Inpatient Penicillin Research Articles

Successful pediatric inpatient penicillin allergy delabeling through direct oral challenges

Successful pediatric inpatient penicillin allergy delabeling through direct oral challenges

Impacts of risk-stratified inpatient penicillin allergy label delabeling on subsequent antimicrobial spectrum index and costs

Abstract Penicillin allergy delabeling may benefit antimicrobial stewardship (AS). Cost of initial penicillin treatments following risk-stratified inpatient delabeling were compared to two hypothetical treatment regimens if delabeling had not occurred: (1) AS-guided and (2) Common Treatment. Penicillin allergy delabeling improved antimicrobial spectrum index, was cost-neutral, and averted unnecessary penicillin desensitizations.

Penicillin Allergy Delabeling Program: an exploratory economic evaluation in the Australian context.

Internationally, clinical and economic advantages of low-risk penicillin delabelling have been explored, supporting changes to healthcare delivery systems where penicillin delabelling is embedded into inpatient usual care. To determine if economic advantages of low-risk inpatient penicillin delabelling, described in the international literature, are realised in the Australian context. This explorative economic evaluation had prospective patient data collection between January and August 2019, across two Australian health services. Part 1: determine the cost per effectively delabelled patient for Penicillin Allergy Delabeling Program inpatients (PADP cohort) compared with Outpatient Antibiotic Allergy Testing Service outpatients (OAATS cohort). Part 2: a cost analysis to compare hospital costs for inpatients with low-risk penicillin allergy who did (PADP cohort) and did not (usual care cohort) undergo PADP delabelling. Part 1: the PADP (n = 350) and OAATS (n = 27 patients, n = 36 individual visits) cohorts were comparable. In PADP, costs/proportion delabelled was $20.10/0.98, equating to $20.51 per effectively delabelled patient; in OAATS, it was $181.24/0.50, equating to $362. Compared with OAATS, PADP was associated with savings of $341.97 per effectively delabelled patient, indicating the outpatient testing was the dominated strategy, being more costly and less effective. Part 2: the PADP (n = 218) and usual care (n = 32) cohorts were comparable. Significantly favouring the delabelled PADP cohort, the mean difference per patient was -4.41 days (95% confidence interval: -7.64, -1.18) and -$9467.72 (95% confidence interval: -$15 419.98, -$3515.46). Consistent with international literature, delabelling low-risk penicillin allergies in the inpatient setting had economic advantages in the Australian context. Fully powered economic evaluations are urgently required to consolidate these findings.

Characterization of Pediatric Inpatient Penicillin Allergy Documentation and Evaluation

Drug allergies may be improperly or incompletely characterized in the allergy section of the electronic health record (EHR). This can contribute to unnecessary avoidance of a drug or drug class such as penicillins which has significant implications on clinical care and healthcare utilization. We aim to characterize the documentation of penicillin allergy in the EHR of a pediatric center and hypothesize few patients admitted with penicillin allergy are referred for allergy evaluation.

Improving Aztreonam Stewardship Through a Dedicated Penicillin Allergy Testing Pharmacist

Dedicated pharmacist-led inpatient penicillin allergy testing (PAT) programs have been shown to be an effective delabeling method. We hypothesized that a dedicated PAT pharmacist incorporated into an aztreonam stewardship program results in significant reduction in use of aztreonam, a costly antibiotic.

44. Antibiotic Class-Based Distribution and Analysis of Reported Beta-Lactam Allergies amongst Hospitalized Patients

BackgroundReported β-lactam allergy (BLA) is very common, yet less than 10% of these patients exhibit true hypersensitivity. When faced with reported BLAs, physicians often choose alternative antibiotics which can be associated with C. difficile infection, drug-resistance development, poorer outcomes, & increased costs. Effective identification of these patients is necessary for subsequent, appropriate BLA “de-labeling.” Here, we conducted a single-center analysis of alternative antibiotic utilization amongst patients reporting BLA and compare the frequency of drug-resistant infections and C. difficile infection in allergic & non-allergic patients.MethodsThis is a retrospective review of adult patients hospitalized at The University of Texas Medical Branch from 1/1/2015 to 12/31/2019. Pooled electronic medical records were filtered by antibiotic orders and reported allergies to penicillins or cephalosporins. Patients with drug-resistant and/or C. difficile infection (CDI) were identified by ICD-10 codes. Microsoft Excel & MedCalc were used for statistical calculations.ResultsData were available for 118,326 patients and 9.3% (11,982) reported a BLA, with the highest rates seen in those receiving aztreonam (85.9%, 530/617) & clindamycin (33.7%, 3949/11718). Amongst patients reporting BLA, high ratios-of-consumption (relative to all patients receiving antibiotics) were seen with aztreonam (7.0), clindamycin (2.7), cephalosporin/β-lactamase inhibitors (2.4), & daptomycin (2.1). Compared to the non-BLA population, BLA patients more frequently experienced MRSA infection (3.0% vs 1.5%, OR 1.99, 95% CI 1.79–2.23, p< 0.0001), β-lactam resistance (1.2% vs 0.6%, OR 2.07, 95% CI 1.72–2.49, p< 0.0001), and CDI (1.2% vs 0.7%, OR 1.85, 95% CI 1.54–2.23, p< 0.0001).ConclusionOur measured BLA rate matches approximate expectations near 10%. Moreover, these patients experienced significantly higher frequencies of drug-resistant bacterial infections and CDI. Targeted inpatient penicillin allergy testing stands to be particularly effective in those patients receiving disproportionately utilized alternative agents (e.g. aztreonam, clindamycin, daptomycin). β-lactam allergy “de-labeling” in these patients is likely a valuable antimicrobial stewardship target.Disclosures All Authors: No reported disclosures

