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Rose MT, Holmes NE, Eastwood GM, Vogrin S, James F, De Luca JF, Bellomo R, Warrillow SJ, Phung M, Barnes SL, Murfin B, Rogers B, Lambros B, Collis B, Peel TN, Slavin MA, Trubiano JA. Oral challenge vs routine care to assess low-risk penicillin allergy in critically ill hospital patients (ORACLE): a pilot safety and feasibility randomised controlled trial. Intensive Care Med 2024:10.1007/s00134-024-07448-x. [PMID: 38739277 DOI: 10.1007/s00134-024-07448-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/14/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE Critically ill patients are vulnerable to penicillin allergy labels that may be incorrect. The validity of skin testing in intensive care units (ICUs) is uncertain. Many penicillin allergy labels are low risk, and validated tools exist to identify those amenable to direct oral challenge. This pilot randomised controlled trial explored the feasibility, safety, and validity of direct enteral challenge for low-risk penicillin allergy labels in critical illness. METHODS Consenting patients with a low-risk penicillin allergy label (PAL) (PEN-FAST risk assessment score < 3) in four ICUs (Melbourne, Australia) were randomised 1:1 to penicillin (250 mg amoxicillin or implicated penicillin) direct enteral challenge versus routine care (2-h post-randomisation observation for each arm). Repeat challenge was performed post -ICU in the intervention arm. Patients were reviewed at 24 h and 5 days after each challenge/observation. RESULTS We screened 533 patients. 130 (24.4%) were eligible and 80/130 (61.5%) enrolled (age median 64.5 years (interquartile range, IQR 53.5, 74), PEN-FAST median 1 (IQR 0,1)), with 40 (50%) randomised to direct enteral challenge. A positive challenge rate of 2.5% was identified. No antibiotic-associated serious adverse events were identified. 32/40 (80%) received a repeat challenge (zero positive). Post-randomisation, 13 (32%) of the intervention arm and 4 (10%) of the control arm received penicillin (odds ratio, OR 4.33 [1.27, 14.78] p = 0.019). CONCLUSION These findings support the safety, validity, and feasibility of direct enteral challenge for critically ill patients with PEN-FAST assessed low-risk penicillin allergy. The absence of false negative results was confirmed by subsequent negative repeat challenges. A relatively low recruitment to screened ratio suggests that more inclusive eligibility criteria and integration of allergy assessment into routine ICU processes are needed to optimise allergy delabelling in critical illness.
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Affiliation(s)
- Morgan T Rose
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia.
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia.
| | - Natasha E Holmes
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, Austin Health/University of Melbourne, Melbourne, VIC, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Sara Vogrin
- Department of Medicine (St Vincent's Hospital), University of Melbourne, Melbourne, VIC, Australia
| | - Fiona James
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Joseph F De Luca
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Parkville, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Stephen J Warrillow
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, The University of Melbourne, Parkville, VIC, Australia
| | - Michelle Phung
- Pharmacy Department, Monash Health, Clayton, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, VIC, Australia
| | - Sara L Barnes
- Monash Lung Sleep Allergy and Immunology, Monash Health, Clayton, VIC, Australia
| | - Brendan Murfin
- Intensive Care Unit, Monash Health, Clayton, VIC, Australia
| | - Ben Rogers
- Monash Infectious Diseases, Monash Health, Clayton, VIC, Australia
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Belinda Lambros
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Brennan Collis
- Department of Infectious Diseases, Alfred Health, Melbourne, VIC, Australia
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Health, Melbourne, VIC, Australia
- Department of Infectious Diseases, Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Monica A Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Immunocompromised Host Infection Service, Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases and Immunology, Centre for Antibiotic Allergy and Research, Austin Health, Level 7, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
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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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Brillant-Marquis F, Proulx É, Ratnarajah K, Lavoie A, Gauthier A, Gagnon R, Boursiquot JN, Verreault N, Marois L, Bédard MA, Boivin M, Bédard PM, Ouakki M, De Serres G, Drolet JP. Safety of Direct Drug Provocation for the Evaluation of Penicillin Allergy in Low-Risk Adults. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:451-457.e2. [PMID: 38572700 DOI: 10.1016/j.jaip.2023.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/08/2023] [Accepted: 10/17/2023] [Indexed: 04/05/2024]
Abstract
BACKGROUND About 10% of patients have a penicillin allergy label, but less than 5% of them are actually allergic. Unnecessary penicillin avoidance is associated with serious medical consequences. Given the growing number of these labels, it is imperative that our diagnostic strategy for penicillin allergy be as efficient as possible. The validity of traditionally used skin tests (STs) has been questioned, whereas drug provocation testing (DPT), the criterion standard, without previous ST appears very safe in most cases. OBJECTIVE To evaluate the safety of direct DPT without consideration for ST results and the validity of ST in the diagnosis of penicillin allergy. METHODS In this prospective cohort study without a control group, we recruited patients consulting an allergist for penicillin allergy. Patients underwent ST followed by DPT regardless of ST results. Patients with anaphylaxis to penicillin within the past 5 years or a severe delayed reaction were excluded, as were those with significant cardiorespiratory comorbidity. RESULTS None of the 1002 recruited patients had a serious reaction to DPT. Ten (1.0%) had a mild immediate reaction, of whom only 1 (0.1%) was considered likely IgE-mediated. The positive and negative predictive values of ST for an immediate reaction were 3.6% and 99.1%, respectively. CONCLUSIONS In a low-risk adult population reporting penicillin allergy, ST has very poor positive predictive value. Direct DPT without ST is safe and appears to be an ideal diagnostic strategy to remove penicillin allergy labels that could be implemented in first-line practice.
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Affiliation(s)
- Frédéric Brillant-Marquis
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Émilie Proulx
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Kayadri Ratnarajah
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Aubert Lavoie
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Amélie Gauthier
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Rémi Gagnon
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Jean-Nicolas Boursiquot
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Nina Verreault
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Louis Marois
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Marc-Antoine Bédard
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Martine Boivin
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Pierre-Michel Bédard
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Manale Ouakki
- Institut National de Santé Publique du Québec, Québec City, Québec, Canada
| | - Gaston De Serres
- Institut National de Santé Publique du Québec, Québec City, Québec, Canada
| | - Jean-Philippe Drolet
- Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada.
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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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Banerji A, Solensky R, Phillips EJ, Khan DA. Drug Allergy Practice Parameter Updates to Incorporate Into Your Clinical Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:356-368.e5. [PMID: 36563781 DOI: 10.1016/j.jaip.2022.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
The drug allergy practice parameter was developed to provide guidance on the diagnosis and management of drug hypersensitivity reactions. It was last updated in 2010. With the growth of research and evidence-based data since then, experts came together to update the practice parameter with a focus on sections that the work group deemed to have significant changes (or were not addressed) in the previous practice parameter. This review is a focused update on aspects of the practice parameter deemed to have the greatest impact on clinical practice and includes significant updates on diagnosis of antibiotic allergy including penicillin, cephalosporin, sulfonamide, fluoroquinolone, and macrolide allergies. Other topics include the evolution in our management approach to patients with aspirin/nonsteroidal anti-inflammatory drug allergy, diagnostic testing for delayed drug hypersensitivity and allergy to chemotherapeutics and biologics, and the key consensus-based statements for clinical practice. Specifically, the updated practice parameter helps allergists understand the place of 1- or 2-step drug challenges that are valuable tools often without the need for skin testing in many clinical situations. A proactive approach to delabeling penicillin allergy as well as unnecessary avoidance of safe antibiotic alternatives for patients with proven penicillin allergy is emphasized. New guidance is provided on management of patients with different phenotypes of aspirin and nonsteroidal anti-inflammatory drug hypersensitivity reactions. Approaches to delayed drug hypersensitivity and use of delayed intradermal and patch testing for specific phenotypes are reviewed. Lastly, practical approaches to management of patients with reactions to chemotherapeutics and biologics are discussed.
