logistic and Cox regressions. Results Of 9,670 inpatients (14,088 hospitalizations), 3,570 (37%) were labeled as allergic to ≥1 BLA. Of those, 1,171 (33%) patients received ≥1 BLA. The majority were women (67%), and the mean age was 69.3 ± 19.4 years. Only 30 patients (2.6%) developed a reaction, all mild. Independent predictors to develop an allergic reaction were documented reactions in the past, atopic background, antihistamines administration prior to the BLA challenge, and high risk for cross-reactivity, based on the BLA side chains, between the labeled and the challenged agents. Reaction upon the BLA challenge was not independently associated with any worse outcome. Conclusions Despite the commonality of allergy labeling, and the commonality of BLA administration to labeled inpatients, hypersensitivity reactions were mild and rare. Interventional stewardship strategies for active BLA de-labeling among low-risk patients should be promoted, to improve patients' and institutional health and fiscal outcomes.
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Affiliation(s)
- Naama Epstein-Rigbi
- The Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (Assaf Harofeh) Medical Center, Beer Yaacov, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Sharon Ziv
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Marina Bulanenkova
- Department of Geriatrics, Shmuel Harofeh Medical Center, Beer Yaacov, Israel
| | - Ruth Bouganim
- Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Beer Yaacov, Israel
| | - Ruthy Tal-Jasper
- Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Beer Yaacov, Israel
| | - Dror Marchaim
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Beer Yaacov, Israel
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Burgener-Gasser AV, Fasel J, Halbeisen D, Hartmann K, Weisser-Rohacek M, Kaufmann C, Tschudin-Sutter S. Assessing the rationale of prescribing carbapenems among hospitalized patients with documented penicillin allergy: implications for stewardship. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e37. [PMID: 38500716 PMCID: PMC10945937 DOI: 10.1017/ash.2024.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 03/20/2024]
Abstract
Background A reported history of penicillin allergy frequently leads to the prescription of carbapenems as a substitute for penicillin to avoid allergic reactions. Such self-reported allergies need to be accurately characterized to identify targeted antibiotic stewardship interventions that potentially minimize unnecessary carbapenem use. Design Retrospective cohort study. Method The proportion of hospitalized patients with penicillin allergy history receiving carbapenem prescriptions was evaluated between January 1st, 2017 and December 31st, 2018 at the University Hospital Basel, Switzerland. The appropriateness of carbapenem prescription of each patient was evaluated using institutional guidelines based on previously published recommendations. Results Our analysis revealed that among 212 patients with recorded penicillin allergy, of the 247 carbapenem treatment episodes, 79 (32%) were unjustified. Abdominal and lower respiratory tract infections were most frequently associated with inappropriate carbapenem use (OR 2.64, 95% CI 1.22-5.71, P = .014 and OR 2.26, 95% CI 1.08-4.73, P = .031). The recorded allergy type was not documented or unclear in 153 patients (72%) and penicillin allergy was only confirmed in 2 patients (0.9%). Inconsistencies in allergic symptom documentation and allergy types were found between the institution's two software programs. Conclusion While a multimodal approach to identify and accurately label penicillin allergies remains essential to reduce inappropriate carbapenem use, our findings highlight the need for comprehensive and easily accessible guidelines for carbapenem utilization and structured history-based allergy assessment as an initial screening tool, embedded in a tailored digital allergy record template.
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Affiliation(s)
| | - Jeanne Fasel
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Delia Halbeisen
- Division of clinical Pharmacy, University Hospital Basel, Basel, Switzerland
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | - Maja Weisser-Rohacek
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Carole Kaufmann
- Division of clinical Pharmacy, University Hospital Basel, Basel, Switzerland
| | - Sarah Tschudin-Sutter
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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Han N, Oh OH, Oh J, Kim Y, Lee Y, Cha WC, Yu YM. The Application of Knowledge-Based Clinical Decision Support Systems to Detect Antibiotic Allergy. Antibiotics (Basel) 2024; 13:244. [PMID: 38534679 DOI: 10.3390/antibiotics13030244] [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: 02/06/2024] [Revised: 02/29/2024] [Accepted: 03/05/2024] [Indexed: 03/28/2024] Open
Abstract
Prevention of drug allergies is important for patient safety. The objective of this study was to evaluate the outcomes of antibiotic allergy-checking clinical decision support system (CDSS), K-CDSTM. A retrospective chart review study was performed in 29 hospitals and antibiotic allergy alerts data were collected from May to August 2022. A total of 15,535 allergy alert cases from 1586 patients were reviewed. The most frequently prescribed antibiotics were cephalosporins (48.5%), and there were more alerts of potential cross-reactivity between beta-lactam antibiotics than between antibiotics with the same ingredients or of the same class. Regarding allergy symptoms, dermatological disorders were the most common (38.8%), followed by gastrointestinal disorders (28.4%). The 714 cases (4.5%) of immune system disorders included 222 cases of anaphylaxis and 61 cases of severe cutaneous adverse reactions. Alerts for severe symptoms were reported in 6.4% of all cases. This study confirmed that K-CDS can effectively detect antibiotic allergies and prevent the prescription of potentially allergy-causing antibiotics among patients with a history of antibiotic allergies. If K-CDS is expanded to medical institutions nationwide in the future, it can prevent an increase in allergy recurrence related to drug prescriptions through cloud-based allergy detection CDSSs.
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Affiliation(s)
- Nayoung Han
- Jeju Research Institute of Pharmaceutical Sciences, College of Pharmacy, Jeju National University, Jeju 63243, Republic of Korea
| | - Ock Hee Oh
- FirstDIS Ltd., Seoul 07343, Republic of Korea
| | - John Oh
- Kakao Healthcare Corp., Seongnam 13529, Republic of Korea
| | - Yoomi Kim
- Korea Health Information Service, Seoul 04512, Republic of Korea
| | - Younghee Lee
- Department of Pharmacy, Ajou University Hospital, Suwon 16499, Republic of Korea
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul 06355, Republic of Korea
| | - Yun Mi Yu
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon 21983, Republic of Korea
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Mir A, Lanoue D, Zanichelli V, van Walraven C, Olynych T, Nott C, MacFadden D. Introduction of a penicillin allergy de-labelling program with direct oral challenge and its effects on utilization of beta-lactam antimicrobials: a multicenter retrospective parallel cohort study. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2024; 20:20. [PMID: 38444037 PMCID: PMC10913637 DOI: 10.1186/s13223-024-00877-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/31/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Self-reported penicillin allergy labels are common and often inaccurate after assessment. These labels can lead to reduced use of first-line beta-lactam antibiotics and worse outcomes. We measured the impact of a previously performed inpatient proactive systematic penicillin allergy de-labelling program on subsequent antibiotic use. This prior program included assessment, risk-stratification, and low risk direct oral amoxicillin challenge. METHODS We performed a retrospective comparison of parallel cohorts from two separate tertiary care hospital campuses in Ottawa, Canada across two penicillin de-labelling intervention periods across April 15th to April 30th, 2021, and February 15th to March 8th, 2022. Outcomes, including penicillin allergy labelling and antibiotic use, were collected for the index admission and the subsequent 6-month period. Descriptive statistics and multivariate regression analyses were performed. RESULTS A total of 368 patients with penicillin allergy label were included across two campuses and study periods. 24 (13.8%) patients in the intervention groups had sustained penicillin allergy label removal at 30 days from admission vs. 3 (1.5%) in the non-intervention group (p < 0.001). In the 6-months following admission, beta-lactams were prescribed more frequently in the intervention groups vs. the non-intervention groups for all patients (28 [16.1%] vs.15 [7.7%], p = 0.04) and were prescribed more frequently amongst those who received at least one antibiotic (28/46 [60.9%] vs.15/40 [37.5%], p = 0.097). In a multivariate regression analysis, the intervention groups were found to be associated with an increased odds of beta-lactam prescribing in all patients (OR 2.49, 95%CI 1.29-5.02) and in those prescribed at least one antibiotic (OR 2.44, 95%CI 1.00-6.15). No drug-related adverse events were reported. CONCLUSIONS Proactive penicillin allergy de-labelling for inpatients was associated with a reduction in penicillin allergy labels and increased utilization of beta-lactams in the subsequent 6-months.
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Affiliation(s)
- Adhora Mir
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada.
- The University of Ottawa, Ottawa, Canada.
| | - Derek Lanoue
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | | | - Carl van Walraven
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
- The University of Ottawa, Ottawa, Canada
| | | | - Caroline Nott
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
- The University of Ottawa, Ottawa, Canada
| | - Derek MacFadden
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
- The University of Ottawa, Ottawa, Canada
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6
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Cunha F, Cunha I, Gomes E. Safety of direct oral provocation test to delabel reported mild beta-lactam allergy in infants. Allergol Immunopathol (Madr) 2024; 52:10-15. [PMID: 38459885 DOI: 10.15586/aei.v52i2.887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/30/2023] [Indexed: 03/11/2024]
Abstract
BACKGROUND Around 10% of people report a drug allergy and avoid some medications because of fear of allergic reactions. However, only after a proper diagnostic workup can some of these reactions be confirmed as allergic or nonallergic hypersensitivities. Beta-lactams (BLs) are the most common medication suspected of being involved in drug hypersensivity reactions (DHRs) in children. Recently, direct oral provocation tests (DPT) with BLs gained popularity within pediatric populations as a tool for delabeling children with suspected BL allergies. This study aimed to evaluate the safety of direct provocation tests in infants with mild cutaneous non-immediate reactions to BLs. METHODS The authors retrospectively analyzed the data of 151 infants between 2015 and 2022, referred for evaluating a suspected allergy to BLs that occurred before age 24 months. RESULTS The mean age of the children, including 55% male kids, at the suspected reaction was 15.9 months and the mean age at the time of the DPT was 39.6 months. In most cases, antibiotics were prescribed to treat common upper respiratory infections, such as acute otitis (54.3%) and acute tonsillitis (27.2%). Amoxicillin was considered the culprit drug in 62.9% of the cases, and the combination of amoxicillin-clavulanic acid in the case of 33.8% of children. The most frequent associated cutaneous clinical manifestations were maculopapular exanthema in 74.8% and delayed urticaria/angioedema in 25.2%. Of the 151 infants evaluated, parents of 149 infants agreed for a direct DPT, and only three had a positive test (2%). Symptoms resulting from the DPT were mild and easily treatable. CONCLUSIONS A direct DPT without prior tests is a safe and effective procedure to delabel BL allergy, even in infants. The authors wish to emphasize the importance of properly validating BL allergy suspicions by promoting appropriate diagnostic procedures in infants as, in most cases, DHRs can be excluded and there is no need for further therapeutic restrictions.
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Affiliation(s)
- Francisca Cunha
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal;
| | - Inês Cunha
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Eva Gomes
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
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Krishna MT, Bhogal R, Ng BY, Kildonaviciute K, Jani YH, Williams I, Sandoe JAT, Pollard R, Jones N, Dunsmure L, Powell N, Hullur C, Balaji A, Moriarty C, Jackson B, Warner A, Daniels R, West R, Thomas C, Misbah SA, Savic L. A multicentre observational study to investigate feasibility of a direct oral penicillin challenge in de-labelling 'low risk' patients with penicillin allergy by non-allergy healthcare professionals (SPACE study): Implications for healthcare systems. J Infect 2024; 88:106116. [PMID: 38331329 PMCID: PMC10961940 DOI: 10.1016/j.jinf.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/17/2024] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE The huge burden of inaccurate penicillin allergy labels (PALs) is an important driver of antimicrobial resistance. This is magnified by insufficient allergy specialists and lack of 'point-of-care' tests. We investigated the feasibility of non-allergy healthcare professionals (HCPs) delivering direct oral penicillin challenges (DPCs) for penicillin allergy de-labelling. METHODS This prospective observational study was conducted in three hospitals in England across three settings (acute medical, pre-surgical and haematology-oncology). Patients with a PAL were screened and stratified as low risk/high risk. Low risk patients (non-immune mediated symptoms, benign rash, tolerated amoxicillin since and family history) underwent a DPC. RESULTS N = 2257 PALs were screened, 1054 were eligible; 643 were approached, 373 declined, 270 consented and 259 risk stratified (low risk = 155; high risk = 104). One hundred and twenty-six low risk patients underwent DPC, 122 (96.8%) were de-labelled with no serious allergic reactions. Conversion rate from screening-to-consent was 12% [3.3% and 17.9% in acute and elective settings respectively; odds ratios for consent were 3.42 (p < 0.001) and 5.53 (p < 0.001) in haematology-oncology and pre-surgical setting respectively. Common reasons for failure to progress in the study included difficulty in reaching patients, clinical instability/medical reasons, lacking capacity to consent and psychological factors. INTERPRETATION DPCs can be delivered by non-allergy HCPs. A high proportion of patients with PALs did not progress in the study pathway. Strategies to deliver DPC at optimal points of the care pathway are needed to enhance uptake. Elective settings offer greater opportunities than acute settings for DPC. The safety and simplicity of DPCs lends itself to adoption by healthcare systems beyond the UK, including in resource-limited settings.
