153. Development of a Pathway for Removal of Inappropriate Penicillin Allergy Labels in Hospitalized Patients

Background

More than 90% of reported penicillin allergies are found inaccurate when formally assessed. These allergy labels lead to decreased utilization of first-line beta-lactam antibiotics, and adverse clinical outcomes. The objective of this study was to develop a multi-disciplinary approach to decrease inaccurate labeling among hospitalized patients with documented penicillin allergy.

Methods

A team of clinicians, pharmacists, and nurses utilized the DMAIC quality strategy to improve accuracy of penicillin allergy labeling. Allergic reactions were stratified to develop a penicillin allergy de-labeling algorithm (Figure 1). Admission to the intensive care unit (ICU) for anaphylaxis was defined as a balancing measure. We reviewed baseline data from patients with a documented penicillin allergy admitted to a single inpatient floor at Mayo Clinic, Rochester between June and October 2019. A cause and effect diagram was used to conduct a root cause analysis. The intervention was then applied to patients who reported penicillin allergy admitted to the same floor from November 2019 to January 2020. Study data were collected and basic descriptive statistics generated.

Figure 1: Penicillin allergy delabeling algorithm

Results

96 patients were included in the control group with mean age of 71 years (range 65–84 years) and 55% females. Breakdown of documented allergic reactions are represented in Figure 2. 58 (60%) received an antibiotic for a median duration of 1.5 days (IQR: 0 – 6). Of these, 7(12%) received penicillin-class antibiotics, and 41 (70.6%) received non-beta-lactam antibiotics. 2 (2%) of these patients were de-labeled without any penicillin skin tests. Detailed metrics of each PDSA cycle are shown in Table 1. During PDSA cycle 2, inaccurate penicillin documentation was removed in 9/19 (47.4%) of hospitalized patients. There were no ICU admissions for anaphylaxis.

Figure 2: Graphic representation of proportion of type of documented allergic reactions to penicillin

Table 1: Metrics and outcomes at baseline and during successive PDSA cycles

Conclusion

Various factors contribute to penicillin allergy mislabeling. Our comprehensive algorithm addresses nuances of penicillin allergic reactions and increased accurate penicillin allergy labeling in 47.4% of the cases. Beta-lactam use also increased to 37% through our pilot project while maintaining patient safety. A multi-disciplinary and patient-centered approach aligned with institutional workflows is necessary to improve patient outcomes.

Disclosures

All Authors: No reported disclosures

Diagnostic Utility of Urinary LTE4 in Asthma, Allergic Rhinitis, Chronic Rhinosinusitis, Nasal Polyps, and Aspirin Sensitivity

BACKGROUND

Urinary leukotriene E4 (LTE4) is a well-validated marker of the cysteinyl leukotriene pathway, and LTE4 elevation has been described in conditions such as asthma, aspirin sensitivity, and chronic rhinosinusitis (CRS). There have been a number of reports investigating the role of spot urine LTE4 to predict aspirin sensitivity; however, variability in urinary LTE4 may affect the accuracy of this approach.

OBJECTIVE

Here, we explored the utility of 24-hour urinary LTE4 in 5 clinical diagnoses of allergic rhinitis, asthma, chronic rhinosinusitis with nasal polyps (CRSwNP), CRS without nasal polyps, and aspirin sensitivity.

METHODS

This was a retrospective review of patients who had 24-hour quantification of urinary LTE4 by a clinically validated liquid chromatography tandem mass spectrometry method and their assigned diagnoses after assessment and clinical care.

RESULTS

Twenty-four-hour urinary LTE4 elevations were seen in those with asthma and those with CRSwNP but influenced by underlying aspirin sensitivity. Elevation in LTE4 was significant in those with CRSwNP after adjusting for aspirin sensitivity. Allergic rhinitis was not associated with elevated LTE4 excretion. Receiver operator characteristic analysis of 24-hour urinary LTE4 showed that a cutoff value of 166 pg/mg Cr suggested the presence of history of aspirin sensitivity with 89% specificity, whereas a cutoff value of 241 pg/mg Cr discriminated "challenge-confirmed" aspirin-sensitive subjects with 92% specificity.

CONCLUSIONS

Elevated 24-hour excretion of urinary LTE4 is a reliable and simple test to identify aspirin sensitivity in patients with respiratory diagnoses.

Increases in airway eosinophilia and a th1 cytokine during the chronic asymptomatic phase of asthma

BACKGROUND

Studies using allergen challenge models have suggested Th2 cytokines promote airway inflammation in asthma. We assessed mediators of airway inflammation during the chronic asymptomatic phase of asthma.

METHODS

Nine non-atopic asthma (NAA) patients, 19 atopic asthma (AA) patients, 20 atopic controls (AC), and 38 normal controls (NC) underwent sputum induction while asymptomatic. Sputum total cell counts and differentials were determined; levels of cytokines IL-4, IL-5, IL-13, GM-CSF, and IFN-gamma, and chemokines eotaxin (CCL11) and RANTES (CCL5) were measured by ELISA; and levels of eosinophil-derived neurotoxin (EDN) were measured by radioimmunoassay.

RESULTS

NAA patients showed higher % eosinophils and total eosinophils compared to AA. NAA and AA patients showed higher IFN-gamma and EDN levels compared to AC and NC, with no differences in IL-4, IL-5, or IL-13 levels among the four groups. GM-CSF levels were higher in AA patients compared to AC or NC. In NAA, AA, and AC patients, % eosinophils and EDN levels correlated positively with IFN-gamma, GM-CSF, eotaxin, and RANTES, but not with IL-5 levels.

CONCLUSIONS

Baseline airway inflammation of intrinsic and extrinsic asthma is characterized by eosinophilic inflammation and the Th1 cytokine, IFN-gamma. GM-CSF, instead of IL-5, and chemokines may coordinate airway eosinophilia during the chronic asymptomatic phase of asthma.