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Affiliation(s)
- Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
| | - Roland Solensky
- The Corvallis Clinic and Oregon State University/Oregon Health & Science University College of Pharmacy, Corvallis, Ore
| | - Elizabeth J Phillips
- Departments of Medicine, Dermatology, Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - David A Khan
- Department of Internal Medicine, Allergy and Immunology, The University of Texas Southwestern Medical Center, Dallas, Tex
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Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J, Khan DA, Golden DBK, Shaker M, Stukus DR, Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333-1393. [PMID: 36122788 DOI: 10.1016/j.jaci.2022.08.028] [Citation(s) in RCA: 131] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Aleena Banerji
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Roland Solensky
- Corvallis Clinic, Oregon State University/Oregon Health Science University College of Pharmacy, Corvallis, Ore
| | - Andrew A White
- Department of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St Joe's Hamilton, Hamilton, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew J Greenhawt
- Food Challenge and Research Unit Section of Allergy and Immunology, Children's Hospital Colorado University of Colorado School of Medicine, Aurora, Colo
| | - Caroline C Horner
- Department of Pediatrics, Division of Allergy Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla; James A. Haley Veterans Affairs Hospital, Tampa, Fla
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | - John Oppenheimer
- Division of Allergy, Rutgers New Jersey Medical School, Rutgers, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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7
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Infectious Diseases Management in Wound Care Settings: Common Causative Organisms and Frequently Prescribed Antibiotics. Adv Skin Wound Care 2022; 35:535-543. [PMID: 36125453 DOI: 10.1097/01.asw.0000855744.86686.ea] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
GENERAL PURPOSE To provide information about the management of infected wounds in wound care settings. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant will:1. Identify a host factor that may predispose a patient to a wound infection as well as characteristics of each stage of wound infection.2. Distinguish a common organism that causes early, acute wound infections and explain the preferred method for obtaining a wound specimen for culture.3. Apply knowledge of commonly prescribed antibiotics in wound care settings.
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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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9
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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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10
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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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11
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Abstract
Anaphylaxis is a multi-system syndrome resulting from the release of mediators from mast cells and basophils. Drugs are common causes. Anaphylaxis to certain drugs, vaccines, and biological agents present clinical challenges, and merit referral to a board-certified allergist/immunologist for further evaluation and management.
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Affiliation(s)
- Ruchi H Shah
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic
| | - Margaret M Kuder
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic.
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12
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Suzuki H, Perencevich E, Goto M, Alexander B, Nair R, Puig-Asensio M, Ernst E, Livorsi DJ. A comprehensive assessment of carbapenem use across 90 Veterans Health Administration hospitals with defined stewardship strategies for carbapenems. J Antimicrob Chemother 2021; 76:1358-1365. [PMID: 33523128 DOI: 10.1093/jac/dkab008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/29/2020] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES Carbapenems are an important target for antimicrobial stewardship (AS) efforts. In this study, we sought to compare different hospital-based strategies for improving carbapenem use. METHODS We analysed a cohort of all patients hospitalized at Veterans Health Administration (VHA) acute care hospitals during 2016 and a mandatory survey that characterized each hospital's carbapenem-specific AS strategy into one of three types: no strategy (NS), prospective audit and feedback (PAF) or restrictive policies (RP). Carbapenem use was compared using risk-adjusted generalized estimating equations that accounted for clustering within hospitals. Two infectious disease (ID) physicians independently performed manual chart reviews in 425 randomly selected cases. Auditors assessed carbapenem appropriateness with an assessment score on Day 4 of therapy. RESULTS There were 429 062 admissions in 90 sites (24 NS, 8 PAF, 58 RP). Carbapenem use was lower at PAF than NS sites [rate ratio (RR) 0.6 (95% CI 0.4-0.9); P = 0.01] but similar between RP and NS sites. Carbapenem prescribing was considered appropriate/acceptable in 215 (50.6%) of the reviewed cases. Assessment scores were lower (i.e. better) at RP than NS sites (mean 2.3 versus 2.7; P < 0.01) but did not differ significantly between NS and PAF sites. ID consultations were more common at PAF/RP than NS sites (51% versus 29%; P < 0.01). ID consultations were associated with lower (i.e. better) assessment scores (mean 2.3 versus 2.6; P < 0.01). CONCLUSIONS In this VHA cohort, PAF strategies were associated with lower carbapenem use and ID consultation and RP strategies were associated with more appropriate carbapenem prescribing. AS and ID consultations may work complementarily and hospitals could leverage both to optimize carbapenem use.
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Affiliation(s)
- Hiroyuki Suzuki
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Eli Perencevich
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michihiko Goto
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Bruce Alexander
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Rajeshwari Nair
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Mireia Puig-Asensio
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.,Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Erika Ernst
- University of Iowa College of Pharmacy, Iowa City, IA, USA
| | - Daniel J Livorsi
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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13
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Yuson C, Shakib S, Smith W. Prevalence of drug allergy in South Australia. Intern Med J 2021; 52:1957-1961. [PMID: 34160122 DOI: 10.1111/imj.15440] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Drug allergy is commonly reported in patient notes and electronic health records. The prevalence of self-reported drug allergy in the general Australian population has not previously been studied. METHODS We surveyed a representative sample of the South Australian adult population regarding their own perception of drug allergy, including drug type and severity as well as the use of medical alert devices. Data were weighted to correspond to age and sex of the South Australian population. RESULTS 22.2% of adults in South Australia consider themselves allergic to one or more drugs, 9.3% declared themselves to be allergic to penicillin, 5% to an antibiotic other than penicillin, and 13% to one or more antibiotics. Drug allergy and penicillin allergy was significantly more prevalent in females, and increased with age. Thirteen percent of those with an antibiotic allergy reported a severe reaction, of whom 27% wore a medical notification device. Of those allergic to penicillin, 75% had their index reaction more than 10 years ago and did not report severe features. DISCUSSION Self-reported drug allergy is common in the general population, as it is in medical clinic and hospital populations. The majority of those reporting penicillin allergy would be considered low-risk and suitable for delabelling procedures. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Carlo Yuson
- Immunology and Allergy Department, Royal Adelaide Hospital, Adelaide, Australia
| | - Sepehr Shakib
- Clinical Pharmacology Department, Royal Adelaide Hospital, Adelaide, Australia
| | - William Smith
- Immunology and Allergy Department, Royal Adelaide Hospital, Adelaide, Australia
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14
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Cardoso‐Fernandes A, Blumenthal KG, Chiriac AM, Tarrio I, Afonso‐João D, Delgado L, Fonseca JA, Azevedo LF, Sousa‐Pinto B. Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta-analysis. Clin Transl Allergy 2021; 11:e12008. [PMID: 34161664 PMCID: PMC8215894 DOI: 10.1002/clt2.12008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Patients with a penicillin allergy label tend to have worse clinical outcomes and increased healthcare use. Drug provocation tests (DPT) are the gold-standard in the diagnostic workup of penicillin allergy, but safety concerns may hinder their performance. We aimed to assess the frequency of severe reactions following a DPT in patients with reported allergy to penicillins or other β-lactams. METHODS We performed a systematic review, searching MEDLINE, Scopus, and Web of Science. We included primary studies assessing participants with a penicillin allergy label who underwent a DPT. We performed a Bayesian meta-analysis to estimate the pooled frequency of severe reactions to penicillin DPTs. Sources of heterogeneity were explored by subgroup and metaregression analyses. RESULTS We included 112 primary studies which included a total of 26,595 participants. The pooled frequency of severe reactions was estimated at 0.06% (95% credible interval [95% CrI] = 0.01%-0.13%; I2 = 57.9%). Most severe reactions (80/93; 86.0%) consisted of anaphylaxis. Compared to studies where the index reaction was immediate, we observed a lower frequency of severe reactions for studies assessing non-immediate index reactions (OR = 0.05; 95% CrI = 0-0.31). Patients reporting anaphylaxis as their index reaction were found to be at increased risk of developing severe reactions (OR = 13.5; 95% CrI = 7.7-21.5; I2 = 0.3%). Performance of direct DPTs in low-risk patients or testing with the suspected culprit drug were not associated with clinically relevant increased risk of severe reactions. CONCLUSIONS In patients with a penicillin allergy label, severe reactions resulting from DPTs are rare. Therefore, except for patients with potentially life-threatening index reactions or patients with positive skin tests-who were mostly not assessed in this analysis -, the safety of DPTs supports their performance in the diagnostic assessment of penicillin allergy.
