Acute care beta-lactam allergy pathways: approaches and outcomes

Abstract

Key Messages•Acute care beta-lactam allergy pathways are coordinated allergy assessment programs for hospitalized patients as an antibiotic stewardship tool, which can be based on the allergy history alone, or use the allergy history to guide procedures such as drug challenges and/or penicillin skin testing.•Pathways commonly targeted patients likely to benefit from acute care penicillin allergy evaluations: patients on specific broad-spectrum antibiotics, referred from Infectious Diseases specialists, and/or patients with specific infections or bacterial culture results.•Acute care beta-lactam pathways were safe and report decreased alternative antibiotic use and increased beta-lactam antibiotic use.InstructionsCredit can now be obtained, free for a limited time, by reading the review article and completing all activity components. Please note the instructions listed below:•Review the target audience, learning objectives and all disclosures.•Complete the pre-test.•Read the article and reflect on all content as to how it may be applicable to your practice.•Complete the post-test/evaluation and claim credit earned. At this time, physicians will have earned up to 1.0 AMA PRA Category 1 CreditTM. Minimum passing score on the post-test is 70%.Overall PurposeParticipants will be able to demonstrate increased knowledge of the clinical treatment of allergy/asthma/immunology and how new information can be applied to their own practices.Learning ObjectivesAt the conclusion of this activity, participants should be able to:•Identify the benefits of inpatient beta-lactam allergy assessments.•Describe different approaches to beta-lactam allergy pathways including the methods used to identify patients.Release Date: July 1, 2019Expiration Date: June 30, 2021Target AudiencePhysicians involved in providing patient care in the field of allergy/asthma/immunologyAccreditationThe American College of Allergy, Asthma & Immunology (ACAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.DesignationThe American College of Allergy, Asthma & Immunology (ACAAI) designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Disclosure PolicyAs required by the Accreditation Council for Continuing Medical Education (ACCME) and in accordance with the American College of Allergy, Asthma and Immunology (ACAAI) policy, all CME planners, presenters, moderators, authors, reviewers, and other individuals in a position to control and/or influence the content of an activity must disclose all relevant financial relationships with any commercial interest that have occurred within the past 12 months. All identified conflicts of interest must be resolved and the educational content thoroughly vetted for fair balance, scientific objectivity, and appropriateness of patient care recommendations. It is required that disclosure be provided to the learners prior to the start of the activity. Individuals with no relevant financial relationships must also inform the learners that no relevant financial relationships exist. Learners must also be informed when off-label, experimental/investigational uses of drugs or devices are discussed in an educational activity or included in related materials. Disclosure in no way implies that the information presented is biased or of lesser quality. It is incumbent upon course participants to be aware of these factors in interpreting the program contents and evaluating recommendations. Moreover, expressed views do not necessarily reflect the opinions of ACAAI.Disclosure of Relevant Financial RelationshipsAll identified conflicts of interest have been resolved. Any unapproved/investigative uses of therapeutic agents/devices discussed are appropriately noted.Planning Committee•Larry Borish, MD, Consultant, Fees/Contracted Research: AstraZeneca, Novartis, Regeneron, Teva•Mariana C. Castells, MD, PhD, has no relevant financial relationships to disclose•Anne K. Ellis, MD, MSc, Advisory Board/Speaker, Honorarium: Alk-Abello, Aralez, AstraZeneca, Boehringer Ingelheim, Circassia