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Affiliation(s)
- Mamidipudi Thirumala Krishna
- Institute of Immunology and Immunotherapy, University of Birmingham and Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Rashmeet Bhogal
- Department of Pharmacy, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bee Yean Ng
- Department of Pharmacy, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Yogini H Jani
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust and UCL School of Pharmacy, London, UK
| | - Iestyn Williams
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Jonathan A T Sandoe
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rachel Pollard
- Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicola Jones
- Department of Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Louise Dunsmure
- Department of Pharmacy, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Neil Powell
- Department of Pharmacy, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Chidanand Hullur
- Department of Anaesthesia, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ariyur Balaji
- Acute Medicine Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Catherine Moriarty
- Theatres and Anaesthetics Research Team, St James' University Hospital, Leeds Teaching Hospitals, Leeds, UK
| | - Beverley Jackson
- Theatres and Anaesthetics Research Team, St James' University Hospital, Leeds Teaching Hospitals, Leeds, UK
| | | | | | - Robert West
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Caroline Thomas
- Department of Anaesthesia, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Siraj A Misbah
- Department of Clinical Immunology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Louise Savic
- Department of Anaesthesia, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Felix MMR, Kuschnir FC, Boechat JL, Castells M. Recent findings on drug hypersensitivity in children. FRONTIERS IN ALLERGY 2024; 5:1330517. [PMID: 38384771 PMCID: PMC10879301 DOI: 10.3389/falgy.2024.1330517] [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: 10/31/2023] [Accepted: 01/24/2024] [Indexed: 02/23/2024] Open
Abstract
Drug hypersensitivity reactions (DHR) in children have a significant impact on clinical practice and public health. Both under-diagnosis (due to under-reporting) and over-diagnosis (due to the overuse of the term "allergy") are potential issues. The aim of this narrative review is to describe the most recent findings of DHR in children/adolescents and gaps regarding epidemiology, antibiotic allergy, antiepileptic hypersensitivity, vaccine allergy, and severe cutaneous adverse reactions (SCAR) in this age group.
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Affiliation(s)
- Mara Morelo Rocha Felix
- Department of General Medicine, School of Medicine and Surgery, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fábio Chigres Kuschnir
- Department of Pediatrics, Faculty of Medicine, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - José Laerte Boechat
- Clinical Immunology Service, Internal Medicine Department, Faculty of Medicine, Universidade Federal Fluminense, Niterói, Brazil
- Basic and Clinical Immunology Unit, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Mariana Castells
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States
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Shapiro K, Anger J, Cameron AP, Chung D, Daignault-Newton S, Ippolito GM, Lee U, Mourtzinos A, Padmanabhan P, Smith AL, Suskind AM, Tenggardjaja C, Van Til M, Brucker BM. Antibiotic use, best practice statement adherence, and UTI rate for intradetrusor onabotulinumtoxin-A injection for overactive bladder: A multi-institutional collaboration from the SUFU Research Network (SURN). Neurourol Urodyn 2024; 43:407-414. [PMID: 38032120 DOI: 10.1002/nau.25334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/11/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
INTRODUCTION Onabotulinumtoxin A (BTX-A) is a well-established treatment for overactive bladder (OAB). The American Urological Association (AUA) 2008 Antibiotic Best Practice Statement (BPS) recommended trimethoprim-sulfamethoxazole or fluoroquinolone for cystoscopy with manipulation. The aim of the study was to evaluate concordance with antibiotic best practices at the time of BTX-A injection and urinary tract infection (UTI) rates based on antibiotic regimen. METHODS Men and women undergoing first-time BTX-A injection for idiopathic OAB with 100 units in 2016, within the SUFU Research Network (SURN) multi-institutional retrospective database were included. Patients on suppressive antibiotics were excluded. The primary outcome was concordance of periprocedural antibiotic use with the AUA 2008 BPS antimicrobials of choice for "cystoscopy with manipulation." As a secondary outcome we compared the incidence of UTI among women within 30 days after BTX-A administration. Each outcome was further stratified by procedure setting (office vs. operating room; OR). RESULTS Of the cohort of 216 subjects (175 women, 41 men) undergoing BTX-A, 24 different periprocedural antibiotic regimens were utilized, and 98 (45%) underwent BTX-A injections in the OR setting while 118 (55%) underwent BTX-A injection in the office. Antibiotics were given to 86% of patients in the OR versus 77% in office, and 8.3% of subjects received BPS concordant antibiotics in the OR versus 82% in office. UTI rates did not vary significantly among the 141 subjects who received antibiotics and had 30-day follow-up (8% BPS-concordant vs. 16% BPS-discordant, CI -2.4% to 19%, p = 0.13). A sensitivity analysis of UTI rates based on procedure setting (office vs. OR) did not demonstrate any difference in UTI rates (p = 0.14). CONCLUSIONS This retrospective multi-institutional study demonstrates that antibiotic regimens and adherence to the 2008 AUA BPS were highly variable among providers with lower rates of BPS concordant antibiotic use in the OR setting. UTI rates at 30 days following BTX-A did not vary significantly based on concordance with the BPS or procedure setting.
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Affiliation(s)
- Katherine Shapiro
- Department of Urology, New York University, New York City, New York, USA
| | - Jennifer Anger
- Department of Urology, University of California San Diego, San Diego, California, USA
| | - Anne P Cameron
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Doreen Chung
- Department of Urology, Columbia University Medical Center, New York City, New York, USA
| | | | - Giulia M Ippolito
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Una Lee
- Virginia Mason Medical Center, Seattle, Washington, District of Columbia, USA
| | - Arthur Mourtzinos
- Department of Urology, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
| | - Priya Padmanabhan
- Department of Urology, William Beaumont University Hospital, Royal Oak, Michigan, USA
| | - Ariana L Smith
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne M Suskind
- Department of Urology, University of California San Francisco, San Francisco, California, USA
| | | | - Monica Van Til
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Benjamin M Brucker
- Department of Urology, New York University, New York City, New York, USA
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10
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Gruber MM, Weber A, Jung J, Strehlau A, Tsilimparis N, Draenert R. The impact of antibiotic stewardship interventions and patient related factors on antibiotic prescribing in a vascular surgical department. Infection 2024; 52:83-91. [PMID: 37289423 PMCID: PMC10810951 DOI: 10.1007/s15010-023-02056-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/23/2023] [Indexed: 06/09/2023]
Abstract
PURPOSE The development of guidelines tailored to the departments' needs and counselling during ward rounds are important antibiotic stewardship (AS) strategies. The aim was to analyse the impact of AS ward rounds and institutional guidelines as well as patient-related factors on antibiotic use in vascular surgical patients. METHODS A retrospective prescribing-analysis of 3 months (P1, P2) before and after implementing weekly AS ward rounds and antimicrobial treatment guidelines was performed. Choice of systemic antibiotics, days of antibiotic therapy and clinical data were obtained from electronic patient records. RESULTS During P2, the overall antibiotic consumption as well as the use of last-resort compounds like linezolid and fluoroquinolones decreased distinctly (overall: 47.0 days of therapy (DOT)/100 patient days (PD) vs. 35.3 DOT/100PD, linezolid: 3.7 DOT/100PD vs. 1.0 DOT/100PD, fluoroquinolones: 7.0 DOT/100PD vs. 3.2 DOT/100PD) while narrow-spectrum beta-lactams increased by 48.4%. Courses of antibiotics were de-escalated more often during P2 (30.5% vs. 12.1%, p = 0.011). Only in P2, an antibiotic therapy was initiated in patients suffering from more comorbidities (i.e. higher Charlson Comorbidity Index) more frequently. Other patient factors had no distinct impact on antibiotic prescribing. CONCLUSION Weekly AS ward rounds improved adherence to institutional antibiotic treatment guidelines and antibiotic prescribing in vascular surgical patients. Clear patient-related determinants affecting choice of antibiotic therapies could not be identified.
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Affiliation(s)
- M M Gruber
- Stabsstelle Antibiotic Stewardship, LMU University Hospital, LMU Munich, Munich, Germany
- Hospital Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany
| | - A Weber
- Stabsstelle Antibiotic Stewardship, LMU University Hospital, LMU Munich, Munich, Germany
- Hospital Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany
| | - J Jung
- Stabsstelle Antibiotic Stewardship, LMU University Hospital, LMU Munich, Munich, Germany
- Max von Pettenkofer Institute, Faculty of Medicine, LMU Munich, Munich, Germany
| | - A Strehlau
- Hospital Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany
| | - N Tsilimparis
- Division of Vascular Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - R Draenert
- Stabsstelle Antibiotic Stewardship, LMU University Hospital, LMU Munich, Munich, Germany.
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11
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Lanoue D, Mir A, van Walraven C, Olynych T, Nott C, MacFadden DR. Resource utilization and cost assessment of a proactive penicillin allergy de-labeling program for low-risk inpatients. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2024; 20:7. [PMID: 38254221 PMCID: PMC10804656 DOI: 10.1186/s13223-023-00864-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 12/05/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Resource utilization and costs can impede proactive assessment and de-labeling of penicillin allergy among inpatients. METHODS Our pilot intervention was a proactive penicillin allergy de-labeling program for new inpatients with penicillin allergy. Patients deemed appropriate for a challenge with a low-risk penicillin allergy history were administered 250 mg amoxicillin and monitored for 1 h. We performed an explorative economic evaluation using various healthcare professional wages. RESULTS Over two separate 2-week periods between April 2021 and March 2022, we screened 126 new inpatients with a penicillin allergy. After exclusions, 55 were appropriate for formal assessment. 19 completed the oral challenge, and 12 were directly de-labeled, resulting in a number needed to screen of 4 and a number needed to assess of 1.8 to effectively de-label one patient. The assessor's median time in the hospital per day de-labeling was 4h08 with a range of (0h05, 6h45). A single-site annual implementation would result in 715 penicillin allergy assessments with 403 patients de-labeled assuming 20,234 annual weekday admissions and an 8.9% penicillin allergy rate. Depending on the assessor used, the annual cost of administration would be between $21,476 ($53.29 per effectively de-labeled patient) for a pharmacy technician and $61,121 ($151.67 per effectively de-labeled patient) for a Nurse Practitioner or Physician Assistant. CONCLUSION A proactive approach, including a direct oral challenge for low-risk in-patients with penicillin allergy, appears safe and feasible. Similar programs could be implemented at other institutions across Canada to increase access to allergy assessment.
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Affiliation(s)
- Derek Lanoue
- Division of Clinical Immunology and Allergy, McGill University, 1650 Cedar Ave., H3G1A4, Montreal, QC, Canada
| | | | - Carl van Walraven
- The Ottawa Hospital, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Caroline Nott
- The Ottawa Hospital, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Derek R MacFadden
- The Ottawa Hospital, Ottawa, ON, Canada.
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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12
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Wrenn RH, Trubiano JA. Penicillin Allergy Impact and Management. Infect Dis Clin North Am 2023; 37:793-822. [PMID: 37537003 DOI: 10.1016/j.idc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
There is international evidence that penicillin allergies are associated with inferior prescribing and patient outcomes. A host of tools now exist from assessment (risk assessment tools, clinical decision rules) to delabeling (the removal of a beta-lactam allergy via testing or medical reconciliation) to reduce the impact of these "labels" in the hospital and community setting, as a primary antimicrobial stewardship intervention.
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Affiliation(s)
- Rebekah H Wrenn
- Duke University Medical Center, Durham, NC, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA.
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, Melbourne, Australia; Department of Infectious Diseases, University of Melbourne, at The Peter Doherty Institute for Infection and Immunity, Victoria 3000, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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13
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Abbott IJ, Peel TN, Cairns KA, Stewardson AJ. Antibiotic management of urinary tract infections in the post-antibiotic era: a narrative review highlighting diagnostic and antimicrobial stewardship. Clin Microbiol Infect 2023; 29:1254-1266. [PMID: 35640839 DOI: 10.1016/j.cmi.2022.05.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/03/2022] [Accepted: 05/11/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND As one of the most common indications for antimicrobial prescription in the community, the management of urinary tract infections (UTIs) is both complicated by, and a driver of, antimicrobial resistance. OBJECTIVES To highlight the key clinical decisions involved in the diagnosis and treatment of UTIs in adult women, focusing on clinical effectiveness and both diagnostic and antimicrobial stewardship as we approach the post-antimicrobial era. SOURCES Literature reviewed via directed PubMed searches and manual searching of the reference list for included studies to identify key references to respond to the objectives. A strict time limit was not applied. We prioritised recent publications, randomised trials, and systematic reviews (with or without meta-analyses) where available. Searches were limited to English language articles. A formal quality assessment was not performed; however, the strengths and limitations of each paper were reviewed by the authors throughout the preparation of this manuscript. CONTENT We discuss the management of UTIs in ambulatory adult women, with particular focus on uncomplicated infections. We address the diagnosis of UTIs, including the following: definition and categorisation; bedside assessments and point-of-care tests; and the indications for, and use of, laboratory tests. We then discuss the treatment of UTIs, including the following: indications for treatment, antimicrobial sparing approaches, key considerations when selecting a specific antimicrobial agent, specific treatment scenarios, and duration of treatment. We finally outline emerging areas of interest in this field. IMPLICATIONS The steady increase in antimicrobial resistance among common uropathogens has had a substantial affect on the management of UTIs. Regarding both diagnosis and treatment, the clinician must consider both the patient (clinical effectiveness and adverse effects, including collateral damage) and the community more broadly (population-level antimicrobial selection pressure).
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Affiliation(s)
- Iain J Abbott
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia; Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia.
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kelly A Cairns
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
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14
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Hampton LL, DeBoy JT, Gunaratne A, Stallings AP, Bell T, Phillips MA, Kamath SS, Sterrett EC, Nazareth-Pidgeon KM. Improving the Documentation of Penicillin Allergy Labels Among Pediatric Inpatients. Hosp Pediatr 2023; 13:811-821. [PMID: 37565275 DOI: 10.1542/hpeds.2022-006730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Penicillin allergy is the most common medication allergy, and the penicillin allergy label is commonly over-applied without adequate reaction history inquiry or documentation. Because penicillin allergy labels are often applied in childhood and carried into adulthood, we sought to increase the completeness of reaction history documentation from 20% to 70% for pediatric hospital medicine patients and from 20% to 50% for all other pediatric inpatients within 12 months. As a secondary outcome, we also aimed to increase the proportion of delabeling unnecessary penicillin labels to 20% for all pediatric inpatients. METHODS To address our aims, our quality improvement initiative included education for pediatric faculty and staff, development and implementation of a clinical pathway for allergy risk stratification, and electronic health record optimizations. Statistical process control charts were used to track the impact of the interventions facilitated by an automated dashboard. RESULTS Within 12 months of interventions, the completeness of allergy labels improved from 20% to 64% among patients admitted to the pediatric hospital medicine service and improved from 20% to 45% for all other pediatric inpatients. The frequency of penicillin allergy delabeling remained unchanged; however, 98 patients were risk stratified and 34 received outpatient allergy referrals for further testing. The number of adverse drug reactions to penicillin, a balancing measure, did not change during the study period. CONCLUSIONS We increased the completeness of penicillin allergy documentation using a standardized workflow facilitated by a multidisciplinary clinical pathway. With ongoing efforts, more penicillin delabeling in low-risk patients is anticipated.
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Affiliation(s)
- Laura L Hampton
- Division of Hospital Medicine, Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, Georgia
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15
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Gillespie C, Sitter K, McConeghy KW, Strymish J, Gupta K, Hartmann CW, Borzecki AM. Facilitators and Barriers to Verifying Penicillin Allergies in a Veteran Nursing Home Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2848-2854.e3. [PMID: 37352930 DOI: 10.1016/j.jaip.2023.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Unconfirmed penicillin allergies are common and may contribute to adverse outcomes, especially in frail older patients. Evidence-based clinical pathways for evaluating penicillin allergies have been effectively and safely applied in selected settings, but not in nursing home populations. OBJECTIVE To identify potential facilitators and barriers to implementing a strategy to verify penicillin allergies in Veterans Health Administration nursing homes, known as Community Living Centers (CLCs). METHODS We conducted semistructured interviews with staff, patients, and family members at 1 CLC to assess their understanding of penicillin allergies and receptiveness to verifying the allergy. We also asked staff about the proposed allergy assessment strategy, including willingness to delabel by history and feasibility of performing oral challenges or skin testing on their unit. RESULTS From 24 interviews (11 front-line staff, 4 leadership, 3 patients, 6 family members), we identified several facilitators or barriers. Staff recognized the importance of allergy verification and were willing to support and assist in implementing verification strategies. The CLC residents were willing to have their allergy status verified. However, some family members expressed reluctance to verifying their relative's allergy status owing to safety concerns. Front-line staff also expressed concern over having the necessary resources, including time and expertise, to implement the strategy. Staff suggested involving clinical pharmacists and educating staff, patients, and family members as ways to overcome these barriers. CONCLUSIONS Concerns about safety and staff resources are important potential barriers to implementing verification strategies. Involvement of pharmacists and education of both staff and patients and family members will be important components of any successful intervention.
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Affiliation(s)
- Chris Gillespie
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass.
| | - Kailyn Sitter
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass
| | - Kevin W McConeghy
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, RI; Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI
| | - Judith Strymish
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Infectious Diseases, VA Boston Healthcare System, Boston, Mass
| | - Kalpana Gupta
- Division of Infectious Diseases, VA Boston Healthcare System, Boston, Mass; Center for Healthcare Organization and Implementation Research (CHOIR), Boston Campus, VA Boston Healthcare System, Boston, Mass; Department of General Internal Medicine, Boston University School of Medicine, Boston, Mass
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass; Zuckerberg College of Health Sciences, Department of Public Health, University of Massachusetts Lowell, Lowell, Mass
| | - Ann M Borzecki
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford Campus, VA Bedford Healthcare System, Bedford, Mass; Department of General Internal Medicine, Boston University School of Medicine, Boston, Mass; School of Public Health, Department of Health Law, Policy and Management, Boston University School of Public Health, Boston University, Boston, Mass
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16
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Al-Obaydi S, Popadiuk CA, Al-Shaikhly T. Proton pump inhibitors and the risk of acquiring a penicillin allergy label. Intern Med J 2023; 53:1481-1484. [PMID: 37548300 PMCID: PMC10529584 DOI: 10.1111/imj.16197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/04/2023] [Indexed: 08/08/2023]
Abstract
The negative consequences of having a penicillin allergy label are well established. Penicillin allergy de-labelling improves healthcare outcomes; however, less attention is paid to modifying risk factors leading to penicillin allergy development. In this propensity score-matched retrospective cohort study, we used a de-identified population-based database (TriNetX Research Network) and examined the 30-day risk of acquiring a penicillin allergy label in patients using proton pump inhibitors (PPIs). We demonstrated a higher risk of acquiring a penicillin allergy label among PPI users compared to controls.
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Affiliation(s)
- Sarah Al-Obaydi
- Department of Medicine, Penn State College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, U.S.A
| | - Catherine A. Popadiuk
- Division of Pulmonary, Allergy & Critical Care, Department of Medicine, Penn State College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, U.S.A
| | - Taha Al-Shaikhly
- Division of Pulmonary, Allergy & Critical Care, Department of Medicine, Penn State College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, U.S.A
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17
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Oh J, Singh A, Fonseca M, Muppidi M. A Case of Amoxicillin-Induced Drug Reaction With Eosinophilia and Systemic Symptoms (Dress) Syndrome Associated With Significant Reactive Hypereosinophilia (HE): A Case Report. Cureus 2023; 15:e41646. [PMID: 37565132 PMCID: PMC10411546 DOI: 10.7759/cureus.41646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/12/2023] Open
Abstract
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a severe cutaneous drug reaction characterized by a skin rash, eosinophilia, atypical lymphocytosis, and involvement of multiple organs. The mortality rate of DRESS syndrome is moderate, and prompt diagnosis and treatment are essential. When DRESS syndrome is presented with significant hypereosinophilia (HE), it should be differentiated from other conditions that can cause HE through a comprehensive approach to diagnostic evaluation. Amoxicillin has been well-documented as a potential cause of DRESS syndrome. It is important to note that amoxicillin can trigger DRESS syndrome in patients who already have a known allergy to sulfasalazine, as well as when it is administered with a beta-lactamase inhibitor such as clavulanic acid. Here, we describe a case of amoxicillin alone-induced DRESS syndrome associated with significant reactive HE. A 39-year-old female presented with three days of shortness of breath, fatigue, facial swelling, and a generalized maculopapular skin rash. The patient endorsed taking amoxicillin two to three weeks prior to the presentation. Diagnostic tests revealed HE, significant generalized lymphadenopathy on computed tomography (CT) scans of the neck and abdomen, and bilateral interstitial infiltration on a CT scan of the chest suggestive of eosinophilic infiltration. Based on the European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) scoring system, the case was categorized as "probable" DRESS syndrome related to amoxicillin. High-dose steroids were initiated as the treatment of choice for suspected DRESS syndrome. Other potential causes of HE were investigated and ruled out. The patient showed significant clinical improvement, with the normalization of absolute eosinophil count (AEC) and complete resolution of lung infiltrates on a repeat CT scan of the chest. The case highlights the importance of conducting a comprehensive diagnostic evaluation to differentiate DRESS syndrome from other causes of HE when significant HE is present. Prompt treatment with high-dose steroids is essential in managing patients with severe symptoms associated with DRESS syndrome. It is crucial to consider amoxicillin as a potential trigger for DRESS syndrome, even when there is no history of sulfasalazine allergy or concurrent administration of a beta-lactamase inhibitor.
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Affiliation(s)
- Jaha Oh
- Department of Internal Medicine, NYC Health and Hospitals/Lincoln, New York City, USA
| | - Amandeep Singh
- Department of Internal Medicine, NYC Health and Hospitals/Lincoln, New York City, USA
| | - Maira Fonseca
- Department of Dermatology, NYC Health and Hospitals/Lincoln, New York City, USA
| | - Monica Muppidi
- Department of Oncology, NYC Health and Hospitals/Lincoln, New York City, USA
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18
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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] [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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19
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Jones NK, Morris B, Santos R, Nasser S, Gouliouris T. Characterizing Antibiotic Allergy Labels in a Large UK Hospital Population to Inform Antimicrobial Stewardship and Delabeling Assessment Strategy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2180-2189.e4. [PMID: 37088372 DOI: 10.1016/j.jaip.2023.03.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Antibiotic allergy labels are important barriers to treatment and antimicrobial stewardship, but their prevalence in UK hospitals is poorly described. OBJECTIVE To ascertain the prevalence and characteristics of antibiotic allergy labels in a large UK hospital setting and estimate the proportion of penicillin allergy labels for which point-of-care (POC) delabeling assessment would be appropriate. METHODS Electronic health records data were analyzed from all patients treated at Cambridge University Hospitals NHS Foundation Trust in 2019. Validated POC delabeling risk stratification criteria were retrospectively applied to penicillin allergy labels. RESULTS Recorded reactions to antibiotics were present in 11.8% of all patients (32,148 of 273,216), 16.3% of inpatients (13,874 of 85,230), and 9.7% of outpatients (18,274 of 187,986). Penicillins were the commonest reaction precipitant described (9.0% of patients; 24,646 of 273,216), followed by sulfonamides/trimethoprim (1.4%; 3869 of 273,216) and macrolides/lincosamides (1.3%; 3644 of 273,216). A total of 3.9% of inpatients had recorded reactions to >1 antibiotic class (3348 of 85,230). Cutaneous manifestations were the most commonly described reaction features (40.7% of labels; 15,821 of 38,902). Of 15,949 labels describing probable or possible penicillin "allergy" with sufficient detail to allow for the retrospective assessment of POC delabeling suitability, 1702 were deemed suitable for removal or downgrading of the label to "intolerance" without further investigation (10.7%), 11,887 were appropriate for POC assessment using an oral penicillin challenge (OPC) or OPC with prior bedside skin testing (74.5%), and 2360 were identified as unsuitable for any form of POC assessment (14.8%). CONCLUSIONS Antibiotic allergy labels are highly prevalent in a UK hospital setting. A large proportion of penicillin allergy labels may be suitable for POC delabeling assessment.
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Affiliation(s)
- Nick K Jones
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
| | - Bethan Morris
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Reem Santos
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Theodore Gouliouris
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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20
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Christopher DJ, Natania A, Daniel J, Balamugesh T, Isaac B, Krishna MT. Prevalence of drug allergy labels in a tertiary pulmonary service in South India. Clin Exp Allergy 2023. [PMID: 37365847 DOI: 10.1111/cea.14365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023]
Affiliation(s)
| | - Arin Natania
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jefferson Daniel
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Barney Isaac
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mamidipudi Thirumala Krishna
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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21
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Dunham TB, Gardner RM, Lippner EA, Fasani DE, Moir E, Halpern-Felsher B, Sundaram V, Liu AY. Digital Antibiotic Allergy Decision Support Tool Improves Management of β-Lactam Allergies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1243-1252.e6. [PMID: 36736957 PMCID: PMC10085826 DOI: 10.1016/j.jaip.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/20/2022] [Accepted: 01/02/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Frontline providers frequently make time-sensitive antibiotic choices, but many feel poorly equipped to handle antibiotic allergies. OBJECTIVE We hypothesized that a digital decision support tool could improve antibiotic selection and confidence when managing β-lactam allergies. METHODS A digital decision support tool was designed to guide non-allergist providers in managing patients with β-lactam allergy labels. Non-allergists were asked to make decisions in clinical test cases without the tool, and then with it. These decisions were compared using paired t tests. Users also completed surveys assessing their confidence in managing antibiotic allergies. RESULTS The tool's algorithm was validated by confirming its recommendations aligned with that of five allergists. Non-allergist providers (n = 102) made antibiotic management decisions in test cases, both with and without the tool. Use of the tool increased the proportion of correct decisions from 0.41 to 0.67, a difference of 0.26 (95% CI, 0.22-0.30; P < .001). Users were more likely to give full-dose antibiotics in low-risk situations, give challenge doses in medium-risk situations, and avoid the antibiotic and/or consult allergy departments in high-risk situations. A total of 98 users (96%) said the tool would increase their confidence when choosing antibiotics for patients with allergies. CONCLUSIONS A point-of-care clinical decision tool provides allergist-designed guidance for non-allergists and is a scalable system for addressing antibiotic allergies, irrespective of allergist availability. This tool encouraged appropriate antibiotic use in low- and medium-risk situations and increased caution in high-risk situations. A digital support tool should be considered in quality improvement and antibiotic stewardship efforts.
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Affiliation(s)
- Theresa B Dunham
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, Calif.
| | - Rebecca M Gardner
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Elizabeth A Lippner
- Division of Allergy and Immunology, Department of Pediatrics, Anne and Robert H. Lurie Children's Hospital and Northwestern Feinberg School of Medicine, Chicago, Ill
| | | | - Elwyn Moir
- Clinical Observation and Medical Transcription Program, Stanford, Calif
| | - Bonnie Halpern-Felsher
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, Calif
| | - Vandana Sundaram
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Anne Y Liu
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, Calif; Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
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22
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Taylor MG, Joerger T, Anvari S, Li Y, Gerber JS, Palazzi DL. The Quality and Management of Penicillin Allergy Labels in Pediatric Primary Care. Pediatrics 2023; 151:e2022059309. [PMID: 36740967 PMCID: PMC10680064 DOI: 10.1542/peds.2022-059309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Penicillin allergy labels are the most common drug allergy label. The objective of this study was to describe the quality and management of penicillin allergy labels in the pediatric primary care setting. METHODS Retrospective chart review of 500 of 18 015 children with penicillin allergy labels born from January 1, 2010 to June 30, 2020 randomly selected from an outpatient birth cohort from Texas Children's Pediatrics and Children's Hospital of Philadelphia networks. Penicillin allergy risk classification ("not allergy," "low risk," "moderate or high risk," "severe risk," "unable to classify") was determined based on documentation within (1) the allergy tab and (2) electronic healthcare notes. Outcomes of allergy referrals and penicillin re-exposure were noted. RESULTS Half of penicillin allergy labels were "unable to classify" based on allergy tab documentation. Risk classification agreement between allergy tabs and healthcare notes was fair (Cohen's ĸ = 0.35 ± 0.02). Primary care physicians referred 84 of 500 (16.8%) children to an allergist, but only 54 (10.8%) were seen in allergy clinic. All children who were challenged (25 of 25) passed skin testing. Removal of allergy labels was uncommon (69 of 500, 13.8%) but occurred more often following allergy appointments (26 of 54, 48%) than not (43 of 446, 9.6%, P < .001). Children delabeled by primary care physicians were as likely to tolerate subsequent penicillin-class antibiotics as those delabeled by an allergist (94% vs 93%, P = .87). CONCLUSIONS Penicillin allergy documentation within the allergy tab was uninformative, and children were infrequently referred to allergists. Future quality improvement studies should improve penicillin allergy documentation and expand access to allergy services.
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Affiliation(s)
- Margaret G Taylor
- Division of Infectious Diseases
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Torsten Joerger
- Division of Infectious Diseases
- Division of Immunology, Allergy, and Retrovirology
| | - Sara Anvari
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
- Division of Immunology, Allergy, and Retrovirology
| | - Yun Li
- Division of Immunology, Allergy, and Retrovirology
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness
- Department of Biostatistics, Epidemiology, and Informatics
| | - Jeffrey S Gerber
- Division of Infectious Diseases
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debra L Palazzi
- Division of Infectious Diseases
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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23
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Michaud L, Yen HH, Engen DA, Yen D. Outcome of preoperative cefazolin use for infection prophylaxis in patients with self-reported penicillin allergy. BMC Surg 2023; 23:32. [PMID: 36755308 PMCID: PMC9906882 DOI: 10.1186/s12893-023-01931-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 02/01/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Cephalosporins are the preferred antibiotics for prophylaxis against surgical site infections. Most studies give a rate of combined IgE and non-IgE penicillin allergy yet it is recommended that cephalosporins be avoided in patients having the former but can be used in those with the latter. Some studies use penicillin allergy while others penicillin family allergy rates. The primary goal of this study was to determine the rates of IgE and non-IgE allergy as well as cross reactions to both penicillin and the penicillin family. Secondary goals were to determine the surgical services giving preoperative cefazolin and the types of self reported reactions that patients' had to penicillin prompting their allergy status. METHODS All patients undergoing elective and emergency surgery at a University Health Sciences Centre were retrospectively studied. The hospital electronic medical record was used for data collection. RESULTS 8.9% of our patients reported non-IgE reactions to penicillin with a cross reactivity rate of 0.9% with cefazolin. 4.0% of our patients reported IgE reactions to penicillin with a cross reactivity rate of 4.0% with cefazolin. 10.5% of our patients reported non-IgE reactions to the penicillin family with a cross reactivity rate of 0.8% with cefazolin. 4.3% of our patients reported IgE reactions to the penicillin family with a cross reactivity rate of 4.0% with cefazolin. CONCLUSIONS Our rate of combined IgE and non-IgE reactions for both penicillin and penicillin family allergy was within the range reported in the literature. Our rate of cross reactivity between cefazolin and combined IgE and non-IgE allergy both to penicillin and the penicillin family were lower than reported in the old literature but within the range of the newer literature. We found a lower rate of allergic reaction to a cephalosporin than reported in the literature. We documented a wide range of IgE and non-IgE reactions. We also demonstrated that cefazolin is frequently the preferred antibiotics for prophylaxis against surgical site infections by many surgical services and that de-labelling patients with penicillin allergy is unnecessary.
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Affiliation(s)
- Laura Michaud
- grid.410356.50000 0004 1936 8331Department of Surgery, Queen’s University, Kingston, ON Canada
| | - Hope H. Yen
- grid.410356.50000 0004 1936 8331Department of Biostatistics, Queen’s University, Kingston, ON Canada
| | - Dale A. Engen
- grid.410356.50000 0004 1936 8331Department of Anaesthesia and Perioperative Medicine, Queen’s University, Kingston, ON Canada
| | - David Yen
- Department of Surgery, Queen's University, Kingston, ON, Canada.
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24
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Impact of Patient-Reported Penicillin Allergy on Antibiotic Prophylaxis and Surgical Site Infection Among Patients Undergoing Colorectal Surgery. Dis Colon Rectum 2022; 65:1397-1404. [PMID: 34856589 DOI: 10.1097/dcr.0000000000002190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surgical site infections are a major preventable source of morbidity, mortality, and increased health care expenditures after colorectal surgery. Patients with penicillin allergy may not receive the recommended preoperative antibiotics, putting them at increased risk for surgical site infections. OBJECTIVE This study aimed to evaluate the impact of patient-reported penicillin allergy on preoperative antibiotic prophylaxis and surgical site infection rates among patients undergoing major colon and rectal procedures. DESIGN This is a retrospective observational study. SETTING This study was conducted at a tertiary teaching hospital in Dallas. PATIENTS Adults undergoing colectomy or proctectomy between July 2012 and July 2019 were included. MAIN OUTCOME MEASURES The primary outcomes measured were preoperative antibiotic choice and surgical site infection. RESULTS Among 2198 patients included in the study, 12.26% (n = 307) reported a penicillin allergy. Patients with penicillin allergy were more likely to be white (82%) and female (54%; p < 0.01). The most common type of allergic reaction reported was rash (36.5%), whereas 7.2% of patients reported anaphylaxis. Patients with self-reported penicillin allergy were less likely to receive beta-lactam antibiotics than patients who did not report a penicillin allergy (79.8% vs 96.7%, p < 0.001). Overall, 143 (6.5%) patients had surgical site infections. On multivariable logistic regression, there was no difference in rates of surgical site infection between patients with penicillin allergy vs those without penicillin allergy (adjusted OR 1.14; 95% CI, 0.71-1.82). LIMITATIONS A limitation of this study was its retrospective study design. CONCLUSIONS Self-reported penicillin allergy among patients undergoing colorectal surgery is common; however, only a small number of these patients report any serious adverse reactions. Patients with self-reported penicillin allergy are less likely to receive beta-lactam antibiotics and more likely to receive non-beta-lactam antibiotics. However, this does not affect the rate of surgical site infection among these patients, and these patients can be safely prescribed non-beta-lactam antibiotics without negatively impacting surgical site infection rates. See Video Abstract at http://links.lww.com/DCR/B838 .IMPACTO DE LA ALERGIA A LA PENICILINA INFORMADA POR EL PACIENTE EN LA PROFILAXIS ANTIBIÓTICA Y LA INFECCIÓN DEL SITIO OPERATORIO ENTRE PACIENTES DE CIRUGÍA COLORECTAL. ANTECEDENTES Las infecciones del sitio operatorio son una de las principales fuentes prevenibles de morbilidad, mortalidad y aumento del gasto sanitario después de cirugía colorrectal. Es posible que los pacientes con alergia a la penicilina no reciban los antibióticos preoperatorios recomendados, lo que los pone en mayor riesgo de infecciones en el sitio operatorio. OBJETIVO Este estudio tuvo como objetivo evaluar el impacto de la alergia a la penicilina informada por el paciente sobre la profilaxis antibiótica preoperatoria y las tasas de infección del sitio operatorio entre pacientes sometidos a procedimientos mayores de colon y recto. DISEO Estudio observacional retrospectivo. AJUSTE Hospital universitario terciario en Dallas. PACIENTES Adultos sometidos a colectomía o proctectomía entre julio de 2012 a julio de 2019. PRINCIPALES MEDIDAS DE DESENLACE Elección de antibióticos preoperatorios e infección del sitio operatorio. RESULTADOS Entre los 2198 pacientes incluidos en el estudio, el 12,26% (n = 307) informó alergia a la penicilina. Los pacientes con alergia a la penicilina tenían más probabilidades de ser blancos (82%) y mujeres (54%) ( p < 0,01). El tipo más común de reacción alérgica notificada fue erupción cutánea (36,5%), mientras que el 7,2% de los pacientes notificó anafilaxia. Los pacientes con alergia a la penicilina autoinformada tenían menos probabilidades de recibir antibióticos betalactámicos en comparación con los pacientes que no informaron alergia a la penicilina (79,8% frente a 96,7%, p < 0,001). En general, hubo 143 (6,5%) pacientes con infecciones del sitio operatorio. En la regresión logística multivariable no hubo diferencias en las tasas de infección del sitio operatorio entre los pacientes con alergia a la penicilina frente a los que no tenían alergia a la penicilina (razón de probabilidades ajustada 1,14; intervalo de confianza del 95%, 0,71-1,82). LIMITACIONES Diseño de estudio retrospectivo. CONCLUSIONES La alergia a la penicilina autoinformada entre los pacientes de cirugía colorrectal es común, sin embargo, solo un pequeño número de estos pacientes informan reacciones adversas graves. Los pacientes con alergia a la penicilina autoinformada tienen menos probabilidades de recibir antibióticos betalactámicos y más probabilidades de recibir antibióticos no betalactámicos. Sin embargo, esto no afecta la tasa de infección del sitio quirúrgico entre estos pacientes y se les puede recetar de forma segura con antibióticos no betalactámicos sin afectar negativamente las tasas de infección del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/B838 . (Traducción-Dr. Juan Carlos Reyes ).