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Affiliation(s)
- António Cardoso‐Fernandes
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolHarvard UniversityBostonMassachusettsUSA
| | - Anca Mirela Chiriac
- Department of PulmonologyDivision of Allergy, Hôpital Arnaud de VilleneuveUniversity Hospital of MontpellierMontpellierFrance
- UMR‐S 1136 INSERM‐Sorbonne UniversitéEquipe Epidémiologie des Maladies Allergiques et Respiratoires (EPAR)Institut Pierre Louis d’Epidémiologie et de Santé PubliqueParisFrance
| | - Isabel Tarrio
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - David Afonso‐João
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Luís Delgado
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
- Basic and Clinical Immunology Unit, Department of Pathology, Faculty of MedicineUniversity of PortoPortoPortugal
| | - João Almeida Fonseca
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Luís Filipe Azevedo
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Bernardo Sousa‐Pinto
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
- Basic and Clinical Immunology Unit, Department of Pathology, Faculty of MedicineUniversity of PortoPortoPortugal
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15
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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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16
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Pagani NR, Moverman MA, Puzzitiello RN, Menendez ME, Barnes CL, Kavolus JJ. Preoperative Allergy Testing for Patients Reporting Penicillin and Cephalosporin Allergies is Cost-Effective in Preventing Infection after Total Knee and Hip Arthroplasty. J Arthroplasty 2021; 36:700-704. [PMID: 32933797 DOI: 10.1016/j.arth.2020.08.045] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/29/2020] [Accepted: 08/21/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Routine preoperative allergy testing in patients reporting penicillin and cephalosporin allergies increases the number able to receive cefazolin, which should reduce the risk of infection after total knee and hip arthroplasty (TKA/THA), but it remains unclear whether this practice is cost-effective. Using a break-even analysis, we calculated the cost-effectiveness of routine preoperative allergy testing for infection prevention in total joint arthroplasty patients reporting penicillin and cephalosporin allergies. METHODS The cost of a penicillin allergy evaluation, the cost of revision arthroplasty for prosthetic joint infection (PJI), and baseline rates of PJI in patients receiving a noncefazolin antibiotic in the perioperative period were derived from existing literature. A break-even economic model using these variables was constructed to calculate the absolute risk reduction (ARR) in infection rate needed for preoperative allergy testing to be cost-effective. The number needed to treat (NNT) was calculated from the ARR. RESULTS Preoperative allergy testing before TKA and THA in patients reporting penicillin and cephalosporin allergies was cost-effective if the initial infection rate decreased by an ARR of 0.810% (NNT = 123) and 0.655% (NNT = 153) for TKA and THA, respectively. Cost-effectiveness was maintained with varying allergy consultation costs, infection rates, and costs associated with PJI treatment. CONCLUSION Routine preoperative allergy testing and clearance are cost-effective infection prevention strategies among patients reporting penicillin and cephalosporin allergies in the setting of elective joint arthroplasty. Widespread adoption of this practice may considerably reduce the economic and societal burden associated with prosthetic infections.
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Affiliation(s)
| | | | | | | | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Joseph J Kavolus
- Tufts Medical Center, Department of Orthopaedic Surgery, Boston, MA
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17
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Rose MT, Slavin M, Trubiano J. The democratization of de-labeling: a review of direct oral challenge in adults with low-risk penicillin allergy. Expert Rev Anti Infect Ther 2020; 18:1143-1153. [PMID: 32662696 DOI: 10.1080/14787210.2020.1792775] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Penicillin antibiotic allergy labels (AALs) are common and lead to significant negative health and health system outcomes. Direct oral challenge offers a rapid and cost-effective way of removing inaccurate AALs and improving outcomes. AREAS COVERED A narrative review (Medline, May 2020) of direct oral challenge in low-risk penicillin allergy in adults is described, and the evidence for the safety and efficacy of this approach in inpatients, outpatients, and special patient groups is presented. EXPERT OPINION Whilst the current literature demonstrates the safety and efficacy of direct oral challenge in de-labeling low-risk penicillin allergy in adults, novel approaches are needed to improve access to antibiotic allergy assessment and address the growing global need.
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Affiliation(s)
- Morgan Thomas Rose
- Department of Infectious Diseases, Austin Health , Melbourne, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Parkville, Australia.,Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre , Melbourne, Australia
| | - Monica Slavin
- The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Parkville, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne , Parkville, Australia
| | - Jason Trubiano
- Department of Infectious Diseases, Austin Health , Melbourne, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Parkville, Australia.,Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre , Melbourne, Australia.,Department of Medicine (Austin Health), University of Melbourne , Parkville, Australia
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18
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Brockow K. Triage Strategies for Clarifying Reported Betalactam Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:1066-1067. [PMID: 30832886 DOI: 10.1016/j.jaip.2018.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 08/20/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, München, Germany.
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19
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Abstract
Clostridioides difficile remains a leading cause of healthcare-associated infection. Efforts at C. difficile prevention have been hampered by an increasingly complex understanding of transmission patterns and a high degree of heterogeneity among existing studies. Effective prevention of C. difficile infection requires multimodal interventions, including contact precautions, hand hygiene with soap and water, effective environmental cleaning, use of sporicidal cleaning agents, and antimicrobial stewardship. Roles for probiotics, avoidance of proton pump inhibitors, and isolation of asymptomatic carriers remain poorly defined.
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Affiliation(s)
- Nicholas A Turner
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Deverick J Anderson
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
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20
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Sakoulas G, Geriak M, Nizet V. Is a Reported Penicillin Allergy Sufficient Grounds to Forgo the Multidimensional Antimicrobial Benefits of β-Lactam Antibiotics? Clin Infect Dis 2020; 68:157-164. [PMID: 29986019 DOI: 10.1093/cid/ciy557] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/07/2018] [Indexed: 12/18/2022] Open
Abstract
The majority of patients with reported penicillin allergy are not allergic when tested or challenged. Penicillin allergy testing has been shown to significantly reduce annual healthcare expenditures. Data have emerged showing β-lactams have multidimensional antibacterial effects in vivo, far beyond what is appreciated in standard bacteriological susceptibility testing media. These include enhancing bacterial killing by the innate immune system. Supporting the clinical relevance of these secondary underappreciated effects are recent clinical and pharmacoeconomic analyses that show worse outcomes in patients with reported penicillin allergies who receive non-β-lactam antibiotics when compared to their non-penicillin-allergic counterparts. This is particularly relevant in the treatment of Staphylococcus aureus bacteremia. This article reviews the tremendous advantages offered by β-lactam therapy and makes a strong case that the debunking of false penicillin allergies through a detailed allergy history and penicillin allergy testing should be a vital component of antimicrobial stewardship practices.
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Affiliation(s)
- George Sakoulas
- Sharp Memorial Hospital, San Diego, La Jolla.,School of Medicine, University of California, San Diego, La Jolla
| | | | - Victor Nizet
- School of Medicine, University of California, San Diego, La Jolla.,Skaggs School of Pharmacy, University of California, San Diego, La Jolla
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21
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Van Eyk N, van Schalkwyk J. No. 275-Antibiotic Prophylaxis in Gynaecologic Procedures. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:e723-e733. [PMID: 30390951 DOI: 10.1016/j.jogc.2018.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To review the evidence and provide recommendations on antibiotic prophylaxis for gynaecologic procedures. OUTCOMES Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in gynaecologic procedures. EVIDENCE Medline and The Cochrane Library were searched for articles published between January 1978 and January 2011 on the topic of antibiotic prophylaxis in gynaecologic procedures. Results were restricted to systematic reviews, randomized control trials/ controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to June 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence obtained was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). BENEFITS, HARMS, AND COSTS Guideline implementation should result in a reduction of cost and related harm of administering antibiotics when not required and a reduction of infection and related morbidities when antibiotics have demonstrated a proven benefit. RECOMMENDATIONS
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22
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Modi AR, Majhail NS, Rybicki L, Athans V, Carlstrom K, Srinivas P, Lang DM, Sobecks R, Kovacs CS. Penicillin allergy skin testing as an antibiotic stewardship intervention reduces alternative antibiotic exposures in hematopoietic stem cell transplant recipients. Transpl Infect Dis 2019; 21:e13175. [PMID: 31539459 DOI: 10.1111/tid.13175] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/14/2019] [Accepted: 09/14/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antibiotic allergy de-labeling using penicillin allergy skin testing (PAST) can reduce the use and cost of alternative, non-β-lactam antibiotics in general inpatient populations. This strategy's role in hematopoietic stem cell transplant (HSCT) recipients is unclear. METHODS This study aimed to determine the effect of a pre-transplant PAST protocol on antibiotic use, days of therapy (DOT), and cost in an immunocompromised population at a single center from 7/1/2010-2/1/2019. Patients who received chimeric antigen receptor (CAR) T-cell therapy and those who underwent transplantation in the outpatient setting were excluded. RESULTS Of 1560 patients who underwent inpatient HSCT during the study period, 208 reported β-lactam allergy (136/844 [16%] pre- and 72/716 [10%] post-implementation; P < .001). PAST was performed on 7% and 54% of HSCT recipients pre- and post-implementation, respectively. Only two positive PAST were noted. There were no adverse reactions to PAST. There were no significant differences in the disease and transplant characteristics between the two groups. Days of therapy and cost of alternative antibiotics significantly decreased post-implementation (mean 788 vs 627 days, P = .01; mean $24 425 vs $17 518, P = .009). CONCLUSION Penicillin allergy skin testing adjudicates reported β-lactam allergy in HSCT recipients, lowering use, DOT, and cost of alternative antibiotics and promoting effective formulary agents to treat immunocompromised HSCT recipients.
