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Porto JR, Lavu MS, Hecht CJ, McNassor R, Burkhart RJ, Kamath AF. Is Penicillin Allergy a Clinical Problem? A Systematic Review of Total Joint Arthroplasty Procedures With Implications for Patient Safety and Antibiotic Stewardship. J Arthroplasty 2024; 39:1616-1623. [PMID: 38040064 DOI: 10.1016/j.arth.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Patients undergoing total joint arthroplasty (TJA) who report penicillin allergy (PA) are frequently administered second-line antibiotics, although recent evidence suggests that this may be unnecessary and could increase infection risk. Many institutions have aimed to improve antibiotic deployment via allergy testing and screening; however, there is little standardization to this process. This review aimed to evaluate (1) antibiotic selection in patients who report PA and assess the impact of screening and testing interventions, (2) rates of allergic reactions in patients who report PA, and (3) the association between reported PA and screening or testing programs and odds of surgical site infection or periprosthetic joint infection. METHODS PubMed, EBSCOhost, and Google Scholar electronic databases were searched on February 4, 2023 to identify all studies published since January 1, 2000 that evaluated the impact of PA on patients undergoing TJA (PROSPERO study protocol registration: CRD42023394031). Articles were included if full-text manuscripts in English were available, and the study analyzed the impact of PA and related interventions on TJA patients. There were 11 studies evaluating 1,276,663 patients included. Interventions were compared via presentation of key findings regarding rates of clinically relevant or high-risk PA reported upon screenings or testings, cephalosporin utilizations, allergic reactions, and postoperative infections (surgical site infection and periprosthetic joint infection). RESULTS All 6 studies found that PA screening and testing markedly increase the use of first-line antibiotics. Testing showed low rates of true allergy (0.7 to 3%) and allergic reaction frequency for patients who have reported PA receiving cephalosporins was between 0% and 2%. Although there were mixed findings across studies, there was a trend toward second-line antibiotic prophylaxis being associated with a slightly higher rate of infection in PA patients. CONCLUSIONS Using PA screening and testing can promote antibiotic stewardship by safely increasing the use of first-line antibiotics in patients who have a reported PA. LEVEL OF EVIDENCE Level III, Therapeutic Study.
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Affiliation(s)
- Joshua R Porto
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Monish S Lavu
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christian J Hecht
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ryan McNassor
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, Michigan
| | - Robert J Burkhart
- Department of Orthopaedic Surgery, University Hospitals, Cleveland, Ohio
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Gupta A, Shin J, Oliver D, Vives M, Lin S. Incidence and risk factors for surgical site infection (SSI) after primary hip hemiarthroplasty: an analysis of the ACS-NSQIP hip fracture procedure targeted database. ARTHROPLASTY (LONDON, ENGLAND) 2023; 5:1. [PMID: 36593517 PMCID: PMC9808930 DOI: 10.1186/s42836-022-00155-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/16/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Primary hip hemiarthroplasty (HHA) is frequently utilized to treat geriatric hip fractures, which are associated with significantly higher morbidity and mortality. While not particularly common, surgical site infection (SSI) is a major complication that frequently requires revision surgery in a frail population. The objective of this study was to determine the incidence of and risk factors for SSI after HHA in hip fracture patients. MATERIALS AND METHODS This retrospective cohort study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Geriatric patients (65+) who underwent HHA for non-pathologic, traumatic hip fractures between 2016-2017 were included. Demographic variables, comorbidities, operative variables, and complications were compared between "SSI" and "non-SSI" groups. Multivariate regression identified independent risk factors for postoperative SSI. Significance was set at P = 0.05. RESULTS A total of 6169 patients were included. The overall incidence of SSI was 1.3%. SSI was significantly associated with body mass index (BMI), preoperative functional status, congestive heart failure, chronic corticosteroid use, intraoperative time, sepsis, wound dehiscence, readmission within 30-days, and reoperation. On multivariate analysis, chronic steroid use (OR: 2.30, 95% CI: 1.13-4.70), BMI ≥ 35 kg/m2 (OR: 3.59, 95% CI: 1.57-8.18), and intraoperative time ≥120 mins (OR: 2.15, 95% CI: 1.08-4.27) were found to be independent risk factors. CONCLUSIONS Postoperative SSI is a serious complication that is responsible for prolonged hospital stays, increased mortality, and greater healthcare costs. Here, we identified multiple risk factors for SSI after primary HHA in the US elderly population.
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Affiliation(s)
- Arjun Gupta
- grid.430387.b0000 0004 1936 8796Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ 07103 USA
| | - John Shin
- grid.430387.b0000 0004 1936 8796Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ 07103 USA
| | - Dylan Oliver
- grid.430387.b0000 0004 1936 8796Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ 07103 USA
| | - Michael Vives
- grid.430387.b0000 0004 1936 8796Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ 07103 USA
| | - Sheldon Lin
- grid.430387.b0000 0004 1936 8796Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ 07103 USA
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De-labeling Beta-lactam in Adult Population. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00316-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sarrazin JF, Laaouaj J, Philippon F, Sanchez M, Gervais P, Champagne J, Steinberg C, Nault I, Roy K, Plourde B, Blier L, O’Hara G. Safety of Cefazolin Test Dose in Patients with Penicillin Allergy Just Prior Cardiac Device Implantation: A Single Center Experience. CJC Open 2022; 4:695-700. [PMID: 36035731 PMCID: PMC9402946 DOI: 10.1016/j.cjco.2022.04.007] [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: 02/01/2022] [Accepted: 04/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background Cephalosporins are the cornerstone of cardiac device infection prophylaxis. Owing to fears of cross-reactivity, penicillin-allergic patients are exposed to potentially more-toxic drugs, with decreased efficacy. We evaluated the safety of a cefazolin test dose (CTD) in self-reported penicillin-allergic patients. Methods In this single-centre study, we evaluated consecutive patients with chart documentation of penicillin allergy undergoing cardiac device implantation, over a 2-year period. A CTD was performed if no cephalosporin allergy or severe anaphylactic reaction to penicillin had been documented. Patients were given 2 doses of 100 mg IV cefazolin, and if no allergic reaction occurred after 5 minutes, the full dose (1800 mg) was administered in the electrophysiology laboratory just before the implantation procedure. Results A total of 2200 patients were included. The frequency of reported penicillin allergy was 9.3% (n = 204). In 80% of cases, the type of allergic reaction was not reported in medical notes or was unknown by the patient. A CTD was performed in 67.6% of patients with a penicillin allergy (n = 138). A total of 5 adverse events occurred (3.6% of patients [95% confidence interval, 1.1%-6.1%]) — 4 skin rashes and 1 tongue edema. These 5 patients became asymptomatic after antihistaminic and corticosteroid IV treatment. Even if the test dose was negative, 79% of patients also were administered vancomycin before the procedure, as it requires a 1-hour infusion prior to the CTD in the implantation procedure room. Conclusion A CTD in most penicillin-allergic patients appears to be safe and allows its use per recommended guidelines.
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Affiliation(s)
- Jean-François Sarrazin
- Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec City, Canada
- Corresponding author: Dr Jean-François Sarrazin, Institut universitaire de cardiologie et de pneumologie de Québec, 2725 chemin Sainte-Foy, Quebec, QC G1V 4G5, Canada. Tel.: +1-418-656-4598; fax: +1-418-656-4581.
| | - Jamal Laaouaj
- Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec City, Canada
| | - François Philippon
- Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec City, Canada
| | - Marina Sanchez
- Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec City, Canada
| | - Philippe Gervais
- Department of Infectious Disease, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec City, Canada
| | - Jean Champagne
- Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec City, Canada
| | - Christian Steinberg
- Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec City, Canada
| | - Isabelle Nault
- Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec City, Canada
| | - Karine Roy
- Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec City, Canada
| | - Benoît Plourde
- Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec City, Canada
| | - Louis Blier
- Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec City, Canada
| | - Gilles O’Hara
- Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec City, Canada
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Anstey KM, Tsao L, Otani IM. Drug Allergy Delabeling Programs: Recent Strategies and Targeted Populations. Clin Rev Allergy Immunol 2022; 62:484-504. [PMID: 35031956 DOI: 10.1007/s12016-021-08913-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 12/12/2022]
Abstract
Drug allergy delabeling programs have become an essential element of antibiotic stewardship. Development of delabeling programs involves careful selection of target patient population, thoughtful design of delabeling approach, stakeholder engagement, assembly of key team members, implementation, and evaluation of clinical and safety outcomes. Recent programs have targeted patients thought to be most likely to benefit from removal of inaccurate antibiotic allergy labels, those with β-lactam antibiotic allergies and high-risk populations likely to need β-lactam antibiotics as first-line treatment. This review provides an overview of current risk stratification methods and β-lactam cross-reactivity data and summarizes how different inpatient and outpatient delabeling programs have used these concepts in delabeling algorithms. β-Lactam delabeling programs for inpatients, pediatric patients, and programs utilizing telehealth have been implemented with good outcomes. This review also focuses on delabeling programs for high-risk populations likely to benefit from first-line β-lactam antibiotics. These populations include perioperative, prenatal, and immunocompromised patients. Delabeling programs have been successful in the inpatient and outpatient settings at enabling appropriate antibiotic use. This article reviews delabeling strategies utilized by these programs with a focus on highlighting elements key to their success and future areas for innovation.
