Penicillin Allergy Research Articles

Prescription of antibiotics during endodontic treatments: Survey of senegalese dentists

: Irrational antibiotic prescribing is a phenomenon common to several countries, including Senegal.The aim of this study was to assess the level of antibiotic prescribing among Senegalese dental surgeons during the management of pulpal and periapical pathologies. This descriptive, analytical, cross-sectional study involved 132 dentists regularly registered with the Senegalese Dental Surgeons' Association.Data were collected and analyzed using SPSS version 17.0 software (SPSS, Inc., Chicago, IL, USA).The results of X2 tests showed a statistically significant difference between the private and public sectors for the management of root resorption (P≤0.005).: In patients with penicillin allergy, clindamycin was the first-line treatment (31.1%), followed by metronidazole combined with spiramycin (25%) and azithromycin 500mg (22.7%).: As with previous studies carried out in other countries, this study shows that very few practitioners make appropriate use of antibiotics for pulpal and periapical pathologies.

Improving the performance of machine learning penicillin adverse drug reaction classification with synthetic data and transfer learning.

Machine learning may assist with the identification of potentially inappropriate penicillin allergy labels. Strategies to improve the performance of existing models for this task include the use of additional training data, synthetic data and transfer learning. The aims of this study were to investigate the use of additional training data and novel machine learning strategies, namely synthetic data and transfer learning, to improve the performance of penicillin adverse drug reaction (ADR) machine learning classification. Machine learning natural language processing was applied to free-text penicillin ADR data extracted from a public health system electronic health record (EHR). The models were developed by training on various labelled data sets. ADR entries were split into training and testing data sets and used to develop and test a variety of machine learning models. The effect of training on additional data and synthetic data versus the use of transfer learning was analysed. Following the application of these techniques, the area under the receiver operator curve of best-performing models for the classification of penicillin allergy (vs intolerance) and high-risk allergy (vs low-risk allergy) improved to 0.984 (using the artificial neural network model) and 0.995 (with the transfer learning approach) respectively. Machine learning models demonstrate high levels of accuracy in the classification and risk stratification of penicillin ADR labels using the reaction documented in the EHR. The model can be further optimised by incorporating additional training data and using transfer learning. Practical applications include automating case detection for penicillin allergy delabelling programmes.

A nurse-driven penicillin allergy risk score in the preoperative setting was associated with increased cefazolin use perioperatively

Study objectiveTo characterize and assess the effects of a preoperative, nurse-driven penicillin allergy risk stratification tool on rates of perioperative cefazolin and second-line antibiotic use. DesignQuasi-experimental quality improvement study of penicillin-allergic surgical patients undergoing procedures for which cefazolin is indicated. SettingOutpatient Perioperative Care Clinic (PCC) for preoperative surgical patients at a tertiary care center. Patients670 and 1371 adult penicillin-allergic PCC attendants and non-attendants, respectively. InterventionA paper penicillin allergy risk stratification questionnaire was administered during the PCC visit. Nurses were educated on its use. MeasurementsAntibiotic (cefazolin, clindamycin, vancomycin) use rates in the 24 months before and 17 months after intervention implementation in November 2020 (November 2018 – April 2022) were assessed in penicillin-allergic PCC attendants with statistical process control charts. Multivariable logistic regression assessed antibiotic use rates pre- and post-intervention adjusting for age, sex, surgical specialty and penicillin allergy history severity. Similar analyses were done in penicillin-allergic PCC non-attendants. Main resultsOf 670 penicillin-allergic PCC attendants, 451 (median [IQR] age, 66 (Sousa-Pinto et al., 2021 [14])) were analyzed pre-intervention and 219 (median [IQR] age, 66 (Mine et al., 1970 [13])) post-intervention. One month after implementation, process measures demonstrated an upward shift in cefazolin use for PCC attendants versus no shift or other special cause variation for PCC non-attendants. There were increased odds of cefazolin use (aOR 1.67, 95% CI [1.09–2.57], P = 0.019), decreased odds of clindamycin use (aOR 0.61, 95% CI [0.42–0.89], P = 0.010) and decreased odds of vancomycin use (aOR 0.56, 95% CI [0.35–0.88], P = 0.013) in PCC attendants post-intervention. This effect did not occur in PCC non-attendants. There was no increase in perioperative anaphylaxis post-intervention. ConclusionsA simple penicillin allergy risk stratification tool implemented in the preoperative setting was associated with increased use of cefazolin and decreased rates of second-line agents post implementation.

Can we give cefazolin to patients with penicillin allergy label?

Can we give cefazolin to patients with penicillin allergy label?

