Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project

Christiane Querbach,Markus Heim,Knut Brockow,Susanne Feihl,Christiane Filser,Rüdiger Eisenhart-Rothe,Monika Trojan,Kathrin Rothe,Helmut Renz,Christian Suren,Tilo Biedermann,Christoph D Spinner,Friedemann Gebhardt,Melanie Starzner,Dirk H Busch

doi:10.1007/s40629-020-00135-5

Abstract

Summary Background Beta-lactam antibiotics (BLA) are the treatment of choice for a large number of bacterial infections. Putative BLA allergies are often reported by patients, but rarely confirmed. Many patients do not receive BLA due to suspected allergy. There is no systematic approach to risk stratification in the case of a history of suspected BLA allergy. Methods Using the available stratification programs and taking current guidelines into account, an algorithm for risk stratification, including recommendations on the use of antibiotics in cases of compellingly indicated BLA despite suspected BLA allergy, was formulated by the authors for their maximum care university hospital. Results The hospital is in great need of recommendations on how to deal with BLA allergies. Patient-reported information in the history forms the basis for classifying the reactions into four risk categories: (1) BLA allergy excluded, (2) benign delayed reaction, (3) immediate reaction, and (4) severe cutaneous and extracutaneous drug reaction. Recommendations strictly depend on this classification and range from use of full-dose BLA or use of BLA under certain conditions (e.g., two-stage dose escalation, non-cross-reactive BLA only) to prohibiting all BLA and the use of alternative non-BLA. In case of suspected immediate or delayed allergic reactions, there is an additional recommendation regarding subsequent allergy testing during a symptom-free interval. Conclusion Triage of patients with suspected BLA is urgently required. While allergy testing, including provocation testing, represents the most reliable solution, this is not feasible in all patients due to the high prevalence of BLA allergies. The risk stratification algorithm developed for the authors’ hospital represents a tool suitable to making a contribution to rational antibiotic therapy.

Highlights

Beta-lactam antibiotics (BLA) are the drugs of choice for the treatment of numerous bacterial infections, and the most frequent triggers of drug allergies and fatal drug-related anaphylaxis [1, 2]
Situations in which antibiotic use is compellingly indicated for severe or acute infection in the setting of a concomitant history of BLA allergy arise in almost 10% of patients at the authors’ hospital
These patients need to be triaged with regard to the further approach according to a risk stratification system, either receiving direct administration of alternative non-BLA and a recommendation for later allergy testing during a symptom-free interval, or direct use of BLA under certain conditions and taking into account possible cross-reactivity

Summary

Introduction

Beta-lactam antibiotics (BLA) are the drugs of choice for the treatment of numerous bacterial infections, and the most frequent triggers of drug allergies and fatal drug-related anaphylaxis [1, 2]. 3–10% of all patients or parents of affected children in the population and up to 19% of all hospitalized patients report a BLA allergy [1, 2]. The high number of BLA allergies reported in patient histories hampers the selection of a suitable antibiotic. The possible consequences of incorrectly classified BLA allergies in the patient history include the following: increased use of broad-spectrum antibiotics, ineffective treatment of bacterial infections, a high number of sick days and hospitalization days, the induction of bacterial multiresistance and high costs

Methods

Results

Discussion

Conclusion