Management Of Penicillin Allergy Research Articles

Management of Penicillin Allergy in the Perioperative Setting.

The selection of perioperative antibiotic prophylaxis is challenging in patients with a history of penicillin allergy; as such, we present a literature review exploring current best practices and the associated supporting evidence, as well as areas for future research. Guidelines recommend the use of alternative agents in patients with an IgE-mediated hypersensitivity reaction, but those alternative agents are associated with worse outcomes, including an increased risk of surgical site infection, and higher cost. More recent data suggest that the risk of cross-reactivity between penicillins and cephalosporins, particularly cefazolin, is extremely low, and that cefazolin can be used safely in most penicillin-allergic patients. Studies have therefore explored how best to implement first-line cefazolin use in patients with a penicillin allergy label. A variety of interventions, including preoperative allergy de-labeling with incorporation of penicillin skin testing, use of patient risk-stratification questionnaires, and utilization of clinician algorithms to guide antibiotic selection intraoperatively, have all been shown to significantly increase cefazolin utilization without a corresponding increase in adverse events. Further studies are needed to clarify the most effective interventions and implementation strategies, as well as to evaluate whether patients with severe delayed hypersensitivity reactions to penicillin should continue to be excluded from receipt of other beta-lactams.

Penicillin Allergy label - the unmet needs - causes and potential solutions.

Background. Penicillin allergy is the most prevalent drug allergy. Its overdiagnosis has been associated with inappropriate antibiotic prescribing, increased antimicrobial resistance, worse clinical outcomes, and increased healthcare costs. Methods. 403 inpatients were audited against National Institute of Clinical Excellence (NICE) Clinical Guidance 183 (CG183) on diagnosis, investigations, documentation, and management of penicillin allergy. 50 junior doctors were surveyed to explore barriers to best practice, investigating their knowledge of, and confidence using the NICE CG183 guidelines. Their views on potential solutions were also explored. Results. The audit identified: 13% (54/403) of patients labelled penicillin allergic; 24% (13/54) fulfilled criteria for referral but none were referred to specialists. With regards to documentation: 33% (18/54) documented exact drug name; 72% (39/54) documented signs and symptoms; 20% (11/54) documented reaction severity; 2% (1/54) documented indication for the drug taken; 4% (2/54) documented number of doses taken or days before onset of the reaction and 0% documented route of administration. The survey revealed barriers including: 1- lack of awareness and confidence in applying the NICE CG183 on diagnosis and management; 2- tendency to err on the side of caution when de-labelling patients. All agreed that decision support tools would address barriers to best practice and appropriate penicillin allergy de-labelling Conclusions.The current practice of diagnosing, documenting, and managing penicillin allergies does not meet NICE CG183. A lack of awareness and confidence using NICE CG183 are the main contributing barriers to best practice. Decision support tools, including a drug allergy app, would help overcome these barriers.

Current Knowledge and Management of Penicillin Allergy by Primary Care Physicians and Points for Improvement

Penicillin allergy is commonly misdiagnosed, leading to a negative impact on patients' health. This study aimed to evaluate the knowledge and management of penicillin allergy by primary care physicians (PCP), to investigate if PCP are willing to perform penicillin allergy evaluation (PAE) and what will facilitate such an evaluation.

How We Approach Difficult to Eradicate Helicobacter pylori

How We Approach Difficult to Eradicate Helicobacter pylori

Management of penicillin allergy in primary care: a qualitative study with patients and primary care physicians

