Outcomes from an inpatient beta-lactam allergy guideline across a large US health system

Blumenthal, Kimberly G.; Yu, Liang; Hsu, Joyce T.; Wolfson, Anna R.; Berkowitz, David N.; Carballo, Victoria; Schwartz, Jesse M.; Marquis, Kathleen A.; Elshaboury, Ramy H.; Gandhi, Ronak G.; Lambl, Barbara B.; Freeley, Monique; Gruszecki, Alana; Wickner, Paige G.; Shenoy, Erica S.

doi:10.1017/ice.2019.50

Cited by 48 publications

(54 citation statements)

References 39 publications

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“…29 Although PHS pathways used direct full-dose and test dose challenges as the major component of their intervention, PST was also available at 3 sites, and therefore PHS pathways are considered comprehensive pathways. 6,30,[32][33][34][35]…”

Section: Drug Challengeebasedmentioning

confidence: 99%

“…Comprehensive beta-lactam allergy pathway approaches included those primarily implemented by generalists (Table 4) 6,30,[32][33][34][35][49][50][51] and those that placed the specialist at the center of the evaluations (Table 5). 52e54 The PHS pathway approach was studied in 7 total articles and was implemented by generalists and described and evaluated in 2 academic and 3 community hospitals in the greater Boston area.…”

Section: Comprehensivementioning

confidence: 99%

“…52e54 The PHS pathway approach was studied in 7 total articles and was implemented by generalists and described and evaluated in 2 academic and 3 community hospitals in the greater Boston area. 6,30,[32][33][34][35] The PHS approach includes penicillin and cephalosporin hypersensitivity algorithms reliant on the allergy history to guide challenge doses that are largely performed without preceding PST (Fig 1). 30 The pathways direct PST when needed (ie, patients reporting immunoglobulin E [IgE]-mediated allergy symptoms to a penicillin who required a penicillin or potentially cross-reactive cephalosporin), and institutionally available, but encourage full dose and test dose (ie, standardized 2-step graded) drug challenges.…”

Section: Comprehensivementioning

confidence: 99%

“…30 The pathways direct PST when needed (ie, patients reporting immunoglobulin E [IgE]-mediated allergy symptoms to a penicillin who required a penicillin or potentially cross-reactive cephalosporin), and institutionally available, but encourage full dose and test dose (ie, standardized 2-step graded) drug challenges. 30,[32][33][34][35] This approach was initially implemented at MGH; when PST was indicated based on the allergy history and desired therapeutic antibiotic, PST was performed by allergy/ immunology consultation. 6,30 This intervention was modified to include optional decision support on a mobile-friendly website (functionally, an "app"), and studied at the Brigham and Women's Hospital (BWH).…”

Section: Comprehensivementioning

confidence: 99%

“…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. 37,41 One study developed antibiotic treatment guidelines along with their PST-based intervention, so that the patient note after PST contained standardized antibiotic guidance.…”

Section: Patient Selection Targeting Antibioticsmentioning

confidence: 99%

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Acute care beta-lactam allergy pathways: approaches and outcomes

Wolfson

Huebner

Blumenthal

2019

Annals of Allergy, Asthma & Immunology

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Acute care beta-lactam allergy pathways are coordinated allergy assessment programs for hospitalized patients as an antibiotic stewardship tool, which can be based on the allergy history alone, or use the allergy history to guide procedures such as drug challenges and/or penicillin skin testing. Pathways commonly targeted patients likely to benefit from acute care penicillin allergy evaluations: patients on specific broadspectrum antibiotics, referred from Infectious Diseases specialists, and/or patients with specific infections or bacterial culture results. Acute care beta-lactam pathways were safe and report decreased alternative antibiotic use and increased beta-lactam antibiotic use. Instructions Credit can now be obtained, free for a limited time, by reading the review article and completing all activity components. Please note the instructions listed below: Review the target audience, learning objectives and all disclosures. Complete the pre-test. Read the article and reflect on all content as to how it may be applicable to your practice. Complete the post-test/evaluation and claim credit earned. At this time, physicians will have earned up to 1.0 AMA PRA Category 1 Credit TM. Minimum passing score on the post-test is 70%. Overall Purpose Participants will be able to demonstrate increased knowledge of the clinical treatment of allergy/asthma/immunology and how new information can be applied to their own practices. Learning Objectives At the conclusion of this activity, participants should be able to: Identify the benefits of inpatient beta-lactam allergy assessments. Describe different approaches to beta-lactam allergy pathways including the methods used to identify patients.

