12
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

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

      research-article

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          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.

          Related collections

          Most cited references43

          • Record: found
          • Abstract: found
          • Article: not found

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

          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.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk

            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.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: found
              Is Open Access

              Risk of meticillin resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy: population based matched cohort study

              Abstract Objective To evaluate the relation between penicillin allergy and development of meticillin resistant Staphylococcus aureus (MRSA) and C difficile. Design Population based matched cohort study. Setting United Kingdom general practice (1995-2015). Participants 301 399 adults without previous MRSA or C difficile enrolled in the Health Improvement Network database: 64 141 had a penicillin allergy and 237 258 comparators matched on age, sex, and study entry time. Main outcome measures The primary outcome was risk of incident MRSA and C difficile. Secondary outcomes were use of β lactam antibiotics and β lactam alternative antibiotics. Results Among 64 141 adults with penicillin allergy and 237 258 matched comparators, 1365 developed MRSA (442 participants with penicillin allergy and 923 comparators) and 1688 developed C difficile (442 participants with penicillin allergy and 1246 comparators) during a mean 6.0 years of follow-up. Among patients with penicillin allergy the adjusted hazard ratio for MRSA was 1.69 (95% confidence interval 1.51 to 1.90) and for C difficile was 1.26 (1.12 to 1.40). The adjusted incidence rate ratios for antibiotic use among patients with penicillin allergy were 4.15 (95% confidence interval 4.12 to 4.17) for macrolides, 3.89 (3.66 to 4.12) for clindamycin, and 2.10 (2.08 to 2.13) for fluoroquinolones. Increased use of β lactam alternative antibiotics accounted for 55% of the increased risk of MRSA and 35% of the increased risk of C difficile. Conclusions Documented penicillin allergy was associated with an increased risk of MRSA and C difficile that was mediated by the increased use of β lactam alternative antibiotics. Systematically addressing penicillin allergies may be an important public health strategy to reduce the incidence of MRSA and C difficile among patients with a penicillin allergy label.
                Bookmark

                Author and article information

                Journal
                Infect Control Hosp Epidemiol
                Infect Control Hosp Epidemiol
                ICE
                Infection Control and Hospital Epidemiology
                Cambridge University Press (New York, USA )
                0899-823X
                1559-6834
                May 2019
                : 40
                : 5
                : 528-535
                Affiliations
                [1 ]Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital , Boston, Massachusetts
                [2 ]The Mongan Institute , Massachusetts General Hospital, Boston, Massachusetts
                [3 ]Harvard Medical School , Boston, Massachusetts
                [4 ]University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
                [5 ]Division of Rheumatology, Allergy and Immunology, Department of Medicine, Brigham and Women’s Hospital, Boston , Massachusetts
                [6 ]Department of Pharmacy, Newton-Wellesley Hospital , Newton, Massachusetts
                [7 ]Partners HealthCare System, Quality, Safety, and Value, Boston, Massachusetts
                [8 ]Division of Allergy and Clinical Immunology, Jewish General Hospital, McGill University , Montreal, Quebec, Canada
                [9 ]Department of Pharmacy, Brigham and Women’s Hospital , Boston, Massachusetts
                [10 ]Department of Pharmacy, Massachusetts General Hospital , Boston, Massachusetts
                [11 ]Division of Infectious Diseases, Department of Medicine, North Shore Medical Center , Salem, Massachusetts
                [12 ]Pharmacy Department, North Shore Medical Center , Salem, Massachusetts
                [13 ]Pharmacy Department, Brigham and Women’s Faulkner Hospital , Boston, Massachusetts
                [14 ]Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital , Boston, Massachusetts
                [15 ]Infection Control Unit, Massachusetts General Hospital , Boston, Massachusetts
                Author notes
                Author for correspondence: Kimberly G. Blumenthal, Email: kblumenthal@ 123456mgh.harvard.edu
                [a]

                Authors of equal contribution.

                Article
                00050 S0899823X19000503
                10.1017/ice.2019.50
                6536839
                30915929
                e3628adf-9094-4b4e-8efa-d1390b7a6615
                © The Society for Healthcare Epidemiology of America 2019

                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

                Page count
                Figures: 1, Tables: 2, References: 42, Pages: 8
                Product
                Categories
                Original Article

                Comments

                Comment on this article