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Outcomes from an inpatient beta-lactam allergy guideline across a large US health system

  • Kimberly G. Blumenthal (a1) (a2) (a3), Yu Li (a4), Joyce T. Hsu (a3) (a5), Anna R. Wolfson (a1) (a3), David N. Berkowitz (a6), Victoria A. Carballo (a7), Jesse M. Schwartz (a8), Kathleen A. Marquis (a5) (a9), Ramy Elshaboury (a10), Ronak G. Gandhi (a10), Barbara B. Lambl (a11), Monique M. Freeley (a12), Alana Gruszecki (a13), Paige G. Wickner (a3) (a5) and Erica S. Shenoy (a3) (a14) (a15)...
Abstract
Objective:

To assess the safety of, and subsequent allergy documentation associated with, an antimicrobial stewardship intervention consisting of test-dose challenge procedures prompted by an electronic guideline for hospitalized patients with reported β-lactam allergies.

Design:

Retrospective cohort study.

Setting:

Large healthcare system consisting of 2 academic and 3 community acute-care hospitals between April 2016 and December 2017.

Methods:

We evaluated β-lactam antibiotic test-dose outcomes, including adverse drug reactions (ADRs), hypersensitivity reactions (HSRs), and electronic health record (EHR) allergy record updates. HSR predictors were examined using a multivariable logistic regression model. Modification of the EHR allergy record after test doses considered relevant allergy entries added, deleted, and/or specified.

Results:

We identified 1,046 test-doses: 809 (77%) to cephalosporins, 148 (14%) to penicillins, and 89 (9%) to carbapenems. Overall, 78 patients (7.5%; 95% confidence interval [CI], 5.9%–9.2%) had signs or symptoms of an ADR, and 40 (3.8%; 95% CI, 2.8%–5.2%) had confirmed HSRs. Most HSRs occurred at the second (ie, full-dose) step (68%) and required no treatment beyond drug discontinuation (58%); 3 HSR patients were treated with intramuscular epinephrine. Reported cephalosporin allergy history was associated with an increased odds of HSR (odds ratio [OR], 2.96; 95% CI, 1.34–6.58). Allergies were updated for 474 patients (45%), with records specified (82%), deleted (16%), and added (8%).

Conclusion:

This antimicrobial stewardship intervention using β-lactam test-dose procedures was safe. Overall, 3.8% of patients with β-lactam allergy histories had an HSR; cephalosporin allergy histories conferred a 3-fold increased risk. Encouraging EHR documentation might improve this safe, effective, and practical acute-care antibiotic stewardship tool.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited
Corresponding author
Author for correspondence: Kimberly G. Blumenthal, Email: kblumenthal@mgh.harvard.edu
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References
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1. Conway, EL, Lin, K, Sellick, JA, et al. Impact of penicillin allergy on time to first dose of antimicrobial therapy and clinical outcomes. Clin Ther 2017;39:22762283.
2. Lee, CE, Zembower, TR, Fotis, MA, et al. The incidence of antimicrobial allergies in hospitalized patients: implications regarding prescribing patterns an demerging bacterial resistance. Arch Intern Med 2000;160:28192822.
3. Blumenthal, KG, Ryan, EE, Li, Y, Lee, H, Kuhlen, JL, Shenoy, ES. The impact of a reported penicillin allergy on surgical site infection risk. Clin Infect Dis 2018;66:329336.
4. Jeffres, MN, Narayanan, PP, Shuster, JE, Schramm, GE. Consequences of avoiding beta-lactams in patients with beta-lactam allergies. J Allergy Clin Immunol Pract 2016;137:11481153.
5. Macy, E, Blumenthal, KG. Are cephalosporins safe for use in penicillin allergy without prior allergy evaluation? J Allergy Clin Immunol Pract 2018;6:8289.
6. Blumenthal, KG, Shenoy, ES, Huang, M, et al. The impact of reporting a prior penicillin allergy on the treatment of methicillin-sensitive Staphylococcus aureus bacteremia . PLoS One 2016;11:e0159406.
7. 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 2014;133:790796.
8. Blumenthal, KG, Lu, N, Zhang, Y, Li, Y, Walensky, RP, Choi, HK. Risk of meticillin resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy: population based matched cohort study. BMJ 2018;361:k2400.
9. Sacco, KA, Bates, A, Brigham, TJ, Imam, JS, Burton, MC. Clinical outcomes following inpatient penicillin allergy testing: a systematic review and meta-analysis. Allergy 2017;72:12881296.
10. Barlam, TF, Cosgrove, SE, Abbo, LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62:e51e77.
11. Chen, JR, Tarver, SA, Alvarez, KS, Tran, T, Khan, DA. A proactive approach to penicillin allergy testing in hospitalized patients. J Allergy Clin Immunol Pract 2017;5:686693.
12. Blumenthal, KG, Wickner, PG, Hurwitz, S, et al. Tackling inpatient penicillin allergies: assessing tools for antimicrobial stewardship. J Allergy Clin Immunol 2017;140:154161.
13. Rimawi, RH, Cook, PP, Gooch, M, et al. The impact of penicillin skin testing on clinical practice and antimicrobial stewardship. J Hosp Med 2013;8:341345.
14. Blumenthal, KG, Shenoy, ES, Hurwitz, S, Varughese, CA, Hooper, DC, Banerji, A. Effect of a drug allergy educational program and antibiotic prescribing guideline on inpatient clinical providers’ antibiotic prescribing knowledge. J Allergy Clin Immunol Pract 2014;2:407413.
15. Blumenthal, KG, Shenoy, ES, Wolfson, AR, et al. Addressing inpatient beta-lactam allergies: a multihospital implementation. J Allergy Clin Immunol Pract 2017;5:616625.
16. Blumenthal, KG, Shenoy, ES, Varughese, CA, Hurwitz, S, Hooper, DC, Banerji, A. Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy. Ann Allergy Asthma Immunol 2015;115:294300.
17. Harris, PA, Taylor, R, Thielke, R, Payne, J, Gonzalez, N, Conde, JG. Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377381.
18. Heil, EL, Bork, JT, Schmalzle, SA, et al. Implementation of an infectious disease fellow-managed penicillin allergy skin testing service. Open Forum Infect Dis 2016;3(3):ofw155.
19. Sacco, KA, Cochran, BP, Epps, K, Parkulo, M, Gonzalez-Estrada, A. Inpatient beta-lactam test-dose protocol promotes antimicrobial stewardship in patients with history of penicillin allergy. Ann Allergy Asthma Immunol 2019;122:184188.
20. Vaisman, A, McCready, J, Hicks, S, Powis, J. Optimizing preoperative prophylaxis in patients with reported beta-lactam allergy: A novel extension of antimicrobial stewardship. J Antimicrob Chemother 2017;72:26572660.