Penicillin Allergy Evaluation Access: A National Survey.

In a study of 121 hospitals from 38 US states, 44% had access to an allergist for inpatient consultations and 39% had access to inpatient penicillin skin testing, indicating that the majority of US hospitals lack sufficient resources to address inpatient penicillin allergies.

Direct amoxicillin challenge without preliminary skin testing for pediatric patients with penicillin allergy labels

Although approximately 10% of the US population carry penicillin allergy labels, the majority of these patients are not truly allergic. 1 Trubiano J.A. Stone C.A. Grayson M.L. et al. The 3 Cs of antibiotic allergy-classification, cross-reactivity, and collaboration. J Allergy Clin Immunol Pract. 2017; 5: 1532-1542 Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar ,2 Macy E. Ngor E.W. Safely diagnosing clinically significant penicillin allergy using only penicilloyl-poly-lysine, penicillin, and oral amoxicillin. J Allergy Clin Immunol Pract. 2013; 1: 258-263 Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar Antibiotic allergy labels have a direct impact on antibiotic stewardship and contribute to prolonged hospitalizations, secondary infections such as Clostridium difficile, and drug-resistant strains such as methicillin-resistant Staphylococcus aureus, leading to increased costs and resource burden for hospital systems. 3 Blumenthal K.G. Wickner P.G. Hurwitz S. et al. Tackling inpatient penicillin allergies: assessing tools for antimicrobial stewardship. J Allergy Clin Immunol. 2017; 140: 154-161.e6 Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar

Inpatient Penicillin Allergy Testing Via Clinical Decision Support and Proactive Antibiotic Changes Decreases Aztreonam Use

Inpatient Penicillin Allergy Testing Via Clinical Decision Support and Proactive Antibiotic Changes Decreases Aztreonam Use

Implementation and Follow Up of an In-patient Penicillin Allergy Skin Testing Program at One Large University Hospital

Implementation and Follow Up of an In-patient Penicillin Allergy Skin Testing Program at One Large University Hospital

A001 A RETROSPECTIVE ANALYSIS OF PENICILLIN ALLERGY RELABELING DURING READMISSION AFTER NEGATIVE INPATIENT PENICILLIN ALLERGY TESTING

10% of hospitalized patients have a history of penicillin allergy with several studies demonstrating the clinical benefits of inpatient penicillin allergy testing (iPAT). However, relabeling errors continue. We studied the use of electronic medical record (EMR) on relabeling penicillin allergy (RPA).

Beta-lactam Administration Patterns at a Safety-net Hospital with Limited Access to Inpatient Penicillin Skin Testing

Beta-lactam Administration Patterns at a Safety-net Hospital with Limited Access to Inpatient Penicillin Skin Testing

1792. Assessing Outcomes of Antimicrobial Stewardship Interventions Along With a Hospital-Wide β-Lactam Allergy Guideline Through Aztreonam Use: A 5-Year Observation