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Section: Drug Challengeebasedmentioning

confidence: 99%

Section: Comprehensivementioning

confidence: 99%

Section: Comprehensivementioning

confidence: 99%

Section: Comprehensivementioning

confidence: 99%

Section: Patient Selection Targeting Antibioticsmentioning

confidence: 99%

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Acute care beta-lactam allergy pathways: approaches and outcomes

Wolfson

Huebner

Blumenthal

2019

Annals of Allergy, Asthma & Immunology

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Reaction Risk to Direct Penicillin Challenges

Blumenthal,

Smith,

Mann

et al. 2024

JAMA Intern Med

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ImportanceWhile direct penicillin challenges might support the expansion of penicillin allergy delabeling efforts, the perceived risk of reactions remains a key barrier.ObjectiveTo evaluate the frequency of reactions to direct penicillin challenges in individuals with penicillin allergy labels and to identify factors associated with such reactions.Data SourcesThree electronic databases were searched (MEDLINE, Web of Science, and Scopus) from inception to July 19, 2023, for primary studies assessing patients undergoing direct penicillin challenges. Articles were included regardless of publication year, language, status, or definition of allergy risk.Study SelectionTwo reviewers independently selected original studies reporting the frequency of immunologically mediated reactions following a direct penicillin challenge in patients reporting a penicillin allergy.Data Extraction and SynthesisTwo reviewers independently extracted data and independently assessed the quality of each primary study using a risk-of-bias tool for prevalence studies.Main Outcomes and MeasuresThe primary outcome was the frequency of reactions to direct penicillin challenges as calculated using random-effects bayesian meta-analysis of proportions. Secondary outcomes included risk factors for reactions and the frequency of severe reactions.ResultsA total of 56 primary studies involving 9225 participants were included. Among participants, 438 experienced reactions to direct penicillin challenges without prior testing, corresponding to an overall meta-analytic frequency of 3.5% (95% credible interval [CrI], 2.5%-4.6%). Meta-regression analyses revealed that studies performed in North America had lower rates of reaction to direct challenges (odds ratio [OR], 0.36; 95% CrI, 0.20-0.61), while studies performed in children (OR, 3.37; 95% CrI, 1.98-5.98), in outpatients (OR, 2.19; 95% CrI, 1.08-4.75), and with a graded (OR, 3.24; 95% CrI, 1.50-7.06) or prolonged (OR, 5.45; 95% CrI, 2.38-13.28) challenge had higher rates of reaction. Only 5 severe reactions (3 anaphylaxis, 1 fever with rash, and 1 acute kidney injury) were reported, none of which were fatal.Conclusions and RelevanceThis systematic review and meta-analysis found that reactions to direct penicillin challenges are infrequent, with rates comparable to indirect challenges after allergy testing. These findings suggest that direct challenges are safe for incorporation into penicillin allergy evaluation efforts across age groups and clinical settings.

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Assessment of the Frequency of Dual Allergy to Penicillins and Cefazolin

et al. 2021

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IMPORTANCE Cefazolin is the preoperative antibiotic of choice because it is safer and more efficacious than second-line alternatives. Surgical patients labeled as having penicillin allergy are less likely to prophylactically receive cefazolin and more likely to receive clindamycin or vancomycin, which results in higher rates of surgical site infections.OBJECTIVE To examine the incidence of dual allergy to cefazolin and natural penicillins.DATA SOURCES MEDLINE/PubMed, Web of Science, and Embase were searched without language restrictions for relevant articles published from database inception until July 31, 2020.STUDY SELECTION In this systematic review and meta-analysis, a search of MEDLINE/PubMed, Web of Science, and Embase was performed for articles published from database inception to July 31, 2020, for studies that included patients who had index allergies to a natural penicillin and were tested for tolerability to cefazolin or that included patients who had index allergies to cefazolin and were tested for tolerability to a natural penicillin. A total of 3228 studies were identified and 2911 were screened for inclusion.DATA EXTRACTION AND SYNTHESIS Data were independently extracted by 2 authors. Bayesian meta-analysis was used to estimate the frequency of allergic reactions. MAIN OUTCOMES AND MEASURESDual allergy to cefazolin and a natural penicillin. RESULTSSeventy-seven unique studies met the eligibility criteria, yielding 6147 patients. