Beta-lactam Allergy Research Articles

Delabeling of allergy to beta-lactam antibiotics in hospitalized patients: a prospective study evaluating cost savings.

Patients with a penicillin allergy label are at risk of an associated increase in adverse antibiotic events and hospitalization costs. We aimed to study the economic savings derived from the correct diagnosis and delabeling inpatients with suspected beta-lactam allergy, considering the acquisition cost of antimicrobials prescribed during a patient's hospital stay. We prospectively evaluated patients admitted to the University Hospital of Salamanca who had been labeled as allergic to beta-lactams and performed a delabeling study. Subsequently, cost differences between antibiotics administered before and after the allergy study and those derived from those patients who received alternative antibiotics during admission and those who switched to beta-lactams after the allergy study were calculated. One hundred seventy-seven inpatients labeled as allergic to beta-lactams underwent a delabeling study; 34 (19.2%) were confirmed to have allergy to beta-lactams. Of the total number of patients, 136 (76.8%) received antibiotics during their hospitalization, involving a mean (SD) cost of €203.07 (318.42) and a median (IQR) cost of €88.97 (48.86-233.56). After delabeling in 85 (62.5%) patients, the antibiotic treatment was changed to beta-lactams. In this group of patients, the mean cost (SD) decreased from €188.91 (351.09) before the change to 91.31 (136.07) afterward, and the median cost (IQR) decreased from €72.92 (45.82-211.99) to €19.24 (11.66-168). The reduction was significant compared to the median cost of patients whose treatment was not changed to beta-lactams (p<0.001). Delabeling hospitalized patients represents a cost-saving measure for treating patients labeled as allergic to beta-lactams.

Bibliometric analysis of the trends and evolution in β-lactam allergy research

BackgroundBeta-lactams remain the most reported drug allergy globally, with the volume and diversity of related drug allergy research continuing to accumulate. Recognizing evolving research trends can help inform future directions and encourage synergistic collaborations. ObjectiveWe conducted a comprehensive bibliometric analysis of all publications relevant to beta-lactam allergy, with a focus on longitudinal publication rates, international collaborations and keyword/ trend analysis. MethodsMeta-data from all original articles, letters and reviews relevant to beta-lactam allergy on the Web of Science Core Collection up till 31-Dec-2023 were analysed. ResultsFrom 1966-2023, there were 4451 records (3536 articles, 631 reviews, 284 letters) from 78 countries. There was an exponential increase in publications, especially during the last decade, with half of all publications on beta-lactam allergy published during this time (50.6%, 2252/4452). Overall, 18.1% (805/4452) involved international co-authorships, with significant increase since the last decade (12.7% vs. 23.3%, p<0.001). The most frequent keywords, in the first published half of articles were “skin testing” (84/1919), “IgE” (57/1919) and “anaphylaxis” (49/1919); in contrast to “skin testing” (137/3351), “drug provocation test” (121/3351), “antimicrobial resistance” (120/3351) and “antimicrobial stewardship” (118/3351) in the latter. ConclusionThere has been a surge in publications, international collaboration and shifting paradigms in beta-lactam allergy research. The field has evolved beyond focusing on “in vitro tests” or “desensitization”, toward “antimicrobial stewardship”. However, there is still seems to relatively fewer collaborations with non-Western countries. Further international collaborations to harmonize delabelling strategies against the threat of mislabelled beta-lactam allergy should be encouraged.