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Affiliation(s)
- Karen M Anstey
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code UHN67, Portland, OR, 97239, USA.
| | - Lulu Tsao
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
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6
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Understanding Penicillin Allergy, Cross-reactivity, and Antibiotic Selection in the Preoperative Setting. J Am Acad Orthop Surg 2022; 30:e1-e5. [PMID: 34669610 PMCID: PMC8928301 DOI: 10.5435/jaaos-d-21-00422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/08/2021] [Indexed: 02/01/2023] Open
Abstract
Penicillin allergies are reported by 8% to 15% of the US population, but up to 95% of these allergies do not correspond to a true allergy when tested. Recent studies have demonstrated that having a penicillin allergy label (PAL) results in a 50% increased odds of surgical site infection among patients reporting a penicillin allergy entirely attributable to the use of a beta-lactam alternative antibiotic (primarily clindamycin or vancomycin). This study provides a review of the prevalence of PAL, the cross-reactivity with cefazolin, immunogenic components of cefazolin and penicillin, and current guidelines for preoperative antibiotic selection in patients with PALs. On understanding these principles, a new set of guidelines and a risk stratification tool are proposed for assessing allergies and determining appropriate antibiotic choice, dosage, and timing in the orthopaedic preoperative setting.
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7
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Feder OI, Yeroushalmi D, Lin CC, Galetta MS, Meftah M, Lajam CM, Slover JD, Schwarzkopf R, Bosco JA, Macaulay WB. Incomplete Administration of Intravenous Vancomycin Prophylaxis is Common and Associated With Increased Infectious Complications After Primary Total Hip and Knee Arthroplasty. J Arthroplasty 2021; 36:2951-2956. [PMID: 33840539 DOI: 10.1016/j.arth.2021.03.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/03/2021] [Accepted: 03/14/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Vancomycin is often used as antimicrobial prophylaxis in patients undergoing total hip or knee arthroplasty. Vancomycin requires longer infusion times to avoid associated side effects. We hypothesized that vancomycin infusion is often started too late and that delayed infusion may predispose patients to increased rates of surgical site infections and prosthetic joint infections. METHODS We reviewed clinical data for all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients at our institution between 2013 and 2020 who received intravenous vancomycin as primary perioperative gram-positive antibiotic prophylaxis. We calculated duration of infusion before incision or tourniquet inflation, with a cutoff of 30 minutes defining adequate administration. Patients were divided into two groups: 1) appropriate administration and 2) incomplete administration. Surgical factors and quality outcomes were compared between groups. RESULTS We reviewed 1047 primary THA and TKA patients (524 THAs and 523 TKAs). The indication for intravenous vancomycin usage was allergy (61%), methicillin-resistant staphylococcus aureus colonization (17%), both allergy and colonization (14%), and other (8%). 50.4% of patients began infusion >30 minutes preoperatively (group A), and 49.6% began infusion <30 minutes preoperatively (group B). Group B had significantly higher rates of readmissions for infectious causes (3.6 vs 1.3%, P = .017). This included a statistically significant increase in confirmed prosthetic joint infections (2.2% vs 0.6%, P = .023). Regression analysis confirmed <30 minutes of vancomycin infusion as an independent risk factor for PJI when controlling for comorbidities (OR 5.22, P = .012). CONCLUSION Late infusion of vancomycin is common and associated with increased rates of infectious causes for readmission and PJI. Preoperative protocols should be created to ensure appropriate vancomycin administration when indicated.
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Affiliation(s)
- Oren I Feder
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - David Yeroushalmi
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Charles C Lin
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Matthew S Galetta
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Moretza Meftah
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Claudette M Lajam
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - James D Slover
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - William B Macaulay
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
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8
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Kunze KN, Polce EM, Nwachukwu BU, Chahla J, Nho SJ. Development and Internal Validation of Supervised Machine Learning Algorithms for Predicting Clinically Significant Functional Improvement in a Mixed Population of Primary Hip Arthroscopy. Arthroscopy 2021; 37:1488-1497. [PMID: 33460708 DOI: 10.1016/j.arthro.2021.01.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 12/30/2020] [Accepted: 01/03/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE To (1) develop and validate a machine learning algorithm to predict clinically significant functional improvements after hip arthroscopy for femoroacetabular impingement syndrome and to (2) develop a digital application capable of providing patients with individual risk profiles to determine their propensity to gain clinically significant improvements in function. METHODS A retrospective review of consecutive hip arthroscopy patients who underwent cam/pincer correction, labral preservation, and capsular closure between January 2012 and 2017 from 1 large academic and 3 community hospitals operated on by a single high-volume hip arthroscopist was performed. The primary outcome was the minimal clinically important difference (MCID) for the Hip Outcome Score (HOS)-Activities of Daily Living (ADL) at 2 years postoperatively, which was calculated using a distribution-based method. A total of 21 demographic, radiographic, and patient-reported outcome measures were considered as potential covariates. An 80:20 random split was used to create training and testing sets from the patient cohort. Five supervised machine learning algorithms were developed using 3 iterations of 10-fold cross-validation on the training set and assessed by discrimination, calibration, Brier score, and decision curve analysis on an independent testing set of patients. RESULTS A total of 818 patients with a median (interquartile range) age of 32.0 (22.0-42.0) and 69.2% female were included, of whom 74.3% achieved the MCID for the HOS-ADL. The best-performing algorithm was the stochastic gradient boosting model (c-statistic = 0.84, calibration intercept = 0.20, calibration slope = 0.83, and Brier score = 0.13). Of the initial 21 candidate variables, the 8 most important features for predicting the MCID for the HOS-ADL included in model training were body mass index, age, preoperative HOS-ADL score, preoperative pain level, sex, Tönnis grade, symptom duration, and drug allergies. The algorithm was subsequently transformed into a digital application using local explanations to provide customized risk assessment: https://orthoapps.shinyapps.io/HPRG_ADL/. CONCLUSIONS The stochastic boosting gradient model conferred excellent predictive ability for propensity to gain clinically significant improvements in function after hip arthroscopy. An open-access digital application was created, which may augment shared decision-making and allow for preoperative risk stratification. External validation of this model is warranted to confirm the performance of these algorithms, as the generalizability is currently unknown. LEVEL OF EVIDENCE IV, Case series.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopedic Surgery, Division of Sports Medicine, Hospital for Special Surgery, New York, New York, U.S.A..
| | - Evan M Polce
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Benedict U Nwachukwu
- Department of Orthopedic Surgery, Division of Sports Medicine, Hospital for Special Surgery, New York, New York, U.S.A
| | - Jorge Chahla
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
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Self-reported beta-lactam allergy and the risk of surgical site infection: A retrospective cohort study. Infect Control Hosp Epidemiol 2020; 41:438-443. [PMID: 31969205 DOI: 10.1017/ice.2019.374] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess whether a self-reported β-lactam allergy is associated with an increased risk of surgical site infection (SSI) across a broad range of procedures and to determine whether this association is mediated by the receipt of an alternate antibiotic to cefazolin. DESIGN Retrospective cohort study. PARTICIPANTS Surgical procedures sampled by an institutional National Surgical Quality Improvement Program database over an 18-month period (January 2017 to June 2018) from 7 surgical specialties. SETTING Tertiary-care academic hospital. RESULTS Of the 3,589 surgical procedures included in the study, 369 (10.3%) were performed in patients with a reported β-lactam allergy. Those with a reported β-lactam allergy were significantly less likely to receive cefazolin (38.8% vs 95.5%) or metronidazole (20.3% vs 26.1%) and were more likely to receive clindamycin (52.0% vs 0.2%), gentamicin (3.5% vs 0%), or vancomycin (2.2% vs 0.1%) than those without allergy. An SSI occurred in 154 of 3,220 procedures (4.8%) in patients without reported allergy and 27 of 369 (7.3%) with reported allergy. In the multivariable regression model, a reported β-lactam allergy was associated with a statistically significant increase in SSI risk (adjusted odds ratio [aOR], 1.61; 95% confidence interval [CI], 1.04-2.51; P = .03). This effect was completely mediated by receipt of an alternate antibiotic to cefazolin (indirect effect aOR, 1.68; 95% CI, 1.17-2.34; P = .005). CONCLUSIONS Self-reported β-lactam allergy was associated with an increased SSI risk mediated through receipt of alternate antibiotic prophylaxis. Safely increasing use of cefazolin prophylaxis in patients with reported β-lactam allergy can potentially lower the risk of SSIs.
