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Gray MP, Kellum JA, Kirisci L, Boyce RD, Kane-Gill SL. Long-Term Outcomes Associated With β-Lactam Allergies. JAMA Netw Open 2024; 7:e2412313. [PMID: 38758551 PMCID: PMC11102016 DOI: 10.1001/jamanetworkopen.2024.12313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/19/2024] [Indexed: 05/18/2024] Open
Abstract
Importance β-lactam (BL) allergies are the most common drug allergy worldwide, but most are reported in error. BL allergies are also well-established risk factors for adverse drug events and antibiotic-resistant infections during inpatient health care encounters, but the understanding of the long-term outcomes of patients with BL allergies remains limited. Objective To evaluate the long-term clinical outcomes of patients with BL allergies. Design, Setting, and Participants This longitudinal retrospective cohort study was conducted at a single regional health care system in western Pennsylvania. Electronic health records were analyzed for patients who had an index encounter with a diagnosis of sepsis, pneumonia, or urinary tract infection between 2007 and 2008. Patients were followed-up until death or the end of 2018. Data analysis was performed from January 2022 to January 2024. Exposure The presence of any BL class antibiotic in the allergy section of a patient's electronic health record, evaluated at the earliest occurring observed health care encounter. Main Outcomes and Measures The primary outcome was all-cause mortality, derived from the Social Security Death Index. Secondary outcomes were defined using laboratory and microbiology results and included infection with methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, or vancomycin-resistant Enterococcus (VRE) and severity and occurrence of acute kidney injury (AKI). Generalized estimating equations with a patient-level panel variable and time exposure offset were used to evaluate the odds of occurrence of each outcome between allergy groups. Results A total of 20 092 patients (mean [SD] age, 62.9 [19.7] years; 12 231 female [60.9%]), of whom 4211 (21.0%) had BL documented allergy and 15 881 (79.0%) did not, met the inclusion criteria. A total of 3513 patients (17.5%) were Black, 15 358 (76.4%) were White, and 1221 (6.0%) were another race. Using generalized estimating equations, documented BL allergies were not significantly associated with the odds of mortality (odds ratio [OR], 1.02; 95% CI, 0.96-1.09). BL allergies were associated with increased odds of MRSA infection (OR, 1.44; 95% CI, 1.36-1.53), VRE infection (OR, 1.18; 95% CI, 1.05-1.32), and the pooled rate of the 3 evaluated antibiotic-resistant infections (OR, 1.33; 95% CI, 1.30-1.36) but were not associated with C difficile infection (OR, 1.04; 95% CI, 0.94-1.16), stage 2 and 3 AKI (OR, 1.02; 95% CI, 0.96-1.10), or stage 3 AKI (OR, 1.06; 95% CI, 0.98-1.14). Conclusions and Relevance Documented BL allergies were not associated with the long-term odds of mortality but were associated with antibiotic-resistant infections. Health systems should emphasize accurate allergy documentation and reduce unnecessary BL avoidance.
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Affiliation(s)
- Matthew P. Gray
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - John A. Kellum
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Levent Kirisci
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Richard D. Boyce
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sandra L. Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
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Sexton ME, Kuruvilla ME. Management of Penicillin Allergy in the Perioperative Setting. Antibiotics (Basel) 2024; 13:157. [PMID: 38391543 PMCID: PMC10886174 DOI: 10.3390/antibiotics13020157] [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: 12/15/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
The selection of perioperative antibiotic prophylaxis is challenging in patients with a history of penicillin allergy; as such, we present a literature review exploring current best practices and the associated supporting evidence, as well as areas for future research. Guidelines recommend the use of alternative agents in patients with an IgE-mediated hypersensitivity reaction, but those alternative agents are associated with worse outcomes, including an increased risk of surgical site infection, and higher cost. More recent data suggest that the risk of cross-reactivity between penicillins and cephalosporins, particularly cefazolin, is extremely low, and that cefazolin can be used safely in most penicillin-allergic patients. Studies have therefore explored how best to implement first-line cefazolin use in patients with a penicillin allergy label. A variety of interventions, including preoperative allergy de-labeling with incorporation of penicillin skin testing, use of patient risk-stratification questionnaires, and utilization of clinician algorithms to guide antibiotic selection intraoperatively, have all been shown to significantly increase cefazolin utilization without a corresponding increase in adverse events. Further studies are needed to clarify the most effective interventions and implementation strategies, as well as to evaluate whether patients with severe delayed hypersensitivity reactions to penicillin should continue to be excluded from receipt of other beta-lactams.