Introduction of a penicillin allergy de-labelling program with direct oral challenge and its effects on utilization of beta-lactam antimicrobials: a multicenter retrospective parallel cohort study

BackgroundSelf-reported penicillin allergy labels are common and often inaccurate after assessment. These labels can lead to reduced use of first-line beta-lactam antibiotics and worse outcomes. We measured the impact of a previously performed inpatient proactive systematic penicillin allergy de-labelling program on subsequent antibiotic use. This prior program included assessment, risk-stratification, and low risk direct oral amoxicillin challenge.MethodsWe performed a retrospective comparison of parallel cohorts from two separate tertiary care hospital campuses in Ottawa, Canada across two penicillin de-labelling intervention periods across April 15th to April 30th, 2021, and February 15th to March 8th, 2022. Outcomes, including penicillin allergy labelling and antibiotic use, were collected for the index admission and the subsequent 6-month period. Descriptive statistics and multivariate regression analyses were performed.ResultsA total of 368 patients with penicillin allergy label were included across two campuses and study periods. 24 (13.8%) patients in the intervention groups had sustained penicillin allergy label removal at 30 days from admission vs. 3 (1.5%) in the non-intervention group (p < 0.001). In the 6-months following admission, beta-lactams were prescribed more frequently in the intervention groups vs. the non-intervention groups for all patients (28 [16.1%] vs.15 [7.7%], p = 0.04) and were prescribed more frequently amongst those who received at least one antibiotic (28/46 [60.9%] vs.15/40 [37.5%], p = 0.097). In a multivariate regression analysis, the intervention groups were found to be associated with an increased odds of beta-lactam prescribing in all patients (OR 2.49, 95%CI 1.29–5.02) and in those prescribed at least one antibiotic (OR 2.44, 95%CI 1.00–6.15). No drug-related adverse events were reported.ConclusionsProactive penicillin allergy de-labelling for inpatients was associated with a reduction in penicillin allergy labels and increased utilization of beta-lactams in the subsequent 6-months.

Penicillin allergy reassessment for treatment improvement: A dental office tool to support appropriate penicillin allergy labeling

BackgroundDental appointments offer an opportunity to evaluate a documented penicillin (PCN) allergy and determine whether the patient might be a candidate for medical reassessment of their allergy. The authors gathered feedback on the Penicillin Allergy Reassessment for Treatment Improvement (PARTI) tool, designed to enhance dentist-patient communications regarding PCN allergies. MethodsFrom January 2022 through May 2023, the authors conducted a mixed-methods study, collecting focus group data from patients with PCN allergies and surveying health care workers (HCWs) regarding the PARTI tool. Feedback focused on reassessment procedures, patient-centered allergy information, and medical records updates. Thematic analysis was used for focus group data. ResultsThe study included 15 patients in focus groups and 50 HCW survey respondents representing diverse US regions. Patient demographic characteristics included varied races, the mean age was 52 years, and most of the patients were female (53.3%). Most patients had health care interactions within the preceding year, at which 86.6% of patients were asked about drug allergies. HCW respondents primarily consisted of pharmacists (30%) and dentists, dental hygienists, and dental assistants (28%). Feedback on the PARTI tool was constructive, with both patients and HCWs recognizing its potential benefits and providing insights for improvement. Many HCWs (68%) highlighted the importance of step 3 of the PARTI tool, that is, the section on PCN allergy testing. Feedback from participants was incorporated into the final PARTI tool. ConclusionsPatient and HCW feedback on the PARTI tool was used to finalize a tool for the dental office to provide to patients who are candidates for PCN allergy reassessment. The feedback will also be used to inform an upcoming pilot study in US dental offices, focused on the process for PCN allergy reassessment and health record documentation. Practical ImplicationsDeploying the PARTI tool in dental offices is pivotal, as mislabeling patients with PCN allergies could have severe consequences, such as hindering the prescription of lifesaving antibiotics for conditions like endocarditis, in the future. This implementation not only enhances communication between dentists and patients, but it is also crucial for ensuring improved patient safety and maintaining accurate medical records among health care settings.

Getting to the heart of the matter—are two agents really better than one for the treatment of staphylococcal infective endocarditis?

The recently published European Society of Cardiology guidelines for infective endocarditis management recommends daptomycin combination therapy for the treatment of staphylococcal endocarditis in severe penicillin allergy, rather than daptomycin monotherapy. We discuss the evidence base behind this recommendation, highlighting concerns regarding the lack of robust clinical studies, increased cost and logistical considerations, and adverse effects of combination therapy. Although further studies are required to elucidate the role of combination vs monotherapy in these patients, we propose a pragmatic management approach to reduce the risk of adverse antimicrobial side effects and limit costs, while aiming to maintain treatment efficacy.