Comparing Skin and Serum Testing to Direct Challenge Outcomes in Children With β-Lactam Allergies

BackgroundThere is a scarcity of prospective studies investigating the relative roles of skin prick and intradermal testing, serum-specific Immunoglobulin E, and extended oral challenges in diagnosing children with reported beta-lactam allergies. ObjectiveTo determine the sensitivity and specificity of skin testing and serum-specific Immunoglobulin E in children with beta-lactam allergies, with immediate and non-immediate historic reactions. MethodsFour hundred children with parent-reported beta-lactam allergies were recruited into an open-label prospective study. Detailed allergy histories were collected. Those with medically observed and documented histories of anaphylaxis, requiring epinephrine, or SCARs were excluded. In total, 380 children underwent all testing modalities and a direct provocation test. Each child was followed up for a minimum of three years. ResultsTrue allergy in children was uncommon, 8·3% reacted to the direct provocation challenge or the 5-day extended oral provocation challenge. Children reporting cephalosporin allergy or a reaction within one year were more likely to react to direct provocation testing. The sensitivity, specificity, and positive predictive value of skin testing was 12·5%, 98·8% and 20·0% for direct challenge outcomes, 4·76%, 99·0% and 25·0% for extended challenge outcomes, and 6·9%, 99·0% and 40·0% for both challenges combined. Follow-up investigations revealed that 5·7% of children had a mild repeat reaction and 2·7% continued to avoid the culprit despite successful delabeling. The relabeling rate for children readmitted to hospital was 15% with the relabeing being unfounded. ConclusionGenuine beta-lactam allergies were rare, with over 90% of children effectively delabeled. Skin and serum-specific Immunoglobulin E testing did not aid the diagnosis of beta-lactam antibiotic allergy in children, regardless of medical history. Extended oral challenges proved valuable in confirming allergies and boosted parental confidence.

OPTIMIS PRO – A Novel Algorithm to Improve Perioperative Antibiotic Administration

Objectives The selection and dosing of surgical antimicrobial prophylaxis (SAP) to prevent surgical site infections (SSIs) is often improvisational and inappropriate in clinical settings resulting in increased risk of SSI. We therefore developed and implemented a novel computer decision support tool, OPTIMIS PRO (OPTIMIzing PROphylaxis), to improve appropriate SAP selection specific to each patient’s procedure and clinical context. Methods: This quality improvement study was conducted at a tertiary hospital network over 2 years, divided into pre-intervention (June 2021-June 2022) and post-intervention (June 2022-June 2023) periods. The intervention was a computer decision support tool programmed within the hospital’s health information system to provide patient-specific SAP recommendations based on four variables: procedure name, patient’s beta-lactam allergy status, MRSA status, and weight. Approximately 3046 unique surgical procedures were identified and a specific best practice SAP recommendation for each surgery was identified based on international practice guidelines, up-to-date literature, and panel expertise input from 14 surgical divisions at our institution. Safety of cefazolin prophylaxis among patients with self-reported beta-lactam allergy was established in the pre-operative clinic using a validated simple two-item questionnaire (Figure 1). During each standard preoperative preparation, a best practice SAP recommendation alert was then provided to the responsible anesthesiologist based on the inputs from the four aforementioned variables (Figure 2). To assess the impact of the OPTIMIS PRO tool on antibiotic prescribing, we retrospectively audited SAP selection before and after implementation, also assessing appropriateness for each of the specific inputs using evidence-based criteria. Results: Over 30 000 OPTIMIS PRO recommendation alerts were logged in the 12-month post-intervention period. A random sample audit of 408 surgical encounters were selected from the pre- and post-intervention period for analysis. Overall, appropriate antibiotic administration rose from 77% (161/208) to 92.5% (185/200) (x2=18.0, p &lt; 0 .001) post-intervention. Usage of cefazolin among patients reporting a beta lactam allergy rose from 48% (16/33) to 100% (12/12). None of these 12 patients experienced adverse reactions as a result of beta lactam exposure. Appropriate antibiotic selection based on MRSA status was high pre- and post-implementation (98.4% vs 99.4%); but significant improvements were made for procedure-specific antibiotic selection (80.5 vs 94.5%; x2=19.3, p &lt; 0 .001) and weight-based dosing (92.5% vs 98.4%; x2=7.45, p=0.006). Conclusion: In this first-ever intervention designed to direct SAP prescribing based on patient specific variables, we significantly improved appropriate SAP selection across a comprehensive list of surgical procedures. Future analysis should include assessing potential reductions in SSIs as result of using the support