BackgroundSix percent of patients are allergic to penicillin according to their medical records. While this designation protects a small number of truly allergic patients from serious reactions, those who are incorrectly labelled may be denied access to recommended first line treatment for many infections. Removal of incorrect penicillin allergy may have positive health consequences for the individual and the general population.We aimed to explore primary care physicians’ (PCPs) and patients’ views and understanding of penicillin allergy with a focus on clinical management of infections in the face of a penicillin allergy record.MethodsWe conducted an interview study with 31 patients with a penicillin allergy record, and 19 PCPs in the North of England. Data were analysed thematically.ResultsPatients made sense of their allergy status by considering the timing and severity of symptoms. Diagnosis of penicillin allergy was reported to be ‘imperfect’ with PCPs relying on patient reports and incomplete medical records. PCPs and patients often suspected that an allergy record was incorrect, but PCPs were reluctant to change records. PCPs had limited knowledge of allergy services. PCPs often prescribed alternative antibiotics which were easy to identify. Both patients and PCPs differed in the extent to which they were aware of the negative consequences of incorrect penicillin allergy records, their relevance and importance to their lives, and management of penicillin allergy.ConclusionsPCPs and patients appear insufficiently aware of potential harms associated with incorrect penicillin allergy records. Some of the problems experienced by PCPs could be reduced by ensuring the details of newly diagnosed reactions to antibiotics are clearly documented. In order for PCPs to overturn more incorrect penicillin records through appropriate use of allergy services, more information and training about these services will be needed.

1001 Survey of maternity care providers to assess knowledge and management of penicillin allergy in pregnancy

Penicillin allergy is commonly reported but only 10% are truly allergic. Reported penicillin allergy in pregnancy is associated with adverse maternal outcomes. Therefore, allergy evaluation should be considered during pregnancy. We sought to assess clinical practice patterns and baseline knowledge among maternity care providers to identify knowledge gaps. An anonymous electronic survey containing 23 questions assessing respondent characteristics, practice patterns, and antibiotic allergy knowledge was administered to all maternity care providers at a single tertiary hospital. Data were analyzed using descriptive statistics and bivariable analyses. 125 providers (29 attendings, 31 residents and fellows, 23 midwives and advance practice providers, and 42 nurses) responded. Respondent practice patterns and comfort with managing antibiotic allergies were assessed (Table 1). Most reported taking <2 minutes to assess allergy history. Only the minority always asked how long ago an allergic reaction occurred, asked if the patient received a similar antibiotic since the index reaction, or reported utilizing the medical record to determine what antibiotics were administered since. The distribution of knowledge responses are in Table 2. Most did not know the correct percentages of tolerance in reportedly allergic patients or the cross-reactivity between penicillins and cephalosporins. Most did not know that allergies can wane over time or how to test for an allergy. Physicians were significantly more likely to respond correctly compared to non-physicians, but years of experience was not significant. 54% (43/79) reported they never refer patients to an Allergy specialist, and the majority (53% (42/79) cited “limited knowledge” as their barrier. Significant knowledge gaps exist among maternity providers, which represent a missed opportunity to evaluate pregnant women with reported penicillin allergies. Educational interventions to improve provider knowledge would likely improve evaluation and referral of patients and positively impact pregnancy and maternal health outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Perioperative Management of the Penicillin-Allergic Patient