Ltd., GlaxoSmithKline, Meda, Merck, Novartis, Pediapharma, Pfizer, Sanofi, Takeda; Research, Grants: Bayer, Circassia Ltd., Green Cross Pharmaceuticals, GlaxoSmithKline, Merck, Novartis, Pfizer, Sanofi, Sun Pharma•Mitchell Grayson, MD, Advisory Board, Honorarium: AstraZeneca, Genentech, Novartis•Matthew Greenhawt, MD, Advisory Board/Consultant/Speaker, Fees/Honorarium: Allergenis, Aquestive, DVB Technologies, Genentech, Intrommune, Kaleo, Nutricia, Sanofi/Genzyme•William Johnson, MD, has no relevant financial relationships to disclosure•Donald Leung, MD, Chair, DSMC/ Consultant, Fees: AbbVie, Aimmune, Regeneron, Sanofi-Aventis Pharma; Research, Grants: Incyte Corp, Pfizer•Jay Lieberman, MD, Advisory Board/Author/Speaker, Honorarium/Contracted Research: Aimmune, ALK-Abello, Aquestive Therapeutics, DBV Technologies•Gailen D. Marshall, Jr, MD, PhD, has no relevant financial relationships to disclose•Anna Nowak-Wegrzyn, MD, Chair, Honorarium/Contracted Research: Alk-Abello, Merck; Consultant, Fees: LabCorp; Co-Investigator, Fees: Sanofi Aventis; Private Investigator, Contracted Research/Honorarium: Abbott, Astellas Pharma, Danone Nutricia, DBV Technologies, Nestle•John J. Oppenheimer, MD, Consultant, Fees: DBV Technologies, GlaxoSmithKline, Sanofi, Teva; Adjudication, Fees: MedImmune•Jonathan M. Spergel, MD, PhD, Advisory Board/Consultant/Research, Fees/Contracted Research/Honorarium: Aimmune Therapeutics, DBV Technologies, Regeneron, Pfizer; Speaker, Honorarium: AbbottAuthorThe following individuals have no relevant financial relationships to disclose:•Anna R. Wolfson, MD•Emily M. Huebner, MD•Kimberly Gold Blumenthal, MD, MScRecognition of Commercial Support: This activity has not received external commercial support.Copyright Statement: 2015-2019 ACAAI. All rights reserved.CME Inquiries: Contact the American College of Allergy, Asthma & Immunology at [email protected] or 847-427-1200. •Acute care beta-lactam allergy pathways are coordinated allergy assessment programs for hospitalized patients as an antibiotic stewardship tool, which can be based on the allergy history alone, or use the allergy history to guide procedures such as drug challenges and/or penicillin skin testing.•Pathways commonly targeted patients likely to benefit from acute care penicillin allergy evaluations: patients on specific broad-spectrum antibiotics, referred from Infectious Diseases specialists, and/or patients with specific infections or bacterial culture results.•Acute care beta-lactam pathways were safe and report decreased alternative antibiotic use and increased beta-lactam antibiotic use. Credit can now be obtained, free for a limited time, by reading the review article and completing all activity components. Please note the instructions listed below:•Review the target audience, learning objectives and all disclosures.•Complete the pre-test.•Read the article and reflect on all content as to how it may be applicable to your practice.•Complete the post-test/evaluation and claim credit earned. At this time, physicians will have earned up to 1.0 AMA PRA Category 1 CreditTM. Minimum passing score on the post-test is 70%. Overall Purpose Participants will be able to demonstrate increased knowledge of the clinical treatment of allergy/asthma/immunology and how new information can be applied to their own practices. Learning Objectives At the conclusion of this activity, participants should be able to:•Identify the benefits of inpatient beta-lactam allergy assessments.•Describe different approaches to beta-lactam allergy pathways including the methods used to identify patients. Release Date: July 1, 2019 Expiration Date: June 30, 2021 Target Audience Physicians involved in providing patient care in the field of allergy/asthma/immunology Accreditation The American College of Allergy, Asthma & Immunology (ACAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Designation The American College of Allergy, Asthma & Immunology (ACAAI) designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Disclosure Policy As required by the Accreditation Council for Continuing Medical Education (ACCME) and in accordance with