Concordance with Preoperative Intravenous Antibiotics Guidelines and Risk of Surgical Site Infection (SSI)

Background: Administration of antimicrobial prophylaxis close to incision time is recommended as an essential practice to prevent surgical site infections (SSI). Despite guideline recommendations, adherence to preoperative intravenous antibiotic guidelines is variable. We aim to assess perioperative factors associated with guideline concordant (GC), guideline second line (GSL) and non-guideline concordant (NGC) antibiotic choice and timing and impact on odds of SSI. Methods: 3173 patients at 9 hospitals with National Health Safety Network (NHSN) procedure codes for colon surgery and abdominal hysterectomy between January 1, 2023, and October 31, 2023, were identified from the electronic medical record. Data on preoperative intravenous antibiotic choice and timing, history of allergy and methicillin resistant staphylococcus aureus (MRSA) history was collated. SSI were identified using NHSN definitions by trained infection preventionists. SSI identified as present at the time of surgery were excluded. Antibiotic choice and timing were compared to institutional guidelines and patients were categorized as having received GC, GSL or NGC antibiotic choice, and GC or NGC antibiotic timing. Descriptive statistics were used to describe clinical data for patient population and subgroups who received GC, GSL and NGC antibiotics. Univariate logistic regression was performed to assess the association of procedural and clinical factors with the likelihood of an SSI. Results: GC was high overall for both antibiotic choice (94%) and timing (94%). (Table 1) NGC and GSL antibiotic choice were more common in colon surgery, urgent/emergent cases, patients with beta lactam allergies and those with a recent history of MRSA. GSL antibiotic choice was more frequent in inpatients. (Table 2). GC antibiotic timing was more common with GC antibiotic choice (98%) than with NGC (37%) or GSL (51$) antibiotic choice. Odds of SSI were lower in patients who were GC for both antibiotic choice and timing (OR 0.4, p &lt; 0 .001) and increased in patients who received GSL antibiotic choice (OR 5.7 compared to GC, p &lt; 0 .001), underwent urgent/emergent surgeries (OR 4.6, p &lt; 0 .001) or had a history of MRSA in the past year (OR 8.4, p &lt; 0 .001). We found a non-significant trend toward lower infections in patients with GC antibiotic timing (OR 0.5, p 0.08). (Table 3) Conclusion: Combined GC for antibiotic choice and timing was high and associated with lower odds of SSI. NGC and GSL antibiotic choice were associated with patient level factors such as history of MRSA and emergent procedures which may also impact risk of SSI.

Supposed allergy to beta-lactam antibiotics: is it time for reflections and actions?

The excessive, often unconfirmed suspicions of beta-lactam allergy affect up to 10% of the general population, improperly denying a significant percentage of individuals the opportunity to be treated with first-line antibiotics, forcing clinicians to resort to second-line choices that are not always equally effective, safe, and contribute to the increase in antibiotic resistance. Pediatricians and general practitioners can play a crucial role in recognizing and addressing weak suspicions of beta-lactam allergy, actively participating in removing the "label" of being allergic. The article, based on Who AWaRe Manual recommendations, presents current evidence on the issue with practical guidance to promote accurate interpretation and management of an overestimated problem that does not encourage a culture of optimal and prudent antibiotic use.

Beta-lactam allergy risk stratification in a maternity population in Australia: Scope for allergy de-labelling.