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Affiliation(s)
- Anita R Modi
- Department of Infectious Diseases, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Navneet S Majhail
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Lisa Rybicki
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Vasilios Athans
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kelley Carlstrom
- Department of Pharmacy Services, Cleveland Clinic, Cleveland, OH, USA
| | - Pavithra Srinivas
- Department of Pharmacy Services, Cleveland Clinic, Cleveland, OH, USA
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ronald Sobecks
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Christopher S Kovacs
- Department of Infectious Diseases, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
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23
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics (Abrams), Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Man.; Department of Pediatrics (Abrams), Division of Allergy and Immunology, University of British Columbia, Vancouver, BC; Department of Internal Medicine (Khan), Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex.
| | - David A Khan
- Department of Pediatrics (Abrams), Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Man.; Department of Pediatrics (Abrams), Division of Allergy and Immunology, University of British Columbia, Vancouver, BC; Department of Internal Medicine (Khan), Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
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24
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Castells M. New role for the modern allergist in drug allergy: Assess, diagnose, and de-label. Ann Allergy Asthma Immunol 2019; 121:515-516. [PMID: 30389081 DOI: 10.1016/j.anai.2018.09.455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 09/12/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Mariana Castells
- Drug Hypersensitivity and Desensitization Center, Mastocytosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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25
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van Schalkwyk J, Van Eyk N. No. 247-Antibiotic Prophylaxis in Obstetric Procedures. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 39:e293-e299. [PMID: 28859772 DOI: 10.1016/j.jogc.2017.06.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To review the evidence and provide recommendations on antibiotic prophylaxis for obstetrical procedures. OUTCOMES Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in obstetrical procedures. EVIDENCE Published literature was retrieved through searches of Medline and The Cochrane Library on the topic of antibiotic prophylaxis in obstetrical procedures. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and articles published from January 1978 to June2009 were incorporated in the guideline. Current guidelines published by the American College of Obstetrics and Gynecology were also incorporated. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS Implementation of this guideline should reduce the cost and harm resulting from the administration of antibiotics when they are not required and the harm resulting from failure to administer antibiotics when they would be beneficial. SUMMARY STATEMENTS RECOMMENDATIONS.
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26
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Oppenheimer J, Lang DM. Once You Label Me…. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:1886-1887. [PMID: 31279467 DOI: 10.1016/j.jaip.2019.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 06/09/2023]
Affiliation(s)
| | - David M Lang
- Cleveland Clinic, Respiratory Institute, Department of Allergy and Clinical Immunology, Cleveland, Ohio.
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27
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Torres MJ, Celik GE, Whitaker P, Atanaskovic-Markovic M, Barbaud A, Bircher A, Blanca M, Brockow K, Caubet JC, Cernadas JR, Chiriac A, Demoly P, Garvey LH, Merk HF, Mosbech H, Nakonechna A, Romano A. A EAACI drug allergy interest group survey on how European allergy specialists deal with β-lactam allergy. Allergy 2019; 74:1052-1062. [PMID: 30637768 DOI: 10.1111/all.13721] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/09/2018] [Accepted: 08/22/2018] [Indexed: 12/18/2022]
Abstract
An accurate diagnosis of β-lactam (BL) allergy can reduce patient morbidity and mortality. Our aim was to investigate the availability of BL reagents, their use and test procedures in different parts of Europe, as well as any differences in the diagnostic workups for evaluating subjects with BL hypersensitivity. A survey was emailed to all members of the EAACI Drug Allergy Interest Group (DAIG) between February and April 2016, and the questionnaire was meant to study the management of suspected BL hypersensitivity. The questionnaire was emailed to 82 DAIG centres and answered by 57. Amoxicillin alone or combined to clavulanic acid were the most commonly involved BL except in the Danish centre, where penicillin V was the most frequently suspected BL. All centres performed an allergy workup in subjects with histories of hypersensitivity to BL: 53 centres (93%) followed DAIG guidelines, two national guidelines and two local guidelines. However, there were deviations from DAIG recommendations concerning allergy tests, especially drug provocation tests. A significant heterogeneity exists in current practice not only among countries, but also among centres within the same country. This suggests the need to re-evaluate, update and standardize protocols on the management of patients with suspected BL allergy.
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Affiliation(s)
- Maria Jose Torres
- Allergy Unit; Regional University Hospital of Malaga-IBIMA-UMA; Malaga Spain
| | - Gulfem Elif Celik
- Department of Immunology and Allergy; Ankara University School of Medicine; Ankara Turkey
| | - Paul Whitaker
- Regional Adult Cystic Fibrosis Unit; St James's Hospital; Leeds UK
| | | | - Annick Barbaud
- Dermatology and Allergology Department; Tenon Hospital (AP-HP); Sorbonne Universities; UPMC University Paris 06; Paris France
| | | | - Miguel Blanca
- Allergy Service; Infanta Leonor University Hospital; Madrid Spain
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Munich Germany
| | | | | | - Anca Chiriac
- Division of Allergy; Department of Pulmonology; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- UMRS 1136; Equipe - EPAR - IPLESP; Sorbonne Universités; UPMC Univ Paris 06; Paris France
| | - Pascal Demoly
- Division of Allergy; Department of Pulmonology; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
| | - Lene Heise Garvey
- Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - Hans F. Merk
- Department of Dermatology and Allergology; RWTH Aachen University; Aachen Germany
| | - Holger Mosbech
- Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - Alla Nakonechna
- Allergy and Immunology Clinic; Royal Liverpool and Broadgreen University Hospitals; Liverpool UK
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28
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Penicillin Allergy Evaluation: A Prospective, Multicenter, Open-Label Evaluation of a Comprehensive Penicillin Skin Test Kit. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1876-1885.e3. [PMID: 30878711 DOI: 10.1016/j.jaip.2019.02.040] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/21/2019] [Accepted: 02/22/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Ten percent of the population claims an allergy to penicillin, but 90% of these individuals are not allergic. Patients labeled as penicillin-allergic have higher medical costs, longer hospital stays, are more likely to be treated with broad-spectrum antibiotics, and develop drug-resistant bacterial infections. Most penicillin skin test reagents are not approved by the Food and drug Administration or readily available to evaluate patients labeled penicillin-allergic. OBJECTIVE To determine the negative predictive value (NPV) of the Penicillin Skin Test Kit containing the major allergenic determinant (penicilloyl polylysine), a minor determinant mixture (penicillin G, penicilloate, penilloate), and amoxicillin, produced according to Food and Drug Administration standards. METHODS This was a prospective, multicenter, open-label investigation of penicillin skin testing using the Penicillin Skin Test Kit. Skin test-negative subjects were challenged with 250 mg amoxicillin, whereas skin test-positive patients were not challenged. The primary end point was NPV of the Penicillin Skin Test Kit, defined as the percentage of subjects with negative skin test results who did not experience an IgE-dependent reaction within 72 hours of amoxicillin challenge. RESULTS In total, 455 patients with a history of penicillin allergy underwent skin testing and 63 (13.8%) had 1 or more positive test results; 65% of the positive test results were to the minor determinant mixture and/or amoxicillin alone. In the per protocol group of 373 skin test-negative subjects, 8 developed potential IgE-dependent reactions following oral amoxicillin challenge, translating to an NPV of 97.9% (95% CI, 95.8-99.1; P < .0001). All but 1 of the reactions was mild or moderate, and most subjects who required treatment received only antihistamines. CONCLUSIONS The Penicillin Skin Test Kit, containing all relevant penicillin allergenic determinants, demonstrated very high NPV. Removal of a penicillin allergy label in a large majority of currently mislabeled patients has substantial personal and public health implications.