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10
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Kwon JW, Kim YJ, Yang MS, Song WJ, Kim SH, Cho SH, Chang YS. Results of Intradermal Skin Testing with Cefazolin according to a History of Hypersensitivity to Antibiotics. J Korean Med Sci 2019; 34:e319. [PMID: 31880416 PMCID: PMC6935558 DOI: 10.3346/jkms.2019.34.e319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/28/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The relationship between cephalosporin hypersensitivity and a history of β-lactam hypersensitivity is unclear. We evaluated the usefulness of routine intradermal cefazolin skin testing and its relationship with the history of β-lactam hypersensitivity. METHODS The electronic medical records of patients who underwent intradermal cefazolin (0.3 mg/mL) skin testing without negative controls from January 2010 to January 2011 at Seoul National University Bundang Hospital were evaluated. The history of β-lactam hypersensitivity of the patients was taken. Immediate adverse reactions after cefazolin injection were evaluated by searching the electronic medical records for key words and reviewing consultation documents of allergy specialists or dermatologists. The medical records of the patients were reviewed by an allergist. RESULTS There were 13,153 cases of cefazolin skin testing over the 13-month study period. Among the 12,969 cases with negative skin test results, 8 had immediate hypersensitivity related to cefazolin (0.06%). The negative predictive value of cefazolin skin testing alone was 99.94%. The overall positivity rate of cefazolin skin tests was 1.4% (184/13,153). Of the cases with a history of allergy to β-lactams, 15% (6/40) showed a positive cefazolin skin test result compared to only 1.36% (178/13,113) of cases with no such history (P < 0.001) including some false-positive tests. CONCLUSION The results suggest that routine screening involving cefazolin skin testing without negative controls is not useful for all patients, but could be helpful for those with a history of β-lactam hypersensitivity, although a large prospective study is needed to confirm this.
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Affiliation(s)
- Jae Woo Kwon
- Department of Allergy and Clinical Immunology, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Yoon Jeong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Min Suk Yang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Woo Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sae Hoon Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon Seok Chang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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Kufel WD, Justo JA, Bookstaver PB, Avery LM. Penicillin Allergy Assessment and Skin Testing in the Outpatient Setting. PHARMACY 2019; 7:pharmacy7030136. [PMID: 31546887 PMCID: PMC6789533 DOI: 10.3390/pharmacy7030136] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/05/2019] [Accepted: 09/12/2019] [Indexed: 01/09/2023] Open
Abstract
Penicillin allergies are among of the most commonly reported allergies, yet only 10% of these patients are truly allergic. This leads to potential inadvertent negative consequences for patients and makes treatment decisions challenging for clinicians. Thus, allergy assessment and penicillin skin testing (PST) are important management strategies to reconcile and clarify labeled penicillin allergies. While PST is more common in the inpatient setting where the results will immediately impact antibiotic management, this process is becoming of increasing importance in the outpatient setting. PST in the outpatient setting allows clinicians to proactively de-label and educate patients accordingly so beta-lactam antibiotics may be appropriately prescribed when necessary for future infections. While allergists have primarily been responsible for PST in the outpatient setting, there is an increasing role for pharmacist involvement in the process. This review highlights the importance of penicillin allergy assessments, considerations for PST in the outpatient setting, education and advocacy for patients and clinicians, and the pharmacist’s role in outpatient PST.
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Affiliation(s)
- Wesley D Kufel
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY 13902, USA.
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY 13210, USA.
- Department of Pharmacy, State University of New York Upstate University Hospital, Syracuse, NY 13210, USA.
| | - Julie Ann Justo
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia, SC 29208, USA.
- Department of Pharmacy, Prisma Health Richland Hospital, Columbia, SC 29203, USA.
| | - P Brandon Bookstaver
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia, SC 29208, USA.
- Department of Pharmacy, Prisma Health Richland Hospital, Columbia, SC 29203, USA.
| | - Lisa M Avery
- Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY 14618, USA.
- Department of Pharmacy, St. Josephs Health, Syracuse, NY 13203, USA.
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Wyles CC, Hevesi M, Osmon DR, Park MA, Habermann EB, Lewallen DG, Berry DJ, Sierra RJ. 2019 John Charnley Award: Increased risk of prosthetic joint infection following primary total knee and hip arthroplasty with the use of alternative antibiotics to cefazolin: the value of allergy testing for antibiotic prophylaxis. Bone Joint J 2019; 101-B:9-15. [PMID: 31146571 DOI: 10.1302/0301-620x.101b6.bjj-2018-1407.r1] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIMS The aims of this study were to characterize antibiotic choices for perioperative total knee arthroplasty (TKA) and total hip arthroplasty (THA) prophylaxis, assess antibiotic allergy testing efficacy, and determine rates of prosthetic joint infection (PJI) based on perioperative antibiotic regimen. PATIENTS AND METHODS We evaluated all patients undergoing primary TKA or THA at a single academic institution between January 2004 and May 2017, yielding 29 695 arthroplasties (22 705 patients), with 3411 arthroplasties in 2576 patients (11.5%) having undergone preoperative allergy testing. A series of institutional databases were combined to identify allergy consultation outcomes, perioperative antibiotic regimen, and infection-free survivorship until final follow-up. RESULTS Among 2576 allergy-tested patients, 2493 patients (97%) were cleared to use cephalosporins. For the entire cohort, 28 174 arthroplasties (94.9%) received cefazolin and 1521 (5.1%) received non-cefazolin antibiotics. Infection-free survivorship was significantly higher among arthroplasties receiving cefazolin compared with non-cefazolin antibiotics, with 0.06% higher survival free of infection at one month, 0.56% at two months, 0.61% at one year, and 1.19% at ten years (p < 0.001). Overall, the risk of PJI was 32% lower in patients treated with cefazolin after adjusting for the American Society of Anesthesiologists (ASA) classification, joint arthroplasty (TKA or THA), and body mass index (BMI; p < 0.001). The number needed to treat with cefazolin to prevent one PJI was 164 patients at one year and 84 patients at ten years. Therefore, potentially 6098 PJIs could be prevented by one year and 11 905 by ten years in a cohort of 1 000 000 primary TKA and THA patients. CONCLUSION PJI rates are significantly higher when non-cefazolin antibiotics are used for perioperative TKA and THA prophylaxis, highlighting the positive impact of preoperative antibiotic allergy testing to increase cefazolin usage. Given the low rate of true penicillin allergy positivity, and the readily modifiable risk factor that antibiotic choice provides, we recommend perioperative testing and clearance for all patients presenting with penicillin and cephalosporin allergies. Cite this article: Bone Joint J 2019;101-B(6 Supple B):9-15.
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Affiliation(s)
- C C Wyles
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - D R Osmon
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - M A Park
- Division of Allergy and Immunology, Mayo Clinic, Rochester, Minnesota, USA
| | - E B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Rochester, Minnesota, USA
| | - D G Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - D J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - R J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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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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14
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Patient and Prescriber Views of Penicillin Allergy Testing and Subsequent Antibiotic Use: A Rapid Review. Antibiotics (Basel) 2018; 7:antibiotics7030071. [PMID: 30082596 PMCID: PMC6164736 DOI: 10.3390/antibiotics7030071] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/27/2018] [Accepted: 07/31/2018] [Indexed: 11/16/2022] Open
Abstract
About 10% of U.K. patients believe that they are allergic to penicillin and have a "penicillin allergy label" in their primary care health record. However, around 90% of these patients may be mislabelled. Removing incorrect penicillin allergy labels can help to reduce unnecessary broad-spectrum antibiotic use. A rapid review was undertaken of papers exploring patient and/or clinician views and experiences of penicillin allergy testing (PAT) services and the influences on antibiotic prescribing behaviour in the context of penicillin allergy. We reviewed English-language publications published up to November 2017. Limited evidence on patients' experiences of PAT highlighted advantages to testing as well as a number of concerns. Clinicians reported uncertainty about referral criteria for PAT. Following PAT and a negative result, a number of clinicians and patients remained reluctant to prescribe and consume penicillins. This appeared to reflect a lack of confidence in the test result and fear of subsequent reactions to penicillins. The findings suggest lack of awareness and knowledge of PAT services by both clinicians and patients. In order to ensure correct penicillin allergy diagnosis, clinicians and patients need to be supported to use PAT services and equipped with the skills to use penicillins appropriately following a negative allergy test result.