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Affiliation(s)
- Mary Elizabeth Sexton
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Merin Elizabeth Kuruvilla
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
- Novartis Pharmaceuticals, East Hanover, NJ 07936, USA
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Nguyen N, Chua HC, Drake T, Jo J, Stramel SA, Vuong NN, Gonzales-Luna AJ, Olson K, On Behalf Of The Houston Infectious Diseases Network. Significant Publications on Infectious Diseases Pharmacotherapy in 2021. J Pharm Pract 2024; 37:198-211. [PMID: 36122416 DOI: 10.1177/08971900221128334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To summarize the most noteworthy infectious diseases (ID) pharmacotherapy articles published in peer-reviewed literature in 2021. Summary: Members of the Houston Infectious Diseases Network (HIDN) nominated articles that were deemed to have significant contributions to ID pharmacotherapy in 2021. These nominations included articles pertaining to both general ID, including coronavirus disease 2019 (COVID-19), and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pharmacotherapy. A total of 35 articles were nominated by HIDN: 30 articles pertaining to general ID pharmacotherapy and 5 articles with HIV/AIDS focus. To select the most influential articles of 2021, a survey was created and distributed to members of the Society of Infectious Diseases Pharmacists (SIDP). Of the 239 SIDP members who responded to the survey, there were 192 recorded votes for the top 10 general ID pharmacotherapy articles and 47 recorded votes for the top HIV/AIDS article, respectively. The top publications are summarized. Conclusion: Antimicrobial stewardship and the optimal management of infectious disease states continues to be a priority in the midst of the ongoing coronavirus disease 2019 (COVID-19) global pandemic. In light of the sheer volume of ID-related articles published in the past year, this review aims to aid clinicians in remaining up-to-date on key practice-changing ID pharmacotherapy publications from 2021.
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Affiliation(s)
- Nhi Nguyen
- Department of Pharmacy, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hubert C Chua
- Department of Pharmacy, CHI Baylor St Luke's Medical Center, Houston, TX, USA
| | - Ty Drake
- Department of Pharmacy, Houston Methodist Willowbrook Hospital, Houston, TX, USA
| | - Jinhee Jo
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Stefanie Anne Stramel
- Department of Pharmacy, Memorial Hermann Memorial City Medical Center, Houston, TX, USA
| | - Nancy N Vuong
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Kelsey Olson
- Department of Pharmacy, HCA Houston Healthcare Clear Lake, Webster, TX, USA
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Kalmanson OA, McLoughlin KC, Kiser TH, Gubbels SP. Debilitating Gentamicin Ototoxicity: Case Report and Recommendations Against Routine Use in Surgical Prophylaxis. Ann Otol Rhinol Laryngol 2023; 132:1686-1689. [PMID: 37243327 DOI: 10.1177/00034894231176333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Aminoglycoside antibiotics such as gentamicin are bactericidal and effective against gram negative organisms and act synergistically against gram positive organisms, including Staphylococcus aureus. However, they have serious adverse effects such as nephrotoxicity and ototoxicity. Gentamicin ototoxicity may occur after a single dose and results in decreased vestibular function, which is frequently debilitating and often permanent. OBJECTIVE To emphasize the risk of gentamicin ototoxicity and suggest alternative antibiotics in penicillin-allergic patients undergoing surgery. CASE SUMMARY We present a case of a woman with preexisting Meniere's Disease who received gentamicin 400 mg perioperatively for a sigmoidectomy due to a penicillin allergy listed in the patient's medical record. The patient developed severe ototoxicity preventing her from working or driving. Physical examination was remarkable for a broad-based gait requiring assistance to walk and bilateral corrective saccades. Vestibular testing revealed high-grade bilateral vestibular loss associated with all semicircular canals, a considerable decline compared to her function 3 years prior. DISCUSSION Gentamicin is indicated for surgical prophylaxis when a patient has a true allergy to penicillins and cannot receive cephalosporins, though alternatives exist. True allergies include IgE-mediated illness (anaphylaxis, bronchospasm, or urticaria 30-60 minutes after administration) or exfoliative reactions (Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis). The authors encourage more prudent use of gentamicin, especially in patients susceptible for debilitating otologic insults, and offer recommendations for alternative agents prior to using gentamicin.
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Affiliation(s)
- Olivia A Kalmanson
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kaitlin C McLoughlin
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Samuel P Gubbels
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, CO, USA
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Hitchcock AM, Kufel WD, Seabury RW, Steele JM. Impact of a Pharmacist-Conducted Preoperative Beta-Lactam Allergy Assessment on Perioperative Cefazolin Prescribing. J Pharm Pract 2023:8971900231214581. [PMID: 37931904 DOI: 10.1177/08971900231214581] [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: 11/08/2023]
Abstract
Background: Cefazolin is guideline recommended for perioperative prophylaxis in orthopedic surgery. Despite its unique R1 side chain, cefazolin is often avoided in patients with beta-lactam allergy with concern for cross reactivity. Objectives: The primary outcome was the percentage of patients who received cefazolin perioperatively. Secondary outcomes included the percentage of patients with a beta-lactam allergy clarified following the telephone interview and clinical outcomes including acute kidney injury, surgical site infection, Clostridioides difficile infection, and re-admission at 30 and 90 days. Methods: This single-center, quasi-experimental study evaluated a pilot program in which a pharmacist phoned patients > 18 years of age with a scheduled orthopedic surgery and a documented beta-lactam allergy to assess their allergy preoperatively. Recommendations to use cefazolin were based on an algorithm. Patients were divided into pre- and post-intervention cohorts. Results: A total of 832 patients were screened for inclusion with 135 and 66 patients included in the pre- and post-intervention cohorts. No significant difference was identified in the primary outcome. In the post-intervention cohort, 62% had a beta-lactam reaction updated in the electronic medical record. Those with a beta-lactam allergy delabeled or made less severe were numerically more likely to receive cefazolin than those with an unchanged reaction or a reaction made more severe (95.2% vs 68% vs 65%). There were no differences in clinical outcomes between groups. Conclusion: A pharmacist-conducted preoperative beta-lactam allergy interview in adult patients undergoing elective orthopedic surgery improved beta-lactam allergy documentation but, did not result in increased utilization of cefazolin.
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Affiliation(s)
- Allison M Hitchcock
- Department of Pharmacy, State University of New York Upstate University Hospital, Syracuse, NY, USA
- Department of Pharmacy, University of Pittsburgh Medical Center Harrisburg, Harrisburg, PA, USA
| | - Wesley D Kufel
- Department of Pharmacy, State University of New York Upstate University Hospital, Syracuse, NY, USA
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Robert W Seabury
- Department of Pharmacy, State University of New York Upstate University Hospital, Syracuse, NY, USA
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Jeffrey M Steele
- Department of Pharmacy, State University of New York Upstate University Hospital, Syracuse, NY, USA
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA
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6
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Hornuß D, Rieg S. [Antibiotic allergies: targeted approach in suspected β‑lactam allergy]. UROLOGIE (HEIDELBERG, GERMANY) 2023; 62:1096-1106. [PMID: 37819359 DOI: 10.1007/s00120-023-02191-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Allergic reactions to antibiotics belong to hypersensitivity drug reactions and can trigger both immunoglobulin E-mediated symptoms and T cell-mediated symptoms. Skin manifestations are the most common symptoms. Although reporting a penicillin allergy results in considerable restrictions in the treatment of acute infections, which may be associated with poor treatment outcomes, in most cases the label 'penicillin allergy' is not called into question or critically reviewed. However, in 85-90% of patients, 'penicillin allergy' constitutes a mislabeling of a non-specific intolerance reaction that does not pose a risk to the patient when re-exposed to penicillins. Careful history taking, an evaluation of manifestations in the past, and easy-to-perform initial diagnostic steps are crucial in differentiating non-specific intolerance reactions from penicillin allergy sensu stricto. Thus, a penicillin de-labeling strategy allows for optimized antibiotic therapy in the event of a future infection. Although allergic cross-reactivity between different β‑lactam antibiotics can occur, the risk for a severe cross-reactivity is dependent on chemical properties of the specific β‑lactam. Published cross-reactivity tables can help in risk stratification and choice of alternative β‑lactam agents.
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Affiliation(s)
- Daniel Hornuß
- Klinik für Innere Medizin II, Abteilung Infektiologie, Universitätsklinikum Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland.
| | - Siegbert Rieg
- Klinik für Innere Medizin II, Abteilung Infektiologie, Universitätsklinikum Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland
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Quartuccio KS, Golden K, Tesini B, Stern J, Seligman NS. Impact of antimicrobial stewardship interventions on peripartum antibiotic prescribing in patients with penicillin allergy. Am J Obstet Gynecol MFM 2023; 5:101074. [PMID: 37499906 DOI: 10.1016/j.ajogmf.2023.101074] [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: 03/27/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Beta-lactam antibiotics (eg, penicillins, cephalosporins, and carbapenems) are preferred for group B streptococcus prophylaxis, intra-amniotic infection, and cesarean surgical site infection prophylaxis. Non-beta-lactam alternatives are associated with inferior efficacy and contribute to higher rates of surgical site infection and longer lengths of stay. Most patients who report a penicillin allergy can tolerate penicillins without any adverse reaction. There are low rates of cross-reactivity between penicillins and other beta-lactams, including cephalosporins and carbapenems. Efforts to evaluate penicillin allergy and promote the use of beta-lactams are needed. OBJECTIVE This study aimed to evaluate whether an antimicrobial stewardship intervention improved the use of first-line antibiotics for peripartum indications in patients with a reported penicillin allergy, following updates to institutional guidelines. STUDY DESIGN This was a retrospective study of adult patients presenting for vaginal or cesarean delivery at 2 hospitals within a healthcare system. Patients received at least 1 dose of antibiotics for a peripartum indication between May 1, 2018, and October 31, 2018 (preintervention group) and May 1, 2020, to October 31, 2020 (postintervention group). The stewardship intervention bundle, which was implemented between March 2019 and April 2020, included updates to institutional antibiotic guidelines, reclassification of severe penicillin allergy, development of obstetrical prophylaxis and treatment order sets, promotion of allergy referral services, and establishment of a physician champion. The primary outcome was the composite rates of patients with reported penicillin allergy who received a preferred antibiotic for a peripartum indication. The secondary measures included maternal and neonatal outcomes. RESULTS A total of 192 patients with a history of documented penicillin allergy were evaluated (96 patients in the preintervention group and 96 patients in the postintervention group). Hives were the most commonly reported index symptom in both groups (40/96 [41.7%] vs 39/96 [40.6%]; P=.883). After stewardship interventions, there was a significant increase in the rate of preferred antibiotic use (33/96 [34.3%] vs 81/96 [84.3%]; P<.001). The effect was the greatest in patients with nonsevere allergy (14/76 [18.4%] vs 68/82 [82.9%]; P<.001). There was no difference in the rates of postpartum endometritis, 30-day readmission, 90-day surgical site infection, or neonatal early-onset sepsis between the pre- and postintervention groups. Of note, 1 patient in the postintervention group experienced itching, and another patient developed a rash, both of which resolved with medical management. CONCLUSION A comprehensive antibiotic stewardship intervention was associated with a 50% increase in the use of preferred antibiotics for peripartum indications in patients with penicillin allergy. Allergic reactions with first-line beta-lactams were minimal and manageable.
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Affiliation(s)
- Katelyn S Quartuccio
- Department of Pharmacy, Highland Hospital, University of Rochester Medical Center, Rochester, NY (Drs Quartuccio and Golden)
| | - Kelly Golden
- Department of Pharmacy, Highland Hospital, University of Rochester Medical Center, Rochester, NY (Drs Quartuccio and Golden)
| | - Brenda Tesini
- Departments of Medicine (Dr Tesini) and Allergy, Immunology, and Rheumatology (Dr Stern), University of Rochester School of Medicine, Rochester, NY
| | - Jessica Stern
- Departments of Medicine (Dr Tesini) and Allergy, Immunology, and Rheumatology (Dr Stern), University of Rochester School of Medicine, Rochester, NY
| | - Neil S Seligman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Rochester School of Medicine, Rochester, NY (Dr Seligman).
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Norvell MR, Porter M, Ricco MH, Koonce RC, Hogan CA, Basler E, Wong M, Jeffres MN. Cefazolin vs Second-line Antibiotics for Surgical Site Infection Prevention After Total Joint Arthroplasty Among Patients With a Beta-lactam Allergy. Open Forum Infect Dis 2023; 10:ofad224. [PMID: 37363051 PMCID: PMC10289809 DOI: 10.1093/ofid/ofad224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/20/2023] [Indexed: 06/28/2023] Open
Abstract
Background Cefazolin is a first-line agent for prevention of surgical site infections (SSIs) after total joint arthroplasty. Patients labeled allergic to beta-lactam antibiotics frequently receive clindamycin or vancomycin perioperatively due to the perceived risk of a hypersensitivity reaction after exposure to cefazolin. Methods This single-system retrospective review included patients labeled allergic to penicillin or cephalosporin antibiotics who underwent a primary total hip and/or knee arthroplasty between January 2020 and July 2021. A detailed chart review was performed to compare the frequency of SSI within 90 days of surgery and interoperative hypersensitivity reactions (HSRs) between patients receiving cefazolin and patients receiving clindamycin and/or vancomycin. Results A total of 1128 hip and/or knee arthroplasties from 1047 patients were included in the analysis (cefazolin n = 809, clindamycin/vancomycin n = 319). More patients in the clindamycin and/or vancomycin group had a history of cephalosporin allergy and allergic reactions with immediate symptoms. There were fewer SSIs in the cefazolin group compared with the clindamycin and/or vancomycin group (0.9% vs 3.8%; P < .001) including fewer prosthetic joint infections (0.1% vs 1.9%). The frequency of interoperative HSRs was not different between groups (cefazolin = 0.2% vs clindamycin/vancomycin = 1.3%; P = .06). Conclusions The use of cefazolin as a perioperative antibiotic for infection prophylaxis in total joint arthroplasty in patients labeled beta-lactam allergic is associated with decreased postoperative SSI without an increase in interoperative HSR.
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Affiliation(s)
- Miranda R Norvell
- Correspondence: Meghan N. Jeffres, PharmD, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy and Pharmaceutical Sciences, Mail Stop C 238, 12850 E. Montview Blvd, V20-1212, Aurora, CO 80045 (); or Miranda R. Norvell, PharmD, Barnes-Jewish Hospital, Department of Pharmacy, One Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, St Louis, MO 63110-1026 ()
| | - Melissa Porter
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Madison H Ricco
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ryan C Koonce
- Department of Orthopedic Surgery, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Craig A Hogan
- Department of Orthopedic Surgery, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Eric Basler
- Department of Orthopedic Surgery, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Megan Wong
- UCHealth University of Colorado Hospital, Aurora, Colorado, USA
| | - Meghan N Jeffres
- Correspondence: Meghan N. Jeffres, PharmD, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy and Pharmaceutical Sciences, Mail Stop C 238, 12850 E. Montview Blvd, V20-1212, Aurora, CO 80045 (); or Miranda R. Norvell, PharmD, Barnes-Jewish Hospital, Department of Pharmacy, One Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, St Louis, MO 63110-1026 ()
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Wrynn AF. An overview of penicillin allergies for nurses. Nursing 2023; 53:27-31. [PMID: 37074275 DOI: 10.1097/01.nurse.0000923664.66265.a4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
ABSTRACT Antibiotics are frequently reported as allergies by patients, particularly antibiotics from the penicillin family. Most of these reported allergies are benign, and the consequences of alternative therapies can be significant. This article provides background information on penicillin allergies and serves as a guide to penicillin allergy management.Reprinted with permission from Wrynn, A.F. An overview of penicillin allergies for nurses. Nurse Pract 2022; 47(9): 30-36. Copyright Wolters Kluwer. All rights reserved.