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29
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Savic LC, Khan DA, Kopac P, Clarke RC, Cooke PJ, Dewachter P, Ebo DG, Garcez T, Garvey LH, Guttormsen AB, Hopkins PM, Hepner DL, Kolawole H, Krøigaard M, Laguna JJ, Marshall SD, Mertes PM, Platt PR, Rose MA, Sabato V, Sadleir PHM, Savic S, Takazawa T, Voltolini S, Volcheck GW. Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations. Br J Anaesth 2019; 123:e82-e94. [PMID: 30916014 DOI: 10.1016/j.bja.2019.01.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/21/2018] [Accepted: 01/09/2019] [Indexed: 11/30/2022] Open
Abstract
Unsubstantiated penicillin-allergy labels are common in surgical patients, and can lead to significant harm through avoidance of best first-line prophylaxis of surgical site infections and increased infection with resistant bacterial strains. Up to 98% of penicillin-allergy labels are incorrect when tested. Because of the scarcity of trained allergists in all healthcare systems, only a minority of surgical patients have the opportunity to undergo testing and de-labelling before surgery. Testing pathways can be modified and shortened in selected patients. A variety of healthcare professionals can, with appropriate training and in collaboration with allergists, provide testing for selected patients. We review how patients might be assessed, the appropriate testing strategies that can be used, and the minimum standards of safe testing.
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Affiliation(s)
- L C Savic
- Anaesthetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - D A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - P Kopac
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - R C Clarke
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Nedlands, Western Australia, Australia
| | - P J Cooke
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - P Dewachter
- Service d'Anesthésie-Réanimation, Groupe Hospitalier de Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris 13, Sorbonne-Paris-Cité, Paris, France
| | - D G Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - T Garcez
- Department of Immunology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - L H Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - A B Guttormsen
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - P M Hopkins
- Anaesthetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - D L Hepner
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA, USA
| | - H Kolawole
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia; Department of Anaesthesia, Peninsula Health, Melbourne, Australia
| | - M Krøigaard
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital, Gentofte, Denmark
| | - J J Laguna
- Allergy Unit, Allergo-Anaesthesia Unit, Hospital Central de la Cruz Roja, Faculty of Medicine, Alfonso X El Sabio University, ARADyAL, Madrid, Spain
| | - S D Marshall
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia; Department of Anaesthesia, Peninsula Health, Melbourne, Australia
| | - P M Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France
| | - P R Platt
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Nedlands, Western Australia, Australia
| | - M A Rose
- Department of Anaesthesia, Royal North Shore Hospital, and University of Sydney, Sydney, NSW, Australia
| | - V Sabato
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - P H M Sadleir
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Nedlands, Western Australia, Australia; Department of Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - S Savic
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - T Takazawa
- Intensive Care Unit, Gunma University Hospital, Maebashi, Gunma, Japan
| | - S Voltolini
- Allergy Unit, Policlinic Hospital San Martino, Genoa, Italy
| | - G W Volcheck
- Division of Allergic Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
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30
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To challenge or not to challenge: Literature data on the positive predictive value of skin tests to beta-lactams. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2404-2408.e11. [PMID: 30844483 DOI: 10.1016/j.jaip.2019.01.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/31/2018] [Accepted: 01/14/2019] [Indexed: 12/19/2022]
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31
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Penicillin Allergy Testing Should Be Performed Routinely in Patients with Self-Reported Penicillin Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 5:333-334. [PMID: 28283158 DOI: 10.1016/j.jaip.2016.12.010] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 12/20/2016] [Indexed: 11/30/2022]
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32
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Moran R, Devchand M, Smibert O, Trubiano JA. Antibiotic allergy labels in hospitalized and critically ill adults: A review of current impacts of inaccurate labelling. Br J Clin Pharmacol 2019; 85:492-500. [PMID: 30521088 DOI: 10.1111/bcp.13830] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 11/04/2018] [Accepted: 11/19/2018] [Indexed: 11/29/2022] Open
Abstract
Antibiotic allergy labels (AALs) are reported by approximately 20% of hospitalized patients, yet over 85% will be negative on formal allergy testing. Hospitalized patients with an AAL have inferior patient outcomes, increased colonization with multidrug-resistant organisms and frequently receive inappropriate antimicrobials. Hospitalized populations have been well studied but, to date, the impact of AALs on patients with critical illness remains less well defined. We review the prevalence and impact of AALs on hospitalized patients, including those in in critical care.
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Affiliation(s)
- Rebekah Moran
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Misha Devchand
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of Pharmacy, Austin Health, Heidelberg, VIC, Australia
| | - Olivia Smibert
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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33
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Mungo N, Reddy K, Gutierrez-Sereno J, Lopez-Alvarez S, Gonzalez-Estrada A. Penicillin skin testing without minor determinate mixture and amoxicillin challenge in the Appalachian region. Ann Allergy Asthma Immunol 2019; 120:217-219. [PMID: 29413346 DOI: 10.1016/j.anai.2017.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/19/2017] [Accepted: 11/20/2017] [Indexed: 01/18/2023]
Affiliation(s)
- Nicolas Mungo
- Department of Internal Medicine, East Tennessee State University Johnson City, Tennessee
| | - Keerthi Reddy
- Department of Pediatrics, East Tennessee State University Johnson City, Tennessee
| | | | | | - Alexei Gonzalez-Estrada
- Department of Allergy and Clinical Immunology, East Tennessee State University Johnson City, Tennessee.
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34
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The Importance of Delabeling β-Lactam Allergy in Children. J Pediatr 2019; 204:291-297.e1. [PMID: 30322703 DOI: 10.1016/j.jpeds.2018.09.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/29/2018] [Accepted: 09/12/2018] [Indexed: 01/09/2023]
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35
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Sacco KA, Cochran BP, Epps K, Parkulo M, Gonzalez-Estrada A. Inpatient β-lactam test-dose protocol and antimicrobial stewardship in patients with a history of penicillin allergy. Ann Allergy Asthma Immunol 2018; 122:184-188. [PMID: 30465860 DOI: 10.1016/j.anai.2018.11.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 10/17/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Penicillin allergy is the most commonly reported drug allergy in hospitalized patients, resulting in increased second-line antibiotic use, nosocomial infections, and health care use. Given that most patients are not truly allergic, a safe strategy that empowers the admitting physician is needed. OBJECTIVE To assess the effect on antibiotic prescribing practices for hospitalized patients with penicillin allergy using a validated intervention. METHODS An intervention was implemented to educate health care professionals on management of patients with penicillin allergy using a validated risk stratification algorithm to guide testing and antibiotic use. Thirty days of control data using current standard of care was compared with 60 days of postintervention data measuring documentation of penicillin allergy history and antibiotic selection. RESULTS The relative use of cephalosporin and penicillin antibiotics increased by 121.2% (P = .03) and 256% (P = .04), respectively, without an increase in adverse drug reactions. There was a decrease in the use of broad-spectrum antibiotics: vancomycin, 67.2% (P = .04); quinolones, 33.3% (P = .31); carbapenems, 81.9% (P = .08); and aztreonam, 73.8% (P = .18). CONCLUSION The antibiotic choice in patients admitted to the hospital with a reported penicillin allergy can be improved by better evaluation of the allergy history and the use of a risk stratification guideline.
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Affiliation(s)
- Keith A Sacco
- Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Kevin Epps
- Department of Pharmacy, Mayo Clinic, Jacksonville, Florida
| | - Mark Parkulo
- Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Florida.
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Eyk NV, Schalkwyk JV. N o 275 - Antibioprophylaxie dans le cadre d'interventions gynécologiques. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:e734-e745. [PMID: 30390952 DOI: 10.1016/j.jogc.2018.07.008] [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: 11/25/2022]
Abstract
OBJECTIF Analyser les données et formuler des recommandations sur l'antibioprophylaxie dans le cadre d'interventions gynécologiques. ISSUES Parmi les issues évaluées, on trouvait la nécessité du recours aux antibiotiques et leur efficacité pour ce qui est de la prévention des infections dans le cadre d'interventions gynécologiques. RéSULTATS: Des recherches ont été menées dans Medline et The Cochrane Library afin d'en tirer les articles publiés entre janvier 1978 et janvier 2011 sur le sujet de l'antibioprophylaxie dans le cadre d'interventions gynécologiques. Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en juin 2011. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. VALEURS La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). AVANTAGES, DéSAVANTAGES ET COûTS: La mise en œuvre de la directive clinique devrait entraîner une baisse des coûts et des torts liés à l'administration superflue d'antibiotiques, ainsi qu'une atténuation des infections et des morbidités connexes dans les cas où il a été démontré que l'administration d'antibiotiques confère un avantage pour la patiente. RECOMMANDATIONS.