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Vaisman A, McCready J, Hicks S, Powis J. Optimizing preoperative prophylaxis in patients with reported β-lactam allergy: a novel extension of antimicrobial stewardship. J Antimicrob Chemother 2018; 72:2657-2660. [PMID: 28605452 DOI: 10.1093/jac/dkx171] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/03/2017] [Indexed: 02/06/2023] Open
Abstract
Background Use of alternative second-line antibiotics is associated with adverse events in patients reporting β-lactam allergy. In the perioperative setting, we hypothesized that structured allergy histories, without the use of skin testing, can reduce alternative prophylactic antibiotic use. Objectives Assess the impact of structured allergy histories on patients with self-reported β-lactam allergy (SRBA) undergoing elective surgical procedures. Methods Structured allergy histories were performed by a pharmacist and reviewed with an infectious diseases physician. Patients were deemed safe to proceed with cefazolin prophylaxis if they did not describe a history of type I-mediated or severe reaction. Antibiotic prophylaxis orders (with approval by the surgical team) were scheduled into the computerized order entry system to be given prior to first incision of the operation. Results Of the 485 patients with SRBA that underwent structured allergy histories, 117 (24.1%) reported a type I-mediated allergy history; 267 (55.1%) patients received cefazolin prophylaxis and none subsequently experienced an adverse reaction. After intervention implementation, the overall use of alternative antibiotic prophylaxis at Michael Garron Hospital (Toronto, Canada) among those with SRBA decreased from 81.9% to 55.9%. This drop was associated with the number of monthly assessments (P < 0.001) in a regression analysis. Conclusions Using a simple structured history and the principles of prospective audit and feedback, we were able to increase the use of cefazolin perioperative prophylaxis without any serious adverse events and in the absence of skin testing or diagnostic challenges.
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Affiliation(s)
- Alon Vaisman
- Division of Infectious Diseases, University Health Network, Toronto, Ontario M5G 2C4, Canada
| | - Janine McCready
- Division of Infectious Diseases, Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario M4C 3E7, Canada
| | - Sandy Hicks
- Preoperative Assessment Clinic, Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario M4C 3E7, Canada
| | - Jeff Powis
- Division of Infectious Diseases, Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario M4C 3E7, Canada
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Mattingly TJ, Fulton A, Lumish RA, Williams AMC, Yoon S, Yuen M, Heil EL. The Cost of Self-Reported Penicillin Allergy: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1649-1654.e4. [PMID: 29355644 DOI: 10.1016/j.jaip.2017.12.033] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/11/2017] [Accepted: 12/28/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients who report a penicillin (PCN) allergy receive suboptimal antibiotic therapy compared with patients not reporting an allergy. However, a majority of patients who report PCN allergy are not truly allergic on confirmatory testing. Ruling out PCN allergy by testing may improve clinical and economic outcomes for patients with reported allergies requiring antibiotic therapy. OBJECTIVE The objective of this study was to summarize clinical and economic outcomes associated with PCN allergy and provide recommendations for future cost-effectiveness analyses for PCN allergy testing. METHODS A literature search was conducted using SCOPUS, EMBASE, and PubMed, including all articles published any date through April 25, 2017 (PROSPERO Registration number 42017064112). A total of 1518 abstracts were found during the initial search with 96 duplicates, for a total of 1422 articles for screening. Thirty articles were included for qualitative synthesis and full data extraction. RESULTS The majority of the studies included had an observational design focusing on inpatient admissions. The most frequently measured outcome in the context of PCN allergy was optimizing antibiotic therapy. Patients with PCN allergy were found to have direct drug costs during inpatient admission ranging from no difference to an additional $609/patient compared with patients without PCN allergy. Outpatient prescription costs were estimated from $14 to $193/patient higher for PCN allergic patients. Total inpatient costs were less for patients without PCN allergy with average savings from $1145 to $4254/patient. CONCLUSIONS Evaluations of clinical and economic outcomes of PCN allergy are primarily observational and focus on inpatient populations. Long-term relationships between PCN allergy and clinical and economic outcomes are unknown.
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Affiliation(s)
- T Joseph Mattingly
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md.
| | - Anne Fulton
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - Rachel A Lumish
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - Anne M C Williams
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - SeJeong Yoon
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - Melissa Yuen
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Md
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McDanel DL, Azar AE, Dowden AM, Murray-Bainer S, Noiseux NO, Willenborg M, Clark CR, Callaghan JJ, Haleem A. Screening for Beta-Lactam Allergy in Joint Arthroplasty Patients to Improve Surgical Prophylaxis Practice. J Arthroplasty 2017; 32:S101-S108. [PMID: 28236547 DOI: 10.1016/j.arth.2017.01.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/08/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The reliability of patient-reported penicillin allergies has been disputed. A Drug Allergy Clinic (DAC) was established at our institution in combination with an electronic best practice alert (BPA) in the Orthopedic Clinic. Joint arthroplasty patients with a reported history of beta-lactam allergy (HOBA) were preoperatively referred via the BPA to the DAC. The purpose of this study was to determine the effectiveness of beta-lactam allergy screening in enabling the surgical team to optimize antimicrobial prophylaxis. METHODS Between February 2013 and May 2015, 161 patients with a HOBA were referred to the DAC where they underwent penicillin skin testing (PST), a drug challenge to a beta-lactam antibiotic, and/or had no intervention depending on the history obtained. RESULTS PST was performed on 140 of 161 (87%) patients. A negative PST was noted in 139 (99%) patients, indicating no penicillin allergy. Cefazolin was safe to use in 145 (90%) patients evaluated. Significantly more patients evaluated in the DAC vs those not seen got cefazolin in any surgical prophylaxis regimen (90% vs 77%) without any adverse perioperative reactions. Concurrently, the use of non-beta-lactam antibiotics was significantly less in the patients evaluated vs not evaluated (16% vs 27%). The overall use of cefazolin in orthopedic surgeries in patients with HOBA was >84% over the course of the study period. CONCLUSION Beta-lactam allergy screening using a BPA and a DAC promotes the use of standard surgical prophylaxis with cefazolin. Joint arthroplasty surgeons should consider implementing allergy screening programs to promote antimicrobial stewardship.