AN ESTIMATED 32 MILLION AMERICANS have a documented penicillin allergy in their medical record, which equates to approximately 10% of the population in the United States. 1 Evaluation and diagnosis of penicillin allergy for healthcare professionals: is it really a penicillin allergy. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP), 2017https://www.cdc.gov/antibiotic-use/community/for-hcp/Penicillin-Allergy.htmlDate accessed: August 1, 2019 Google Scholar Yet more than 97% are not at risk for an acute allergic reaction to penicillin. 2 Fox S. Park M.A. Penicillin skin testing in the evaluation and management of penicillin allergy. Ann Allergy Asthma Immunol. 2011; 106: 1-7 Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar Many agents recommended as first-line therapy for surgical infection prophylaxis are among the β-lactam pharmaceutical class, such as penicillin, aminopenicillins, cephalosporins, monobactams, and carbapenems (Table 1). 3 Bratzler D.W. Dellinger E.P. Olsen K.M. et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013; 70: 195-283 Crossref PubMed Scopus (1275) Google Scholar Studies indicate that 76% to 93% of patients who report a penicillin allergy receive second-line antibiotics for surgical infection prophylaxis. 4 Stone A.H. Kelmer G. MacDonald J.H. Clance M.R. King P.J. The impact of patient-reported penicillin allergy on risk for surgical site infection in total joint arthroplasty. J Am Acad Orthop Surg. 2019; ([Epub ahead of print])https://doi.org/10.5435/JAAOS-D-18-00709 Crossref Scopus (22) Google Scholar , 5 Blumenthal 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: 329-336 Crossref PubMed Scopus (204) Google Scholar , 6 Beltran R.J. Kako H. Chovanec T. Ramesh A. Bissonnette B. Tobias J.D. Penicillin allergy and surgical prophylaxis: cephalosporin cross-reactivity risk in a pediatric tertiary care center. J Pediatr Surg. 2015; 50: 856-859 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Table 1β-Lactam Antimicrobials in the Surgical Prophylaxis Guidelines 3 Bratzler D.W. Dellinger E.P. Olsen K.M. et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013; 70: 195-283 Crossref PubMed Scopus (1275) Google Scholar Penicillin Derivatives Cephalosporins Monobactam Carbapenem Ampicillin Cefazolin Aztreonam Ertapenem Ampicillin-sulbactam Cefotetan Piperacillin-tazobactam Cefoxitin Cefotaxime Ceftriaxone Cefepime Open table in a new tab Rachel C. Wolfe, PharmD, MHA, BCCCP, Pharmacy Department, Barnes-Jewish Hospital, St. Louis, MO

Reported Knowledge and Management of Potential Penicillin Allergy in Children

BackgroundPediatric emergency medicine (PEM) and primary care provider (PCP) providers are the most likely physicians to initially label a child as allergic to penicillin. Differences in knowledge and management of reported penicillin allergy between these 2 groups have not been well characterized. MethodsA cross-sectional, 20-question survey was administered to PEM and PCPs to ascertain differential knowledge and management of penicillin allergy. Knowledge regarding high- and low-risk symptoms for true allergy and extent of history taking regarding allergy were compared between the 2 groups using t tests, Chi-square, and Wilcoxon tests. ResultsIn total, 182 PEM and 54 PCPs completed the survey. PEM and PCPs reported that 74.1 ± 19.5% and 69.0 ± 23.8% of patients with remote low-risk symptoms of allergy could tolerate penicillin without an allergic reaction. PEM and PCPs incorrectly identified low-risk symptoms of allergy as high-risk, including vomiting with medication administration and delayed skin rash. PCPs took more detailed allergy histories when compared with PEM providers. In total, 143 (78.5%) of PEM providers and 51 (94.4%) PCPs were interested in using a penicillin allergy questionnaire to segregate children into high- or low-risk categories. ConclusionsMost pediatric providers believe that children with a remote history of low-risk allergy symptoms could tolerate penicillin without an allergic reaction; however, this is infrequently acted upon. Both PEM and PCP providers were likely to classify low-risk symptoms as high-risk and infrequently referred children for further detailed allergy assessment. Both groups were receptive to decision support measures to facilitate improved penicillin allergy classification and labeling and support antibiotic appropriateness in their patients.

Penicillin skin testing in the management of penicillin allergy in an outpatient pediatric population

Eight to ten percent of patients believe that they are allergic to penicillin, yet only 10% of those patients have evidence of an immunoglobulin E (IgE) mediated allergy upon penicillin skin testing (PST). In the adult population, a negative PST result is associated with a low risk of immediate reaction on oral challenge, but further studies are needed in the pediatric population. To calculate the negative predictive value (NPV) of the current skin testing regimen of penicillin, benzylpenicilloyl-polylysine (the major determinant), and ampicillin in a pediatric outpatient population to assess the utility of adding the minor determinant mixture to the skin testing regimen. A retrospective chart review was conducted of all pediatric patients seen in a single-center pediatric allergy/immunology outpatient clinic between January 1, 2010, and March 1, 2016, who underwent PST for presumed penicillin drug allergy. Only 38% of patients who underwent PST had a drug reaction history consistent with an IgE-mediated reaction. 28.8% of the patients had a positive PST result. The addition of ampicillin to the standard PST regimen of penicillin and benzylpenicilloyl-polylysine identified an additional 4.1% of patients. Two patients (3.2%) reacted on oral challenge with a minor rash. The NPV of the PST regimen was 98%. No significant predictive variables for a positive PST result were identified. Given the high NPV of the current PST regimen, we do not recommend additional testing with the minor determinant mixture. Despite this high NPV, the utility of PST in the low-risk, low-pretest probability outpatient pediatric population was limited, and select patients may be able to proceed directly to oral challenge.

The Differences and Similarities between Allergists and Non-Allergists for Penicillin Allergy Management

The purpose of this study was to compare the management of patients with a history of penicillin allergy between allergists and non-allergists in Thailand. A questionnaire was distributed to Thai physicians by online survey. The answers from 205 physicians were analyzed. The discrepancy of penicillin allergy management between allergists and non-allergists was clearly demonstrated in patients with a history of an immediate reaction in the presence of penicillin skin test (P < 0.01) and in patients with a history of Stevens-Johnson syndrome (P < 0.05) from penicillin. Allergists are more willing to confirm penicillin allergic status, more likely to carefully administer penicillin even after negative skin test, but less concerned for the potential cross-reactivity with 3rd and 4th generation cephalosporins, compared to non-allergists. The lack of penicillin skin test reagents, the reliability of penicillin allergy history, and medicolegal problem were the main reasons for prescribing alternate antibiotics without confirmation of penicillin allergic status. In summary, the different management of penicillin allergy between allergists and non-allergists was significantly demonstrated in patients with a history of severe non-immediate reaction and in patients with a history of an immediate reaction when a penicillin skin test is available.

Penicillin skin testing in the evaluation and management of penicillin allergy

Penicillin skin testing in the evaluation and management of penicillin allergy

Diagnosis and management of penicillin allergy

Diagnosis and management of penicillin allergy

Advances in the Diagnosis and Management of Penicillin Allergy

IgE-mediated acute systemic reactions to penicillin continue to be an important clinical problem. Advances in our understanding of the immunochemistry of penicillin allergy have improved our ability to predict and to avoid these reactions. Immunodiagnostic techniques can identify patients at risk for anaphylaxis to beta-lactam antibiotics with a high degree of precision. Clinical and immunologic studies have demonstrated that penicillin allergic subjects may have allergic reactions to cephalosporins although the absolute frequency of clinical cross-reactions is not clear. If beta-lactam drugs are needed for treatment of penicillin allergic patients, acute desensitization appears to be an acceptably safe procedure for avoiding anaphylaxis.

Desensitization of anaphylactic hypersensitivity specific for the penicilloate minor determinant of penicillin and carbenicillin

A 68-yr-old man with a history of a morbilliform rash caused by intravenous penicillin required carbenicillin (CB) therapy for refractory Serratia marcescens septicemia. Skin testing showed a positive immediate skin test to the penicilloate minor determinant in the presence of negative tests to benzylpenicilloylpolylysine (BPL) and penicillin G (PG), as well as cross-reactivity between the penicilloate derivatives of PG and CB. True densensitization was accomplished by gradual administration of CB intravenously and was accompanied by a diffuse flush reaction. There was specific loss of wheal-and-flare reactivity as well as of specific serum reaginic antibody activity during the procedure, and there was no evidence of activation of serum complement. This case illustrates the usefulness of skin tests in the prediction and management of penicillin allergy and presents data pertaining to immunologic mechanisms involved in true desensitization.