Unconfirmed beta-lactam allergy in pregnant people has been associated with higher morbidity, unnecessary exposure to broad-spectrum antibiotics and prolonged hospitalisation. There are no published data on beta-lactam allergies in pregnant people in Australia. The aim was to describe patient-reported beta-lactam allergies and appropriateness for antibiotic allergy de-labelling in a maternity cohort in Australia. Maternity patients aged ≥18 years admitted to our institution between March 2021 and June 2021 with a beta-lactam allergy documented in their electronic medical record were interviewed for details of their allergy. The documented allergies were compared to the allergy history obtained from the interview. Severity of the allergy was rated, and appropriateness for allergy de-labelling was assessed using the Victorian Therapeutics Advisory Group beta-lactam antibiotic allergy assessment tool. One hundred and fifty-three beta-lactam allergies (182 reactions) were reported by 145 patients. Penicillin class antibiotics were the most frequently implicated, including unspecified penicillins (95/153, 62%), amoxicillin (19/153, 13%) and amoxicillin-clavulanate (8/153, 5%). Allergy documentation required amending in 52 of 145 patients (36%); 85 of 153 (56%) of the beta-lactam allergies were considered low risk and potentially appropriate for direct oral re-challenge. Beta-lactam allergies were inaccurately documented in more than one third of the maternity patients included in our study. As such, education of maternity care providers about the importance of accurate allergy history taking remains an urgent unmet need. Furthermore, allergy assessment and de-labelling during pregnancy should be considered in maternity patients to optimise antibiotic prescribing and to improve maternal and neonatal health outcomes.

Management and Implications of Beta-Lactam Allergies.

Beta-lactam antibiotics are essential components in the current antimicrobial treatment strategy, playing a crucial role in ambulatory patients and hospitalized patients. Despite their prominent therapeutic index, the use of beta-lactam can lead to adverse effects, with allergic reactions being the most concerning because of their severity. Additionally, the phenomenon of cross-reactivity may occur among various beta-lactam families, with side chains significantly contributing to immunological recognition, making these structures often responsible for the cross-allergic reactivity of beta-lactams. Tools to assess beta-lactam allergy include taking a patient's medical history, performing skin tests, and conducting provocation tests. This research aims to analyze the relevant aspects related to the safe administration of beta-lactam antibiotics in hospitalized patientsas well as provideknowledge on the proper management of patients with such hypersensitivity, by doing systemic research. This research was made using Google Scholar and keywords such as "Beta-lactam allergy," "Hypersensitivity," "Cross-reactivity," "Desensitization," and "Beta-lactam allergy management."In conclusion, substituting a beta-lactam antibiotic with an alternative antibiotic may not always be the best management option for these patients, as it may lead to more adverse effects, be less effective, and prolong hospitalization time. It may also result in higher rates of antibiotic-resistant infections and increased medical costs, as these alternatives are often more expensive. However, an alternative within the beta-lactam family can be sought by conducting the appropriate analyses. Although cross-reactivity does not always occur among all beta-lactams, potential cross-reactivity should always be considered.

Improving inpatient paediatric de-labelling of allergies to beta-lactams: a quality improvement study

ObjectiveTo evaluate the implementation of an antimicrobial stewardship programme-led inpatient beta-lactam allergy de-labelling programme using a direct oral provocation test (OPT).DesignOne-year quality improvement study using a before–after design.SettingFree-standing tertiary care...

Beta-Lactam Allergy De-labeling in a Pediatric Hospital.

To assess the ability to de-label pediatric patients of their beta-lactam allergy by using a newly implemented institutional protocol and to identify potential barriers to the de-labeling process. All patients with reported allergies to prespecified beta-lactam antibiotics were eligible for a -beta-lactam allergy interview. Following the interview, patients were grouped into 4 risk categories-no risk, low risk, moderate risk, and high risk-and assessed for intervention eligibility. Potential interventions included de-labeling based on the interview alone or proceeding to an oral amoxicillin challenge with or without penicillin allergy skin testing. Of the 62 patients eligible for beta-lactam allergy interviews, 40% (n = 25) were de-labeled. Among de-labeled patients, 60% (n = 15) were de-labeled on the basis of the interview alone. Additionally, no failures were documented in patients who underwent an oral amoxicillin challenge or penicillin skin testing. Barriers to performing oral amoxicillin challenges or penicillin skin testing included concomitant systemic steroid or antihistamine use, refusal of intervention, and insufficient resources to perform penicillin skin testing. There was a high frequency of patients de-labeled of their beta-lactam allergies in this study. Increased education to patients, parents, and providers on the de-labeling process, as well as increased personnel available to coordinate and perform de-labeling interventions, may result in more beta-lactam allergy de-labeling.

