Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations

Savic, Louise; Khan, David A.; Kopač, Peter; Clarke, Russell C.; Cooke, Peter; Dewachter, Pascale; Ebo, Didier G.; Garcez, Tomaz; Garvey, Lh; Guttormsen, Anne Berit; Hopkins, Philip M.; Hepner, David L.; Kolawole, Helen; Krøigaard, Mogens; Laguna, José Julio; Marshall, Stuart; Mertès, P. M.; Platt, Peter; Rose, Michael; Sabato, Vito; Sadleir, P. H. M.; Savic, Sinisa; Takazawa, Tomonori; Voltolini, Susanna; Volcheck, Gerald W.

doi:10.1016/j.bja.2019.01.026

Cited by 42 publications

(34 citation statements)

References 86 publications

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“…3,18 Guidelines from the International Suspected Perioperative Allergic Reactions group (ISPAR) published in 2019 detail a consensus-based approach to the management of patients with a label of penicillin allergy where a penicillin is the first-line antimicrobial choice; other strategies found in the worldwide literature are generally tailored to settings where cephalosporins are the first-line choice. 19,20 The key determinant of crossreactivity between penicillins and cephalosporins is side chain similarity. Incidence of clinically significant crossreactivity appears to be very low, but these figures may be falsely reassuring as most patients' penicillin allergy labels are incorrect in the first instance.…”

Section: Untested Penicillin Allergy Labelsmentioning

confidence: 99%

Allergy and anaesthesia: managing the risk

2020

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Learning objectivesBy reading this article you should be able to:Identify which patients require preoperative assessment by an allergy specialist and the key features in their history that indicate increased risk of allergy. Describe measures that can be taken during anaesthesia and surgery to minimise the risk of allergic reactions. Outline the key postoperative actions needed to ensure patients' safety during future anaesthetics.Perioperative hypersensitivity reactions are unpredictable adverse events that can range in severity from minor to lifethreatening. The underlying mechanism may be allergic or non-allergic, although reactions are indistinguishable in clinical practice regardless of the underlying cause. The purpose of this article is to identify key points in the perioperative period where an increased risk of allergy might be identified and to provide clinicians with pragmatic strategies with which to mitigate this risk.The Ring and Mesmer classification system is the most widely known and may be used to grade hypersensitivity reactions. Anaphylaxis is the most severe grade of reaction and by definition may be life-threatening. Less severe reactions, of Grades 1 and 2, are nonetheless important and require investigation because future exposure to the triggering drug may result in a serious and avoidable reaction.The quoted incidence of life-threatening anaphylaxis varies around the world, partly because of the different reporting mechanisms used and variable inclusion of prospective and retrospective work. 1 The UK National Audit Project study (NAP6) estimated an incidence of 1:11,752 in the UK, or one event every 7.25 anaesthetist years, although this was thought to be an underestimate of up to 70%. 2 Despite optimum clinical care, perioperative anaphylaxis is still associated with significant morbidity and mortality. In the NAP6 report more than 50% of patients required admission to critical care, 70% of whom required Level 3 care. Mortality Louise Savic MCRP FRCA is a consultant anaesthetist with an interest in drug allergy at the Leeds Teaching Hospitals NHS Trust. Her research interest is in perioperative hypersensitivity and anaphylaxis, including antibiotic allergy and delabelling.Naina Stannard FRCA is a specialty registrar at the York Teaching Hospital NHS Foundation Trust.Sophie Farooque MRCP is a consultant allergist and clinical lead for adult allergy in the Imperial College Healthcare NHS Trust. Her areas of expertise include drug allergy, immunotherapy, anaphylaxis, rhinitis and urticaria. She is a member of the British Society of Allergy and Clinical Immunology Council. Louise Savic and Sophie Farooque are both members of the International Suspected Perioperative Allergic Reaction (ISPAR) group.

