scholarly journals Penicillin Allergy Assessment and Skin Testing in the Outpatient Setting

Pharmacy ◽  
2019 ◽  
Vol 7 (3) ◽  
pp. 136 ◽  
Author(s):  
Wesley D. Kufel ◽  
Julie Ann Justo ◽  
P. Brandon Bookstaver ◽  
Lisa M. Avery
Keyword(s):  
Skin Testing ◽  
Management Strategies ◽  
Treatment Decisions ◽  
Outpatient Setting ◽  
Penicillin Allergy ◽  
Inpatient Setting ◽  
Negative Consequences ◽  
Beta Lactam ◽  
Beta Lactam Antibiotics ◽  
Antibiotic Management

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.

Review of Pharmacist Driven Penicillin Allergy Assessments and Skin Testing: A Multi-Center Case-Series

2021 ◽  
pp. 001857872110468
Author(s):  
Hanna M. Harper ◽  
Michael Sanchez
Keyword(s):  
Skin Testing ◽  
Case Series ◽  
Cost Savings ◽  
Penicillin Allergy ◽  
Teaching Hospitals ◽  
Beta Lactam ◽  
Retrospective Case ◽  
Beta Lactam Antibiotics ◽  
Case Series Study ◽  
The Impact

Objective: To describe the impact of pharmacy driven penicillin allergy assessments on de-labeling penicillin allergies and antibiotic streamlining opportunities for hospitalized patients. Design: Multi-center, retrospective case-series study. Setting: A health system of 4 non-teaching hospitals. Participants: Patients aged 18 years and older with a physician order for a pharmacist penicillin allergy assessment. Exclusion criteria consisted of patients with anaphylaxis or a type II penicillin allergy, anaphylaxis of any cause within 4 weeks, refusal of penicillin allergy skin test (PAST), antihistamine use within 24 hours, penicillin intolerance, immunosuppression or immunosuppressive medications, or skin conditions that could interfere with PAST. Interventions: The primary endpoint evaluated the number of de-labeled penicillin allergies after pharmacists provided penicillin allergy assessments. Secondary endpoints evaluated the percent of patients with antibiotics deescalated to beta-lactam antibiotics and classification of notable interventions made by pharmacists. Measurements and Main Results: There were 35 patients who met inclusion criteria. Twenty-four patients underwent both penicillin allergy skin testing and oral (PO) amoxicillin challenge. Five patients had allergies de-labeled only after a pharmacist interview. Four patients received only the PO amoxicillin challenge and 2 patients received only PAST. Penicillin allergies were de-labeled from the electronic health record (EHR) in 31 (89%) patients despite all testing negative for a penicillin allergy from PAST or a PO amoxicillin challenge. Four patients had the allergy re-added to the chart on subsequent admissions. No patients experienced a reaction from PAST, PO amoxicillin challenge, or subsequent beta-lactam antibiotics. Twenty-eight (80%) patients had their antibiotic therapy changed as a result of the allergy assessment. Seventeen patients were de-escalated onto beta-lactam antibiotics and aztreonam was stopped in 6 patients. Conclusion: Results from this study suggests that pharmacists expanding their scope of practice with PAST is a safe and effective allergy de-labeling tool. Pharmacist-driven penicillin allergy assessments could provide antibiotic cost savings and avoid aztreonam use. The study supports the need to emphasize education for patients and caretakers regarding allergy testing results to avoid relabeling in future hospital visits.

scholarly journals 162. Assessment of Beta-lactam Allergies as Rationale for Receipt of Vancomycin for Surgical Prophylaxis

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S90-S90
Author(s):  
Kendall J Tucker ◽  
YoungYoon Ham ◽  
Haley K Holmer ◽  
Caitlin M McCracken ◽  
Ellie Sukerman ◽  
...  
Keyword(s):  
Antimicrobial Prophylaxis ◽  
Skin Testing ◽  
Cross Reactivity ◽  
Penicillin Allergy ◽  
Beta Lactam ◽  
First Line ◽  
Surgical Prophylaxis ◽  
Inappropriate Use ◽  
Oral Amoxicillin ◽  
Ige Mediated

Abstract Background Beta-lactam (BL) antibiotics are first-line agents for most patients receiving antimicrobial prophylaxis in surgical procedures. Despite evidence showing low cross-reactivity between classes of BLs, patients with allergies commonly receive vancomycin as an alternative to avoid allergic reaction. The objective of this study was to identify potentially inappropriate use of vancomycin surgical prophylaxis among patients with reported BL allergies. Methods Adult patients (≥18 years) receiving vancomycin for surgical prophylaxis with a reported penicillin and/or cephalosporin allergy at our institution between August 2017 to July 2018 were retrospectively evaluated for potential eligibility for penicillin allergy testing and/or receipt of standard prophylaxis. Surgery type and allergy history were extracted from the electronic medical record. Per our institution’s penicillin-testing protocol, patients with IgE-mediated reactions < 10 years ago were eligible for penicillin skin testing (PST), mild reactions or IgE-mediated reaction > 10 years ago were eligible for direct oral amoxicillin challenge, and severe non-IgE mediated allergies were ineligible for penicillin allergy evaluation or BL prophylaxis. Results Among 830 patients who received vancomycin for surgical prophylaxis, 196 reported BL allergy and were included in the analysis (155 with penicillin allergy alone; 21 with cephalosporin allergy; 20 with both cephalosporin and penicillin allergy). Approximately 40% of surgeries were orthopedic. Six patients were ineligible for BL prophylaxis. Per institutional protocol, 73 of 155 patients (48%) may have qualified for PST; 81 of 155 (52%) patients may have received a direct oral amoxicillin challenge. Only 3 of 22 patients with history of methicillin-resistant Staphylococcus aureus appropriately received additional prophylaxis with vancomycin and a BL. Conclusion Patients with BL allergies often qualify for receipt of a first-line BL antibiotic. An opportunity exists for improved BL allergy assessment as an antimicrobial stewardship intervention. Future studies should evaluate outcomes associated with BL allergy evaluation and delabeling in patients receiving surgical prophylaxis. Disclosures All Authors: No reported disclosures

scholarly journals Beta-lactam allergy in the paediatric population

2020 ◽  
Vol 25 (1) ◽  
pp. 62-62 ◽  
Author(s):  
Tiffany Wong ◽  
Adelle Atkinson ◽  
Geert t’Jong ◽  
Michael J Rieder ◽  
Edmond S Chan ◽  
...  
Keyword(s):  
Paediatric Population ◽  
Outpatient Setting ◽  
Stevens Johnson Syndrome ◽  
Beta Lactam ◽  
Antibiotic Resistant ◽  
Beta Lactam Antibiotics ◽  
Johnson Syndrome ◽  
Ige Mediated ◽  
Systemic Symptoms ◽  
Exanthematous Pustulosis

Abstract Beta-lactam allergy is commonly diagnosed in paediatric patients, but over 90% of individuals reporting this allergy are able to tolerate the medications prescribed after evaluation by an allergist. Beta-lactam allergy labels are associated with negative clinical and administrative outcomes, including use of less desirable alternative antibiotics, longer hospitalizations, increasing antibiotic-resistant infections, and greater medical costs. Also, children with true IgE-mediated allergy to penicillin medications are often advised to avoid all beta-lactam antibiotics, including cephalosporins, which is likely unnecessary in greater than 97% of those reporting penicillin allergies. Most patients can be safely treated with penicillin or amoxicillin if they do not have a history compatible with IgE-mediated or systemic, delayed reactions such as Stevens-Johnson syndrome (SJS), serum sickness-like reactions, drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, or acute generalized exanthematous pustulosis (AGEP). Guidance is provided on how to stratify risk of beta-lactam allergy, and on test dosing and monitoring in the outpatient setting for patients deemed low risk. Guidance for patients at higher risk of beta-lactam allergy includes criteria for appropriate referral to allergists and the use of alternative antimicrobials, such as cephalosporins, while awaiting specialist assessment.

scholarly journals First pediatric electronic algorithm to stratify risk of penicillin allergy

2020 ◽  
Vol 16 (1) ◽  
Author(s):  
Hannah Roberts ◽  
Lianne Soller ◽  
Karen Ng ◽  
Edmond S. Chan ◽  
Ashley Roberts ◽  
...  
Keyword(s):  
Health Care Professionals ◽  
Pediatric Population ◽  
Skin Testing ◽  
Low Risk ◽  
Penicillin Allergy ◽  
Oral Drug ◽  
Beta Lactam ◽  
Paper Version ◽  
Pediatric Study ◽  
Risk Patients

AbstractBeta-lactam allergy is reported in 5–10% of children in North America, but up to 94–97% of patients are deemed not allergic after allergist assessment. The utility of standardized skin testing for penicillin allergy in the pediatric population has been recently questioned. Oral drug challenges when appropriate, are preferred over skin testing, and can definitively rule out immediate, IgE-mediated drug allergy. To our knowledge, this is the only pediatric study to assess the reliability of a penicillin allergy stratification tool using a paper and electronic clinical algorithm. By using an electronic algorithm, we identified 61 patients (of 95 deemed not allergic by gold standard allergist decision) as low risk for penicillin allergy, with no false negatives and without the need for allergist assessment or skin testing. In this study, we demonstrate that an electronic algorithm can be used by various pediatric clinicians when evaluating possible penicillin allergy to reliably identify low risk patients. We identified the electronic algorithm was superior to the paper version, capturing an even higher percentage of low risk patients than the paper version. By developing an electronic algorithm to accurately assess penicillin allergy risk based on appropriate history, without the need for diagnostic testing or allergist assessment, we can empower non-allergist health care professionals to safely de-label low risk pediatric patients and assist in alleviating subspecialty wait times for penicillin allergy assessment.

scholarly journals Australian and New Zealand Anaesthetic Allergy Group Perioperative Anaphylaxis Investigation Guidelines

2017 ◽  
Vol 45 (5) ◽  
pp. 543-555 ◽  
Author(s):  
R. J. Scolaro ◽  
H. M. Crilly ◽  
E. J. Maycock ◽  
P. T. McAleer ◽  
K. A. Nicholls ◽  
...  
Keyword(s):  
New Zealand ◽  
Skin Testing ◽  
Working Party ◽  
Neuromuscular Blocking ◽  
Beta Lactam ◽  
Beta Lactam Antibiotics ◽  
Consensus Document ◽  
Anaesthetic Agents ◽  
The Individual

These guidelines are a consensus document developed by a working party of the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) to provide an approach to the investigation of perioperative anaphylaxis. They focus primarily on the use of skin testing as it is the investigation with the greatest clinical utility for the identification of the likely causative agent and potentially safer alternatives. The practicalities and process of skin testing, its limitations, and the place of other tests are discussed. These guidelines also address the roles of graded challenge and in vitro testing. The implications of anaphylaxis associated with neuromuscular blocking agents, beta-lactam antibiotics, local anaesthetic agents and chlorhexidine are discussed. Evidence for the recommendations is derived from literature searches using the words skin test, allergy, anaphylaxis, anaesthesia, and each of the individual agents listed in these guidelines. The individual articles were then reviewed for suitability for inclusion in these guidelines. Where evidence was not strong, as is the situation for many perioperative agents, expert consensus from the ANZAAG working party was used. These guidelines are intended for use by specialists involved in the investigation of perioperative allergy. They have been approved following peer review by members of ANZAAG and are available on the ANZAAG website: http://www.anzaag.com/anaphylaxis-management/testing-guidelines.pdf .

Factors associated with negative histamine control for penicillin allergy skin testing in the inpatient setting

2015 ◽  
Vol 115 (1) ◽  
pp. 33-38 ◽  
Author(s):  
Bob Geng ◽  
Ami Thakor ◽  
Elisabeth Clayton ◽  
Lindsay Finkas ◽  
Marc A. Riedl
Keyword(s):  
Skin Testing ◽  
Penicillin Allergy ◽  
Inpatient Setting ◽  
Factors Associated ◽  
Allergy Skin Testing

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

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S86-S87
Author(s):  
Fnu Shweta ◽  
Pooja Gurram ◽  
Natalia E Castillo Almeida ◽  
Douglas Challener ◽  
Edison J Cano ◽  
...  
Keyword(s):  
Pilot Project ◽  
Study Data ◽  
Hospitalized Patients ◽  
Penicillin Allergy ◽  
Skin Tests ◽  
Control Group ◽  
Allergic Reactions ◽  
Beta Lactam ◽  
Beta Lactam Antibiotics ◽  
Pdsa Cycle

Abstract 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

OR092 Utility of inpatient penicillin allergy testing at reducing exposure to non-beta lactam antibiotics

2017 ◽  
Vol 119 (5) ◽  
pp. S13
Author(s):  
K. Sacco ◽  
R. Chirila ◽  
C. Libertin ◽  
A. Bhasin ◽  
T. Pongdee ◽  
...  
Keyword(s):  
Penicillin Allergy ◽  
Beta Lactam ◽  
Allergy Testing ◽  
Beta Lactam Antibiotics

scholarly journals 171. Effectiveness and Feasibility of Pharmacist-Driven Penicillin Allergy De-Labeling Pilot Program

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S93-S93
Author(s):  
Youchan Song ◽  
Zachary Nelson ◽  
Krista Gens
Keyword(s):  
Program Implementation ◽  
Skin Testing ◽  
Surgical Site Infections ◽  
Cross Reactivity ◽  
Adverse Outcomes ◽  
Penicillin Allergy ◽  
Beta Lactam ◽  
Patient Interview ◽  
Clostridioides Difficile ◽  
Increased Risk

Abstract Background Prevalence of true hypersensitivity to penicillins is low (0.5–2%). Documented penicillin allergies have been associated with an increased risk of adverse outcomes, including methicillin resistant Staphylococcus aureus infections, Clostridioides difficile infections, and surgical site infections. “De-labeling” of inappropriately documented allergies can decrease the use of unnecessary broad-spectrum antibiotics and prevent negative outcomes, but labor-intensive skin testing and oral challenges can be a barrier to program implementation. The goal of this project is to assess the effectiveness and feasibility of a pharmacist-led penicillin allergy de-labeling process that does not involve skin testing or oral challenges. Methods Adult patients with penicillin allergies were identified using a report within the electronic health record during a 3-month pilot period. Patients identified were interviewed by an infectious diseases pharmacy resident, and an allergy history was assessed utilizing a standardized checklist. The patients’ answers determined the ability to de-label via pharmacist utilization of an evidence-based and standardized checklist developed for this project. All documentation included a detailed patient allergy history along with a beta-lactam cross-reactivity chart to help guide future antibiotic choices. Results 66 patients were interviewed during the pilot. 12 patients (18%) met criteria for de-labeling and consented to the removal of the allergy. 4 patients (6%) met criteria for de-labeling but declined the removal of the allergy. Average time spent during patient interview was 5.2 minutes per patient. 58.3% of patients (7/12) who were de-labeled were subsequently prescribed a beta-lactam, and 100% (7/7) were able to tolerate the agents. 1 out of 4 patients (25%) who declined de-labeling but had their allergy updated to reflect intolerance was prescribed beta-lactams and was able to tolerate the agents (1/1, 100%). Conclusion A pharmacist-led penicillin allergy de-labeling process utilizing a standardized checklist is an effective method for removing penicillin allergies in patients who do not have a true allergy to penicillins. This pharmacist-led process is a feasible method for sites unable to perform oral challenges or skin testing. Disclosures All Authors: No reported disclosures

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