Full-dose challenge of moderate, severe, and unknown beta-lactam allergies in the emergency department.

This study aims to assess the outcome of challenging documented moderate, severe, or unknown beta-lactam allergies with full dose administration of a beta-lactam antibiotic in emergency department (ED) patients admitted for acute bacterial infection. A single-center, retrospective, descriptive study of adult patients challenged with a full dose of beta-lactam in the ED from January 2021 to December 2022 was conducted. Included patients had at least one documented moderate, severe, or unknown beta-lactam allergy in the electronic medical record (EMR) without documentation of prior tolerance. Patient demographics, prior beta-lactam antibiotic reaction, beta-lactam administered in the ED, inpatient beta-lactam continuation, adverse drug reactions, and updates to allergy profiles were collected. Descriptive statistics for data analysis were performed using SPSS Version 22. Of the 184 ED encounters with full-dose beta-lactam challenges, five (2.7%) patients with documented moderate, severe, or unknown beta-lactam allergies experienced an allergic reaction after the challenge; one (0.5%) patient had an allergic reaction in the ED, and the remaining four (2.2%) occurred after admission. No anaphylactic reactions occurred. All allergic reactions were limited to mild rash or itching. Most patients (98.9%) were challenged with a cephalosporin. A beta-lactam was continued in 86.4% of cases, and the allergy profile was updated for future utilization in 73.4% of patients. This study suggests that full-dose challenge of moderate, severe, or unknown beta-lactam allergies can be safely accomplished in the ED. This approach avoids unnecessary penicillin allergy skin testing and reduces utilization of suboptimal alternative antibiotic regimens.

Identifying the most at-risk age-group and longitudinal trends of drug allergy labeling amongst 7.3 million individuals in Hong Kong

BackgroundIncorrect drug ‘allergy’ labels remain a global public health concern. Identifying regional trends of drug allergy labeling can guide appropriate public health interventions, but longitudinal or population drug allergy studies remain scarce. We analysed the serial epidemiology of drug allergy labeling to identify specific subgroups at highest risk of drug allergy labeling for potential interventions.MethodsLongitudinal, population-wide drug allergy labels and clinical data from over 7,337,778 individuals in Hong Kong between 2016 and 2021 were analysed.ResultsThe absolute prevalence and incidence of documented drug allergy were 5.61% and 277/100,000 population, respectively. Annual incidence of new allergy labels was stable between 2016 and 2019, until a significant drop in 2020 (−16.3%) during the COVID19 pandemic. The most common allergy labels were anti-infectives (245,832 [44.5%]), non-steroidal anti-inflammatory (106,843 [19.3%]), and nervous system drugs (45,802 [8.3%]). The most common labeled culprits for the most severe immediate-type (anaphylaxis) and non-immediate-type (Stevens-Johnson syndrome) reactions were beta-lactams and nervous system drugs, respectively. For individuals at highest risk of labeling, there was significantly higher incidence of overall drug and beta-lactam allergy labeling amongst individuals aged > 40 years which contributed to the majority of newly labeled allergies (377,004, 68.2%).ConclusionsContrary to traditional dogma, we identified disproportionately higher incidence of drug allergy labeling amongst older individuals, rather than the paediatric age group. We advocate for more population-wide drug allergy studies to investigate this phenomenon in other cohorts as well as future preventative and delabeling efforts focusing on the adult population.