BackgroundAztreonam (AZT) is an alternative antibiotic for Gram-negative infections requiring IV therapy and anti-pseudomonal coverage in patients with an IgE mediated penicillin allergy. However, many reported allergic reactions to penicillins are either unknown or mis-categorized. In 2012, significant use of AZT was observed at our institution coupled with a 29% resistance rate for Pseudomonas aeruginosa (PA) to AZT. The aim of this study was to track and assess AZT use during a 5-year period during which antimicrobial stewardship interventions along with a hospital-wide allergy guideline were implemented to optimize antibiotic use.MethodsA retrospective review of AZT use was conducted at RUSH University Medical Center from January 2012 to December 2017. September of 2012, AZT was restricted for use in patients with an immediate type-1 hypersensitivity reaction to a β-lactam (BL) with approval from the infectious diseases (ID) consult service. January 2015, a hospital-wide BL allergy guideline, including a clinical pathway for BL graded challenges, was implemented. November 2015 and April 2017, computerized order-sets for BL graded challenges and in-patient penicillin skin tests were executed, respectively. AZT usage was tracked yearly and stratified by the number of patient cases, total number of doses and average days of therapy (DOT) to assess for differences. AZT cost, PA susceptibility, BL graded challenges and ID consultations for approval were also tracked for assessment.ResultsPatient cases using AZT decreased by 76% in 2017. The total number of doses decreased by 84%. The mean DOT for AZT declined from 5.5 days in 2012 to 3.4 days in 2017. The expenditure of AZT reduced by 86%. Hospital-wide resistance rates for PA to AZT declined to 22% in 2017. Compliance with the BL allergy guideline improved post implementation as the number of BL graded challenges rose to a mean of 30 orders with an 82% decrease in ID consults in 2017.20122017% Decrease P valuePatient cases (n)2596276<0.0001Doses (n)3,11249784<0.0001DOT (mean days)5.53.438<0.0001AZT expenditure ($)157,35421,55086<0.0001ID consults (n)1713082<0.0001ConclusionMultiple stewardship interventions, including restrictions and guidelines, can significantly decrease use of AZT and improve susceptibility of PA to AZT.Disclosures All authors: No reported disclosures.

269. De-Labeling of Allergies to Β-Lactam Antibiotics (De-LABeL) Program: Development and Pilot of an Inpatient Pediatric Program

BackgroundSelf-reported β-lactam allergy (BLA) labels are common. The implementation of inpatient penicillin allergy testing in the adult setting has been shown to improve antimicrobial use. The impact of this intervention in the pediatric inpatient setting is unknown.ObjectivesWe sought to develop and pilot an inpatient β-lactam allergy delabeling program in a pediatric tertiary-care center.MethodsIn collaboration with the Allergy and Immunology, Infectious Diseases and Pharmacy Divisions, a De-Labeling of Allergies to Β-Lactams (De-LABeL) program has been developed for integration into routine patient care at the Hospital for Sick Children. The oral provocation challenge (OPC) was chosen as the delabeling intervention and the program has been piloted on the General Pediatric service.ResultsAn algorithm was created to assist clinicians in identifying appropriate candidates for an inpatient OPC. Reported reactions were risk stratified using a systematic framework. A two-step OPC (10% followed by 90% of a weight-based treatment dose of the potential allergen) was used. Following the OPC, patient families received a letter to take to their primary care provider and pharmacist, to provide communication about the status of their BLA. During the 3-month pilot on the General Pediatric service, 32 children with a BLA label were assessed, and one-third of patients (n = 11, 34.4%) were delabeled. Four families declined the OPC. Nine patients (28.1%) were not eligible for an OPC based on the algorithm. The majority of the remaining patients (n = 6, 18.7%) could not complete the OPC during their admission and were referred for outpatient allergy assessment. All assessments were completed in less than 48 hours from the time of admission. No adverse events were observed during the OPCs.ConclusionPreliminary data from the De-LABeL program pilot is promising and the feedback from knowledge users has been positive. The next phase will be program implementation hospital-wide.Disclosures All authors: No reported disclosures.

Utilization and timeliness of an inpatient penicillin allergy evaluation.

A history of penicillin allergy is associated with an increased risk of nosocomial infections because patients are exposed to non-beta lactam antibiotics. Ruling out inaccurate penicillin allergy during hospitalization decreases prescription of beta lactam antibiotics. However, the utilization of penicillin allergy testing and timeliness in relation to initiation of antibiotics is not known. Our aim was to describe the proportion and characteristics of patients who underwent inpatient penicillin allergy testing in a hospital without a guideline or infrastructure for inpatient penicillin allergy testing. We performed a retrospective chart review of patients admitted to our institution between January 1, 2008, and December 31, 2015, who underwent penicillin allergy testing. Forty-nine patients were identified; 27 (55.1%) were women. The median age was 61.5 years (interquartile range [IQR], 48.5-71 years). The median Charlson-Comorbidity index score was 4 (IQR, 2-5.5). Of these patients, 42.86% (21) were admitted to the intensive care unit, 79.6% of allergy consults were requested by infectious disease physicians, and 87.8% of patients were receiving non-beta lactam antibiotics at the time of testing. The patients received a median of 5 days of antibiotics before testing (range, 0-16 days; IQR, 3-7 days). Antimicrobial therapy was changed in 78.0% of the patients (32), of whom 68.3% (21/32) was attributable to penicillin allergy testing. Inpatient penicillin allergy testing is a critical component of antibiotic stewardship; however, an adequate infrastructure is essential for timely evaluation. Inpatient penicillin allergy evaluation requires a multidisciplinary approach focused on patient selection; risk stratification; and optimization of a timely, safe, and cost-effective approach to optimize patient outcomes.