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25
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Negishi S, Miyao K, Ohara F, Motegi K, Wakabayashi H, Yokota H, Kuwano S, Takeuchi Y, Sawa H, Inagaki Y, Sawa M. Feasibility of trimethoprim/sulfamethoxazole desensitization therapy in hematological diseases. Clin Exp Med 2022:10.1007/s10238-022-00868-3. [PMID: 35976516 DOI: 10.1007/s10238-022-00868-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/22/2022] [Indexed: 11/29/2022]
Abstract
The effectiveness and safety of trimethoprim/sulfamethoxazole (TMP/SMX) desensitization therapy is insufficiently evaluated in hematological diseases. From 2002 to 2019, we retrospectively analyzed 112 patients with hematological diseases who underwent desensitization therapy after TMP/SMX prophylaxis withdrawal due to adverse events. They orally started TMP/SMX at 0.4 mg/2 mg, which was then increased daily to 80 mg/400 mg for 5 or 9 days. Eighty-eight patients (79%) had complete desensitization, and the major reason for failure was rash seen in 21 cases (19%). The cause of desensitization and reasons for failure matched in 22 cases (92%). Pneumocystis pneumonia was not observed throughout the study. In the failure group, the number of eosinophils and alanine aminotransferase (ALT) levels were significantly increased after desensitization. In particular in the failure group, the slight increase in eosinophils was seen through the beginning to halfway during desensitization (36/μL (0-900/μL) and 48/μL (0-2560/μL), respectively, p = 0.025). These data show that TMP/SMX desensitization therapy is effective and safe in hematological diseases. The recurrence of adverse events could help predict desensitization success.
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Affiliation(s)
- Shuto Negishi
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan.
| | - Kotaro Miyao
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Fumiya Ohara
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Kenta Motegi
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Hiroya Wakabayashi
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Hirofumi Yokota
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Shihomi Kuwano
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Yuki Takeuchi
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Hitomi Sawa
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Yuichiro Inagaki
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Masashi Sawa
- Department of Hematology and Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi, 446-8602, Japan
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26
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DesBiens MT, Calderwood MS, Reigh EL. Expanding Penicillin Allergy Evaluation in Hospitalized Patients. Am J Med 2022; 135:958-963.e13. [PMID: 35339433 DOI: 10.1016/j.amjmed.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/08/2021] [Accepted: 12/08/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Martha T DesBiens
- Department of Medicine, Section of Infectious Disease, Nuvance Health, Southbury, Conn; The Robert Larner M.D. College of Medicine at The University of Vermont, Burlington; Department of Medicine, Section of Infectious Disease & International Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - Michael S Calderwood
- Department of Medicine, Section of Infectious Disease & International Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Erin L Reigh
- Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Medicine, Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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27
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Zhang HL, Anesi JA, Hamilton KW, Cressman L, Bilker WB, Lautenbach E. The Impact of Reported β-Lactam Allergy on Clinical Outcomes and Antibiotic Use Among Solid Organ Transplant Recipients. Open Forum Infect Dis 2022; 9:ofac384. [PMID: 35983261 PMCID: PMC9379814 DOI: 10.1093/ofid/ofac384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background Reported β-lactam allergies (BLAs) are common and frequently inaccurate, but there are limited data on the clinical implications of BLA among solid organ transplant (SOT) recipients. We examined the impact of BLA on clinical outcomes and antibiotic use among SOT recipients. Methods This retrospective cohort study included adult patients undergoing single-organ heart, kidney, liver, lung, or pancreas transplant at a United States academic medical center from 1 April 2017 to 31 December 2020. Demographic and clinical data were collected from the electronic health record. Multivariate median regression was performed to evaluate the association between BLA and days alive and out of the hospital in the first 180 days posttransplant (DAOH180). Multivariate logistic regression was performed to evaluate the association between BLA and antibiotic use. Results Among 1700 SOT recipients, 285 (16.8%) had a BLA at the time of transplant. BLA was not associated with DAOH180 (adjusted median difference, -0.8 days [95% confidence interval {CI}, -2.7 to 1.2]; P = .43). Patients with BLA were more likely to receive intravenous vancomycin (adjusted odds ratio [aOR], 1.8 [95% CI, 1.3-2.6]; P < .001), clindamycin (aOR, 9.9 [95% CI, 5.1-18.9]; P < .001), aztreonam (aOR, 19.6 [95% CI, 5.9-64.4]; P < .001), fluoroquinolones (aOR, 3.8 [95% CI, 2.8-5.0]; P < .001), or aminoglycosides (aOR, 3.9 [95% CI, 2.5-6.2]; P < .001). Conclusions BLA was associated with use of β-lactam alternative antibiotics but not DAOH180 among SOT recipients.
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Affiliation(s)
- Helen L Zhang
- Correspondence: Helen L. Zhang, MD, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 Silverstein Ste. E, Philadelphia, PA 19104, USA ()
| | - Judith A Anesi
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Keith W Hamilton
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Leigh Cressman
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Warren B Bilker
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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28
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Wang XM, Kennard L, Rutkowski K, Bruco MEF, Mirakian R, Wagner A. Amoxicillin hypersensitivity: patient outcomes in a seven-year retrospective study. Ann Allergy Asthma Immunol 2022; 129:507-514.e2. [PMID: 35788420 DOI: 10.1016/j.anai.2022.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The beta-lactam antibiotic amoxicillin and the beta-lactamase inhibitor clavulanic acid in combination with amoxicillin are known to both cause immediate and non-immediate type hypersensitivity. OBJECTIVE To characterize a large cohort of patients with a history of amoxicillin or amoxicillin-clavulanic acid hypersensitivity. METHODS Retrospective analysis of demographics, presentation, investigation, and management of 331 patients presenting to one allergy center with a history of hypersensitivity to amoxicillin or amoxicillin-clavulanic acid. RESULTS Hypersensitivity was confirmed in 37/221 (17%) patients who took amoxicillin and 47/110 (43%) patients who took amoxicillin-clavulanic acid as the index drug. In immediate hypersensitivity, skin testing confirmed the diagnosis in 66/139 (47%) patients. Penicillin cross-reactivity was observed in 16/36 (44%). 13/16 (81%) cross-reactive patients reacted to amoxicillin-clavulanic acid as the index drug. All skin test negative patients (73/139) underwent drug provocation. The negative predictive value of skin tests was 89%. In non-immediate hypersensitivity, delayed intradermal tests confirmed diagnosis in 12/170 (7%). 8/12 (67%) skin test positive patients presented with DRESS. All skin test negative patients (158/170) underwent drug provocation. The negative predictive value of skin tests was 95%. Penicillin cross-reactivity was observed in 3/12 (25%). Ten patients were diagnosed with hypersensitivity to clavulanic acid. CONCLUSION The negative predictive value of skin tests in both immediate and non-immediate hypersensitivity reactions is excellent and excludes severe allergy. Non-immediate hypersensitivity is rare. Confirmed hypersensitivity is more likely if amoxicillin-clavulanic acid is the index drug. Cross-reactivity was more common in patients presenting with immediate hypersensitivity, most commonly involving benzylpenicillin. A minority of patients were allergic to clavulanic acid.
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Affiliation(s)
- Xingyue Maria Wang
- Oxford University Hospitals, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
| | - Lucinda Kennard
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Krzysztof Rutkowski
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Rita Mirakian
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Annette Wagner
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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29
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Hampton LL, DeBoy JT, Hornik CP, White MJ, Nazareth-Pidgeon KM. Association of Sociodemographic Factors With Reported Penicillin Allergy in Pediatric Inpatients. Hosp Pediatr 2022; 12:625-631. [PMID: 35660855 DOI: 10.1542/hpeds.2021-006462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Characterize the association of sociodemographic factors with reported penicillin allergy in pediatric inpatients. METHODS We conducted a retrospective cohort study of pediatric inpatients admitted to general pediatric units at an academic medical center with reported penicillin allergy and reaction history. Sociodemographic factors evaluated were gender, age, race, ethnicity, language, and insurance payer. We conducted univariable and multivariable logistic regression models to evaluate associations between demographic variables and penicillin allergy. RESULTS Of 3890 pediatric inpatients, 299 (7.7%) had a reported penicillin allergy. The majority of documented reaction histories were hives, rash, or unknown. In univariable analysis, odds of penicillin allergy were lower in patients who identify as Black and who prefer a language other than English, and higher in patients of non-Hispanic/Latino ethnicity, those with private insurance, and with increasing age. In multivariable logistic regression, only Black race (adjusted odds ratio 0.42, 95% confidence interval CI 0.30-0.59) and young age were significantly associated with lower odds of penicillin allergy. CONCLUSIONS After adjustment for covariates, Black race was associated with lower odds of reported penicillin allergy in hospitalized children. Penicillin allergy reporting may be an indicator of racial differences in the prescribing of antimicrobial agents, patient-clinician communication, and access to health care.
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Affiliation(s)
- Laura L Hampton
- Division of Hospital Medicine, Department of Pediatrics, and
| | - Jason T DeBoy
- Management Engineer Team, Department of Performance Services; and
| | - Christoph P Hornik
- Department of Pediatrics, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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30
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Miceli LM, Chang OH, Zhang S, Yao M, Propst K. Antimicrobial Stewardship in Patients with Penicillin Allergy Undergoing Hysterectomy for Benign Indications. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2021.0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lia M. Miceli
- Department of Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Olivia H. Chang
- Department of Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Salina Zhang
- Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Katie Propst
- Department of Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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31
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Hughes KM, Price D, Torriero AAJ, Symonds MRE, Suphioglu C. Impact of Fungal Spores on Asthma Prevalence and Hospitalization. Int J Mol Sci 2022; 23:ijms23084313. [PMID: 35457129 PMCID: PMC9025873 DOI: 10.3390/ijms23084313] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 02/06/2023] Open
Abstract
Despite making up a significant proportion of airborne allergens, the relationship between fungal spores and asthma is not fully explored. Only 80 taxa of fungi have so far been observed to exacerbate respiratory presentations, with Cladosporium spp., Aspergillus spp., Penicillium spp., and Alternaria spp. found to comprise the predominant allergenic airborne spores. Fungal spores have been found in indoor environments, such as hospitals and housing due to poor ventilation. Meanwhile, outdoor fungal spores exhibit greater diversity, and higher abundance and have been associated with hospitalizations from acute asthma presentations. In addition, fungal spores may be the underlying, and perhaps the “missing link”, factor influencing the heightened rate of asthma presentations during epidemic thunderstorm asthma events. To improve our knowledge gap on fungal spores, airborne allergen monitoring must be improved to include not only dominant allergenic fungi but also provide real-time data to accurately and quickly warn the general public. Such data will help prevent future asthma exacerbations and thus save lives. In this review, we examine the health risks of prominent allergenic fungal taxa, the factors influencing spore dispersal and distribution, and why improvements should be made to current sampling methods for public health and wellbeing.
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Affiliation(s)
- Kira M. Hughes
- NeuroAllergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia; (K.M.H.); (D.P.)
- Deakin AIRwatch Pollen and Spore Counting and Forecasting Facility, Deakin University, Burwood, VIC 3125, Australia
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), Deakin University, 75 Pigdons Road, Waurn Ponds, VIC 3216, Australia
| | - Dwan Price
- NeuroAllergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia; (K.M.H.); (D.P.)
- Deakin AIRwatch Pollen and Spore Counting and Forecasting Facility, Deakin University, Burwood, VIC 3125, Australia
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), Deakin University, 75 Pigdons Road, Waurn Ponds, VIC 3216, Australia
- NeuroAllergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 75 Pigdons Road, Waurn Ponds, VIC 3216, Australia
- COVID-19 Response, Department of Health, 50 Lonsdale Street, Melbourne, VIC 3000, Australia
| | - Angel A. J. Torriero
- School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia;
| | - Matthew R. E. Symonds
- Centre for Integrative Ecology, School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia;
| | - Cenk Suphioglu
- NeuroAllergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia; (K.M.H.); (D.P.)