Impact of penicillin allergy records on antimicrobial prescribing in hospitalised patients

The overdiagnosis of penicillin allergy and misclassification of non-truly allergic reactions is a growing public health problem, associated with the overuse of broad-spectrum and restricted antimicrobials. We aimed to evaluate the impact of penicillin allergy status on antimicrobial prescribing. A retrospective study of inpatients with a documented penicillin allergy receiving antimicrobials was conducted from 1 April to 1 July 2021. Antimicrobial prescribing and clinical characteristics were compared between patients with an active penicillin allergy label and those whose label was removed following antimicrobial stewardship team review. Antimicrobials were classified in two categories: i) 'Access' (recommended), ii) 'Watch and Reserve' (restricted) according to WHO AWaRe classification, a tool to guide appropriate antibiotic use. 437 patients with a documented penicillin allergy receiving antimicrobials were included. 353 patients with an active penicillin allergy label, more frequently received antimicrobials from the 'Watch and Reserve list' (283;80% vs 30;37%; p<0.001). In contrast, 84 patients who were de-labelled received more often antimicrobials from the 'Access list' (53;63% vs 64;18%; p<0.001). Penicillin allergy reviews and de-labelling strategies may reduce the use of restricted antimicrobials under the 'Watch and Reserve list'. This practice should be encouraged and reinforced in all hospitals.

Barriers to and Facilitators of Delabelling of Antimicrobial Allergies: A Qualitative Meta-synthesis.

Patients who report penicillin allergies may receive alternative antibiotics. Such substitution contributes to antimicrobial resistance, lower treatment efficacy, increased frequency of adverse events, and increased costs. Approximately 90% of individuals who report a penicillin allergy can tolerate a penicillin. To identify the barriers to and facilitators of removal by health care workers of inaccurate antimicrobial allergies from patient records, known as delabelling. The MEDLINE database was searched from inception to December 29, 2020. Qualitative studies evaluating health care professionals' perceptions of barriers to and/or facilitators of the act of delabelling a patient's antimicrobial allergies were included in the meta-synthesis. The Theoretical Domains Framework was used to code and group individual utterances from the included studies, which were mapped to the Behaviour Change Wheel and corresponding intervention function and policy categories. Four studies met the inclusion criteria. Eight themes were identified as representing barriers to delabelling: delabelling skills, patient education skills, knowledge, electronic health records (EHRs), communication frameworks, time, fear about allergic reactions, and professional roles. Behaviour change interventions that may overcome these barriers include education, training, algorithms and toolkits, changes to EHRs, use of dedicated personnel, policies, incentivization of correct labelling, and an audit system. Eight themes were identified as barriers to delabelling of antimicrobial allergies. Future behaviour change interventions to address these barriers were proposed. Confidence in the findings of this study was judged to be moderate, according to the GRADE CERQual approach.

Randomized Multicenter Trial for the Validation of an Easy-to-Administer Algorithm to Define Penicillin Allergy Status in Sexually Transmitted Infection Clinic Outpatients.

Approximately 15% of patients in sexually transmitted infection (STI) clinics report penicillin allergies, complicating treatment for syphilis and gonorrhea. Nonetheless, >90% do not have a penicillin allergy when evaluated. We developed and validated an algorithm to define which patients reporting penicillin allergy can be safely treated at STI clinics with these drugs. Randomized controlled trial to assess feasibility and safety of penicillin allergy evaluations in STI clinics. Participants with reported penicillin allergy answered an expert-developed questionnaire to stratify risk. Low-risk participants underwent penicillin skin testing (PST) followed by amoxicillin 250 mg challenge or a graded oral challenge (GOC)-amoxicillin 25 mg followed by 250 mg. Reactions were recorded, and participant/provider surveys were conducted. Of 284 participants, 72 (25.3%) were deemed high risk and were excluded. Of 206 low-risk participants, 102 (49.5%) underwent PST without reactions and 3 (3%) had mild reactions during the oral challenge. Of 104 (50.5%) participants in the GOC, 95 (91.3%) completed challenges without reaction, 4 (4.2%) had mild symptoms after 25 mg, and 4 (4.2%) after 250-mg doses. Overall, 195 participants (94.7%) successfully completed the study and 11 (5.3%) experienced mild symptoms. Of 14 providers, 12 (85.7%) completed surveys and 11 (93%) agreed on the safety/effectiveness of penicillin allergy assessment in STI clinics. An easy-to-administer risk-assessment questionnaire can safely identify patients for penicillin allergy evaluation in STI clinics by PST or GOC, with GOC showing operational feasibility. Using this approach, 67% of participants with reported penicillin allergy could safely receive first-line treatments for gonorrhea or syphilis. Clinical Trials Registration. Clinicaltrials.gov (NCT04620746).