Long waitlists for outpatient drug allergy referrals: An Australian tertiary centre experience

Drug allergy clinic waitlist time data are limited. A 24-month retrospective study of drug allergy referrals was undertaken at a tertiary hospital in Australia. One hundred six patients were reviewed with a median age of 50 years (IQR 40.5–67.3) and a female predominance (n = 76, 71%). Face-to-face consultations were common (n = 83, 78.3%) with the remainder being telephone consultations.General practitioners comprised just over one-third (n = 38, 35.9%) of the referrers but majority being from within the hospital, such as the emergency department (n = 22, 20.8%). Most patients (n = 100, 94.3%) were triaged as Category 1 or urgent. Antibiotic allergies were common (n = 75, 70.8%), of which majority were beta-lactam antibiotics (n = 71, 95%): 55 (73.3%) for penicillins and 16 (15.1%) for cephalosporins.The median waitlist time was 178 days (IQR 48.5–502.5) and only 18 (17%) of Category 1 were seen within urgent timeframe. Telephone consultation had a significantly shorter waitlist time (median 47 days; IQR 6–245) compared to face-to-face consultations (median 267 days; IQR 69–519) (p = 0.026).Large waitlist times are present for drug allergy, and given the majority of referrers are from hospitals, inpatient drug allergy assessment remains paramount. Beta-lactam antibiotic drug allergy labels remain common, and given their negative implications, further work is needed. Economic and human resources evaluations are required to address this shortfall.

Effectiveness of integrated prophylactic antibiotics prescription in patients undergoing radiofrequency and microwave ablation of liver tumors: a retrospective cohort study

An institutionalised in-house antibiotic prophylaxis (AP) guideline was developed in May 2019 to standardize AP prescription. This retrospective cohort study evaluated the effectiveness and clinical outcomes of the newly launched AP guideline on patients undergoing radiofrequency (RFA) and microwave (MWA) ablation of the liver from November 2018 to March 2020. Patients without high risk of biliary tree contamination were recommended a single dose of 2g IV cefazolin (or 600mg IV clindamycin in cases of beta-lactam allergy). Univariate analysis was conducted to evaluate the clinical outcomes.&#x0D; &#x0D; The study included 87 patients who underwent 93 procedures consisting of 18 RFAs and 75 MWAs for liver tumours. Concordance with AP guidelines improved significantly (38.5% vs. 87.0%; p&lt;0.001). There were no ablation-related infections and mortality within 30 days post-ablation, and post-procedural nausea and vomiting were significantly reduced (15.4% vs. 1.9%; p=0.020). No significant difference in post-procedural fever (7.7% vs. 5.6%; p-value=0.693), chest and/or abdominal pain (5.1% vs. 7.4%; p=1.000) were noted.&#x0D; &#x0D; The newly implemented in-house antibiotic prophylaxis guideline streamlined AP prescribing in patients undergoing RFA and MWA. Additional research is needed to determine the effects on infection and mortality in patients with high-risk factors such as bile duct stents, sphincterotomies, and biliary-enteric anastomoses.

Delabelling beta-lactam allergy.

Background: Hypersensitivity to beta-lactam (BL) antibiotics is one of the most frequent reported drug allergies. In our population, it is common to find labels of BL allergy in electronic medical records (EMRs) that have not been assessed. The objective of our study was to detect patients with beta-lactam allergy labels in their EMRs and to assess how many of them are false after a correct diagnostic evaluation. Methods: A multicentre prospective study was performed with patients labelled as allergic to BLs in their EMRs in the previous 5years. Demographical and clinical data, as well as variables regarding the BL allergy label and the characteristics of the index reaction from clinical history and EMRs, were recorded. Then, diagnostic assessments including clinical history, skin tests (STs), and drug provocation tests (DPTs) were conducted in order to confirm or exclude the diagnosis of BL allergy. Results: A total of 249 patients completed the study, of which 160 (64.3%) were women with a median age of 57 years (interquartile range [IQR], 45-68). The most frequent BL allergy labels detected were for penicillin (124), amoxicillin/clavulanic acid (61), and amoxicillin (54). Of the 204 patients who underwent STs, 20.1% were positive. DPTs were performed in 224 patients, showing good tolerance in 87.1% of cases. After the allergy diagnosis work-up, 186 patients (74.7%) were diagnosed as non-allergic to BL antibiotics. Conclusion: In our study population, the number of patients labelled as allergic to BLs in their EMRs was similar to that in previously published studies, with proportions near to 75%-80% being falsely labelled as allergic to BLs.