- Deakin AIRwatch Pollen and Spore Counting and Forecasting Facility, Deakin University, Burwood, VIC 3125, Australia
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), Deakin University, 75 Pigdons Road, Waurn Ponds, VIC 3216, Australia
- NeuroAllergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 75 Pigdons Road, Waurn Ponds, VIC 3216, Australia
- Correspondence: ; Tel.: +61-3-5227-2886
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Iuliano S, Senn L, Moi L, Muller YD, Ribi C, Buss G, Comte D. Management of Beta-Lactam Antibiotics Allergy: A Real-Life Study. FRONTIERS IN ALLERGY 2022; 3:853587. [PMID: 35769578 PMCID: PMC9234877 DOI: 10.3389/falgy.2022.853587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
Beta-lactam allergy is a common problem in everyday medical practice and is recognized as a major public health issue. Carrying this label frequently leads to the avoidance of all beta-lactam antibiotics, favoring the use of other less preferred classes of antibiotics, that are more expensive and associated with more side effects and increased antimicrobial resistance. Therefore, delabeling a beta-lactam allergy is part of antimicrobial stewardship programs. Herein, we retrospectively examined the clinical records of 576 patients who were referred to our center for a label of allergy to beta-lactam antibiotics and were systematically investigated following a standardized algorithm. Our main aim was to evaluate the frequency of confirmed immediate- and delayed-type allergy to commonly prescribed subclasses of beta-lactam antibiotics (penicillin and cephalosporin), as well as the negative predictive value (NPV) and the sensitivity of skin tests. Our secondary aims were to examine the safety of beta-lactam skin testing and drug challenge. We identified that 260 patients reported a history of immediate reactions, 131 of delayed reactions, and 114 of unknown timing or mechanism of reactions. Following assessment and testing, 86 (18.3%) patients had a confirmed allergy to any beta-lactam antibiotics; 63 (13.4%) with an immediate- and 23 (4.9%) with a delayed-type reaction. Most frequently identified confirmed allergy was to penicillins (65 patients), followed by cephalosporins (21 patients). When immediate-type reactions were examined, NPV of skin tests were 96.3% and 100% for penicillins and cephalosporins, respectively. When delayed reactions were considered, NPV were 91.9 and 87.5% for penicillins and cephalosporins, respectively. Evaluation of the safety of skin tests according to the standardized procedure showed that systemic allergic reactions occurred in only 0.7% of skin tests and in 3.1% of drug challenges. Overall, our data indicate that only 18.3% of patients with a beta-lactam allergy label have a confirmed allergy and non-allergic patients can be safely delabeled through allergic workup based on skin tests and drug challenge. This approach supports the policy of saving second-line antibiotics through a standardized allergy workup.
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Affiliation(s)
- Sarah Iuliano
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Laurence Senn
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Service of Hospital Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Laura Moi
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Yannick D. Muller
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Camillo Ribi
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Guillaume Buss
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Denis Comte
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- *Correspondence: Denis Comte
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Taylor MG, Joerger T, Li Y, Scheurer ME, Russo ME, Gerber JS, Palazzi DL. Factors Associated With Penicillin Allergy Labels in Electronic Health Records of Children in 2 Large US Pediatric Primary Care Networks. JAMA Netw Open 2022; 5:e222117. [PMID: 35285918 PMCID: PMC9907342 DOI: 10.1001/jamanetworkopen.2022.2117] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/19/2022] [Indexed: 12/17/2022] Open
Abstract
Importance Penicillin allergy labels influence clinical decision-making, yet most children who are labeled do not have type 1 hypersensitivity allergic reactions and instead have a history of predictable adverse reactions or unspecified illness symptoms while receiving penicillin for viral infections. Studies describing penicillin allergy labeling in the pediatric outpatient setting are lacking. Objective To describe the epidemiology and factors associated with penicillin allergy labels across 2 large US pediatric primary care networks. Design, Setting, and Participants This retrospective, longitudinal birth cohort study was conducted in 90 primary care pediatric practices serving a diverse population of children across Houston, Texas, Austin, Texas, Philadelphia, Pennsylvania, and parts of New Jersey. Participants were children born between January 2010 and June 2020 who had a health care visit in the first 14 days of life and at least 2 additional visits in the first year of life at one of 90 primary care pediatric practices. Censoring criteria were additionally applied to exclude data from children no longer seeking health care in the 90 clinics over time. Statistical analysis was performed from February to May 2021. Exposures Basic patient demographics, health care utilization, penicillin exposure, and primary clinic location. Main Outcomes and Measures Addition of penicillin allergy label in the electronic medical record. Results Among 334 465 children in the birth cohort, 164 173 (49.1%) were female; 72 831 (21.8%) were Hispanic, 59 598 (17.8%) were non-Hispanic Black, and 148 534 (44.4%) were non-Hispanic White; the median (IQR) age at censoring was 3.8 (1.7-6.6) years; 18 015 (5.4%) were labeled as penicillin allergic, but the prevalence of penicillin allergy labeling ranged from 0.9% to 10.2% across practices. Children were labeled at a median (IQR) age of 1.3 (0.9-2.3) years. Non-Hispanic White children were more likely to be labeled compared with non-Hispanic Black children after controlling for potential confounders (adjusted odds ratio, 1.7 [95% CI, 1.6-1.8]). There were 6797 allergic children (37.7%) labeled after receiving 1 penicillin prescription and 1423 (7.9%) labeled after receiving 0 penicillin prescriptions. Conclusions and Relevance In this cohort study of more than 330 000 children, penicillin allergy labeling was common and varied widely across practices. Children were labeled early in life, and almost half were labeled after receiving 1 or 0 penicillin prescriptions. These findings raise questions regarding the validity of penicillin allergy labels. Future work exploring the fidelity of and outcomes associated with penicillin allergy-labeling in children is warranted.
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Affiliation(s)
- Margaret G. Taylor
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston
| | - Torsten Joerger
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Now with Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital Stanford, Stanford
| | - Yun Li
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children’s, Phildelphia
| | - Michael E. Scheurer
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston
| | - Michael E. Russo
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jeffrey S. Gerber
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Debra L. Palazzi
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston
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Zembles TN, Vyles DE, Mitchell ML. Management of Children with Reported Penicillin Allergies. Infect Dis Clin North Am 2022; 36:219-229. [DOI: 10.1016/j.idc.2021.11.001] [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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Improving Antibiotic Stewardship for Inpatients with Reported Beta-Lactam Allergies and Limited Access to Penicillin Skin Testing. Jt Comm J Qual Patient Saf 2022; 48:147-153. [PMID: 35031256 PMCID: PMC8885903 DOI: 10.1016/j.jcjq.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Penicillin allergy is commonly reported, but true allergy is rare. Inpatients with reported beta-lactam allergy are often treated with alternative antibiotics. Penicillin skin testing (PST) is not universally available for inpatients. METHODS We designed a four-phase quality improvement project aimed to increase the percentage of inpatients on medical services with reported beta-lactam allergy who safely receive beta-lactam antibiotics at two hospitals with limited access to PST. First, we updated our hospital guideline to allow for cephalosporin graded challenge without antecedent PST. Second, we educated physicians, physician assistants, and nurses about the new guideline and beta-lactam allergy classification and management. Third, we designed a pocket card to reinforce the education. Last, we used antimicrobial stewardship software to screen our daily census to identify opportunities to improve management of patients with reported beta-lactam allergies. RESULTS We observed a 29.2% increase in the percentage of patients who received beta-lactam antibiotics (excluding carbapenems) among those with reported beta-lactam allergy, from 42.2% (470/1,115) at baseline to 54.5% (379/696), p < 0.001, during the project period. There was a decrease in the use of alternative antibiotics, no change in hospital-onset Clostridioides difficile cases, and no increase in the number of infectious disease or allergy consults. The number of graded challenges increased during the project period, without any anaphylaxis events. CONCLUSION A multiphase quality improvement project aimed to improve management of beta-lactam allergies and access to graded challenges led to an increase in beta-lactam utilization without an increase in anaphylaxis, even with limited access to PST.
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Beddow D, Patel L, Smith CS, Kirven J, Schmidt C, Ruppman D, Kethireddy R, Wankum M, Dawud B, St Hill CA. Outcomes in hospitalised patients with sepsis, severe sepsis or septic shock and reported penicillin allergy: a retrospective cohort study. BMJ Open 2022; 12:e050879. [PMID: 35197334 PMCID: PMC8867335 DOI: 10.1136/bmjopen-2021-050879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To determine outcomes in hospitalised patients with sepsis and reported penicillin allergy (PcnA). DESIGN Observational retrospective cohort study using data from electronic health records. SETTING A large single health system with 11 hospitals of small, medium and large sizes including a 630-bed tertiary care teaching hospital. PARTICIPANTS Patients (n=5238) ≥18 years of age, hospitalised with sepsis, severe sepsis or septic shock between 1 January 2016 and 31 December 2018, received antibacterial agents, and had documented PcnA status. Patients <18 years of age at admission were excluded. OUTCOME MEASURES Primary outcomes evaluated were inpatient mortality and 30-day mortality posthospital discharge. Secondary outcomes were hospital length of stay, 30-day readmissions, duration of antibiotic use, rate of Clostridium difficile infection and total cost of care. RESULTS There was no difference in outcomes including inpatient or 30-day mortality, hospital length of stay, in-hospital antibiotic duration, C. difficile infection, total cost of care and 30-day readmission rate between patients labelled with a PcnA vs patients who did not report PcnA (non-PcnA). CONCLUSION In this retrospective single health system study, there was no difference in key outcomes including inpatient or 30-day mortality in patients admitted with sepsis and reported PcnA compared with patients who reported no PcnA.
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Affiliation(s)
- David Beddow
- Internal Medicine, Allina Health, Minneapolis, Minnesota, USA
| | - Love Patel
- Internal Medicine, Allina Health, Minneapolis, Minnesota, USA
| | - Claire S Smith
- Care Delivery Research, Allina Health, Minneapolis, Minnesota, USA
| | - Justin Kirven
- Internal Medicine, Allina Health, Minneapolis, Minnesota, USA
| | - Christine Schmidt
- Graduate Medical Education, Allina Health, Minneapolis, Minnesota, USA
| | - Daniel Ruppman
- Internal Medicine, Allina Health, Minneapolis, Minnesota, USA
| | | | | | - Barite Dawud
- Care Delivery Research, Allina Health, Minneapolis, Minnesota, USA
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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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Anstey KM, Tsao L, Otani IM. Drug Allergy Delabeling Programs: Recent Strategies and Targeted Populations. Clin Rev Allergy Immunol 2022; 62:484-504. [PMID: 35031956 DOI: 10.1007/s12016-021-08913-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 12/12/2022]
Abstract
Drug allergy delabeling programs have become an essential element of antibiotic stewardship. Development of delabeling programs involves careful selection of target patient population, thoughtful design of delabeling approach, stakeholder engagement, assembly of key team members, implementation, and evaluation of clinical and safety outcomes. Recent programs have targeted patients thought to be most likely to benefit from removal of inaccurate antibiotic allergy labels, those with β-lactam antibiotic allergies and high-risk populations likely to need β-lactam antibiotics as first-line treatment. This review provides an overview of current risk stratification methods and β-lactam cross-reactivity data and summarizes how different inpatient and outpatient delabeling programs have used these concepts in delabeling algorithms. β-Lactam delabeling programs for inpatients, pediatric patients, and programs utilizing telehealth have been implemented with good outcomes. This review also focuses on delabeling programs for high-risk populations likely to benefit from first-line β-lactam antibiotics. These populations include perioperative, prenatal, and immunocompromised patients. Delabeling programs have been successful in the inpatient and outpatient settings at enabling appropriate antibiotic use. This article reviews delabeling strategies utilized by these programs with a focus on highlighting elements key to their success and future areas for innovation.
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Affiliation(s)
- Karen M Anstey
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code UHN67, Portland, OR, 97239, USA.
| | - Lulu Tsao
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
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Gaberino CL, Chiu AM, Mahatme SS. The effects of beta-lactam allergy relabeling on antibiotic prescribing practices. Ann Allergy Asthma Immunol 2021; 128:307-313. [PMID: 34890777 DOI: 10.1016/j.anai.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/05/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Beta-lactam antibiotic allergy labels are highly prevalent but rarely indicate an allergic intolerance. These patient-reported allergies lead to broad-spectrum antibiotic use, conferred resistance, increased expense, and adverse effects. OBJECTIVE To implement and assess the impact of a history-based clinical guideline that directs antibiotic management and beta-lactam allergy relabeling for patients reporting beta-lactam allergies. METHODS Patients with beta-lactam allergy labels were identified by our trained multidisciplinary team in diverse clinical settings. This quality improvement project was conducted to evaluate the safety and impact of the guideline on antibiotic use by comparing prescribing practices before and after guideline implementation. RESULTS A total of 79 patients with beta-lactam allergies were identified (penicillins-90%, cephalosporins-10%). After guideline implementation, outcomes of allergy relabeling included the following: (1) complete removal, indicating an unlikely true allergy (27%); (2) updated to detail successfully tolerated beta-lactam courses (48%); or (3) no change made to current label (25%). Beta-lactam antibiotic courses before and after guideline implementation compared with total antibiotic courses: allergy removed (44% vs 70%; P < .001), allergy updated (32% vs 68%; P < .001), and no change (27% vs 41%; P = .08). Compared with before guideline implementation, beta-lactam antibiotics were 3 times more likely to be prescribed after allergy assessment (odds ratio, 3.22; 95% confidence interval, 2.4-4.3; P < .05). CONCLUSION The implementation of the beta-lactam allergy clinical guideline resulted in most patients' allergy labels being removed or advantageously updated. These allergy label changes correlated with a substantial increase in the percentage of beta-lactam antibiotics prescribed. After guideline implementation, beta-lactam antibiotics had a 3-fold increased odds of being prescribed independent of allergy label outcome.