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Savic L, Gurr L, Kaura V, Toolan J, Sandoe JAT, Hopkins PM, Savic S. Penicillin allergy de-labelling ahead of elective surgery: feasibility and barriers. Br J Anaesth 2018; 123:e110-e116. [PMID: 30915983 DOI: 10.1016/j.bja.2018.09.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/02/2018] [Accepted: 09/03/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Around 10-15% of the in-patient population carry unsubstantiated 'penicillin allergy' labels, the majority incorrect when tested. These labels are associated with harm from use of broad-spectrum non-penicillin antibiotics. Current testing guidelines incorporate both skin and challenge tests; this is prohibitively expensive and time-consuming to deliver on a large scale. We aimed to establish the feasibility of a rapid access de-labelling pathway for surgical patients, using direct oral challenge. METHODS 'Penicillin allergic' patients, recruited from a surgical pre-assessment clinic, were risk-stratified using a screening questionnaire. Patients at low risk of true, immunoglobulin E (IgE)-mediated allergy were offered direct oral challenge using incremental amoxicillin to a total dose of 500 mg. A 3-day course was completed at home. De-labelled patients were followed up to determine antibiotic use in surgery, and attitudes towards de-labelling were explored. RESULTS Of 219 patients screened, 74 were eligible for inclusion and offered testing. We subsequently tested 56 patients; 55 were de-labelled. None had a serious reaction to the supervised challenge, or thereafter. On follow-up, 17 of 19 patients received appropriate antimicrobial prophylaxis during surgery. Only three of 33 de-labelled patients would have been happy for the label to be removed without prior specialist testing. CONCLUSION Rapid access de-labelling, using direct oral challenge in appropriately risk-stratified patients, can be incorporated into the existing surgical care pathway. This provides immediate and potential long-term benefit for patients. Interest in testing is high among patients, and clinicians appear to follow clinic recommendations. Patients are unlikely to accept removal of their allergy label on the basis of history alone. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: AN17/92982.
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Affiliation(s)
- L Savic
- Anaesthetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - L Gurr
- University of Leeds School of Medicine, Leeds, UK
| | - V Kaura
- Leeds Institute of Biomedical and Clinical Sciences, Leeds, UK
| | - J Toolan
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - J A T Sandoe
- University of Leeds School of Medicine, Leeds, UK; Microbiology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - P M Hopkins
- Anaesthetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute of Biomedical and Clinical Sciences, Leeds, UK
| | - S Savic
- University of Leeds School of Medicine, Leeds, UK; Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Adkinson NF, Mendelson LM, Ressler C, Keogh JC. Penicillin minor determinants: History and relevance for current diagnosis. Ann Allergy Asthma Immunol 2018; 121:537-544. [PMID: 30248407 DOI: 10.1016/j.anai.2018.09.459] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/18/2018] [Accepted: 09/18/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To review the history of the penicillin minor determinants and evaluate their relevance for current diagnosis. DATA SOURCES Skin testing to detect immunoglobulin E (IgE) sensitivity to penicillins in patients with a history of penicillin allergy has been the subject of more than 55 years of published research involving tens of thousands of patients. STUDY SELECTIONS Selection of data was based on its relevance to the objective of this article. RESULTS It was established early on that testing with the major penicilloyl determinant using the polyvalent penicilloyl-polylysine (PPL) is negative in a substantial portion (10% to 64%, including recent increases) of those at risk for immediate hypersensitivity reactions. A variety of minor penicillin determinants are clinically significant in that their use in skin testing is essential to detect all those at risk. In particular, a minor determinant mixture of benzylpenicillin, benzylpenicilloate, and benzylpenilloate, used in conjunction with PPL, has been shown in numerous studies to achieve an average negative predictive value (NPV) of 97.9% in history-positive patients. Benzylpenicillin alone, as the sole minor determinant, leaves many skin test-positive patients undiscovered. Use of amoxicillin as an additional minor determinant reagent appears to identify another 2% to 8% of skin test-positive patients in some populations. CONCLUSION IgE skin testing, using both the major and appropriate minor determinants of penicillin, can identify, with a high degree of reliability (NPV ∼97%), penicillin allergy history-positive patients who can receive beta-lactam antibiotics without concern for serious acute allergy, including anaphylaxis. The few false-negative skin tests reported globally are largely confined to minor, self-limited cutaneous reactions.
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Affiliation(s)
- N Franklin Adkinson
- Division of Allergy & Clinical Immunology, Johns Hopkins Asthma & Allergy Center, Baltimore, Maryland; AllerQuest LLC, Plainville, Connecticut.
| | - Louis M Mendelson
- AllerQuest LLC, Plainville, Connecticut; University of Connecticut School of Medicine, New England Food Allergy Center, Farmington, Connecticut
| | - Charlotte Ressler
- AllerQuest LLC, Plainville, Connecticut; University of Connecticut School of Medicine, Farmington, Connecticut
| | - John C Keogh
- AllerQuest LLC, Plainville, Connecticut; Keogh Medical Writing, LLC, Guilford, Connecticut
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Yang MS, Kang D, Seo B, Park HJ, Park SY, Kim MY, Park K, Koo SM, Nam YH, Kim S, Jung JW, Kim TB, Jang GC, Yang HJ, Ahn YM, Park JW, Kang HR. Incidence of cephalosporin-induced anaphylaxis and clinical efficacy of screening intradermal tests with cephalosporins: A large multicenter retrospective cohort study. Allergy 2018. [PMID: 29517808 DOI: 10.1111/all.13435] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Few studies have investigated the incidence of anaphylaxis induced by individual or structurally similar cephalosporins. The aims of the study were to assess the incidence of cephalosporin-induced anaphylaxis and evaluate the clinical efficacy of screening skin tests. METHODS In this retrospective cohort study, we obtained information on total cephalosporin use and cephalosporin-induced anaphylaxis in intravenous cephalosporin recipients in 12 general hospitals between 2013 and 2015. Cephalosporins were divided into 4 groups according to similar side-chain structures. The incidence of cephalosporin-induced anaphylaxis was assessed for each cephalosporin, cephalosporin generation, and side-chain group. To verify the efficacy of screening intradermal tests (IDT) with cephalosporin, the 12 hospitals were assigned to the intervention or control group depending on whether they performed screening IDT before the administration of cephalosporins. RESULTS We identified 76 cases of cephalosporin-induced anaphylaxis with 1 123 345 exposures to intravenous cephalosporins (6.8 per 100 000 exposures), and the incidence of fatal anaphylaxis by cephalosporin was 0.1 cases per 100 000 exposures. The highest incidences of anaphylaxis occurred in the ceftizoxime (13.0 cases per 100 000 exposures) and side-chain group 1 (cefepime, cefotaxime, ceftizoxime, ceftriaxone, and cefuroxime; 9.3 per 100 000). There was no case of anaphylaxis induced by cefoxitin, cefmetazole, cefminox, and cefotiam. The clinical effectiveness of routine screening IDT was not significant (P = .06). CONCLUSIONS The incidence of cephalosporin-induced anaphylaxis differed according to individual drugs and side-chain structure. Screening IDT showed no clinical efficacy at a population level.