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Affiliation(s)
- Deanna L McDanel
- Department of Pharmaceutical Care, University of Iowa Healthcare, Iowa City, Iowa; University of Iowa College of Pharmacy, Iowa City, Iowa
| | - Antoine E Azar
- University of Iowa Carver College of Medicine, Iowa City, Iowa; University of Iowa Healthcare, Iowa City, Iowa; Johns Hopkins University, Baltimore, Maryland
| | - Amy M Dowden
- University of Iowa Carver College of Medicine, Iowa City, Iowa; University of Iowa Healthcare, Iowa City, Iowa
| | - Samantha Murray-Bainer
- University of Iowa Carver College of Medicine, Iowa City, Iowa; University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Nicolas O Noiseux
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Melissa Willenborg
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Charles R Clark
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - John J Callaghan
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Ambar Haleem
- University of Iowa Carver College of Medicine, Iowa City, Iowa; Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, Iowa; Division of Infectious Diseases, University of Wisconsin, Madison, Wisconsin
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18
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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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19
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First Place Award: Can cefazolin be used in orthopaedic surgery for patients with a self-reported non-IgE mediated penicillin allergy? A prospective case series. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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20
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The Effect of Penicillin Allergy Testing on Future Health Care Utilization: A Matched Cohort Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:705-710. [PMID: 28366717 DOI: 10.1016/j.jaip.2017.02.012] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 01/21/2017] [Accepted: 02/22/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND The effect that penicillin allergy testing has on future health care utilization is uncertain. OBJECTIVE Determine whether penicillin allergy testing affects future overall health care utilization as measured by outpatient department (OPD) visits, emergency department (ED) visits, and hospital days. METHODS Potential cases and control subjects were penicillin allergic Kaiser Permanente Southern California members who had at least 2 visits between 2010 and 2012 and at least 1 year of continuous health plan coverage before their index visit. RESULTS It was possible to match 308 (73.2%) of the potential cases to 1251 unique controls, on the basis of age, sex, weighted Charlson comorbidity index, drug class allergies, OPD visits, ED visits, and hospital days during the years before their index visit. Cases and controls were then followed for an average of 3.6 and 4.0 years, respectively. Based on results analyzed using a generalized linear mixed model, cases were estimated to have 0.09 fewer OPD visits (P < .001), 0.13 fewer ED visits (P = .29), and 0.55 fewer hospital days (P < .001) per health plan coverage year during follow-up compared with controls. Cases were exposed to more penicillins and first- and second-generation cephalosporins and less clindamycin and macrolides. CONCLUSIONS Penicillin allergy testing, primarily done in the setting of an outpatient Allergy consultation, was associated with significantly less health care utilization during 3.6+ years of follow-up and greater use of narrow-spectrum antibiotics. Penicillin allergy testing has a favorable cost-benefit ratio for the incremental cost of testing versus future health care utilization and improves antibiotic stewardship.
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21
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Narayanan PP, Jeffres MN. Feasibility, Benefits, and Limitations of a Penicillin Allergy Skin Testing Service. Ann Pharmacother 2017; 51:504-510. [PMID: 28152605 DOI: 10.1177/1060028017690854] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To critically examine the feasibility, benefits, and limitations of an inpatient penicillin skin testing service and how pharmacists can be utilized. DATA SOURCES A PubMed search was performed from July 2016 through September 2016 using the following search terms: penicillin skin testing, penicillin allergy, β-lactam allergy. Additional references were identified from a review of literature citations. STUDY SELECTION AND DATA EXTRACTION All English-language studies assessing the use of penicillin skin testing as well as management and clinical outcomes of patients with a β-lactam allergy were evaluated. DATA SYNTHESIS The prevalence of people self-identifying as penicillin allergic ranges from 10% to 20% in the United States. Being improperly labeled as penicillin allergic is associated with higher health care costs, worse clinical outcomes, and an increased prevalence of multidrug-resistant infections. Penicillin skin testing can be a tool used to clarify penicillin allergies and has been demonstrated to be a successful addition to antimicrobial stewardship programs in multiple health care settings. Prior to implementing a penicillin skin testing service, institutions will need to perform a feasibility analysis of who will supply labor and accept the financial burden as well as identify if the positive benefits of a penicillin skin testing service overcome the limitations of this diagnostic test. CONCLUSION We conclude that institutions with high percentages of patients receiving non-β-lactams because of penicillin allergy labels would likely benefit the most from a penicillin skin testing service.
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Affiliation(s)
| | - Meghan N Jeffres
- 2 University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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22
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Staicu ML, Brundige ML, Ramsey A, Brown J, Yamshchikov A, Peterson DR, Baran A, Laguio-Vila M. Implementation of a penicillin allergy screening tool to optimize aztreonam use. Am J Health Syst Pharm 2016; 73:298-306. [PMID: 26896502 DOI: 10.2146/ajhp150288] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
PURPOSE The implementation of a penicillin allergy screening tool to optimize the use of aztreonam is described. METHODS This study was conducted at a 528-bed tertiary referral community teaching facility and compared the use of aztreonam in patients before and after the implementation of a multipronged intervention consisting of a penicillin allergy screening tool (PAST), education, order set decision support, and prospective review of aztreonam orders by the antimicrobial stewardship team and clinical pharmacists. Patients for whom aztreonam was prescribed at any time during their presentation to the hospital January 1-June 30, 2013 (preintervention period), and September 1, 2013-February 28, 2014 (postintervention period) were eligible for inclusion. Primary outcomes included total and inappropriate aztreonam usage. Secondary outcomes included cost avoidance and safety. RESULTS A total of 496 aztreonam orders were reviewed. The total number of days of therapy (DOT) with aztreonam significantly decreased from 9.5 per 1,000 patient-days in the preintervention group to 4.4 per 1,000 patient-days in the postintervention group (p < 0.0001). The number of inappropriate aztreonam DOT decreased from 4.0 per 1,000 patient days to 0.8 per 1,000 patient-days (p < 0.0001). The median number of inappropriate aztreonam doses decreased significantly in the postintervention period, as did inappropriate aztreonam DOT (p < 0.0001 for both comparisons). An estimated cost avoidance of $60,000-$100,000 was realized, depending on the alternative antibiotic selected. CONCLUSION Implementation of the PAST and provider and pharmacist education reduced the use of aztreonam by promoting the first-line use of β-lactam alternatives.
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Affiliation(s)
- Mary L Staicu
- Pharmacy Department, Rochester General Hospital, Rochester, NY.
| | | | - Allison Ramsey
- Allergy and Immunology, Rochester General Hospital, Rochester, NY
| | - Jack Brown
- Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY
| | | | | | - Andrea Baran
- University of Rochester Medical Center, Rochester, NY
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Mirakian R, Leech SC, Krishna MT, Richter AG, Huber PAJ, Farooque S, Khan N, Pirmohamed M, Clark AT, Nasser SM. Management of allergy to penicillins and other beta-lactams. Clin Exp Allergy 2015; 45:300-27. [PMID: 25623506 DOI: 10.1111/cea.12468] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 10/29/2014] [Accepted: 11/07/2014] [Indexed: 12/15/2022]
Abstract
The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and an expert panel have prepared this guidance for the management of immediate and non-immediate allergic reactions to penicillins and other beta-lactams. The guideline is intended for UK specialists in both adult and paediatric allergy and for other clinicians practising allergy in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking, the panel reached consensus. During the development of the guideline, all BSACI members were consulted using a Web-based process and all comments carefully considered. Included in the guideline are epidemiology of allergic reactions to beta-lactams, molecular structure, formulations available in the UK and a description of known beta-lactam antigenic determinants. Sections on the value and limitations of clinical history, skin testing and laboratory investigations for both penicillins and cephalosporins are included. Cross-reactivity between penicillins and cephalosporins is discussed in detail. Recommendations on oral provocation and desensitization procedures have been made. Guidance for beta-lactam allergy in children is given in a separate section. An algorithm to help the clinician in the diagnosis of patients with a history of penicillin allergy has also been included.
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Affiliation(s)
- R Mirakian
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: A cohort study. J Allergy Clin Immunol 2013; 133:790-6. [PMID: 24188976 DOI: 10.1016/j.jaci.2013.09.021] [Citation(s) in RCA: 542] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 08/15/2013] [Accepted: 09/12/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Penicillin is the most common drug "allergy" noted at hospital admission, although it is often inaccurate. OBJECTIVE We sought to determine total hospital days, antibiotic exposures, and the prevalence rates of Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) in patients with and without penicillin "allergy" at hospital admission. METHODS We performed a retrospective, matched cohort study of subjects admitted to Kaiser Foundation hospitals in Southern California during 2010 through 2012. RESULTS It was possible to match 51,582 (99.6% of all possible cases) unique hospitalized subjects with penicillin "allergy" to 2 unique discharge diagnosis category-matched, sex-matched, age-matched, and date of admission-matched control subjects each. Cases with penicillin "allergy" averaged 0.59 (9.9%; 95% CI, 0.47-0.71) more total hospital days during 20.1 ± 10.5 months of follow-up compared with control subjects. Cases were treated with significantly more fluoroquinolones, clindamycin, and vancomycin (P < .0001) for each antibiotic compared with control subjects. Cases had 23.4% (95% CI, 15.6% to 31.7%) more C difficile, 14.1% (95% CI, 7.1% to 21.6%) more MRSA, and 30.1% (95% CI, 12.5% to 50.4%) more VRE infections than expected compared with control subjects. CONCLUSIONS A penicillin "allergy" history, although often inaccurate, is not a benign finding at hospital admission. Subjects with a penicillin "allergy" history spend significantly more time in the hospital. Subjects with a penicillin "allergy" history are exposed to significantly more antibiotics previously associated with C difficile and VRE. Drug "allergies" in general, but most those notably to penicillin, are associated with increased hospital use and increased C difficile, MRSA, and VRE prevalence.