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Affiliation(s)
- Alexander F Wrynn
- Alexander F. Wrynn is an infectious diseases nurse practitioner at Allegheny Health Network in Pittsburgh, Pa
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Gao J, Wang F, Zhang X, Zhu B, Chen X, Li P, Zhou P, Zheng J, Wang J. Separation and characterization of the polymerized impurities in oxacillin sodium by 2D HPSEC and HPLC IT-TOF MS. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2023; 37:e9466. [PMID: 36597914 DOI: 10.1002/rcm.9466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/28/2022] [Accepted: 12/26/2022] [Indexed: 06/17/2023]
Abstract
RATIONALE The polymerized impurities in oxacillin sodium can induce allergic reaction, which can seriously threaten the health of patients. Gel filtration chromatography (GFC) is currently widely used for the analysis of polymerized impurities, but it has drawbacks. To effectively control the polymerized impurities in oxacillin sodium, a high-performance size exclusion chromatography (HPSEC) method and a reversed-phase high performance liquid chromatography (RP-HPLC) method were established to replace the classical GFC method. METHODS By studying the chromatographic behavior of polymerized impurities and small molecular weight impurities in both methods with different chromatographic separation mechanisms, the polymerized impurities in oxacillin sodium were separated and detected effectively. Column-switching two-dimensional liquid chromatography was applied to eluted polymerized impurities from the HPSEC method for oxacillin sodium. Ion trap/time-of-flight mass spectrometry was applied to characterize the structures of polymerized impurities and unknown impurities eluted from the HPSEC/RP-HPLC method for oxacillin sodium. RESULTS The structures of 25 unknown impurities in oxacillin sodium were elucidated based on the high-resolution massn data. Thirteen polymerized impurities were found and characterized. The corresponding relationship of impurities between the two methods was established and the specificity of the two methods was compared. The RP-HPLC method for analysis of the polymerized impurities not only has higher column efficiency and more specificity than the HPSEC method, but also higher sensitivity. CONCLUSIONS The mechanisms of the formation of degradation impurities in oxacillin sodium were studied. The newly established RP-HPLC methods could effectively separate and detect polymerized impurities and unknown impurities in oxacillin sodium. The study of the impurity profile in oxacillin sodium provided a scientific basis for the improvement of official monographs in pharmacopoeias.
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Affiliation(s)
- Jiarui Gao
- Zhejiang University of Technology, Hangzhou, China
| | - Fan Wang
- Zhejiang University, Hangzhou, China
- Key Laboratory for Core Technology of Generic Drug Evaluation National Medical Product Administration & Key Laboratory of Drug Contacting Materials Quality Control of Zhejiang Province, Zhejiang Institute for Food and Drug Control, Hangzhou, China
| | - Xiangyu Zhang
- Zhejiang University, Hangzhou, China
- Department of General Surgery, Sir Run Run Shaw Hospital, Hangzhou, China
| | - Bingqi Zhu
- Key Laboratory for Core Technology of Generic Drug Evaluation National Medical Product Administration & Key Laboratory of Drug Contacting Materials Quality Control of Zhejiang Province, Zhejiang Institute for Food and Drug Control, Hangzhou, China
| | - Xin Chen
- Zhejiang University, Hangzhou, China
| | - Ping Li
- Zhejiang University of Technology, Hangzhou, China
| | - Ping Zhou
- Zhejiang University of Technology, Hangzhou, China
| | - Jinqi Zheng
- Key Laboratory for Core Technology of Generic Drug Evaluation National Medical Product Administration & Key Laboratory of Drug Contacting Materials Quality Control of Zhejiang Province, Zhejiang Institute for Food and Drug Control, Hangzhou, China
| | - Jian Wang
- Zhejiang University of Technology, Hangzhou, China
- Key Laboratory for Core Technology of Generic Drug Evaluation National Medical Product Administration & Key Laboratory of Drug Contacting Materials Quality Control of Zhejiang Province, Zhejiang Institute for Food and Drug Control, Hangzhou, China
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Hornuß D, Rieg S. [Antibiotic allergies: targeted approach in suspected β‑lactam allergy]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:351-361. [PMID: 36917227 DOI: 10.1007/s00108-023-01490-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 03/16/2023]
Abstract
Allergic reactions to antibiotics belong to hypersensitivity drug reactions and can trigger both immunoglobulin E-mediated symptoms and T cell-mediated symptoms. Skin manifestations are the most common symptoms. Although reporting a penicillin allergy results in considerable restrictions in the treatment of acute infections, which may be associated with poor treatment outcomes, in most cases the label 'penicillin allergy' is not called into question or critically reviewed. However, in 85-90% of patients, 'penicillin allergy' constitutes a mislabeling of a non-specific intolerance reaction that does not pose a risk to the patient when re-exposed to penicillins. Careful history taking, an evaluation of manifestations in the past, and easy-to-perform initial diagnostic steps are crucial in differentiating non-specific intolerance reactions from penicillin allergy sensu stricto. Thus, a penicillin de-labeling strategy allows for optimized antibiotic therapy in the event of a future infection. Although allergic cross-reactivity between different β‑lactam antibiotics can occur, the risk for a severe cross-reactivity is dependent on chemical properties of the specific β‑lactam. Published cross-reactivity tables can help in risk stratification and choice of alternative β‑lactam agents.
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Affiliation(s)
- Daniel Hornuß
- Klinik für Innere Medizin II, Abteilung Infektiologie, Universitätsklinikum Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland.
| | - Siegbert Rieg
- Klinik für Innere Medizin II, Abteilung Infektiologie, Universitätsklinikum Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland
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Bhathal S, Joseph E, Nailor MD, Goodlet KJ. Adherence and outcomes of a surgical prophylaxis guideline promoting cephalosporin use among patients with penicillin allergy. Surgery 2022; 172:1598-1603. [PMID: 35183368 DOI: 10.1016/j.surg.2022.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/06/2022] [Accepted: 01/14/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The study purpose was to assess adherence to a local surgical prophylaxis guideline in patients with reported penicillin allergies, which recommends cephalosporins as first-line prophylaxis. METHODS Adult patients with penicillin allergies admitted for a surgical procedure from July 2020 to June 2021 were retrospectively screened, and the first surgery per admission was included. The primary outcome was the proportion of surgeries using β-lactam prophylaxis. Additional outcomes included prophylaxis timing, hypersensitivity reactions, acute kidney injury, infectious complications, duration of stay, and 30-day mortality or readmission. RESULTS Among 597 procedures, 504 patients (84.4%) received a β-lactam for surgical prophylaxis, including 494 (82.3%) who received a cephalosporin. Patients in the non-β-lactam group were more likely to have a type I IgE-mediated penicillin allergy (48.4% vs 31.7%, P = .002); however, the majority with type I reactions still received β-lactams (78.0%), including in the setting of anaphylaxis or angioedema to penicillin (67.7%). Zero allergic reactions to prophylaxis antibiotics were reported in either group, and there were no significant differences in the proportion of patients receiving drugs associated with the management of allergic reactions. Receipt of non-β-lactams was associated with inappropriate prophylaxis timing (9.7% vs 3.2%, P = .005) and postprocedural acute kidney injury (7.5% vs 0.6%, P < .001). All other outcomes were nonsignificant between the groups. CONCLUSION Among surgical patients with a documented penicillin allergy, most received cephalosporin prophylaxis as recommended by institutional guidelines, with zero allergic reactions. Receipt of non-β-lactam prophylaxis was associated with worsened outcomes. Cephalosporin prophylaxis should be preferred for surgical patients, including in the setting of true penicillin allergy.
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Affiliation(s)
- Salfee Bhathal
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, AZ
| | - Eldo Joseph
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, AZ
| | - Michael D Nailor
- Department of Pharmacy Services, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Kellie J Goodlet
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, AZ.
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Antimicrobial Stewardship in Total Joint Arthroplasty: Outcomes of a Collaborative Program Implementation. J Am Acad Orthop Surg 2022; 30:e1327-e1336. [PMID: 36200821 DOI: 10.5435/jaaos-d-21-00722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 04/26/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Antimicrobial stewardship has been cited as a crucial component of orthopaedic surgical care; however, limited high-quality data exist to guide antibiotic use across the total joint arthroplasty continuum. Antimicrobial stewardship program (ASP) implementation and evaluation is needed in this space. METHODS We pursued a prospective, sequential cohort study of an interprofessional ASP for total joint arthroplasty (TJA) formed in late 2017 at the study institution. Twelve total evidence-based recommendations for protocol change were issued, with 11 accepted and implemented across three project phases spanning March 2018 to December 2019. The primary study outcome was the rate of optimal preoperative intravenous antibiotic selection as assessed for Baseline versus Postintervention time periods. Secondary outcomes included individual antibiotic utilization rates. Descriptive statistics were pursued for institutional surgical site infection (SSI) and postoperative acute kidney injury (AKI) rates across the affected time frame. A cost-benefit analysis of the ASP was estimated from the institutional perspective. RESULTS The rate of optimal preoperative antibiotic selection increased from 64.9% in the Baseline Period (February 2018, n = 57) to 95.4% in the Postimplementation period (June 2018 to December 2019, n = 1,220) (P < 0.001). The rates of second-line preoperative antibiotics and total perioperative antibiotic exposures decreased. Total SSI and AKI rates in primary elective TJA seemed to decrease from calendar year 2018 to 2019 (deep SSI 1.00% to 0.22%, superficial SSI 0.66% to 0.00%, and AKI 1.97% to 1.03%). The institution realized an estimated $197,050 cost savings per 1000 TJA procedures. DISCUSSION A comprehensive ASP for TJA was associated with an increased use of optimal preoperative antibiotic selection, decreased total antibiotic exposures, and cost savings, without apparent detriment to SSI or AKI rates.
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Penicillin allergies: A guide for NPs. Nurse Pract 2022; 47:30-36. [PMID: 36006817 DOI: 10.1097/01.npr.0000855312.11145.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Antibiotics are frequently reported as allergies by patients, particularly antibiotics from the penicillin family. Most of these reported allergies are benign, and the consequences of alternative therapies can be significant. This article will deliver background information on penicillin allergies and serve as a guide to penicillin allergy management.
