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      The challenge of de‐labeling penicillin allergy

      Author(s): 1 , 2 , 3 , 4 , 5 , 1 , 1 , 6 , 7 , 8 , 9
      Publication date Created:
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      Journal: Allergy
      Publisher: Wiley

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          Abstract

          Even though 8%-25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de-labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus.

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          Drug allergy: an updated practice parameter.

          , , … (2010)
          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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            Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: A cohort study.

            Eric Macy, Richard Contreras (2014)
            Penicillin is the most common drug "allergy" noted at hospital admission, although it is often inaccurate. 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. We performed a retrospective, matched cohort study of subjects admitted to Kaiser Foundation hospitals in Southern California during 2010 through 2012. 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. 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. Copyright © 2013 American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc. All rights reserved.
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              The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk

              Kimberly Blumenthal, Erin Ryan, Yu Li … (2018)
              Patients reporting a penicillin allergy had a 50% increased odds of developing a surgical site infection, due to receipt of non–beta-lactam perioperative antibiotics. Clarifying reported penicillin allergies preoperatively may improve perioperative antibiotic prophylaxis choice and decrease surgical site infection risk. Background A reported penicillin allergy may compromise receipt of recommended antibiotic prophylaxis intended to prevent surgical site infections (SSIs). Most patients with a reported penicillin allergy are not allergic. We determined the impact of a reported penicillin allergy on the development of SSIs. Methods In this retrospective cohort study of Massachusetts General Hospital hip arthroplasty, knee arthroplasty, hysterectomy, colon surgery, and coronary artery bypass grafting patients from 2010 to 2014, we compared patients with and without a reported penicillin allergy. The primary outcome was an SSI, as defined by the Centers for Disease Control and Prevention’s National Healthcare Safety Network. The secondary outcome was perioperative antibiotic use. Results Of 8385 patients who underwent 9004 procedures, 922 (11%) reported a penicillin allergy, and 241 (2.7%) had an SSI. In multivariable logistic regression, patients reporting a penicillin allergy had increased odds (adjusted odds ratio, 1.51; 95% confidence interval, 1.02–2.22) of SSI. Penicillin allergy reporters were administered less cefazolin (12% vs 92%; P < .001) and more clindamycin (49% vs 3%; P < .001), vancomycin (35% vs 3%; P < .001), and gentamicin (24% vs 3%; P < .001) compared with those without a reported penicillin allergy. The increased SSI risk was entirely mediated by the patients’ receipt of an alternative perioperative antibiotic; between 112 and 124 patients with reported penicillin allergy would need allergy evaluation to prevent 1 SSI. Conclusions Patients with a reported penicillin allergy had a 50% increased odds of SSI, attributable to the receipt of second-line perioperative antibiotics. Clarification of penicillin allergies as part of routine preoperative care may decrease SSI risk.
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                Author and article information

                Journal
                Title: Allergy
                Abbreviated Title: Allergy
                Publisher: Wiley
                ISSN (Print): 0105-4538
                ISSN (Electronic): 1398-9995
                Publication date Created: May 26 2019
                Publication date (Electronic): May 26 2019
                Affiliations
                [1 ]Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
                [2 ]Department of Infectious Diseases Austin Health Heidelberg Victoria Australia
                [3 ]Department of Infectious Diseases Centre for Antibiotic Allergy and Research, Peter MacCallum Cancer Centre Melbourne Victoria Australia
                [4 ]Department of Medicine (Austin Health) University of Melbourne Parkville Victoria Australia
                [5 ]The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Parkville Victoria Australia
                [6 ]Division of Infectious Diseases, Department of Medicine Vanderbilt University Medical Center Nashville Tennessee
                [7 ]Department of Pharmacology Vanderbilt University School of Medicine Nashville Tennessee
                [8 ]Department of Pathology, Microbiology and Immunology Vanderbilt University Medical Center Nashville Tennessee
                [9 ]Institute for Immunology &amp; Infectious Diseases Murdoch University Murdoch Western Australia Australia
                Article
                DOI: 10.1111/all.13848
                PMC ID: 6824919
                PubMed ID: 31049971
                SO-VID: 37eb15cf-bf0d-4936-a4c8-429cf0c2a92a
                Copyright © © 2019
                License:

                http://doi.wiley.com/10.1002/tdm_license_1.1

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