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Affiliation(s)
- Eric Macy
- Southern California Permanente Medical Group, Department of Allergy, San Diego Medical Center, San Diego, Calif.
| | - Richard Contreras
- Kaiser Permanente Health Care Program, Department of Research and Evaluation, Pasadena, Calif
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25
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Unger NR, Gauthier TP, Cheung LW. Penicillin Skin Testing: Potential Implications for Antimicrobial Stewardship. Pharmacotherapy 2013; 33:856-67. [DOI: 10.1002/phar.1288] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Nathan R. Unger
- Department of Pharmacy Practice; Nova Southeastern University College of Pharmacy; Palm Beach Gardens Florida
| | - Timothy P. Gauthier
- Department of Pharmacy Practice; Nova Southeastern University College of Pharmacy; Fort Lauderdale Florida
| | - Linda W. Cheung
- Pharmacy Service, James A. Haley Veterans' Hospital; Tampa Florida
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26
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Skin testing for Beta-lactam antibiotics: impact of the availability of a major determinant. Curr Allergy Asthma Rep 2013; 13:64-71. [PMID: 23232943 DOI: 10.1007/s11882-012-0323-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Beta-lactam antibiotics are very effective agents for a variety of infections. In patients with beta-lactam allergy, these drugs are withheld due to fear of subsequent allergic reactions. Therefore, increasing their exposure to broad spectrum antibiotics, which are more costly, have greater side effects, and increase the risk of developing resistant organisms. Up to 90 % of patients with a proposed beta-lactam sensitivity can tolerate beta lactam agents after appropriate evaluation. Skin testing to beta-lactam agents is the gold standard in evaluating patients with type I, immediate hypersensitivity reactions. The robust negative predictive value of this test has yet to be surpassed by any other testing modality currently available.
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Picard M, Bégin P, Bouchard H, Cloutier J, Lacombe-Barrios J, Paradis J, Des Roches A, Laufer B, Paradis L. Treatment of patients with a history of penicillin allergy in a large tertiary-care academic hospital. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:252-7. [PMID: 24565481 DOI: 10.1016/j.jaip.2013.01.006] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 01/17/2013] [Accepted: 01/25/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Prescribing antibiotics to patients with a history of penicillin allergy is common in clinical practice. Opting for non-beta-lactam antibiotics has its inconveniences and is often unnecessary, because most of these patients are in fact not allergic. OBJECTIVE This study aimed to determine how physicians in a large Canadian tertiary-care academic hospital without allergists on staff treat patients with a history of penicillin allergy. METHODS A retrospective study was conducted during a 1-year period among all patients hospitalized in the intensive care unit, coronary care unit, and internal medicine wards. Files of patients with a record of penicillin allergy were reviewed to assess the need for antibiotics during their hospitalization and the decision-making process underlying the choice of antibiotic. The additional costs of alternative antibiotics were calculated. RESULTS The files of 1738 patients admitted over a 1-year period were hand reviewed. A history of penicillin allergy was found in 172 patients (9.9%). The allergic reaction was described in only 30% of cases and left unmentioned in 20.7%. Beta-lactam antibiotics were used on 56 occasions despite a history of penicillin allergy. The use of alternative antibiotics in place of the beta-lactam standard of care carried an additional cost of $15,672 Canadian. CONCLUSION Alleged penicillin allergy is common among hospitalized patients and leads to substantial additional costs. Poor documentation of penicillin allergy likely reflects a lack of knowledge on this issue in the medical community, which impairs optimal treatment of these patients. Increased education on this matter is needed, and allergists on staff could be part of the solution.
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Affiliation(s)
- Matthieu Picard
- Department of Medicine, Hôpital Maisonneuve-Rosemont (HMR), Montreal, Quebec, Canada; Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - Philippe Bégin
- Department of Medicine, Hôpital Maisonneuve-Rosemont (HMR), Montreal, Quebec, Canada; Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Hugues Bouchard
- Department of Medicine, Hôpital Maisonneuve-Rosemont (HMR), Montreal, Quebec, Canada
| | - Jonathan Cloutier
- Department of Medicine, Hôpital Maisonneuve-Rosemont (HMR), Montreal, Quebec, Canada
| | - Jonathan Lacombe-Barrios
- Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Jean Paradis
- Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Anne Des Roches
- Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Brian Laufer
- Department of Medicine, Hôpital Maisonneuve-Rosemont (HMR), Montreal, Quebec, Canada
| | - Louis Paradis
- Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
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Impact of Vancomycin Surgical Antibiotic Prophylaxis on the Development of Methicillin-Sensitive Staphylococcus aureus Surgical Site Infections. Ann Surg 2012; 256:1089-92. [DOI: 10.1097/sla.0b013e31825fa398] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Postoperative infections: prevention and management. Crit Care Nurs Clin North Am 2012; 24:323-44. [PMID: 22548866 DOI: 10.1016/j.ccell.2012.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
INTRODUCTION A clear set of guidelines has not been defined in the use of antibiotics in penile prosthesis implantation. Aim. We surveyed urologists throughout the United States to determine current practice patterns regarding antibiotic use in primary and revision penile prosthesis surgery. METHODS Fifty-two Sexual Medicine Society of North America (SMS) member urologist and 164 non-SMS member urologist responses were obtained. MAIN OUTCOME MEASURES The survey contained 10 questions regarding antibiotic selection for primary and revision inflatable penile prosthesis (IPP) implantation. RESULTS One hundred percent of responders in both groups utilize intraoperative antibiotics, most commonly vancomycin and gentamicin in both groups. Of SMS members, 94% prescribed postoperative home oral antibiotics in contrast to 88% of non-SMS members (P = 0.3). Among SMS members, the most common antibiotic prescribed postoperatively was levofloxacin 500 mg daily while among non-SMS members, the most common antibiotic postoperatively was cephalexin 500 mg 2-4 times daily. Of SMS members, antibiotic irrigation intraoperatively occurred with 100% and with 92% of non-SMS members (P = 0.04). Thirty-seven percent SMS physicians and 15% non-SMS physicians made modifications of intraoperative and postoperative antibiotics for high-risk patients (P = 0.001). In the circumstance of revision of a clinically noninfected IPP, 23% SMS and 16% non-SMS member physicians utilized additional antibiotics/treatment (P = 0.3). Sixteen of those surveyed admitted that they had been approached by their institution about their antibiotic use and asked to change. In the past 5 years, 29% surveyed have changed their practice patterns in antibiotic use. CONCLUSIONS There is significant difference between practice patterns of SMS and non-SMS urologists in terms of antibiotic irrigation usage, modifications for high-risk patients, and consensus about the importance of antibiotic use with Coloplast Titan implant (Coloplast, Minneapolis, MN, USA). A significant lack of uniformity exists among urologists performing prosthetic surgery with regard to antibiotic protocols. A standard set of guidelines may prove useful to implanters.
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Affiliation(s)
- Matthew S Wosnitzer
- Department of Urology, Columbia University Medical Center, New York, NY, USA.
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Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol 2011; 105:259-273. [PMID: 20934625 DOI: 10.1016/j.anai.2010.08.002] [Citation(s) in RCA: 652] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 08/02/2010] [Indexed: 01/17/2023]
Abstract
Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient
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Abstract
Hypersensitivity reactions are defined as immunologically based adverse reactions to chemicals or medicinal agents. These reactions are common in the intensive care unit and can present as a simple, mildly symptomatic rash or as life-threatening anaphylactic reactions. Hypersensitivity reactions have traditionally been classified as types I to IV reactions based on the underlying immune mechanisms, although the clinical relevance of the classification is unclear, and new subtypes to this system have been recently proposed. Given the immunologic and often unpredictable nature of these reactions, avoidance or prevention is not a feasible option. Therefore, management has primarily consisted of withdrawal of potential offending agents, supportive therapy, symptomatic management, and, in some specific examples, targeted pharmacotherapy. This article outlines the background and types of hypersensitivity reactions and provides descriptions and management strategies when applicable to common types of hypersensitivity reactions encountered in the intensive care unit.
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Abstract
Postoperative infections continue to be a challenging problem. The incidence of bacterial antibiotic resistance such as methicillin-resistant Staphylococcus aureus is rising. There are numerous intrinsic patient factors that should be optimized before surgery to minimize the risk of surgical site infections. When postoperative infections develop, treatment must be individualized. This article outlines the principles that can help guide treatment.
