A Proactive Approach to Penicillin Allergy Testing in Hospitalized Patients

Chen, Justin R.; Tarver, Scott A.; Alvarez, Kristin; Tran, Trang; Khan, David A.

doi:10.1016/j.jaip.2016.09.045

Cited by 125 publications

(99 citation statements)

References 28 publications

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“…10,13,33 Fewer skin testing studies are reported among highly selected inpatient subsets. 16,34–36 Alternative approaches to address inpatient penicillin allergies have included consultation by allergy specialists 34,37 and guidelines/clinical pathways. 26,38 By implementing and assessing both a skin testing approach and guideline approach in sequential cohorts at the same institution, we were able to determine the overall hospital policy level impact of these interventions.…”

Section: Discussionmentioning

confidence: 99%

“…However, we skin tested 16% of all patients reporting penicillin allergy on antibiotics in this period, and 24% of those who were skin test eligible, largely comparable to the 19% yield achieved through the use of a designated pharmacist performing skin testing in a prior study. 36 Still, more patients would have had testing completed, and overall findings may have differed, had we hired an on-site skin testing clinician.…”

Section: Discussionmentioning

confidence: 99%

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Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship

Blumenthal

Wickner

Hurwitz

et al. 2017

Journal of Allergy and Clinical Immunology

128

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Background Reported penicillin allergy rarely reflects penicillin intolerance. Failure to address inpatient penicillin allergies results in more broad-spectrum antibiotic use, treatment failures, and adverse drug events. Objective We aimed to determine the optimal approach to penicillin allergies among medical inpatients. Methods We evaluated internal medicine inpatients reporting penicillin allergy in three periods: (1) standard of care (SOC), (2) penicillin skin testing (ST), and (3) computerized guideline application with decision support (APP). The primary outcome was use of a penicillin or cephalosporin, comparing interventions to SOC using multivariable logistic regression. Results There were 625 patients: SOC 148, ST 278, and APP 199. Of 278 ST patients, 179 (64%) were skin test eligible; 43 (24%) received testing and none were allergic. In the APP period, there were 292 unique website views; 112 users (38%) completed clinical decision support. While ST period patients did not have an increased odds of penicillin or cephalosporin use overall (aOR 1.3 [95% CI 0.8, 2.0]), we observed a significant increased odds of penicillin or cephalosporin use overall in the APP period (aOR 1.8 [95% CI 1.1, 2.9]), and in a per protocol analysis of the skin tested subset (aOR 5.7 [95% CI 2.6, 12.5]). Conclusions Both the computerized guideline with decision support and penicillin skin testing – when completed – increased use of penicillin and cephalosporin antibiotics among inpatients reporting penicillin allergy. While the skin tested subset showed an almost 6-fold impact, the computerized guideline significantly increased penicillin or cephalosporin use overall nearly 2-fold and was readily implemented.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship

Blumenthal

Wickner

Hurwitz

et al. 2017

Journal of Allergy and Clinical Immunology

128

View full text Add to dashboard Cite

show abstract

“…It was not possible to discern individual reasons for declining the test, but this reiterates the need for continuing education among allergy, infectious diseases, and other inpatient specialists to present a unified message to patients on the importance of penicillin allergy testing. During the AS-CDS period, we skin-tested 27% of eligible patients, an improvement over our previous study, in which patients were manually screened by the study team [24]. …”

Section: Discussionmentioning

confidence: 99%

“…This protocol utilizes an allergy-trained pharmacist assisted by a computer-driven protocol to identify, prioritize, and test admitted patients labeled as penicillin-allergic [24]. A census of these patients is generated daily in the EMR and processed through a series of filters.…”

mentioning

confidence: 99%

Improving Aztreonam Stewardship and Cost Through a Penicillin Allergy Testing Clinical Guideline

Chen

Tarver

Alvarez

et al. 2018

Open Forum Infectious Diseases

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BackgroundPatients reporting penicillin allergy often receive unnecessary and costly broad-spectrum alternatives such as aztreonam with negative consequences. Penicillin allergy testing improves antimicrobial therapy but is not broadly used in hospitals due to insufficient testing resources and short-term expenses. We describe a clinical decision support (CDS) tool promoting pharmacist-administered penicillin allergy testing in patients receiving aztreonam and its benefits toward antimicrobial stewardship and costs.MethodsA CDS tool was incorporated into the electronic medical record, directing providers to order penicillin allergy testing for patients receiving aztreonam. An allergy-trained pharmacist reviewed orders placed through this new guideline and performed skin testing and oral challenges to determine whether these patients could safely take penicillin. Data on tests performed, antibiotic utilization, and cost-savings were compared with patients tested outside the new guideline as part of our institution’s standard stewardship program.ResultsThe guideline significantly increased penicillin allergy testing among patients receiving aztreonam from 24% to 85% (P < .001) while reducing the median delay between admission and testing completion from 3.31 to 1.05 days (P = 0.008). Patients tested under the guideline saw a 58% increase in penicillin exposure (P = .046). Institutional aztreonam administration declined from 2.54 to 1.47 administrations per 1000 patient-days (P = .016). Average antibiotic costs per patient tested before and after CDS decreased from $1265.81 to $592.08 USD, a 53% savings.ConclusionsTargeting penicillin allergy testing to patients on aztreonam yields therapeutic and economic benefits during a single admission. This provides a cost-effective model for inpatient testing.

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“…Programs with routine penicillin skin testing, performed by internists, allergists, and pharmacists were previously implemented with varying success. 10,12,19–23 Other groups used routine allergy consultation, with or without patient screening performed by pharmacists. 11,24 Alternative approaches have targeted penicillin allergy evaluation only for inpatients with particular infections, 21 or those prescribed particular beta-lactam alternative drugs (e.g., aztreonam).…”

Section: Introductionmentioning

confidence: 99%

Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation

Blumenthal

Shenoy

Wolfson

et al. 2017

The Journal of Allergy and Clinical Immunology: In Practice

111

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Addressing inaccurate penicillin allergies is encouraged as part of antibiotic stewardship in the inpatient setting. However, implementing interventions targeted at the 10–15% of inpatients reporting a prior penicillin allergy can pose substantial logistic challenges. We implemented a computerized guideline for patients with reported beta-lactam allergy at five hospitals within a single healthcare system in the Boston area. In this paper, we describe our implementation roadmap, including both successes achieved and challenges faced. We explain key implementation steps, including assembling a team, stakeholder engagement, developing or selecting an approach, spreading the change, establishing measures, and measuring impact. The objective is to detail the lessons learned while empowering others to be part of this important, multi-disciplinary work to improve the care of patients with reported beta-lactam allergies.

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A Proactive Approach to Penicillin Allergy Testing in Hospitalized Patients

Cited by 125 publications

References 28 publications

Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship

Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship

Improving Aztreonam Stewardship and Cost Through a Penicillin Allergy Testing Clinical Guideline

Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation

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