BACKGROUND: Penicillin allergy is reported in up to 10% of the general population; however, .90% of patients reporting an allergy are tolerant. Patients labeled as penicillin allergic have longer hospital stays, increased exposure to suboptimal antibiotics, and an increased risk of methicillin-resistant Staphylococcus aureus and Clostridioides difficile. The primary aim with our quality improvement initiative was to increase penicillin allergy delabeling to at least 10% among all hospitalized pediatric patients reporting a penicillin allergy with efforts directed toward patients determined to be low risk for true allergic reaction.METHODS: Our quality improvement project included several interventions: the development of a multidisciplinary clinical care pathway to identify eligible patients, workflow optimization to support delabeling, an educational intervention, and participation in our institution's quality improvement incentive program. Our interventions were targeted to facilitate appropriate delabeling by the primary hospital medicine team. Statistical process control charts were used to assess the impact of this intervention pre-and postpathway implementation.RESULTS: After implementation of the clinical pathway, the percentage of patients admitted to hospital medicine delabeled of their penicillin allergy by discharge increased to 11.7%. More than one-half of those delabeled (51.2%) received a penicillin-based antimicrobial at time of discharge. There have been no adverse events or allergic reactions requiring emergency medication administration since pathway implementation.CONCLUSIONS: Our quality improvement initiative successfully increased the rate of penicillin allergy delabeling among low-risk hospitalized pediatric patients, allowing for increased use of optimal antibiotics.

Vulvar cytological evaluation did not correlate well with tissue diagnosis of VIN; and thus, our findings do not support the use of vulvar cytology in the clinical management of VIN.

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Background Over 90% of children with reported penicillin allergy can tolerate penicillin without incident. Developing effective and safe strategies to remove inappropriate penicillin allergies has the potential to improve care; however, guidance on how to identify, test, and delabel patients is limited. Methods In April 2019, Children’s Hospital Colorado (CHCO) implemented a penicillin allergy clinical pathway (CP) alongside a risk assessment tool to stratify patients based on allergic history (Figure 1). Patients at “no increased risk” were educated and delabeled without testing. Low risk patients were offered an oral amoxicillin drug challenge with close observation. A single, non-graded, treatment dose of amoxicillin (45 mg/kg, max dose 1000mg) was used for low risk patients, and no preceding allergic skin testing was performed. Patients with no signs or symptoms of allergic response 60 minutes after amoxicillin administration were delabeled. Children delabeled of penicillin allergies on the CHCO hospital medicine service were compared between the pre-CP (1/1/17-3/31/19) and post-CP (4/1/19-3/31/20) cohorts. Figure 1. Penicillin Allergy Risk Assessment Results Pre-CP, 683/10624 (6.4%) patients reported a penicillin allergy and 18/683 (2.6%) were delabeled by discharge. Post-CP, 345/6559 (5.3%) patients reported a penicillin allergy and 47/345 (13.6%) were delabeled by discharge (P-value < 0.0001, Figure 2). Among the 47 post-CP patients, 11 were delabeled by history alone, 19 underwent oral amoxicillin drug challenge per CP, and 17 received a different treatment dose penicillin per treatment team. Only one penicillin-exposed patients had a reaction. This patient developed a delayed, non-progressive rash and had penicillin allergy restored to their chart. No patient required emergency medical intervention, and none were “relabeled” penicillin allergic in the 6 months following discharge. Figure 2. Monthly Rate of Penicillin Allergic Patients Delabeled by Discharge Conclusion A drug challenge using a single non-graded dose of oral amoxicillin is a safe and effective strategy to delabel low risk children of inappropriate penicillin allergies when implemented alongside a risk assessment tool. Further studies are needed to evaluate the long-term benefits of delabeling inappropriate penicillin allergies and to continue monitoring for adverse events. Disclosures All Authors: No reported disclosures

for therapeutic regimen derived from GALLIUM and PRIMA clinical trials: in particular, progression-free survival (PFS), early progressive disease (PD), and treatment duration (TTOT) were extrapolated by fitting parametric distributions on empirical data in GALLIUM, whilst late PD on data in PRIMA, due to immature data in GALLIUM. PD state was split in early (progression within 2-years) and late since patients progressing early have much poorer survival outcomes than those progressing later. Expected survival was weighted by published utilities. Unit costs were collected from official and published Italian sources. Costs, updated to 2018 Euro, and health gains occurring after the first year were discounted at an annual 3% rate. Sensitivity and scenario analyses were carried out, with the aim of evaluating uncertainty around model assumptions. Results: Obinutuzumab is associated with incremental survival (1.3 LYs), even when weighted for quality (1.1 QALYs), and incremental costs (V 24,000), driven by longer treatment duration in the progression-free state relative to rituximab. Incremental ratios (around V 18,000 per LY and V 21,500 per QALY gained) are widely within the range considered acceptable by the Italian NHS. 1,000 PSA simulations confirm robustness of results to sensible variations in assumptions. Conclusions: Obinutuzumab has a superior clinical efficacy, as compared to rituximab, and should be considered a cost-effective option in the first line treatment of advanced FL in Italy: incremental cost-effectiveness ratios are below the threshold considered sustainable by developed countries.