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Affiliation(s)
- Courtney L Gaberino
- Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Asriani M Chiu
- Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; Division of Asthma, Allergy, and Clinical Immunology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sheran S Mahatme
- Medical College of Wisconsin, Milwaukee, Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Barbosa C, Breck A, King G, Bass S, Kook Y, Honeycutt A, Esposito D. Impact analysis of expanding narrow-spectrum antibiotic use for children with ear, sinus and throat infections. J Comp Eff Res 2021; 11:89-98. [PMID: 34792402 DOI: 10.2217/cer-2021-0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Estimate the impacts treating acute respiratory tract infections (ARTIs) in children aged 6 months through 12 years with narrow-spectrum antibiotics. Materials & methods: Decision-tree model to estimate children's health, healthcare utilization and costs, and caregiver's time and costs for using narrow-spectrum antibiotics in eligible children with an ARTI, compared with current use of narrow- and broad-spectrum antibiotics. Results: Reduced adverse drug reactions by 35,750 (14%) cases) and 4750 (12%) fewer emergency department visits, 300 (12%) fewer hospitalizations, and 50,500 (10%) avoided outpatient visits. Annual healthcare costs fell by US$120 million (22%). Total societal costs declined by US$131 million (20%). Conclusion: National implementation of narrow-spectrum antibiotics to treat ARTIs in children improves patient outcomes and reduces caregiver burden and annual healthcare costs.
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Affiliation(s)
- Carolina Barbosa
- RTI International, Health Economics Program, Research Triangle Park, Durham, NC 27709-2194, USA
| | - Andrew Breck
- Insight Policy Research, Arlington, VA 22209 USA
| | - Grant King
- RTI International, Health Economics Program, Research Triangle Park, Durham, NC 27709-2194, USA
| | - Sarah Bass
- RTI International, Health Economics Program, Research Triangle Park, Durham, NC 27709-2194, USA
| | - Yoojin Kook
- Insight Policy Research, Arlington, VA 22209 USA
| | - Amanda Honeycutt
- RTI International, Health Economics Program, Research Triangle Park, Durham, NC 27709-2194, USA
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Mitchell AB, Ness RA, Bennett JG, Bowden JE, Elliott WV, Gillion AR, Pattanaik DN. Implementation and Impact of a β-Lactam Allergy Assessment Protocol in a Veteran Population. Fed Pract 2021; 38:420-425. [PMID: 34737539 DOI: 10.12788/fp.0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Approximately 10% of the US population reports having a β-lactam allergy, although nearly 90% do not have a true immunoglobulin E (IgE)-mediated reaction. This misconception results in using nonpreferred antibiotics, leading to antimicrobial resistance and treatment failure. To evaluate, clarify, and clear β-lactam allergies, we implemented a pharmacist-driven β-lactam allergy assessment (BLAA) protocol and penicillin allergy clinic (PAC). The purpose of this study was to illustrate the BLAA process, including the pharmacist-run PAC, and assess the impact on allergy clearance. Methods Clinical pharmacy specialists (CPS) evaluated hospitalized veterans with β-lactam allergies, using the BLAA protocol. Eligible patients could later be seen in PAC. This was a retrospective observational review of the BLAA protocol to assess recommendations for β-lactam antibiotic use and PAC outcomes. Results Between November 2017 and February 2020, 278 patients were evaluated, and 32 were seen in the clinic. The most common allergen was penicillin, and the most reported reaction was a rash (27%) or pruritus and urticaria (18%). Through PAC and the BLAA protocol, 86 patients (31%) were cleared for allergy removal, and 188 (68%) were cleared for alternative β-lactams. The evaluation revealed that 274 patients (99%) were eligible to receive a β-lactam antibiotic, and only 4 patients (1%) were recommended for avoidance of all β-lactams. Conclusions These findings highlight the utility of the pharmacist-driven BLAA protocol. We illustrated that most patients with documented β-lactam allergies were eligible for alternative β-lactams. The implementation of the BLAA protocol and pharmacist-run PAC facilitated allergy clearance and has the potential to promote alternative β-lactam use.
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Affiliation(s)
- Anna B Mitchell
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
| | - Rachel A Ness
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
| | - Jessica G Bennett
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
| | - Jarred E Bowden
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
| | - Whitney V Elliott
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
| | - Amanda R Gillion
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
| | - Debendra N Pattanaik
- , and are all Clinical Pharmacy Specialists in the Department of Pharmacy; and is a Physician in the Department of Allergy/Immunology, all at the Memphis Veterans Affairs Medical Center in Tennessee. is a Clinical Pharmacy Specialist in the Department of Pharmacy at the New Mexico Veterans Affairs Health System in Albuquerque, New Mexico. is an Inpatient Pharmacy Supervisor in the Department of Pharmacy at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, Tennessee. Debendra Pattanaik is in the Department of Rheumatology at the University of Tennessee Health Science Center in Memphis
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Uda A, Onuma K, Shigemura K, Kitagawa K, Yan Y, Osawa K, Yano I, Miyara T. Impact of Cefazolin Shortage on Clinical Outcomes of Adult Patients with Bacteremia Caused by Methicillin-Susceptible Staphylococcus aureus in a Tertiary Care University Hospital. Antibiotics (Basel) 2021; 10:antibiotics10101247. [PMID: 34680827 PMCID: PMC8532967 DOI: 10.3390/antibiotics10101247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/09/2021] [Accepted: 10/12/2021] [Indexed: 12/20/2022] Open
Abstract
Cefazolin is an essential antibiotic used for treating bacteremia; in particular, it is recommended as a first-line agent for infections caused by methicillin-susceptible Staphylococcusaureus (MSSA). In March 2019, problems with a major antibiotic supplier caused a critical shortage of cefazolin in Japan; however, the impact of the cefazolin shortage on clinical outcomes remains unknown. This study aimed to evaluate the effect of the cefazolin shortage in patients with MSSA bacteremia. Data from 75 patients were compared between the pre-shortage (March 2018–January 2019, n = 39) and post-shortage (March 2019–January 2020, n = 36) periods. There were no significant differences in the demographic characteristics between the two groups, and the cefazolin shortage did not worsen clinical outcomes such as adverse drug reactions, treatment failure, and 30-day mortality. In the post-shortage group, ampicillin/sulbactam and benzylpenicillin were more frequently administered as alternative antibiotics for empirical and definitive therapy (10% vs. 31%, p = 0.042; 0% vs. 19%, p = 0.004, respectively). Multivariate analysis revealed that the broad-spectrum antibiotics for definitive therapy, such as antipseudomonal penicillin, were associated with treatment failure in patients with MSSA bacteremia (OR = 17, p = 0.003). Hence, narrow-spectrum antibiotics should be prescribed for MSSA bacteremia as alternatives during a cefazolin shortage.
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Affiliation(s)
- Atsushi Uda
- Department of Infection Control and Prevention, Kobe University Hospital, Kobe 650-0017, Japan; (K.O.); (K.S.); (T.M.)
- Department of Pharmacy, Kobe University Hospital, Kobe 650-0017, Japan;
- Correspondence: ; Tel.: +81-78-382-5111
| | - Kenichiro Onuma
- Department of Infection Control and Prevention, Kobe University Hospital, Kobe 650-0017, Japan; (K.O.); (K.S.); (T.M.)
- Department of Clinical Laboratory, Kobe University Hospital, Kobe 650-0017, Japan
| | - Katsumi Shigemura
- Department of Infection Control and Prevention, Kobe University Hospital, Kobe 650-0017, Japan; (K.O.); (K.S.); (T.M.)
- Division of Infectious Diseases, Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe 654-0142, Japan;
- Division of Urology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan;
| | - Koichi Kitagawa
- Division of Infectious Diseases, Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe 654-0142, Japan;
- Division of Advanced Medical Science, Kobe University Graduate School of Science, Technology and Innovation, Kobe 657-8501, Japan
| | - Yonmin Yan
- Division of Urology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan;
| | - Kayo Osawa
- Department of Medical Technology, Kobe Tokiwa University, Kobe 653-0838, Japan;
| | - Ikuko Yano
- Department of Pharmacy, Kobe University Hospital, Kobe 650-0017, Japan;
| | - Takayuki Miyara
- Department of Infection Control and Prevention, Kobe University Hospital, Kobe 650-0017, Japan; (K.O.); (K.S.); (T.M.)
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Iammatteo M, Lezmi G, Confino-Cohen R, Tucker M, Ben-Shoshan M, Caubet JC. Direct Challenges for the Evaluation of Beta-Lactam Allergy: Evidence and Conditions for Not Performing Skin Testing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2947-2956. [PMID: 34366093 DOI: 10.1016/j.jaip.2021.04.073] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/19/2021] [Accepted: 04/25/2021] [Indexed: 12/11/2022]
Abstract
In the western world, up to 10% of the general population and more than 15% of hospitalized patients report penicillin allergy. After a comprehensive evaluation, more than 95% of patients who report a penicillin allergy can subsequently tolerate this antibiotic. Traditionally, the most widely accepted protocol to evaluate beta-lactam (BL) allergy consisted of skin testing (ST) followed by a drug provocation test (DPT) in ST-negative patients. DPT is the gold standard for proving or excluding BL allergy and is considered the final and definitive step in the evaluation. Recently, studies have been published that support the use of direct DPTs without preceding ST for both pediatric and adult patients who report a low-risk historical reaction to BLs. However, these studies use various risk-stratification criteria to determine eligibility for a direct DPT. A standardized protocol for DPT is also lacking. In this review, we assess the current literature and evidence for performing direct DPT in the pediatric and adult populations. On the basis of this evidence, we also present risk-based algorithms for the evaluation of BL allergy in pediatric and adult populations based on a description of the historical reaction.
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Affiliation(s)
- Melissa Iammatteo
- Division of Allergy and Immunology, Department of Medicine, Montefiore Medical Center, Bronx, NY
| | - Guillaume Lezmi
- AP-HP, Hôpital Necker-Enfants Malades, Service de Pneumologie et Allergologie Pédiatriques, Paris, France; Equipe Immunorégulation et Immunopathologie, Institut Necker Enfants Malades, Inserm UMR1151, CNRS UMR8253, Université de Paris, Paris, France
| | - Ronit Confino-Cohen
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar-Saba, Israel Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark Tucker
- Department of Allergy and Immunology, Kaiser Permanente Tacoma Medical Center, Tacoma, Wash
| | - Moshe Ben-Shoshan
- Division of Pediatric Allergy, Clinical Immunology and Dermatology, Department of Pediatrics, McGill University Health Center, Montreal, Quebec, Canada
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of the Child and Adolescent, Geneva University Hospital, Geneva, Switzerland.
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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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Catalano AC, Pittet LF, Choo S, Segal A, Stephens D, Cranswick NE, Gwee A. Impact of Antibiotic Allergy Labels on Patient Outcomes in a Tertiary Paediatric Hospital. Br J Clin Pharmacol 2021; 88:1107-1114. [PMID: 34388858 DOI: 10.1111/bcp.15038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Antibiotic allergies are reported in 5 to 15% of children. This study aimed to evaluate the impact of common β-lactam antibiotic allergy labels (AALs) on hospital treatment, focussing on length of stay and appropriateness of antibiotic prescribing. STUDY DESIGN Retrospective cohort study over 21-months at the Royal Children's Hospital Melbourne, Australia. A subset of children with the most common β-lactam allergies, and who required admission for intravenous antibiotics over a 12-month period, was analysed for appropriateness of prescribing. Non-allergic patients were matched to evaluate associations between AALs and hospital treatment. RESULTS There were 98,912 children admitted over the study period, of whom 938 (1%) had at least one AAL on first admission. Of all encounters, 5145 (2.5%) were for children with AALs. The most common AALs were to amoxicillin and amoxicillin-clavulanic acid combinations (40.8%), cefalexin (14.4%) and trimethoprim-sulfamethoxazole (9.7%). For the subset, there were 66 admissions for children who required intravenous antibiotics. Documentation was adequate for 27% of AALs. Inappropriate prescribing occurred in almost half (47%). Hospital stay was longer for children with AALs (median 4.7 days; IQR 2.3 to 9.2) compared to non-allergic controls (median 3.9 days; IQR 1.9 to 6.8; P=0.02). Children with AALs were more likely to receive restricted antibiotics (aOR 3.03; 95%CI, 1.45 to 6.30; p=0.003). CONCLUSION This is the first study to demonstrate high rates of inappropriate prescribing in children with AALs. Children with AALs were significantly more likely to receive restricted antibiotics and had a longer length of stay compared with non-allergic controls.