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Collins CD, Bookal RS, Malani AN, Leo HL, Shankar T, Scheidel C, West N. Antibiotic Use in Patients With β-Lactam Allergies and Pneumonia: Impact of an Antibiotic Side Chain-Based Cross-Reactivity Chart Combined With Enhanced Allergy Assessment. Open Forum Infect Dis 2022; 9:ofab544. [PMID: 34988249 PMCID: PMC8715852 DOI: 10.1093/ofid/ofab544] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/29/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND β-lactam antibiotics with dissimilar R-group side chains are associated with low cross-reactivity. Despite this, patients with β-lactam allergies are often treated with non-β-lactam alternative antibiotics. An institutional β-lactam side chain-based cross-reactivity chart was developed and implemented to guide in antibiotic selection for patients with β-lactam allergies. METHODS This single-center, retrospective cohort study analyzed the impact of the implementation of the cross-reactivity chart for patients with pneumonia. Study time periods were defined as January 2013 to October 2014 prior to implementation of the chart (historical cohort) and January 2017 to October 2018 (intervention cohort) following implementation. The primary outcome was the incidence of β-lactam utilization between time periods. Propensity-weighted scoring and interrupted time-series analyses compared outcomes. RESULTS A total of 341 and 623 patient encounters were included in the historical and intervention cohorts, respectively. There was a significantly greater use of β-lactams in the intervention cohort (70.4% vs 89.3%; P < .001) and decreased use of alternative therapy (58.1% vs 36%; P < .001). There was no difference in overall allergic reactions between cohorts (2.4% vs 1.6%; P = .738) or in reactions caused by β-lactams (1.3% vs 0.9%; P = .703). Inpatient mortality increased (0% vs 6.4%; P < .001); however, no deaths were due to allergic reactions. Healthcare facility-onset Clostridioides difficile infections decreased between cohorts (1.2% vs 0.2%; P = .032). CONCLUSIONS Implementation of a β-lactam side chain-based cross-reactivity chart and enhanced allergy assessment was associated with increased use of β-lactams in patients with pneumonia without increasing allergic reactions.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Renee S Bookal
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Department of Internal Medicine, Division of Infectious Diseases, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Harvey L Leo
- Allergy and Immunology Associates of Ann Arbor, PC, Ann Arbor, Michigan, USA
| | - Tara Shankar
- Allergy and Immunology Associates of Ann Arbor, PC, Ann Arbor, Michigan, USA
| | - Caleb Scheidel
- Methods Consultants of Ann Arbor, Ypsilanti, Michigan, USA
| | - Nina West
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
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Green SB, Stover KR, Barber K, Bouchard JL, Brown ML, Deri CR, Francis BJ, Gauthier TP, Hayes JE, Marx AH, McGee EU, Mediwala K, Musgrove RJ, Slain D, Stramel SA, Bland CM, Bookstaver PB. A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2020. Open Forum Infect Dis 2021; 8:ofab422. [PMID: 34557559 PMCID: PMC8454524 DOI: 10.1093/ofid/ofab422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/10/2021] [Indexed: 11/15/2022] Open
Abstract
The number of articles related to antimicrobial stewardship published each year has increased significantly over the last decade. Keeping up with the literature, particularly the most innovative, well-designed, or applicable to one’s own practice area, can be challenging. The Southeastern Research Group Endeavor (SERGE-45) network reviewed antimicrobial stewardship–related, peer-reviewed literature from 2020 that detailed actionable interventions. The top 13 publications were summarized following identification using a modified Delphi technique. This article highlights the selected interventions and may serve as a key resource for teaching and training, and to identify novel or optimized stewardship opportunities within one’s institution.
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Affiliation(s)
- Sarah B Green
- Department of Pharmacy, Emory University Hospital, Atlanta, Georgia, USA
| | - Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Katie Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Jeannette L Bouchard
- Department of Pharmacy, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | - Matthew L Brown
- Department of Pharmacy, University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Connor R Deri
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Bailey J Francis
- Department of Pharmacy, Novant Health Forsyth Medical Center, Winston-Salem, North Carolina, USA
| | - Timothy P Gauthier
- Baptist Health South Florida, Clinical Pharmacy Enterprise, Miami, Florida, USA
| | - Jillian E Hayes
- Department of Pharmacy AdventHealth Orlando, Orlando, Florida, USA
| | - Ashley H Marx
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Edoabasi U McGee
- Department of Pharmacy Practice, Philadelphia College of Osteopathic Medicine-Georgia Campus, School of Pharmacy, Suwanee, Georgia, USA
| | - Krutika Mediwala
- Pharmacy Services, Medical University of South Carolina Health, Charleston, South Carolina, USA
| | - Rachel J Musgrove
- Department of Pharmacy, St Joseph's/Candler Health System, Savannah, Georgia, USA
| | - Douglas Slain
- Department of Clinical Pharmacy and Section of Infectious Diseases, West Virginia University, Morgantown, West Virginia, USA
| | - Stefanie A Stramel
- Department of Pharmacy, Memorial Hermann Memorial City Medical Center, Houston, Texas, USA
| | - Christopher M Bland
- Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, Georgia, USA
| | - P Brandon Bookstaver
- Department of Pharmacy, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA
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Antibiotic prophylaxis in beta-lactam allergic patients undergoing cesarean and vaginal delivery: An opportunity for stewardship. Infect Control Hosp Epidemiol 2021; 43:1514-1515. [PMID: 34323207 DOI: 10.1017/ice.2021.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Kwiatkowski S, Mulugeta S, Davis S, Kenney R, Kalus J, Walton L, Patel N. Optimizing preoperative antibiotics in patients with β-lactam allergies: A role for pharmacy. Am J Health Syst Pharm 2021; 78:S76-S82. [PMID: 34037708 PMCID: PMC8241474 DOI: 10.1093/ajhp/zxab218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Disclaimer In an effort to expedite the publication of articles related to the COVID-19
pandemic, AJHP is posting these manuscripts online as soon as possible after
acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but
are posted online before technical formatting and author proofing. These
manuscripts are not the final version of record and will be replaced with
the final article (formatted per AJHP style and proofed by the authors) at a
later time. Purpose Patients with a reported β-lactam allergy (BLA) are often given alternative
perioperative antibiotic prophylaxis, increasing risk of surgical site
infections (SSIs), acute kidney injury (AKI), and
Clostridioides difficile infection (CDI). The purpose
of this study was to implement and evaluate a pharmacist-led BLA
clarification interview service in the preoperative setting. Methods A pharmacist performed BLA clarification telephone interviews before elective
procedures from November 2018 to March 2019. On the basis of allergy history
and a decision algorithm, first-line preoperative antibiotics, alternative
antibiotics, or allergy testing referral was recommended. The pharmacist
intervention (PI) group was compared to a standard of care (SOC) group who
underwent surgery from November 2017 to March 2018. Results Eighty-seven patients were included, with 50 (57%) and 37 (43%) in the SOC
and PI groups, respectively. The most common surgeries included orthopedic
surgery in 41 patients (47%) and neurosurgery in 17 patients (20%). In the
PI group, all BLA labels were updated after interview. Twenty-three patients
were referred for allergy testing, 12 of the 23 (52%) completed BLA testing,
and penicillin allergies were removed for 9 of the 12 patients. Overall, 28
of the 37 (76%) pharmacy antibiotic recommendations were accepted. Cefazolin
use significantly increased from 28% to 65% after the intervention (P =
0.001). SSI occurred in 5 (10%) patients in the SOC group and no patients in
the PI group (P = 0.051). All of these SSIs were associated with alternative
antibiotics. Incidence of AKI and CDI was similar between the groups. No
allergic reactions occurred in either group. Conclusion Implementation of a pharmacy-driven BLA reconciliation significantly
increased β-lactam preoperative use without negative safety outcomes.
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Affiliation(s)
- Shaina Kwiatkowski
- Department of Pharmacy Services, Henry Ford Macomb Hospital, Clinton Township, MI, USA
| | - Surafel Mulugeta
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI, USA
| | - Susan Davis
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI, and Department of Pharmacy Practice, Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit, MI, USA
| | - Rachel Kenney
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI, USA
| | - James Kalus
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI, USA
| | - Leslie Walton
- Department of Anesthesiology, Mednax, Warren, MI, USA
| | - Nisha Patel
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI, USA
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Collins CD, Kollmeyer S, Scheidel C, Dietzel CJ, Leeman LR, Morrin C, Malani AN. Impact of a Mortality Prediction Rule for Organizing and Guiding Antimicrobial Stewardship Program Activities. Open Forum Infect Dis 2021; 8:ofab056. [PMID: 33738318 PMCID: PMC7953666 DOI: 10.1093/ofid/ofab056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/28/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Antimicrobial stewardship program (ASP) surveillance at our hospital is supplemented by an internally developed surveillance database. In 2013, the database incorporated a validated, internally developed, prediction rule for patient mortality within 30 days of hospital admission. This study describes the impact of an expanded ASP review in patients at the highest risk for mortality. METHODS This retrospective, quasi-experimental study analyzed adults who received antimicrobials with the highest mortality risk score. Study periods were defined as 2011-Q3 2013 (historical group) and Q4 2013-2018 (intervention group). Primary and secondary outcomes were assessed for confounders and analyzed using both unadjusted and propensity score weighted analyses. Interrupted time-series analyses also analyzed key outcomes. RESULTS A total of 3282 and 5456 patients were included in the historical and intervention groups, respectively. There were significant reductions in median antimicrobial duration (5 vs 4 days; P < .001), antimicrobial days of therapy (8 vs 7; P < .001), antimicrobial cost ($96 vs $85; P = .003), length of stay (LOS) (6 vs 5 days; P < .001), intensive care unit (ICU) LOS (3 vs 2 days; P < .001), total hospital cost ($10 946 vs $9119; P < .001), healthcare facility-onset vancomycin-resistant Enterococcus (HO-VRE) incidence (1.3% vs 0.3%; P ≤ .001), and HO-VRE infections (0.6% vs 0.2%; P = .018) in the intervention cohort. CONCLUSIONS Reductions in antimicrobial use, hospital and ICU LOS, HO-VRE, HO-VRE infections, and costs were associated with incorporation of a novel mortality prediction rule to guide ASP surveillance and intervention.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Scott Kollmeyer
- Department of Pharmacy Services, Covenant Healthcare, Saginaw, Michigan, USA
| | - Caleb Scheidel
- Methods Consultants of Ann Arbor, Ypsilanti, Michigan, USA
| | | | - Lauren R Leeman
- Michigan Data Analytics; St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Cheryl Morrin
- Department of Infection Prevention and Control, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Department of Infection Prevention and Control, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, Division of Infectious Diseases; St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
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