the American College of Allergy, Asthma and Immunology (ACAAI) policy, all CME planners, presenters, moderators, authors, reviewers, and other individuals in a position to control and/or influence the content of an activity must disclose all relevant financial relationships with any commercial interest that have occurred within the past 12 months. All identified conflicts of interest must be resolved and the educational content thoroughly vetted for fair balance, scientific objectivity, and appropriateness of patient care recommendations. It is required that disclosure be provided to the learners prior to the start of the activity. Individuals with no relevant financial relationships must also inform the learners that no relevant financial relationships exist. Learners must also be informed when off-label, experimental/investigational uses of drugs or devices are discussed in an educational activity or included in related materials. Disclosure in no way implies that the information presented is biased or of lesser quality. It is incumbent upon course participants to be aware of these factors in interpreting the program contents and evaluating recommendations. Moreover, expressed views do not necessarily reflect the opinions of ACAAI. Disclosure of Relevant Financial Relationships All identified conflicts of interest have been resolved. Any unapproved/investigative uses of therapeutic agents/devices discussed are appropriately noted. Planning Committee•Larry Borish, MD, Consultant, Fees/Contracted Research: AstraZeneca, Novartis, Regeneron, Teva•Mariana C. Castells, MD, PhD, has no relevant financial relationships to disclose•Anne K. Ellis, MD, MSc, Advisory Board/Speaker, Honorarium: Alk-Abello, Aralez, AstraZeneca, Boehringer Ingelheim, Circassia Ltd., GlaxoSmithKline, Meda, Merck, Novartis, Pediapharma, Pfizer, Sanofi, Takeda; Research, Grants: Bayer, Circassia Ltd., Green Cross Pharmaceuticals, GlaxoSmithKline, Merck, Novartis, Pfizer, Sanofi, Sun Pharma•Mitchell Grayson, MD, Advisory Board, Honorarium: AstraZeneca, Genentech, Novartis•Matthew Greenhawt, MD, Advisory Board/Consultant/Speaker, Fees/Honorarium: Allergenis, Aquestive, DVB Technologies, Genentech, Intrommune, Kaleo, Nutricia, Sanofi/Genzyme•William Johnson, MD, has no relevant financial relationships to disclosure•Donald Leung, MD, Chair, DSMC/ Consultant, Fees: AbbVie, Aimmune, Regeneron, Sanofi-Aventis Pharma; Research, Grants: Incyte Corp, Pfizer•Jay Lieberman, MD, Advisory Board/Author/Speaker, Honorarium/Contracted Research: Aimmune, ALK-Abello, Aquestive Therapeutics, DBV Technologies•Gailen D. Marshall, Jr, MD, PhD, has no relevant financial relationships to disclose•Anna Nowak-Wegrzyn, MD, Chair, Honorarium/Contracted Research: Alk-Abello, Merck; Consultant, Fees: LabCorp; Co-Investigator, Fees: Sanofi Aventis; Private Investigator, Contracted Research/Honorarium: Abbott, Astellas Pharma, Danone Nutricia, DBV Technologies, Nestle•John J. Oppenheimer, MD, Consultant, Fees: DBV Technologies, GlaxoSmithKline, Sanofi, Teva; Adjudication, Fees: MedImmune•Jonathan M. Spergel, MD, PhD, Advisory Board/Consultant/Research, Fees/Contracted Research/Honorarium: Aimmune Therapeutics, DBV Technologies, Regeneron, Pfizer; Speaker, Honorarium: Abbott Author The following individuals have no relevant financial relationships to disclose:•Anna R. Wolfson, MD•Emily M. Huebner, MD•Kimberly Gold Blumenthal, MD, MSc Recognition of Commercial Support: This activity has not received external commercial support. Copyright Statement: 2015-2019 ACAAI. All rights reserved. CME Inquiries: Contact the American College of Allergy, Asthma & Immunology at [email protected] or 847-427-1200. Penicillin allergy is the most commonly reported drug allergy. Although 10% of patients report a penicillin allergy, up to 15% of hospitalized patients report a penicillin allergy.1Zhou L. Dhopeshwarkar N. Blumenthal K.G. et al.Drug allergies documented in electronic health records of a large healthcare system.Allergy. 