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Affiliation(s)
- M.-S. Yang
- Department of Internal Medicine; SMG-SNU Boramae Medical Center; Seoul Korea
| | - D.Y. Kang
- Department of Preventive Medicine; Seoul National University College of Medicine; Seoul Korea
- Drug Safety Monitoring Center; Seoul National University Hospital; Seoul Korea
| | - B. Seo
- Department of Allergy and Clinical Immunology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - H. J. Park
- Department of Internal Medicine; Gangnam Severance Hospital; Yonsei University College of Medicine; Seoul Korea
| | - S.-Y. Park
- Department of Internal Medicine; Eulji General Hospital; Eulji University School of Medicine; Seoul Korea
| | - M.-Y. Kim
- Division of Pulmonary, Allergy and Critical Care Medicine; Department of Internal Medicine; Busan Paik Hospital; Inje University College of Medicine; Busan Korea
| | - K. H. Park
- Division of Allergy and Immunology; Department of Internal Medicine; Yonsei University College of Medicine; Seoul Korea
| | - S.-M. Koo
- Division of Allergy and Respiratory Medicine; Department of Internal Medicine; Soonchunhyang University Seoul Hospital; Soonchunhyang University College of Medicine; Seoul Korea
| | - Y.-H. Nam
- Department of Internal Medicine; Dong-A University College of Medicine; Busan Korea
| | - S. Kim
- Department of Internal Medicine; School of Medicine; Kyungpook National University; Daegu Korea
| | - J.-W. Jung
- Department of Internal Medicine; Chung-Ang University College of Medicine; Seoul Korea
| | - T.-B. Kim
- Department of Allergy and Clinical Immunology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - G. C. Jang
- Department of Pediatrics; National Health Insurance Service; Ilsan Hospital; Goyang Korea
| | - H.-J. Yang
- Pediatric Allergy and Respiratory Center; Department of Pediatrics; Soonchunhyang University Seoul Hospital; Soonchunhyang University College of Medicine; Seoul Korea
| | - Y.-M. Ahn
- Department of Pediatrics; Eulji General Hospital; Eulji University School of Medicine; Seoul Korea
| | - J.-W. Park
- Division of Allergy and Immunology; Department of Internal Medicine; Yonsei University College of Medicine; Seoul Korea
| | - H.-R. Kang
- Drug Safety Monitoring Center; Seoul National University Hospital; Seoul Korea
- Division of Allergy and Clinical Immunology; Department of Internal Medicine; Seoul National University Hospital; Seoul National University College of Medicine; Seoul Korea
- Institute of Allergy and Clinical Immunology; Seoul National University Medical Research Center; Seoul Korea
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Chen JR, Tarver SA, Alvarez KS, Wei W, Khan DA. Improving Aztreonam Stewardship and Cost Through a Penicillin Allergy Testing Clinical Guideline. Open Forum Infect Dis 2018; 5:ofy106. [PMID: 29977963 PMCID: PMC6016425 DOI: 10.1093/ofid/ofy106] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/03/2018] [Indexed: 11/12/2022] Open
Abstract
Background Patients reporting penicillin allergy often receive unnecessary and costly broad-spectrum alternatives such as aztreonam with negative consequences. Penicillin allergy testing improves antimicrobial therapy but is not broadly used in hospitals due to insufficient testing resources and short-term expenses. We describe a clinical decision support (CDS) tool promoting pharmacist-administered penicillin allergy testing in patients receiving aztreonam and its benefits toward antimicrobial stewardship and costs. Methods A CDS tool was incorporated into the electronic medical record, directing providers to order penicillin allergy testing for patients receiving aztreonam. An allergy-trained pharmacist reviewed orders placed through this new guideline and performed skin testing and oral challenges to determine whether these patients could safely take penicillin. Data on tests performed, antibiotic utilization, and cost-savings were compared with patients tested outside the new guideline as part of our institution's standard stewardship program. Results The guideline significantly increased penicillin allergy testing among patients receiving aztreonam from 24% to 85% (P < .001) while reducing the median delay between admission and testing completion from 3.31 to 1.05 days (P = 0.008). Patients tested under the guideline saw a 58% increase in penicillin exposure (P = .046). Institutional aztreonam administration declined from 2.54 to 1.47 administrations per 1000 patient-days (P = .016). Average antibiotic costs per patient tested before and after CDS decreased from $1265.81 to $592.08 USD, a 53% savings. Conclusions Targeting penicillin allergy testing to patients on aztreonam yields therapeutic and economic benefits during a single admission. This provides a cost-effective model for inpatient testing.
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Affiliation(s)
- Justin R Chen
- Department of Internal Medicine, Division of Allergy and Immunology, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Scott A Tarver
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas
| | - Kristin S Alvarez
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas
| | - Wenjing Wei
- Department of Pharmacy Services, Parkland Health and Hospital System, Dallas, Texas
| | - David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, The University of Texas Southwestern Medical Center, Dallas, Texas
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Jeffres MN, Hall-Lipsy EA, King ST, Cleary JD. Systematic review of professional liability when prescribing β-lactams for patients with a known penicillin allergy. Ann Allergy Asthma Immunol 2018; 121:530-536. [PMID: 29551402 DOI: 10.1016/j.anai.2018.03.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/28/2018] [Accepted: 03/13/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To describe medical negligence and malpractice cases in which a patient with a known penicillin allergy received a β-lactam and experienced an adverse reaction related to the β-lactam. DATA SOURCES Lexis-Nexus, Westlaw, and Google Scholar were searched. STUDY SELECTIONS Medical negligence and malpractice cases were eligible for inclusion if they met the following criteria: the plaintiff had a known penicillin allergy, received a β-lactam, and experienced an adverse event. All United States federal and state cases were eligible. RESULTS Twenty-seven unique cases met the inclusion criteria. Eighteen cases involved the receipt of a penicillin-based antibiotic; of these cases with a known legal outcome, the plaintiff (patient or representative) prevailed or settled in 3 cases and defendants (providers) prevailed in 7 cases. Seven cases involved the receipt of a cephalosporin; of these cases with a known legal outcome, the plaintiff settled with physicians before trial in 1 case and defendants prevailed in 3 cases. Two cases involved the receipt of a carbapenem. Defendants prevailed in one case and the legal outcome of the other case is unknown. In cases in which the defense successfully moved for summary judgment, judges cited a lack of scientific evidence demonstrating a cephalosporin or carbapenem was contraindicated for a patient with a penicillin allergy. CONCLUSION The cases with published legal outcomes found limited professional liability for clinicians who prescribed cephalosporins or carbapenems to a patient with a known penicillin allergy. These results may decrease the litigation fears of practitioners and risk managers within health care systems.
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Affiliation(s)
- Meghan N Jeffres
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado.
| | - Elizabeth A Hall-Lipsy
- Department of Pharmacy Practice & Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - S Travis King
- Department of Pharmacy, Ochsner Medical Center, New Orleans, Louisiana
| | - John D Cleary
- St Dominic Hospital, Department of Pharmacy, Jackson, Mississippi
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Turner NA, Moehring R, Sarubbi C, Wrenn RH, Drew RH, Cunningham CK, Fowler VG, Anderson DJ. Influence of Reported Penicillin Allergy on Mortality in MSSA Bacteremia. Open Forum Infect Dis 2018; 5:ofy042. [PMID: 29594180 PMCID: PMC5861429 DOI: 10.1093/ofid/ofy042] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Penicillin allergy frequently impacts antibiotic choice. As beta-lactams are superior to vancomycin in treating methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, we examined the effect of reported penicillin allergy on clinical outcomes in patients with MSSA bacteremia. Methods In this retrospective cohort study of adults with MSSA bacteremia admitted to a large tertiary care hospital, outcomes were examined according to reported penicillin allergy. Primary outcomes included 30-day and 90-day mortality rates. Multivariable regression models were developed to quantify the effect of reported penicillin allergy on mortality while adjusting for potential confounders. Results From 2010 to 2015, 318 patients with MSSA bacteremia were identified. Reported penicillin allergy had no significant effect on adjusted 30-day mortality (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.29-1.84; P = .51). Patients with reported penicillin allergy were more likely to receive vancomycin (38% vs 11%, P < .01), but a large number received cefazolin regardless of reported allergy (29 of 66, 44%). Mortality rates were highest among nonallergic patients receiving vancomycin (22.6% vs 7.4% for those receiving beta-lactams regardless of reported allergy, P < .01). In multivariable analysis, beta-lactam receipt was most strongly associated with survival (OR, 0.26; 95% CI, 0.12-0.54). Conclusions Reported penicillin allergy had no significant effect on 30- or 90-day mortality. Non-penicillin-allergic patients receiving vancomycin for treatment of MSSA bacteremia had the highest mortality rates overall. Receipt of a beta-lactam was the strongest predictor of survival. These results underscore the importance of correct classification of patients with penicillin allergy and appropriate treatment with a beta-lactam when tolerated.
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Affiliation(s)
- Nicholas A Turner
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Rebekah Moehring
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Christina Sarubbi
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina
| | - Rebekah H Wrenn
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina
| | - Richard H Drew
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Coleen K Cunningham
- Division of Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Vance G Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Deverick J Anderson
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Pham MN, Ho HE, Desai M. Penicillin desensitization: Treatment of syphilis in pregnancy in penicillin-allergic patients. Ann Allergy Asthma Immunol 2017; 118:537-541. [PMID: 28477786 DOI: 10.1016/j.anai.2017.03.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Michele N Pham
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hsi-En Ho
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mauli Desai
- Icahn School of Medicine at Mount Sinai, New York, New York.