Exploring Effective Alternatives to Beta-Lactam Antibiotics for Surgical Prophylaxis: A Comprehensive Investigation

Introduction: The significance of administering preventive antibiotics before a surgical procedure is firmly established,moreover the aim of antibiotic prophylaxis is to limit surgical site infections in surgical patients, based essentially on the use of betalactamines, Individuals with a beta-lactam allergy may experience adverse reactions to antibiotics within this class, such as penicillins and cephalosporins, it leeds to life-threatening symptoms that require immediate medical attention, the aim of our study is to evaluate the surgical antibiotic prophylaxis practices by our staff Material and methods: we carried out a survey using a questionnaire aimed at anesthesia-intensive care staff working in different operating rooms of different types of surgeries. to assess antibiotic prophylaxis practices in the case of allergy to betalactam antibiotics (essentially the alternative antibiotic molecules used). The study lasted 3 months and involved 40 anesthesia-intensive care staff. Once the data had been collected from the questionnaires, they were processed using Excel, then presented in the form of tables and figures, reflecting the results obtained in relation to the aim of the study. Results: the results of antibiotic prophylaxis showed that the use of betalactam antibiotics represented 96% of practices and that the antibiotic molecule chosen as an alternative in case of betalactam allergy was compliant in 84.44% of practices in relation to SFAR 2018 recommendations. Conclusion: Antibiotic prophylaxis practices for patients allergic to betalactamines require major caution in order to limit surgical site infections and reduce hospitalization costs.

Intraosseous Regional Administration of Vancomycin Prophylaxis for Primary and Revision Total Knee Arthroplasty.

The advantages of prophylaxis with intraosseous regional administration (IORA) of vancomycin for periprosthetic joint infection (PJI) in primary and revision total knee arthroplasty (TKA) include the ability to deliver antibiotics directly to the surgical bed and avert systemic delivery; the ability to precisely time and quickly administer vancomycin to achieve the highest concentrations at the beginning and throughout the surgical procedure; and the ability to avert several common and potentially serious adverse effects of intravenous vancomycin. Indications for IORA of vancomycin prophylaxis include the following clinical scenarios: revision TKA; obesity; diabetes; beta-lactam allergy; known colonization with methicillin-resistant Staphylococcus aureus (MRSA); individuals coming from institutions with a high MRSA incidence; previous ligamentous surgical procedure or osteotomy; current or recent smokers; in the primary TKA setting if the individual is considered high-risk as defined by the criteria above; and during reimplantation following 2-stage exchange for PJI.

A novel 2-step process for the management of inpatient beta-lactam allergy labels

BackgroundInpatient beta-lactam allergy labels may increase the unnecessary use of aztreonam and non–beta-lactam antibiotics, which can then lead to more adverse events and increased health care costs, ObjectiveTo assess the impact of a novel 2-step process (medication history review followed by risk stratification) on rates of beta-lactam delabeling, aztreonam use, and desensitizations on pediatric, adult, and obstetrics inpatients at a tertiary academic center. MethodsWe prospectively collected data on 700 patients who received inpatient consultation from the Beta-Lactam Allergy Evaluation Service between August 2021 and July 2022. Patients were delabeled either by medication review alone, drug challenge alone if with a low-risk history, or penicillin skin test followed by drug challenge if with a high-risk history. Generalized linear regression modeling was used to compare aztreonam days of therapy in the intervention year with the 2 prior years. Drug desensitizations were assessed by electronic chart review. ResultsMost of the patients (n = 656 of 700, 94%) had more than or equal to 1 beta-lactam allergy label removed, clarified, or both; 77.9% of these patients (n = 511 of 656) had 587 beta-lactam allergy labels removed. Nearly one-third (n = 149, 27.6%) had 162 allergy labels removed solely by medication history review. All 114 penicillin skin tests performed had negative results, and 98% (8 of 381) of the patients who underwent any drug challenge passed. Only 5.7% of the delabeled patients were relabeled. There was a 27% reduction in aztreonam use (P = .007). Beta-lactam desensitizations were reduced by 80%. ConclusionA full-time inpatient beta-lactam allergy service using medication history review and risk stratification can safely and effectively remove inpatient beta-lactam allergy labels, reduce aztreonam use, and decrease beta-lactam desensitizations.

