Optimizing preoperative antibiotics in patients with β-lactam allergies: A role for pharmacy

Abstract

Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Patients with a reported β-lactam allergy (BLA) are often given alternative perioperative antibiotic prophylaxis, increasing risk of surgical site infections (SSIs), acute kidney injury (AKI), and Clostridioides difficile infection (CDI). The purpose of this study was to implement and evaluate a pharmacist-led BLA clarification interview service in the preoperative setting. Methods A pharmacist performed BLA clarification telephone interviews before elective procedures from November 2018 to March 2019. On the basis of allergy history and a decision algorithm, first-line preoperative antibiotics, alternative antibiotics, or allergy testing referral was recommended. The pharmacist intervention (PI) group was compared to a standard of care (SOC) group who underwent surgery from November 2017 to March 2018. Results Eighty-seven patients were included, with 50 (57%) and 37 (43%) in the SOC and PI groups, respectively. The most common surgeries included orthopedic surgery in 41 patients (47%) and neurosurgery in 17 patients (20%). In the PI group, all BLA labels were updated after interview. Twenty-three patients were referred for allergy testing, 12 of the 23 (52%) completed BLA testing, and penicillin allergies were removed for 9 of the 12 patients. Overall, 28 of the 37 (76%) pharmacy antibiotic recommendations were accepted. Cefazolin use significantly increased from 28% to 65% after the intervention (P = 0.001). SSI occurred in 5 (10%) patients in the SOC group and no patients in the PI group (P = 0.051). All of these SSIs were associated with alternative antibiotics. Incidence of AKI and CDI was similar between the groups. No allergic reactions occurred in either group. Conclusion Implementation of a pharmacy-driven BLA reconciliation significantly increased β-lactam preoperative use without negative safety outcomes.

Impact of a Pharmacist-Driven Penicillin Allergy De-Labeling Pilot Program in Preoperative Cardiothoracic and Spine Surgery Patients at a Quaternary Hospital

“…The results of this study add evidence to the increasing literature that demonstrates the positive impact of penicillin allergy de-labeling interventions. Several previous studies have also shown an increase in first-line antibiotic use following pharmacist-led penicillin allergy efforts [6,8,16]. Our study was similar to the study by Kwiatkowski et al in terms of study design and endpoints but differed in key aspects of methodology, including the patient population included, the identification of appropriate patients, the timing of interviews, and making formal antibiotic therapy recommendations to providers.…”

“…Pharmacists assessed penicillin allergies via telephone and then made antibiotic recommendations to providers to increase first-line preoperative antibiotic use. The study found that cefazolin use significantly increased from 28% to 65% after the implementation of this intervention (p = 0.001) [8]. The above study demonstrates that pharmacists are able to assess patients' allergy history and assist providers in appropriate antibiotic selection in patients with documented penicillin allergies.…”

“…Validated algorithms and questionnaires have been developed to aid in the process of de-labeling patients with inaccurate penicillin allergies [6][7][8][9]. In a study by Devchand et al, 13% of patients who were screened for de-labeling were able to have their penicillin allergy label removed without any direct challenge or skin testing [5].…”

“…Several algorithms used by different health systems across the US have been published, and many recommend skin testing, direct oral challenges, or explicit recommendations for alternative cephalosporins [7]. A study published by Kwiatkowski et al in 2021 evaluated a pharmacist-led intervention to help optimize preoperative antibiotics [8]. Pharmacists assessed penicillin allergies via telephone and then made antibiotic recommendations to providers to increase first-line preoperative antibiotic use.…”

Evaluation of hospital pharmacists’ activities using additional reimbursement for infection prevention as an indicator in small and medium-sized hospitals

“…One reason could be that infection control is often achieved through an integrated approach involving different professionals [ 11 ]. However, various pharmacist-led initiatives have been reported to promote the use of antimicrobial agents, improve achievement rate of effective blood concentration range in vancomycin (VCM) therapy [ 12 ], reducing the rate of MRSA in intensive care units and in antimicrobial allergic reactions [ 13 – 16 ]. In addition, a retrospective study has shown that the survival rate at 30 days after starting VCM therapy with pharmacist-led VCM initial dose planning was higher than that of non-intervention groups in MRSA bacteremia patients [ 17 ].…”