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Affiliation(s)
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- Department of Research and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL 60018, USA
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Verma MK, Shah AS, Jebson PJL. Cephalosporins in hand surgery. J Hand Surg Am 2009; 34:755-8. [PMID: 19345883 DOI: 10.1016/j.jhsa.2009.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 02/02/2009] [Indexed: 02/02/2023]
Affiliation(s)
- Maneesh K Verma
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI 48103, USA
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Frigas E, Park MA, Narr BJ, Volcheck GW, Danielson DR, Markus PJ, Olson KEK, Schroeder DR, Kita H. Preoperative evaluation of patients with history of allergy to penicillin: comparison of 2 models of practice. Mayo Clin Proc 2008; 83:651-62. [PMID: 18533082 DOI: 10.4065/83.6.651] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To study whether allergy consultation and penicillin allergy skin testing affects the selection of antibacterial prophylaxis perioperatively in surgical patients with history of allergy to penicillin (HOAP). PATIENTS AND METHODS From January 1 through June 30, 2004, we compared 2 different models of practice at our institution. At the Preoperative Evaluation Clinic (POEC), all patients with HOAP are evaluated by an allergist and undergo skin testing for allergy to penicillin. At other (non-POEC) preoperative evaluation settings (OPES), patients with HOAP do not undergo allergy consultation and penicillin skin testing before surgery. Of the 4889 patients screened at the POEC during the study period, 412 consecutive patients with HOAP were included in the study. Of the 416 patients screened at OPES, 69 consecutive patients with HOAP were studied. Logistic regression was used to assess whether allergy consultation was associated with the choice of antibiotic for antibacterial prophylaxis perioperatively, after adjusting for age, sex, and type of surgery. RESULTS Perioperative cephalosporin use was greater among patients screened at POEC vs those screened at OPES (70% vs 39%, P<.001 unadjusted; P=.04 adjusted for age, sex, and type of surgery). Vancomycin use was lower for patients screened at POEC vs those screened at OPES (10% vs 28%, P<.001 unadjusted; P=.03 adjusted). CONCLUSION For patients with HOAP, evaluation at the POEC was associated with increased use of cephalosporin and decreased use of vancomycin.
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Affiliation(s)
- Evangelo Frigas
- Division of Allergic Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Abstract
The use of prophylactic antibiotics in orthopaedic surgery is effective in reducing surgical site infections in hip and knee arthroplasty, spine surgery, and open reduction and internal fixation of fractures. To maximize the beneficial effect of prophylactic antibiotics while minimizing adverse effects, the correct antimicrobial agent must be selected, the drug must be administered just before incision, and the duration of administration should not exceed 24 hours.
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Schafer JA, Mateo N, Parlier GL, Rotschafer JC. Penicillin allergy skin testing: what do we do now? Pharmacotherapy 2007; 27:542-5. [PMID: 17381381 DOI: 10.1592/phco.27.4.542] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Drug-induced anaphylaxis remains a relatively infrequent event. However, penicillin and associated beta-lactam antibiotics remain a primary cause of anaphylaxis. Penicillin allergies are undoubtedly overreported, and patients with suspected penicillin allergy can be treated with antibiotic alternatives. Penicillin allergy skin testing is a simple and effective way to identify true penicillin allergy. Skin testing involves testing for both major and minor determinants and should be conducted in a facility with available life-support equipment. The commercial major determinant product, benzylpenicilloyl-polylysine, was removed from the market in 2004; this action compromised the ability of clinicians to evaluate a patient's likely response to penicillin therapy. Alternatives to skin testing include laboratory synthesis of major determinants, use of the radioallergosorbent test (RAST), or a combination of RAST and minor determinant skin testing. Patients with suspected penicillin allergy can undergo desensitization if they require penicillin therapy. The planned return of a commercial major determinant will hopefully resolve this issue.
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Affiliation(s)
- Jeremy A Schafer
- College of Pharmacy, University of Minnesota, Minneapolis, Minnesota 55455, USA
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del Real GA, Rose ME, Ramirez-Atamoros MT, Hammel J, Gordon SM, Arroliga AC, Arroliga ME. Penicillin skin testing in patients with a history of beta-lactam allergy. Ann Allergy Asthma Immunol 2007; 98:355-9. [PMID: 17458432 DOI: 10.1016/s1081-1206(10)60882-4] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Vancomycin and fluoroquinolones are commonly used in patients with a history of penicillin allergy. OBJECTIVE To determine the safety and utility of penicillin skin testing (PST). METHODS Retrospective study of patients with a history of penicillin allergy between April 1, 1999, and September 30, 2004. Penicillin skin testing was performed by means of standard methods using benzylpenicilloyl-polysine, penicillin G, and histamine and saline controls. RESULTS Of 596 patients studied, 25.3% were outpatients, 50.3% were inpatients, and 24.3% were intensive care unit patients. The most common antibiotics used during the time of PST were vancomycin and fluoroquinolones. Results of PST were negative in 88.4% of patients, positive in 8.2%, and indeterminate in 3.4%. One patient (0.17%) developed urticaria immediately after PST. Fifty-five percent of patients with negative PST results were changed to a beta-lactam drug, more frequently in the intensive care unit vs the outpatient setting (70.3% vs 8.6%; P < .001) and in adults vs patients younger than 18 years (58.6% vs 8.1%; P < .001). A beta-lactam antibiotic was used in 290 patients with negative PST results. Of the patients given beta-lactam antibiotics, 5 (1.7%) had adverse reactions: 2 had hives after 16 and 20 days of therapy, 1 had a nonspecific rash after 17 days of therapy, 1 had flushing and urticaria 3 hours after a test dose of piperacillin-tazobactam, and 1 had a pruritic rash after 12 hours of therapy. CONCLUSIONS Patients with a history of penicillin allergy can safely use beta-lactam drugs if negative PST results.
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Affiliation(s)
- Gonzalo Alvarez del Real
- Department of Pulmonary, Allergy, and Critical Care Medicine, The Cleveland Clinic, Cleveland, Ohio 44195, USA
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Park M, Markus P, Matesic D, Li JTC. Safety and effectiveness of a preoperative allergy clinic in decreasing vancomycin use in patients with a history of penicillin allergy. Ann Allergy Asthma Immunol 2007; 97:681-7. [PMID: 17165279 DOI: 10.1016/s1081-1206(10)61100-3] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We developed a clinical pathway to optimize the use of antimicrobials by decreasing vancomycin use in preoperative patients with a history of penicillin allergy. OBJECTIVE To decrease the use of vancomycin in surgical patients with a self-reported penicillin allergy. METHODS In June 2002, same-day allergy consultation and penicillin skin testing were made available for preoperative patients with self-reported penicillin allergy at the preoperative evaluation (POE) clinic. We reviewed the penicillin allergy skin test results, recommendations, and beta-lactam antibiotic administration outcomes from July 1, 2002, to September 16, 2003. RESULTS A total of 1,204 of 11,819 patients were evaluated for beta-lactam allergy at the POE clinic. Of these, 1,120 were approved by the institutional review board for inclusion in the study and 9 were excluded from the study. Of the remaining 1,111 patients, 1,030 (93%) underwent skin testing for penicillin allergy. Forty-three (4%) had a positive skin test result to penicillin. A total of 947 (85%) of the 1,111 patients with a history of beta-lactam allergy were advised to use a beta-lactam antibiotic, and 164 (15%) were advised to avoid beta-lactams. A total of 955 patients (86%) actually received preoperative antibiotics. Of these 955 patients, 716 (75%) received cefazolin, and only 149 (16%) received vancomycin compared with 30% historical controls (P < .01). Among the patients with a negative penicillin skin test result who received a cephalosporin, 5 (0.7%) of 675 experienced an adverse drug reaction to a cephalosporin. CONCLUSIONS Establishment of a clinical pathway in a preoperative clinic that includes allergy consultation and penicillin skin testing reduced vancomycin use to only 16% in surgical patients with a history of beta-lactam allergy.