A multicentre observational study to investigate feasibility of a direct oral penicillin challenge in de-labelling ‘low risk’ patients with penicillin allergy by non-allergy healthcare professionals (SPACE study): Implications for healthcare systems

The huge burden of inaccurate penicillin allergy labels (PALs) is an important driver of antimicrobial resistance. This is magnified by insufficient allergy specialists and lack of 'point-of-care' tests. We investigated the feasibility of non-allergy healthcare professionals (HCPs) delivering direct oral penicillin challenges (DPCs) for penicillin allergy de-labelling. This prospective observational study was conducted in three hospitals in England across three settings (acute medical, pre-surgical and haematology-oncology). Patients with a PAL were screened and stratified as low risk/high risk. Low risk patients (non-immune mediated symptoms, benign rash, tolerated amoxicillin since and family history) underwent a DPC. N=2257 PALs were screened, 1054 were eligible; 643 were approached, 373 declined, 270 consented and 259 risk stratified (low risk=155; high risk=104). One hundred and twenty-six low risk patients underwent DPC, 122 (96.8%) were de-labelled with no serious allergic reactions. Conversion rate from screening-to-consent was 12% [3.3% and 17.9% in acute and elective settings respectively; odds ratios for consent were 3.42 (p<0.001) and 5.53 (p<0.001) in haematology-oncology and pre-surgical setting respectively. Common reasons for failure to progress in the study included difficulty in reaching patients, clinical instability/medical reasons, lacking capacity to consent and psychological factors. DPCs can be delivered by non-allergy HCPs. A high proportion of patients with PALs did not progress in the study pathway. Strategies to deliver DPC at optimal points of the care pathway are needed to enhance uptake. Elective settings offer greater opportunities than acute settings for DPC. The safety and simplicity of DPCs lends itself to adoption by healthcare systems beyond the UK, including in resource-limited settings.

Differences in oxazolidinone resistance mechanisms and small colony variants emergence of Staphylococcus aureus induced in an in vitro resistance development model

ABSTRACT Invasive Staphylococcus aureus infections are associated with a high burden of disease, case fatality rate and healthcare costs. Oxazolidinones such as linezolid and tedizolid are considered potential treatment choices for conditions involving methicillin resistance or penicillin allergies. Additionally, they are being investigated as potential inhibitors of toxins in toxin-mediated diseases. In this study, linezolid and tedizolid were evaluated in an in vitro resistance development model for induction of resistance in S. aureus. Whole genome sequencing was conducted to elucidate resistance mechanisms through the identification of causal mutations. After inducing resistance to both linezolid and tedizolid, several partially novel single nucleotide variants (SNVs) were detected in the rplC gene, which encodes the 50S ribosome protein L3 in S. aureus. These SNVs were found to decrease the binding affinity, potentially serving as the underlying cause for oxazolidinone resistance. Furthermore, in opposite to linezolid we were able to induce phenotypically small colony variants of S. aureus after induction of resistance with tedizolid for the first time in literature. In summary, even if different antibiotic concentrations were required and SNVs were detected, the principal capacity of S. aureus to develop resistance to oxazolidinones seems to differ between linezolid and tedizolid in-vivo but not in vitro. Stepwise induction of resistance seems to be a time and cost-effective tool for assessing resistance evolution. Inducted-resistant strains should be examined and documented for epidemiological reasons, if MICs start to rise or oxazolidinone-resistant S. aureus outbreaks become more frequent.

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.

Effectiveness, barriers and facilitating factors of strategies for active delabelling of patients with penicillin allergy labels: a systematic review protocol

IntroductionUp to 15% of adult patients in the clinical setting report to be allergic to penicillin. However, in most cases, penicillin allergy is not confirmed. Due to the negative aspects...

PREPARE: A Pilot RCT in Perioperative Penicillin and Cephalosporin Antibiotic Allergy Assessment and Testing

PREPARE: A Pilot RCT in Perioperative Penicillin and Cephalosporin Antibiotic Allergy Assessment and Testing

Penicillin Allergy Testing: Understanding Access and Outcomes

Penicillin Allergy Testing: Understanding Access and Outcomes

Do They Really Have A Drug Allergy? General Pediatricians Collaborate with Allergists to Delabel False Penicillin Allergies

Do They Really Have A Drug Allergy? General Pediatricians Collaborate with Allergists to Delabel False Penicillin Allergies

Predicting Penicillin Allergy from Patient-Reported Data: A Multi-Site Prospective Study from The United States Drug Allergy Registry

Predicting Penicillin Allergy from Patient-Reported Data: A Multi-Site Prospective Study from The United States Drug Allergy Registry

Multisite primary care led amoxicillin challenge pathway to safely remove penicillin allergy label

Multisite primary care led amoxicillin challenge pathway to safely remove penicillin allergy label

Real world comparison of PENFAST and UK Penicillin allergy clinical decision rules in an Adult Allergy service in the UK

Real world comparison of PENFAST and UK Penicillin allergy clinical decision rules in an Adult Allergy service in the UK