Readmission rates following removal of penicillin allergy label after inpatient penicillin allergy testing

Readmission rates following removal of penicillin allergy label after inpatient penicillin allergy testing

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

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

Utility of minor determinants for skin testing in inpatient penicillin allergy evaluation

BackgroundMost patients with a history of penicillin allergy can tolerate penicillin. Skin testing can identify tolerant patients, but not all known allergenic determinants are commercially available. Protocols exist that use only available reagents, but the sensitivity and safety of these protocols, particularly for hospitalized patients, are controversial. ObjectiveTo determine the number of hospitalized patients referred for penicillin skin testing who showed unique positivity to the minor determinants penicilloate and penilloate. MethodsA retrospective chart review was conducted of all inpatients who underwent penicillin skin testing at 1 institution. Patients were referred by their treating physician. All patients underwent skin prick testing to benzylpenicilloyl polylysine (major determinant), penicillin G, penicilloate, penilloate (minor determinants), amoxicillin, and positive and negative controls. If the result was negative, then intradermal testing was done with the same penicillin determinants and the negative control. A 4-mm wheal with flare was considered a positive reaction. ResultsInpatient penicillin skin testing was done in 528 subjects. Any positive test reaction was found in 107 subjects (20%). Three subjects (3%) reacted to penilloate only, 25 (23%) reacted to penicilloate only, 2 (2%) reacted to penicillin G only, and 8 (8%) reacted to amoxicillin only. Sixty-eight subjects (64%) reacted to a compound other than the major determinant. ConclusionThis study found a high rate of exclusively positive skin test reactions to the minor determinants penicilloate and penilloate. Because patients with positive test reactions are at increased risk of reaction to drug challenge, these data support the use of these reagents for penicillin skin testing in hospitalized patients.

Evaluation of Penicillin Allergy in the Hospitalized Patient: Opportunities for Antimicrobial Stewardship.

Penicillin allergy is often misdiagnosed and is associated with adverse consequences, but testing is infrequently done in the hospital setting. This article reviews historical and contemporary innovations in inpatient penicillin allergy testing and its impact on antimicrobial stewardship. Adoption of the electronic medical record allows rapid identification of admitted patients carrying a penicillin allergy diagnosis. Collaboration with clinical pharmacists and the development of computerized clinical guidelines facilitates increased testing and appropriate use of penicillin and related β-lactams. Education of patients and their outpatient providers is the key to retaining the benefits of penicillin allergy de-labeling. Penicillin allergy testing is feasible in the hospital and offers tangible benefits towards antimicrobial stewardship. Allergists should take the lead in this endeavor and work towards overcoming personnel limitations by partnering with other health care providers and incorporating technology that improves the efficiency of allergy evaluation.

Clinical outcomes following inpatient penicillin allergy testing: A systematic review and meta-analysis.

A documented penicillin allergy is associated with increased morbidity including length of hospital stay and an increased incidence of resistant infections attributed to use of broader-spectrum antibiotics. The aim of the systematic review was to identify whether inpatient penicillin allergy testing affected clinical outcomes during hospitalization. We performed an electronic search of Ovid MEDLINE/PubMed, Embase, Web of Science, Scopus, and the Cochrane Library over the past 20years. Inpatients having a documented penicillin allergy that underwent penicillin allergy testing were included. Twenty-four studies met eligibility criteria. Study sample size was between 24 and 252 patients in exclusively inpatient cohorts. Penicillin skin testing (PST) with or without oral amoxicillin challenge was the main intervention described (18 studies). The population-weighted mean for a negative PST was 95.1% [CI 93.8-96.1]. Inpatient penicillin allergy testing led to a change in antibiotic selection that was greater in the intensive care unit (77.97% [CI 72.0-83.1] vs 54.73% [CI 51.2-58.2], P<.01). An increased prescription of penicillin (range 9.9%-49%) and cephalosporin (range 10.7%-48%) antibiotics was reported. Vancomycin and fluoroquinolone use was decreased. Inpatient penicillin allergy testing was associated with decreased healthcare cost in four studies. Inpatient penicillin allergy testing is safe and effective in ruling out penicillin allergy. The rate of negative tests is comparable to outpatient and perioperative data. Patients with a documented penicillin allergy who require penicillin should be tested during hospitalization given its benefit for individual patient outcomes and antibiotic stewardship.