2016; 71: 1305-1313Crossref PubMed Scopus (111) Google Scholar, 2Picard M. Begin P. Bouchard H. et al.Treatment of patients with a history of penicillin allergy in a large tertirary care academic hospital.J Allergy Clin Immunol Pract. 2013; 1: 252-257Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar, 3Lee C.E. Zembower T.R. Fotis M.A. et al.The incidence of antimicrobial allergies in hospitalized patients: implication regarding prescribing patterns and emerging bacterial resistance.Arch Intern Med. 2000; 160: 2819-2822Crossref PubMed Scopus (269) Google Scholar Given that 90% to 95% of patients with a reported penicillin allergy tolerate penicillin,4Sacco K.A. Bates A. Brigham T.J. Imam J.S. Burton M.C. Clinical outcomes following inpatient penicillin allergy testing: a systematic review and meta-analysis.Allergy. 2017; 72: 1288-1296Crossref PubMed Scopus (94) Google Scholar hospitalized patients with infections often unnecessarily avoid penicillins and other beta-lactams, such as cephalosporins. Reporting a history of penicillin allergy can result in the choice of a clinically inferior antibiotic5Blumenthal K.G. Ryan E.E. Li Y. Lee H. Kuhlen J.L. Shenoy E.S. The impact of a reported penicillin allergy on surgical site infection risk.Clin Infect Dis. 2018; 66: 329-336Crossref PubMed Scopus (150) Google Scholar, 6Blumenthal K.G. Shenoy E.S. 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: e0159406Crossref PubMed Scopus (39) Google Scholar and may lead to more adverse effects.7Blumenthal K.G. Lu N. Zhang Y. Li Y. Walensky R.P. Choi H.K. Risk of methicillin resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy: population based matched cohort study.BMJ. 2018; 361: k2400Crossref PubMed Scopus (123) Google Scholar, 8MacFadden D.R. LaDelfa A. Leen J. et al.Impact of reported beta-lactam allergy on inpatient outcomes: a multicenter prospective cohort study.Clin Infect Dis. 2016; 63: 904-910Crossref PubMed Scopus (118) Google Scholar When the beta-lactam alternative antibiotic chosen is more broad-spectrum, antimicrobial resistance ensues. Indeed, patients with reported penicillin allergies have an increased incidence of methicillin-resistant Staphylococcus aureus.7Blumenthal K.G. Lu N. Zhang Y. Li Y. Walensky R.P. Choi H.K. Risk of methicillin resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy: population based matched cohort study.BMJ. 2018; 361: k2400Crossref PubMed Scopus (123) Google Scholar Unverified beta-lactam allergies interfere with optimal care of infections in the hospital. In methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, giving the alternative drug (vancomycin) results in more treatment failure (15% vs 9%) and death (18% vs 7%) than using the penicillin allergy history to guide beta-lactam treatment.9Blumenthal K.G. Parker R.A. Shenoy E.S. Walensky R.P. Improving clinical outcomes in patients with methicillin-sensitive Staphylococcus aureus bacteremia and reported penicillin allergy.Clin Infect Dis. 2015; 61: 741-749Crossref PubMed Scopus (53) Google Scholar Despite this, a penicillin allergy history was the strongest negative predictor of receiving optimal therapy for patients with MSSA bacteremia.6Blumenthal K.G. Shenoy E.S. 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: e0159406Crossref PubMed Scopus (39) Google Scholar Performing a penicillin skin test (PST) before MSSA bacteremia treatment was determined to be cost-saving over a 1-year time horizon when PST costs less than $959.98.10Mattingly 2nd, T.J. Meninger S. Heil E.L. Penicillin skin testing in methicillin-sensitive staphylococcus aureus bacteremia: a cost-effectiveness analysis.PLoS One. 2019; 14: e0210271Crossref PubMed Scopus (5) Google Scholar Patients with gram-negative bacteremia treated with a beta-lactam alternative because of their allergy history experienced 10% more treatment failures.11Jeffres M.N. Narayanan P.P. Shuster J.E. Schramm G.E. Consequences of avoiding beta-lactams in patients with beta-lactam allergies.J Allergy Clin Immunol. 2016; 137: 1148-1153Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar Although aztreonam is often used for inpatient gram-negative bacterial infections in patients with beta-lactam allergy histories because there is no risk of beta-lactam cross-reactivity—except in patients with ceftazidime allergy—it is less effective against Pseudomonas Spp.12Hogan M. Bridgeman M.B. Min G.H. Dixit D. Bridgeman P.J. Narayanan N. Effectiveness of empiric aztreonam compared to other beta-lactams for treatment of Pseudomonas aeruginosa infections.Infect Drug Resist. 2018; 11: 1975-1981Crossref PubMed Scopus (3) Google Scholar and is more costly (at least double the cost/day compared with the beta-lactams cefepime or ceftazidime).13Micromedex. Greenwood Village. Truven Health Analytics LLC, CO2016Google Scholar The high cost of aztreonam explains some of the higher costs observed for inpatients with reported penicillin allergy. Recently, inpatient costs for patients with reported penicillin allergy were $1145 to $4254 more per patient compared with patients without a penicillin allergy history.14Mattingly 2nd, T.J. Fulton A. Lumish R.A. et al.The cost of self-reported penicillin allergy: a systematic review.J Allergy Clin Immunol Pract. 2018; 6: 1649-1654Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar Inpatients who did not get preferred beta-lactam therapy because of their report of allergy were also found to be at 3-fold greater risk of adverse events (a composite outcome of readmissions for the same infection, acute kidney injury, Clostridioides difficile infection, and drug-related adverse events) compared with those without reported allergy.8MacFadden D.R. LaDelfa A. Leen J. et al.Impact of reported beta-lactam allergy on inpatient outcomes: a multicenter prospective cohort study.Clin Infect Dis. 2016; 63: 904-910Crossref PubMed Scopus (118) Google Scholar Notably, patients in that study who received beta-lactams despite reported penicillin allergy did not have an increased risk of adverse events compared with those without reported allergy.8MacFadden D.R. LaDelfa A. Leen J. et al.Impact of reported beta-lactam allergy on inpatient outcomes: a multicenter prospective cohort study.Clin Infect Dis. 2016; 63: 904-910Crossref PubMed Scopus (118) Google Scholar Confirming allergy histories before medication prescribing is a core aspect of patient safety.15Bates D.W. Drugs and adverse drug reactions: how worried should we be?.JAMA. 1998; 279: 1216-1217Crossref PubMed Scopus (92) Google Scholar, 16Bates D.W. Leape L.L. Cullen D.J. et al.Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.JAMA. 1998; 280: 1311-1316Crossref PubMed Scopus (1622) Google Scholar Layers of both human and electronic (ie, allergy alerts) support ensure that patients do not receive drugs to which they are allergic or potentially allergic given cross-reactivity patterns.17Topaz M. Seger D.L. Slight S.P. et al.Rising drug allergy alert overrides in electronic health records: an observational retrospective study of a decade of experience.J Am Med Inform Assoc. 2016; 23: 601-608Crossref PubMed Scopus (54) Google Scholar Although choosing alternative drugs when faced with documented drug allergies aligns with safety principles generally, evidence supports questioning the allergy history for optimal care when patients with beta-lactam allergy histories need antibiotic treatment. Allergy specialists have performed penicillin allergy evaluations in outpatient settings for decades, but penicillin allergy evaluations have not historically been part of hospital practice. However, given the clear impact that a reported penicillin allergy has on inpatient care of infectious diseases and antibiotic stewardship, penicillin allergy assessments are now considered important to antibiotic stewardship and have multidisciplinary support.18Barlam T.F. Cosgrove S.E. Abbo L.M. et al.Executive summary: 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: 1197-1202Crossref PubMed Scopus (212) Google Scholar, 19Shenoy E.S. Macy E. Rowe T. Blumenthal K.G. Evaluation and management of penicillin allergy: a review.JAMA. 2019; 321: 188-199Crossref PubMed Scopus (184) Google Scholar Prescribing beta-lactam antibiotics to patients with beta-lactam allergy histories occurs in approximately 5% of all US hospital patients, considering that 15% of hospital patients report a penicillin allergy, 40% to 50% require antibiotics, and 75% of hospital infections should be treated with a beta-lactam.8MacFadden D.R. LaDelfa A. Leen J. et al.Impact of reported beta-lactam allergy on inpatient outcomes: a multicenter prospective cohort study.Clin Infect Dis. 2016; 63: 904-910Crossref PubMed Scopus (118) Google Scholar, 20Leis J.A. 