Utility of beta-lactam allergy assessment in patients receiving vancomycin for surgical prophylaxis

BackgroundBeta-lactam antibiotics are first-line agents for most patients receiving antimicrobial prophylaxis in surgical procedures. Despite evidence showing low cross-reactivity between penicillins and cephalosporins, patients with beta-lactam allergies commonly receive vancomycin as an alternative to avoid allergic reaction. MethodsAdult patients receiving vancomycin for surgical prophylaxis with a reported beta-lactam 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. ResultsAmong 830 patients who received vancomycin for surgical prophylaxis, 196 reported beta-lactam allergy and were included in the analysis. Approximately 40 % of surgeries were orthopedic. Of patients receiving vancomycin as first-line therapy, 189 (96.4 %) were potentially eligible for beta-lactam prophylaxis. ConclusionsPatients with beta-lactam allergies often qualify for receipt of a first-line antibiotic. An opportunity exists for improved allergy assessment as an antimicrobial stewardship intervention in surgical prophylaxis.

Development of a Pipeline for Removing Allergy Labels in Patients Undergoing Hematopoietic Stem Cell Transplantation

Penicillin allergy is reported by 10-20 % of patients, but when evaluated only 1-2% may have a true allergy. Patients undergoing HSCT have a high likelihood of requiring beta-lactam antibiotics due to increased infection risk, which can be limited by a penicillin allergy label. When a penicillin allergy is recorded, alternatives are needed including more-expensive, broader-spectrum antibiotics, with increases in drug-resistant bacteria, longer hospital stays, higher expenditures, and increases in nosocomial infections such as C. difficile colitis. This group of patients already has extensive pre-treatment testing, and would particularly benefit from allergy de-labeling. This study aimed to develop a self-sustaining, low-cost pipeline between a HSCT clinic and an allergy clinic to identify and successfully de-label low-risk patients who endorse an allergy to penicillin, amoxicillin, amoxicillin-clavulanate, piperacillin-tazobactam, or ampicillin before admission to the hospital. We developed a survey to triage allergy risk, identified key stakeholders in building the pipeline, and underwent four plan, do, study, act (PDSA) cycles. Changes were made in each of the PDSA cycles to minimize cost and uncompensated provider time as well as increase patient retention throughout the pipeline by increasing appointment availability and decreasing reliance on patients to independently progress through the pathway. Of the 410 patients with planned HSCT who were screened over 11 months, we found that 89 (21.7%) patients were listed as having penicillin and/or beta lactam allergy. 98.5% (n=66/67) of participants completed the survey accurately when confirmed by an allergist, and the survey was 100% accurate in predicting de-labeling success in low-risk patients. Of eligible patients, 43.8% (n=39) were successfully de-labeled before their transplant date and 97.4% (n=38) have undergone HSCT to date. This pipeline is maintained by approximately 5 hours of work per week (1 hour of allergy physician time, 4 hours of nurse and/or clinical coordinator time) and no other direct costs. There is an estimated direct savings of at least $1,914.93 per patient de-labeled. We successfully designed and implemented a pipeline between the HSCT clinic and the allergy clinic as a quality improvement initiative to identify and address high rates of reported beta-lactam allergies. We identified and addressed patient-based factors, logistical, temporal, and financial barriers that impacted patient retention and sustainability. This model is expected to have significant and sustained cost-savings for the healthcare system as well as improve patient outcomes, and this hypothesis is currently undergoing formal analysis. We anticipate that this model can be used to create a similar pipeline in other healthcare systems for HSCT patients as well as other clinical settings such as oncology and CAR-T therapy.