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Affiliation(s)
- Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Wong BBL, Keith PK, Waserman S. Clinical history as a predictor of penicillin skin test outcome. Ann Allergy Asthma Immunol 2006; 97:169-74. [PMID: 16937746 DOI: 10.1016/s1081-1206(10)60008-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Up to 10% of the population reports an "allergy" to penicillin, whereas approximately 1.1% has positive penicillin skin test results. Where penicillin skin tests are unavailable, some have advocated using history to decide whether to use a penicillin-related antibiotic. OBJECTIVE To determine if clinical history predicts penicillin skin test results. METHOD Retrospective medical record review of 94 consecutive patients who had previously taken penicillin referred for penicillin allergy. Case histories were taken, penicillin skin tests performed, and an oral challenge recommended if skin test results were negative. RESULTS Of 91 cases studied, the average patient age was 27 years (range, 6 months to 82 years; 36% female). Fifty-two (57%) experienced hives as their main adverse reaction. Sixteen (18%) had at least 1 positive test result. Of this group, 9 had hives as their main symptom, whereas 1 had respiratory problems and 1 had angioedema. Most patients with positive skin test results had experienced their reaction at least 3 years ago. Regression analysis showed that age, sex, and clinical history, including type of reaction, time of reaction after penicillin ingestion, or time since the last reaction, were not associated with skin test positivity. Seventy-two (96%) of the 75 patients who had negative skin test results underwent oral challenge. Seventy had negative challenge results. The negative predictive value of a negative penicillin skin test result was 97%. CONCLUSION Clinical history was not predictive of subsequent penicillin skin test results.
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Affiliation(s)
- Benjamin B L Wong
- Division of Allergy and Clinical Immunology, Department of Medicine, McMaster University, Ontario, Canada.
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Nadarajah K, Green GR, Naglak M. Clinical outcomes of penicillin skin testing. Ann Allergy Asthma Immunol 2006; 95:541-5. [PMID: 16400893 DOI: 10.1016/s1081-1206(10)61016-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Penicillin or cephalosporin allergy is a common problem with antibiotic drug prescribing in hospitalized patients. OBJECTIVES To study the various clinical outcomes of penicillin skin testing (PST) in a community teaching hospital and to determine the percentage of patients who have an antibiotic drug modification after PST. METHODS This study was a retrospective medical record review of all inpatients who underwent PST in 6.6 years. Information was collected on 101 patients using a detailed data collection form. Data were summarized using descriptive statistics, including frequencies and percentages. RESULTS Of the 101 patients who underwent PST, 92 had a negative result and 5 had a positive result; in 4 patients the test result was indeterminate. There was a 96% (67/70) reduction in the use of vancomycin and a 96% (23/24) reduction in the use of fluoroquinolones after PST in patients with negative results. Forty-nine percent of patients with negative PST results were administered a penicillin-based drug, and 48% were given a cephalosporin. Cultures were positive most commonly for Staphylococcus aureus and enterococcus. There were no serious adverse reactions to PST or to the use of penicillins or cephalosporins after a negative PST result. CONCLUSIONS Penicillin skin testing lowered the use of vancomycin and fluoroquinolones and increased the use of penicillin-based drugs and cephalosporins in patients with a history of beta-lactam drug allergies.
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Affiliation(s)
- Kamalini Nadarajah
- Department of Internal Medicine, Allergy and Immunology, Abington Memorial Hospital, Abington, Pennsylvania 19001, USA.
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Abstract
Allergic drug reactions compose a small percentage of ADRs, yet they are commonly encountered in clinical practice, and physicians are taught routinely to question patients about these reactions during history taking. Among antibiotics, the immunochemistry of penicillins has been elucidated,leading to the development of validated skin test reagents to diagnose type 1 allergy. Currently, the temporary commercial unavailability of Pre-Pen makes accurate penicillin skin testing impossible; however, this important skin test reagent is expected to become available sometime in 2006. Type 1 allergies to most other drugs lack comparable diagnostic tests, and their diagnosis is therefore driven by the patient's history. When readministration of medications to which patients report previous reactions is indicated, it may be almost always successfully accomplished by means of either graded challenge or desensitization.
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Affiliation(s)
- Roland Solensky
- Division of Allergy and Immunology, The Corvallis Clinic, Corvallis, OR 97330, USA.
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Implementation of a Process for Penicillin Skin Testing in Hospitalized Patients With a History of Penicillin Allergy. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2005. [DOI: 10.1097/01.idc.0000179882.64882.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Among patients with a reported history of penicillin allergy, 80% to 90% have no evidence of IgE antibodies to penicillin on skin testing and thus avoid penicillin unnecessarily. Moreover, 97% to 99% of such patients with a penicillin skin test negative to the major and minor determinants can tolerate penicillin without risk of an immediate-type hypersensitivity reaction. A penicillin skin test is valuable for evaluating penicillin allergy in patients who need penicillin or cephalosporin. Assessment of sensitivities to penicillin is important to reduce the unnecessary use of antimicrobial agents such as vancomycin. We review the role of penicillin skin testing for evaluating penicillin allergy and the use of cephalosporin in patients with a history of penicillin allergy.
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Affiliation(s)
- Miguel A Park
- Department of Internal Medicine and Division of Allergic Diseases, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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Abstract
Perioperative antibiotic administration and anesthetic practice have major impacts on infectious complications. Anesthesiologists need to place high importance on perioperative antibiotic administration to allow patients to receive optimal benefit from this therapy and to minimize risk. Many aspects of perioperative care ranging from thermoregulation to glycemic control may have profound longterm affects on infection rate and thereby patient outcome.
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Affiliation(s)
- Mark T Keegan
- Division of Critical Care Medicine, Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Arroliga ME, Radojicic C, Gordon SM, Popovich MJ, Bashour CA, Melton AL, Arroliga AC. A prospective observational study of the effect of penicillin skin testing on antibiotic use in the intensive care unit. Infect Control Hosp Epidemiol 2003; 24:347-50. [PMID: 12785408 DOI: 10.1086/502212] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Patients with penicillin allergy admitted to the intensive care unit (ICU) frequently receive non-beta-lactam antimicrobials for the treatment of infection. The use of these antimicrobials, more commonly vancomycin and fluoroquinolones, is associated with the emergence of multidrug-resistant infections. The penicillin skin test (PST) can help detect patients at risk of developing an immediate allergic reaction to penicillin and those patients with a negative PST may be able to use a penicillin antibiotic safely. METHODS We determined the incidence of true penicillin allergy, the percentage of patients changed to a beta-lactam antimicrobial when the test was negative, the safety of the test, and the safety of administration of beta-lactam antimicrobials in patients with a negative test. Skin testing was performed using standard methodology. RESULTS One hundred patients admitted to 4 ICUs were prospectively studied; 58 of them were male. The mean age was 63 years. Ninety-six patients had the PST: one was positive (1.04%), 10 (10.4%) were nondiagnostic, and 85 (88.5%) were negative. Of the 38 patients who received antimicrobials for therapeutic reasons, 31(81.5%) had the antibiotic changed to a beta-lactam antimicrobial after a negative reading versus 7 patients of the 57 (12%) who had received a prophylactic antimicrobial (P < .001). No adverse effects were reported after the PST or after antimicrobial administration. CONCLUSIONS The PST is a safe, reliable, and effective strategy to reduce the use of non-beta-lactam antimicrobials in patients who are labeled as penicillin allergic and admitted to the ICU.
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Sade K, Holtzer I, Levo Y, Kivity S. The economic burden of antibiotic treatment of penicillin-allergic patients in internal medicine wards of a general tertiary care hospital. Clin Exp Allergy 2003; 33:501-6. [PMID: 12680867 DOI: 10.1046/j.1365-2222.2003.01638.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Penicillin allergy poses a major problem in the management of infectious diseases. OBJECTIVE We estimated the costs and usage of antibiotic treatment of 'penicillin-allergic' patients in comparison to non-allergic patients in a tertiary care hospital. MATERIALS AND METHODS The study was based on the records of 118 randomly chosen in-hospital patients labelled as being 'allergic to penicillin' and who were treated with antibiotics. The antibiotic selection and cost of the patients with alleged penicillin allergy were compared to 118 matched patients without an antibiotic allergy (controls). RESULTS During in-hospital treatment, the mean antibiotic cost for penicillin-allergic patients was 63% higher than the cost for the controls. In addition, there was a 38% higher cost of the recommended anti-microbial treatment regimen to be followed upon discharge by the former compared to the latter. CONCLUSIONS Penicillin-allergic patients were more likely to receive broader spectrum antibiotics compared to the non-allergic ones. Since many of the patients who are labelled as being 'allergic to penicillin' are, in fact, not allergic to it, inaccurate reporting of penicillin allergies may have costly economic and epidemiologic repercussions in addition to more toxic effects which can occur when choosing alternative drugs in case of penicillin allergy.
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Affiliation(s)
- K Sade
- Department of Medicine'T', Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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