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: 1059-1065Crossref PubMed Scopus (33) Google Scholar In this review, we identified a variety of acute care beta-lactam allergy pathways by intervention type, with a focus on unifying themes important to the intervention process and outcome measures considered central to antibiotic stewardship, quality improvement, and patient safety. To identify illustrative beta-lactam allergy pathway articles to include in this review, we performed term-by-term and combined-term PubMed searches of the following keywords: antimicrobial stewardship, outcome, de-labeling, electronic guideline, penicillin, beta-lactam, allergy, skin test, drug challenge, cephalosporin, and hypersensitivity. The last search date was October 31, 2018, but Partners HealthCare System (PHS) papers published after this date were also considered. All studies available in English and full text were included if they described an acute care beta-lactam allergy pathway, defined as a coordinated inpatient program for beta-lactam allergy assessments as a tool of antibiotic stewardship. Pathways were grouped by their primary approach; although some pathways were based solely on the allergy history, many used the allergy history with direct drug challenges, PST, or both (ie, comprehensive beta-lactam allergy pathways). For all identified articles, we reviewed and summarized their intervention details and reported outcomes. Although our approach was intended to comprehensively capture beta-lactam allergy pathway articles, no systematic literature review nor meta analyses were performed. The allergy history alone is a powerful tool that can be used to improve antibiotic prescribing. Eight articles describe pathways exclusively reliant on the allergy history to improve antibiotic choice (Table 1).21Swearingen S.M. White C. Weidert S. Hinds M. Narro J.P. Guarascio A.J. A multidimensional antimicrobial stewardship intervention targeting aztreonam use in patients with a reported penicillin allergy.Int J Clin Pharm. 2016; 38: 213-217Crossref PubMed Scopus (17) Google Scholar, 22Caplinger C. Smith G. Remington R. Madaras-Kelly K. Evaluation of a computerized decision support intervention to decrease use of anti-pseudomonal carbapenems in penicillin allergic patients.Antibiotics (Basel, Switzerland). 2016; 5PubMed Google Scholar, 23Estep P.M. Ferreira J.A. Dupree L.H. Aldridge P.J. Jankowski C.A. Impact of an antimicrobial stewardship initiative to evaluate beta-lactam allergy in patients ordered aztreonam.Am J Health Syst Pharm. 2016; 73: S8-S13Crossref PubMed Scopus (16) Google Scholar, 24Sigona N.S. Steele J.M. Miller C.D. Impact of a pharmacist-driven beta-lactam allergy interview on inpatient antimicrobial therapy: a pilot project.J Am Pharm Assoc. 2016; 56: 665-669Abstract Full Text Full Text PDF Scopus (21) Google Scholar, 25Staicu M.L. Brundige M.L. Ramsey A. et al.Implementation of a penicillin allergy screening tool to optimize aztreonam use.Am J Health Syst Pharm. 2016; 73: 298-306Crossref PubMed Scopus (23) Google Scholar, 26Krey S.C. Waise J. Skrupky L.P. Confronting the challenge of beta-lactam allergies: a quasi-experimental study assessing impact of pharmacy-led interventions.J Pharm Pract. 2017; (897190017743154)Crossref PubMed Scopus (9) Google Scholar, 27Phan A. Allen B. Epps K. Alikhil M. Kamataris K. Tucker C. Initiative to reduce aztreonam use in patients with self-reported penicillin allergy: effects on clinical outcomes and antibiotic prescribing patterns.Am J Health Syst Pharm. 2018; 75: S58-S62Crossref PubMed Scopus (7) Google Scholar, 28Clark K.E. Briand M.E. Kapoor O. Pirasteh A. Impact of a standardized beta-lactam allergy questionnaire on aztreonam use.J Pharm Pract. 2018; (897190018758557)Crossref Scopus (6) Google Scholar These interventions were largely designed and implemented by pharmacists. The most commonly targeted alternative antibiotic was aztreonam, but carbapenem use was a focus of 1 article.21Swearingen S.M. White C. Weidert S. Hinds M. Narro J.P. Guarascio A.J. A multidimensional antimicrobial stewardship intervention targeting aztreonam use in patients with a reported penicillin allergy.Int J Clin Pharm. 2016; 38: 213-217Crossref PubMed Scopus (17) Google Scholar, 22Caplinger C. Smith G. Remington R. Madaras-Kelly K. Evaluation of a computerized decision support intervention to decrease use of anti-pseudomonal carbapenems in penicillin allergic patients.Antibiotics (Basel, Switzerland). 2016; 5PubMed Google Scholar, 23Estep P.M. Ferreira J.A. Dupree L.H. Aldridge P.J. Jankowski C.A. Impact of an antimicrobial stewardship initiative to evaluate beta-lactam allergy in patients ordered aztreonam.Am J Health Syst Pharm. 2016; 73: S8-S13Crossref PubMed Scopus (16) Google Scholar, 25Staicu M.L. Brundige M.L. Ramsey A. et al.Implementation of a penicillin allergy screening tool to optimize aztreonam use.Am J Health Syst Pharm. 2016; 73: 298-306Crossref PubMed Scopus (23) Google Scholar, 27Phan A. Allen B. Epps K. Alikhil M. Kamataris K. Tucker C. Initiative to reduce aztreonam use in patients with self-reported penicillin allergy: effects on clinical outcomes and antibiotic prescribing patterns.Am J Health Syst Pharm. 2018; 75: S58-S62Crossref PubMed Scopus (7) Google Scholar, 28Clark K.E. Briand M.E. Kapoor O. Pirasteh A. Impact of a standardized beta-lactam allergy questionnaire on aztreonam use.J Pharm Pract. 2018; (897190018758557)Crossref Scopus (6) Google Scholar The history in these pathways was often standardized; for example, 1 group used a penicillin allergy screening tool,25Staicu M.L. Brundige M.L. Ramsey A. et al.Implementation of a penicillin allergy screening tool to optimize aztreonam use.Am J Health Syst Pharm. 2016; 73: 298-306Crossref PubMed Scopus (23) Google Scholar and another created a penicillin allergy guidance card.27Phan A. Allen B. Epps K. Alikhil M. Kamataris K. Tucker C. Initiative to reduce aztreonam use in patients with self-reported penicillin allergy: effects on clinical outcomes and antibiotic prescribing patterns.Am J Health Syst Pharm. 2018; 75: S58-S62Crossref PubMed Scopus (7) Google ScholarTable 1History-Based Beta-lactam Allergy Pathways in Acute CareStudyLocationSettingPatient selectionStudy designIntervention descriptionOutcome(s) measuredSwearingen (2016)21Swearingen S.M. White C. Weidert S. Hinds M. Narro J.P. Guarascio A.J. A multidimensional antimicrobial stewardship intervention targeting aztreonam use in patients with a reported penicillin allergy.Int J Clin Pharm. 2016; 38: 213-217Crossref PubMed Scopus (17) Google ScholarKnoxville, TNAcademic medical centerPatients with mild penicillin allergy histories treated with aztreonamPre/post (117 orders pre-period and 63 orders in post-period)Restriction of aztreonam to patients with penicillin anaphylaxis, accomplished by education of pharmacy and patient-specific multidisciplinary communicationAlternative ABX useA significant decrease in median aztreonam DOT (4.0 vs 2.0) post-period and persisted 1-year post-interventionBL use36 ABX changes to BLs: 9 to ceftazidime, 9 to meropenem, 7 to cefepime, 6 to ceftriaxone, 5 to non-BL agentsHospital length of stay and mortalityNo changeCaplinger (2016)22Caplinger C. Smith G. Remington R. Madaras-Kelly K. Evaluation of a computerized decision support intervention to decrease use of anti-pseudomonal carbapenems in penicillin allergic patients.Antibiotics (Basel, Switzerland). 2016; 5PubMed Google ScholarBoise, IDVeterans affairs medical centerPatients receiving an anti-pseudomonal carbapenemPre/post considering all orders for carbapenems (not just in BL allergy)Risk stratification related to BL cross-reactivity inserted into the computerized decision support systemAlternative ABX useReduced anti-pseudomonal carbapenem use, considering initia