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Affiliation(s)
- Anthony C Catalano
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Laure F Pittet
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia
| | - Sharon Choo
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Allergy and Immunology, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Ahuva Segal
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia
| | - David Stephens
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Noel E Cranswick
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | - Amanda Gwee
- Departments of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia
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Wang H, Kozman M, Pierce H, Ma L, Collins C. A Quality Improvement Initiative to Improve Primary Care Referral Rates for Penicillin Allergy Delabeling. Ann Allergy Asthma Immunol 2021; 128:33-38. [PMID: 34352357 DOI: 10.1016/j.anai.2021.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/23/2021] [Accepted: 07/28/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND 10% of the U.S. population report a penicillin allergy but >90% can ultimately tolerate penicillin. Confirmation of these allergies in the pediatric population may improve future health outcomes and decrease costs. Referring patients for confirmatory testing is the first step in clarifying penicillin allergies. OBJECTIVE Utilizing an educational session and a Best Practices Advisory (BPA) in the electronic medical record (EMR) to increase the number of referrals of patients with listed penicillin allergies from the UCSD Academic General Pediatrics (AGP) clinics to Rady Children's Hospital Allergy clinics. METHODS An educational session with attendings and three Plan-Do-Study-Act (PDSA) cycles were completed utilizing a best practice advisory (BPA) alert which triggered for all patients with a documented penicillin-class drug allergy to draw attention and facilitate referral. The BPA was modified at each PDSA cycle based on physician input. RESULTS At baseline, 1.9% of referrals to Allergy Clinic were for penicillin-class drug allergies. Following an attending physician educational session, the percentage increased to 13.7%. The BPA was implemented with further increase to 27.8% of all allergy referrals over the course of three PDSA cycles. Not all patients with penicillinclass drug allergies were referred and the reasons were documented when the physicians dismissed the BPA. 35% of the time, physicians did not refer because of time constraints as opposed to patient/parent disinterest which was 8% of the time. CONCLUSION Referrals to the allergist for confirmatory testing in patients with listed penicillin allergies increased by more than 10 fold. This study illustrates successful tools to support delabeling.
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Affiliation(s)
- Helen Wang
- University of California San Diego School of Medicine, Department of Pediatrics, San Diego, California, USA
| | - Maggie Kozman
- Harbor, UCLA Medical Center and David Geffin School of Medicine at UCLA
| | - Heather Pierce
- University of California San Diego School of Medicine, Department of Pediatrics, San Diego, California, USA; Rady Children's Hospital, San Diego, California, USA
| | - Lawrence Ma
- University of California San Diego School of Medicine, Department of Pediatrics, San Diego, California, USA
| | - Cathleen Collins
- Rady Children's Hospital, San Diego, California, USA; Division of Allergy Immunology, Department of Pediatrics, University of California, San Diego, California, USA.
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Hanssen P, Nieuwhof C, van Mens S, van de Plas A, Horstman K. Implementing a new antibiotic allergy protocol in clinical practice: well-trusted but not used. JAC Antimicrob Resist 2021; 3:dlab077. [PMID: 34223136 PMCID: PMC8210085 DOI: 10.1093/jacamr/dlab077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/30/2021] [Indexed: 11/19/2022] Open
Abstract
Background Suboptimal antibiotic prescriptions in patients with an antibiotic allergy label lead to increased incidence of adverse events and antimicrobial resistance (AMR). An antibiotic allergy protocol was developed in a Dutch academic hospital guiding optimal and safe antibiotic use in potentially penicillin-allergic patients. Informed by previous studies of implementation processes in clinical care, we studied the implementation of this protocol. Methods Medical professionals in the Departments of Surgery, Internal Medicine, and Pulmonary Care were interviewed. Additionally, focus groups were conducted in Internal Medicine and Pulmonary Care to validate the outcomes of the interviews. Results Dissemination of the protocol via the regular online hospital-wide guidance system did not have a significant impact on the knowledge about or use of the protocol. If healthcare professionals found the protocol, they thought it was valuable and expressed trust in the expertise embodied in it. However, its use in practice was rather minimal. Interviewees doubted the accuracy of the patient’s histories about their previous adverse drug reactions, and/or the information in their medical records and concluded that adherence to the expert guideline was needlessly risky. They felt the acute allergic reaction risk for a patient outweighed the risk of suboptimal therapy or future AMR. Conclusions For successful implementation and dissemination of the protocol, the accessibility of the protocol, the information about the actual risks of following the protocol and the registration of allergic history should be improved. However, whether this actually results in improvement also depends on changes in the hospital culture and organization.
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Affiliation(s)
- P Hanssen
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - C Nieuwhof
- Department of Allergology and Clinical Immunology, Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S van Mens
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A van de Plas
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - K Horstman
- Department of Health, Ethics, and Society, Care and Public Health Research Institute CAPHRI, Maastricht University, Maastricht, The Netherlands
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48
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Collins CD, Scheidel C, Anam K, Polega S, Malani AN, Hayward A, Leo HL, Shankar T, Morrin C, Brockhaus K. Impact of an Antibiotic Side-Chain-Based Cross-reactivity Chart Combined With Enhanced Allergy Assessment Processes for Surgical Prophylaxis Antimicrobials in Patients With β-Lactam Allergies. Clin Infect Dis 2021; 72:1404-1412. [PMID: 32155264 DOI: 10.1093/cid/ciaa232] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND β-Lactam antibiotics are first-line therapy for perioperative prophylaxis; however, patient-reported allergies often lead to increased prescribing of alternative antibiotics that may increase the incidence of surgical site infections. The R-group side chain of the β-lactam ring is responsible for allergic cross-reactivity and experts recommend the use of β-lactams that are structurally dissimilar. METHODS An internally developed, antibiotic side-chain-based cross-reactivity chart was developed and implemented alongside enhanced allergy assessment processes. This single-center, quasi-experimental study analyzed antibiotic prescribing in all adult patients with a documented β-lactam allergy undergoing an inpatient surgical procedure between quartile (Q) 1 (2012)-Q3 (2014) (historical group) and Q3 (2016)-Q3 (2018) (intervention group). Propensity-weighted scoring analyses compared categorical and continuous outcomes. Interrupted time-series analysis further analyzed key outcomes. RESULTS A total of 1119 and 1089 patients were included in the historical and intervention cohorts, respectively. There was a significant difference in patients receiving a β-lactam alternative antibiotic between cohorts (84.9% vs 15.1%; P < .001). There was a decrease in 30-day readmissions in the intervention cohort (7.9% vs 6.3%; P = .035); however, there was no difference in the incidence of SSIs in patients readmitted (14.8% vs 13%; P = .765). No significant differences were observed in allergic reactions (0.5% vs 0.3%; P = .323), surgical site infections, in-hospital and 30-day mortality, healthcare facility-onset Clostridiodes difficile infection, acute kidney injury, or hospital costs. CONCLUSIONS Implementation of an antibiotic cross-reactivity chart combined with enhanced allergy assessment processes significantly improved the prescribing of β-lactam antibiotics for surgical prophylaxis.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Caleb Scheidel
- Methods Consultants of Ann Arbor, Ypsilanti, Michigan, USA
| | - Kishore Anam
- Michigan Data Analytics, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Shikha Polega
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Division of Infectious Diseases, Department of Internal Medicine, St Joseph Mercy Health System, Ann Arbor, Michigan, USA.,Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Alexandra Hayward
- Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Harvey L Leo
- Allergy and Immunology Associates of Ann Arbor, PC, Ann Arbor, Michigan, USA
| | - Tara Shankar
- Allergy and Immunology Associates of Ann Arbor, PC, Ann Arbor, Michigan, USA
| | - Cheryl Morrin
- Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Kara Brockhaus
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
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Broyles AD, Banerji A, Barmettler S, Biggs CM, Blumenthal K, Brennan PJ, Breslow RG, Brockow K, Buchheit KM, Cahill KN, Cernadas J, Chiriac AM, Crestani E, Demoly P, Dewachter P, Dilley M, Farmer JR, Foer D, Fried AJ, Garon SL, Giannetti MP, Hepner DL, Hong DI, Hsu JT, Kothari PH, Kyin T, Lax T, Lee MJ, Lee-Sarwar K, Liu A, Logsdon S, Louisias M, MacGinnitie A, Maciag M, Minnicozzi S, Norton AE, Otani IM, Park M, Patil S, Phillips EJ, Picard M, Platt CD, Rachid R, Rodriguez T, Romano A, Stone CA, Torres MJ, Verdú M, Wang AL, Wickner P, Wolfson AR, Wong JT, Yee C, Zhou J, Castells M. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:S16-S116. [PMID: 33039007 DOI: 10.1016/j.jaip.2020.08.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ana Dioun Broyles
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Sara Barmettler
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Catherine M Biggs
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kimberly Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Patrick J Brennan
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca G Breslow
- Division of Sports Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Josefina Cernadas
- Allergology and Immunology Service, Centro Hospitalar Universitário de S.João Hospital, Porto, Portugal
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Elena Crestani
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Pascale Dewachter
- Department of Anesthesiology and Intensive Care Medicine, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Meredith Dilley
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Ari J Fried
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Sarah L Garon
- Associated Allergists and Asthma Specialists, Chicago, Ill
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass
| | - David I Hong
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Joyce T Hsu
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Parul H Kothari
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Timothy Kyin
- Division of Asthma, Allergy & Immunology, University of Virginia, Charlottesville, Va
| | - Timothy Lax
- Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Min Jung Lee
- Allergy and Immunology at Hoag Medical Group, Newport Beach, Calif
| | - Kathleen Lee-Sarwar
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Anne Liu
- Division of Allergy / Immunology, Stanford University School of Medicine, Palo Alto, Calif
| | - Stephanie Logsdon
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Andrew MacGinnitie
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Michelle Maciag
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Samantha Minnicozzi
- Division of Allergy and Clinical Immunology, Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Sarita Patil
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Division of Allergy and Clinical Immunology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Rima Rachid
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Tito Rodriguez
- Drug Allergy Department, Al-Rashed Allergy Center, Sulaibikhat, Al-Kuwait, Kuwait
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Miriam Verdú
- Allergy Unit, Hospital Universitario de Ceuta, Ceuta, Spain
| | - Alberta L Wang
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Paige Wickner
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Johnson T Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Christina Yee
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Joseph Zhou
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Mariana Castells
- Drug hypersensitivity and Desensitization Center, Brigham and Women's Hospital, Boston, Mass
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Lenz KD, Klosterman KE, Mukundan H, Kubicek-Sutherland JZ. Macrolides: From Toxins to Therapeutics. Toxins (Basel) 2021; 13:347. [PMID: 34065929 PMCID: PMC8150546 DOI: 10.3390/toxins13050347] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 12/17/2022] Open
Abstract
Macrolides are a diverse class of hydrophobic compounds characterized by a macrocyclic lactone ring and distinguished by variable side chains/groups. Some of the most well characterized macrolides are toxins produced by marine bacteria, sea sponges, and other species. Many marine macrolide toxins act as biomimetic molecules to natural actin-binding proteins, affecting actin polymerization, while other toxins act on different cytoskeletal components. The disruption of natural cytoskeletal processes affects cell motility and cytokinesis, and can result in cellular death. While many macrolides are toxic in nature, others have been shown to display therapeutic properties. Indeed, some of the most well known antibiotic compounds, including erythromycin, are macrolides. In addition to antibiotic properties, macrolides have been shown to display antiviral, antiparasitic, antifungal, and immunosuppressive actions. Here, we review each functional class of macrolides for their common structures, mechanisms of action, pharmacology, and human cellular targets.
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Affiliation(s)
| | | | | | - Jessica Z. Kubicek-Sutherland
- Physical Chemistry and Applied Spectroscopy, Chemistry Division, Los Alamos National Laboratory, Los Alamos, NM 87545, USA; (K.D.L.); (K.E.K.); (H.M.)
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