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Section: Untested Penicillin Allergy Labelsmentioning

confidence: 99%

Allergy and anaesthesia: managing the risk

2020

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“…5,9,33 Paper and computer-based stratification tools have been developed and employed at various stages of the patient's journey by clinicians and pharmacists in hospitalised patients and for preoperative testing. 5,[34][35][36][37] Application of these tools results in 1 of 3 possible outcomes: removal of spurious PenA label; referral to specialist allergy assessment services for those deemed to be high risk; or confirmation of PenA status.…”

Section: Pena Delabelling Methodsmentioning

confidence: 99%

Sustaining and spreading penicillin allergy delabelling: A narrative review of the challenges for service delivery and patient safety

Jani¹,

Williams

Krishna

2020

Brit J Clinical Pharma

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Many patients report allergies to penicillin, although in over 90% of these the label of penicillin allergy is shown to be incorrect following comprehensive testing. Inappropriate and inaccurate penicillin allergy labelling is a barrier to antimicrobial stewardship and can lead to patient harm. This review assesses an emergent evidence base and trend favouring delabelling using direct oral penicillin challenges following a stratified risk assessment of the likelihood and existence of true penicillin allergy, to identify and make recommendations for key components for implementation in standard practice. Research to date has focussed on the feasibility and clinical and financial outcomes of these direct delabelling strategies. There is a paucity of studies exploring the views and engagement of patients and healthcare professionals, and a gap in the evidence for prerequisites to safely deliver, sustain and spread the implementation of such services across health systems.

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“…Between March 2019 and July 2019, members of the Antibiotic Stewardship (ABS) Unit (hospital pharmacy, medical microbiology, intensive medicine), Infectiology and Allergology at the Klinikum rechts der Isar, Munich, drew up an algorithm in an interdisciplinary approach on how to proceed in the case of suspected BLA allergy when the use of a BLA is compellingly indicated (primarily in severe or acute infection). They analyzed the guidelines and position papers that were available or in preparation, as well as the respective literature [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15]. Recommendations were made on the basis of a risk assessment that takes into account possible cross reactions between BLA and classifies these reactions into putative underlying pathomechanisms.…”

Section: Methodsmentioning

confidence: 99%

“…In recent years, algorithms referred to as "de-labeling strategies", which are proven to reduce antibiotic use and improve treatment outcomes, have been described in the US [12], Australia [10], New Zealand [14], Great Britain [11,13], and Germany [16]. Algorithms such as these, some of which are computerassisted, attempt to classify the most likely mechanism of hypersensitivity reaction on the basis of clinical manifestations of BLA allergy in the patient's history.…”

Section: Introductionmentioning

confidence: 99%

Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project

et al. 2020

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Summary Background Beta-lactam antibiotics (BLA) are the treatment of choice for a large number of bacterial infections. Putative BLA allergies are often reported by patients, but rarely confirmed. Many patients do not receive BLA due to suspected allergy. There is no systematic approach to risk stratification in the case of a history of suspected BLA allergy. Methods Using the available stratification programs and taking current guidelines into account, an algorithm for risk stratification, including recommendations on the use of antibiotics in cases of compellingly indicated BLA despite suspected BLA allergy, was formulated by the authors for their maximum care university hospital. Results The hospital is in great need of recommendations on how to deal with BLA allergies. Patient-reported information in the history forms the basis for classifying the reactions into four risk categories: (1) BLA allergy excluded, (2) benign delayed reaction, (3) immediate reaction, and (4) severe cutaneous and extracutaneous drug reaction. Recommendations strictly depend on this classification and range from use of full-dose BLA or use of BLA under certain conditions (e.g., two-stage dose escalation, non-cross-reactive BLA only) to prohibiting all BLA and the use of alternative non-BLA. In case of suspected immediate or delayed allergic reactions, there is an additional recommendation regarding subsequent allergy testing during a symptom-free interval. Conclusion Triage of patients with suspected BLA is urgently required. While allergy testing, including provocation testing, represents the most reliable solution, this is not feasible in all patients due to the high prevalence of BLA allergies. The risk stratification algorithm developed for the authors’ hospital represents a tool suitable to making a contribution to rational antibiotic therapy.

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Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations

Cited by 42 publications

References 86 publications

Allergy and anaesthesia: managing the risk

Allergy and anaesthesia: managing the risk

Sustaining and spreading penicillin allergy delabelling: A narrative review of the challenges for service delivery and patient safety

Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project

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