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Solensky R. Penicillin skin testing: The devil is in the details. Ann Allergy Asthma Immunol 2017; 119:199-200. [PMID: 28890015 DOI: 10.1016/j.anai.2017.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Roland Solensky
- The Corvallis Clinic, Oregon State University, Oregon Health Science University College of Pharmacy, Corvallis, Oregon.
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Abstract
INTRODUCTION Diagnosing and managing drug hypersensitivity is challenging because there are no clear limits between different types of drug reactions. Distinguishing between type A (predictable) and type B (hypersensitivity) reactions when a drug is introduced on the market is not easy. When many people use a drug, adverse reactions can occur, conditioned by diverse genetic profiles, viral infections or concomitant therapy. Occasionally the only tool clinicians have on which to base the diagnosis is the clinical history. Skins tests or in vitro tests sometimes have low sensitivity or are unavailable, and drug provocation tests may be dangerous or strictly forbidden in case of severe cutaneous reactions. Areas covered: This paper reviews the diagnosis and management of the two main types of immunological reactions: IgE-mediated immediate drug hypersensitivity reactions (IDHRs) and non-immediate drug hypersensitivity reactions (NIDHRs). Expert commentary: Although Europe and the United States use different diagnostic methods, patients with history of drug hypersensitivity must avoid the suspicious drug, and clinicians must assess tolerance to safe alternatives under medical surveillance. Sometimes desensitization may be required. There is a consensus about the need to perform genetic testing for specific drugs and give patients proper documentation to prevent future exposure to culprit drugs.
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Affiliation(s)
- Javier Fernandez
- a Allergy Section , Alicante University Hospital, UMH-ISABIAL , Alicante , Spain
| | - Inmaculada Doña
- b Allergy Service , Carlos Haya Hospital (Pavilion C) , Malaga , Spain
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Chen JR, Khan DA. Evaluation of Penicillin Allergy in the Hospitalized Patient: Opportunities for Antimicrobial Stewardship. Curr Allergy Asthma Rep 2017; 17:40. [PMID: 28540641 DOI: 10.1007/s11882-017-0706-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Penicillin allergy is often misdiagnosed and is associated with adverse consequences, but testing is infrequently done in the hospital setting. This article reviews historical and contemporary innovations in inpatient penicillin allergy testing and its impact on antimicrobial stewardship. RECENT FINDINGS Adoption of the electronic medical record allows rapid identification of admitted patients carrying a penicillin allergy diagnosis. Collaboration with clinical pharmacists and the development of computerized clinical guidelines facilitates increased testing and appropriate use of penicillin and related β-lactams. Education of patients and their outpatient providers is the key to retaining the benefits of penicillin allergy de-labeling. Penicillin allergy testing is feasible in the hospital and offers tangible benefits towards antimicrobial stewardship. Allergists should take the lead in this endeavor and work towards overcoming personnel limitations by partnering with other health care providers and incorporating technology that improves the efficiency of allergy evaluation.
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Affiliation(s)
- Justin R Chen
- Department of Internal Medicine, Division of Allergy & Immunology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8859, USA
| | - David A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8859, USA.
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No 247-Antibioprophylaxie dans le cadre d’interventions obstétricales. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:e300-e308. [DOI: 10.1016/j.jogc.2017.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Ten percent of patients report penicillin allergy, but more than 90% of these individuals can tolerate penicillins. Skin testing remains the optimal method for evaluation of possible IgE-mediated penicillin allergy and is recommended by professional societies, as the harms for alternative antibiotics include antimicrobial resistance, prolonged hospitalizations, readmissions, and increased costs. Removal of penicillin allergy leads to decreased utilization of broad-spectrum antibiotics, such as fluoroquinolones and vancomycin. There is minimal allergic cross-reactivity between penicillins and cephalosporins. IgE-mediated allergy to cephalosporins is usually side-chain specific and may warrant graded challenge with cephalosporins containing dissimilar R1 or R2 group side chains.
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Affiliation(s)
- Daniel Har
- Division of Allergy and Immunology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Roland Solensky
- Division of Allergy and Immunology, The Corvallis Clinic, 3680 NW Samaritan Dr, Corvallis, OR 97330, USA; Oregon State University/Oregon Health & Science University College of Pharmacy, 1601 SW Jefferson Way, Corvallis, OR 97331, USA.
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49
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Sacco KA, Bates A, Brigham TJ, Imam JS, Burton MC. Clinical outcomes following inpatient penicillin allergy testing: A systematic review and meta-analysis. Allergy 2017; 72:1288-1296. [PMID: 28370003 DOI: 10.1111/all.13168] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND A documented penicillin allergy is associated with increased morbidity including length of hospital stay and an increased incidence of resistant infections attributed to use of broader-spectrum antibiotics. The aim of the systematic review was to identify whether inpatient penicillin allergy testing affected clinical outcomes during hospitalization. METHODS We performed an electronic search of Ovid MEDLINE/PubMed, Embase, Web of Science, Scopus, and the Cochrane Library over the past 20 years. Inpatients having a documented penicillin allergy that underwent penicillin allergy testing were included. RESULTS Twenty-four studies met eligibility criteria. Study sample size was between 24 and 252 patients in exclusively inpatient cohorts. Penicillin skin testing (PST) with or without oral amoxicillin challenge was the main intervention described (18 studies). The population-weighted mean for a negative PST was 95.1% [CI 93.8-96.1]. Inpatient penicillin allergy testing led to a change in antibiotic selection that was greater in the intensive care unit (77.97% [CI 72.0-83.1] vs 54.73% [CI 51.2-58.2], P<.01). An increased prescription of penicillin (range 9.9%-49%) and cephalosporin (range 10.7%-48%) antibiotics was reported. Vancomycin and fluoroquinolone use was decreased. Inpatient penicillin allergy testing was associated with decreased healthcare cost in four studies. CONCLUSIONS Inpatient penicillin allergy testing is safe and effective in ruling out penicillin allergy. The rate of negative tests is comparable to outpatient and perioperative data. Patients with a documented penicillin allergy who require penicillin should be tested during hospitalization given its benefit for individual patient outcomes and antibiotic stewardship.
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Affiliation(s)
- K. A. Sacco
- Department of Internal Medicine; Mayo Clinic; Jacksonville FL USA
| | - A. Bates
- Department of Internal Medicine; Mayo Clinic; Jacksonville FL USA
| | - T. J. Brigham
- Winn-Dixie Foundation Medical Library; Mayo Clinic; Jacksonville FL USA
| | - J. S. Imam
- Department of Internal Medicine; Mayo Clinic; Jacksonville FL USA
| | - M. C. Burton
- Department of Internal Medicine; Mayo Clinic; Jacksonville FL USA
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Epidemiology of anaphylaxis at a tertiary care center: A report of 730 cases. Ann Allergy Asthma Immunol 2017; 118:80-85. [PMID: 28007089 DOI: 10.1016/j.anai.2016.10.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/18/2016] [Accepted: 10/26/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Recent data reveal that the rate of anaphylaxis is increasing and suggest that idiopathic anaphylaxis may account for most of these cases. OBJECTIVE To determine the pattern of anaphylaxis at a tertiary care referral center. METHODS A retrospective electronic medical record review spanning 12 years (2002-2013) identified patients with anaphylaxis. RESULTS Of the 4,777 records reviewed, 730 patients met our anaphylaxis definition. Median age was 34.0 years; 72.7% were adults, 58.6% were female, and 86.8% were white. Median time to evaluation by an allergist was 8.8 months. Foods were the most common cause (29.9%), followed by Hymenoptera venom (24.6%), idiopathic anaphylaxis (13.7%), and medications (13.3%). The most common foods were peanuts (23.9%), tree nuts (21.6%), shellfish (16.1%), and egg and milk (both 10.1%). The most common cause of anaphylaxis in adults was Hymenoptera venom. The most frequent symptoms were urticaria and/or angioedema, reported in 84.7% of cases. Atopy was present in 43.8%. In 15.4% of cases, anaphylaxis was not the chief reason for the office visit. CONCLUSION We found food allergy was the most common overall cause of anaphylaxis, with peanut the most frequent food trigger. Idiopathic anaphylaxis was not the most common cause but accounted for 13.7% of all cases. Approximately 1 in 6 cases of anaphylaxis may be missed if a comprehensive evaluation is not performed.
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