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

Abstract

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.

Economic impact of clinical decision support interventions based on electronic health records

“…An overview of the characteristics of the included studies is listed in Table 2. Generally, twenty-two studies (81%) [5,[13][14][15][16]18,[20][21][22][23][24][25][28][29][30][31]32,[34][35][36][37][38] out of the included twenty-seven studies report cost savings after implementing an EHR based CDS intervention. Four studies (15%) [17,26,27,33] report a rise in cost expenditure.…”

“…In the majority of included studies the main cost outcome measures were related to laboratory test cost. [15][16][17]20,21,25,28,29,31,32,38] Exploration of different front-end CDS intervention categories According to the taxonomy by Wright et al [12], we identi ed ten (37%) studies [5,13,15,20,22,23,26,[36][37][38] which explored EHR based CDS interventions based on point-of-care alerts or reminders (category 3). Three interventions (11%) [17,27,34] were order facilitators (category 2).…”

Acute care beta-lactam allergy pathways: approaches and outcomes

“…The most common single antibiotic targeted for reduction was aztreonam. 21,23,25,27,28,46,48 Other targeted antibiotics included carbapenems, vancomycin, linezolid, tigecycline, daptomycin, and moxifloxacin. 22,30,[32][33][34][35]46,49 Targeting Infections One PST-based pathway relied on reviews of each patient's infection and antibiotic data to select patients that would likely have a therapy change with a negative PST.…”

“…34,40 Some PST pathways excluded patients with recent type I reaction or anaphylaxis history. 38,48 Other PST-based pathway exclusions included cutaneous conditions, severe cardiac or pulmonary comorbidities, immunosuppression, pregnancy, altered mental status, and clinical instability. 31,37,48 Implementation Teams Implementation teams were often multidisciplinary with diverse perspectives and varied expertise.…”

Pharmacy driven assessment of appropriate antibiotic selection in patients with reported beta‐lactam allergy

“…Several strategies have been developed and reported in the literature to attempt to decrease the inappropriate labeling of BL allergies and subsequent avoidance of BL therapy including penicillin skin testing, decision support tools for patients with documented penicillin allergies, and pharmacist-driven BL allergy interviews. [9][10][11][12][13][14] In a recent study, patients who received skin testing per hospital protocol and who were subsequently treated after provider utilization of a computerized guideline application with clinical decision support were 5.7 and 1.8 times more likely to receive a penicillin or cephalosporin, respectively. 14 A pilot-study of a standardized BL allergy questionnaire used by pharmacists found that 63% of assessed patients had previously tolerated a BL antibiotic resulting in BL prescriptions for 87.5% of the 24 patients deemed eligible for BL therapy.…”