21. Swearingen, SM, White, C, Weidert, S, Hinds, M, Narro, JP, Guarascio, AJ. A multidimensional antimicrobial stewardship intervention targeting aztreonam use in patients with a reported penicillin allergy. Int J Clin Pharm 2016;38:213217.
22. Staicu, ML, Brundige, ML, Ramsey, A, et al. Implementation of a penicillin allergy screening tool to optimize aztreonam use. Am J Health Syst Pharm 2016;73:298306.
23. Leis, JA, Palmay, L, Ho, G, et al. Point-of-care beta-lactam allergy skin testing by antimicrobial stewardship programs: a pragmatic multicenter prospective evaluation. Clin Infect Dis 2017;65:10591065.
24. Wall, GC, Peters, L, Leaders, CB, Wille, JA. Pharmacist-managed service providing penicillin allergy skin tests. Am J Health Syst Pharm 2004;61:12711275.
25. Wolfe, M, Schoen, J, Bergman, S, May, S, Van Schooneveld, T. Penicillin Allergy Guidance Document. https://www.nebraskamed.com/sites/default/files/documents/for-providers/asp/penicillin-allergy-guidance.pdf. Accessed June 21, 2018.
26. Vaisman, A, McCready, J, Powis, J. Clarifying a “penicillin” allergy: a teachable moment. JAMA Intern Med 2017;177:269270.
27. Blumenthal, KG, Solensky, R. Choice of antibiotics in penicillin-allergic hospitalized patients. UpToDate website. https://www.uptodate.com/contents/choice-of-antibiotics-in-penicillinallergic-hospitalized-patients. Accessed September 6, 2018.
28. Liccardi, G, Senna, G, Russo, M, et al. Evaluation of the nocebo effect during oral challenge in patients with adverse drug reactions. J Investig Allergol Clin Immunol 2004;14:104107.
29. Lombardi, C, Gargioni, S, Canonica, GW, Passalacqua, G. The nocebo effect during oral challenge in subjects with adverse drug reactions. Eur Ann Allergy Clin Immunol 2008;40:138141.
30. Iammatteo, M, Alvarez Arango, S, Ferastraoaru, D, et al. Safety and outcomes of oral graded challenges to amoxicillin without prior skin testing. J Allergy Clin Immunol Pract 2019;7:236243.
31. Blumenthal, KG, Li, Y, Acker, WW, et al. Multiple drug intolerance syndrome and multiple drug allergy syndrome: epidemiology and associations with anxiety and depression. Allergy 2018;73:20122023.
32. Macy, E, Ho, NJ. Multiple drug intolerance syndrome: prevalence, clinical characteristics, and management. Ann Allergy Asthma Immunol 2012;108:8893.
33. Tucker, MH, Lomas, CM, Ramchandar, N, Waldram, JD. Amoxicillin challenge without penicillin skin testing in evaluation of penicillin allergy in a cohort of Marine recruits. J Allergy Clin Immunol Pract 2017;5:813815.
34. Bigby, M, Jick, S, Jick, H, Arndt, K. Drug-induced cutaneous reactions. A report from the Boston Collaborative Drug Surveillance Program on 15,438 consecutive inpatients, 1975 to 1982. JAMA 1986;256: 33583363.
35. Chiriac, AM, Wang, Y, Schrijvers, R, et al. Designing predictive models for beta-lactam allergy using the drug allergy and hypersensitivity database. J Allergy Clin Immunol Pract 2018;6:139148.
36. Romano, A, Valluzzi, RL, Caruso, C, Maggioletti, M, Quaratino, D, Gaeta, F. Cross-reactivity and tolerability of cephalosporins in patients with IgE-mediated hypersensitivity to penicillins. J Allergy Clin Immunol Pract 2018;6:16621672.
37. Macy, E. Penicillin skin testing in pregnant women with a history of penicillin allergy and group B Streptococcus colonization. Ann Allergy Asthma Immunol 2006;97:164168.
38. Romano, A, Gaeta, F, Valluzzi, RL, et al. IgE-mediated hypersensitivity to cephalosporins: cross-reactivity and tolerability of alternative cephalosporins. J Allergy Clin Immunol 2015;136:685691.
39. Zagursky, RJ, Pichichero, ME. Cross-reactivity in beta-lactam allergy. J Allergy Clin Immunol Pract 2018;6:7281.
40. Blumenthal, KG, Park, MA, Macy, EM. Redesigning the allergy module of the electronic health record. Ann Allergy Asthma Immunol 2016;117:126131.
41. Oliver, WD, Heil, EL, Thom, KA, Martinez, JP, Hayes, BD. Allergy profile should be updated after uneventful administration of a penicillin or penicillin-related antibiotic to a patient with penicillin allergy. J Allergy Clin Immunol Pract 2017;5:184186.
42. Bouwmeester, MC, Laberge, N, Bussieres, JF, Lebel, D, Bailey, B, Harel, F. Program to remove incorrect allergy documentation in pediatrics medical records. Am J Health Syst Pharm 2001;58:17221727.
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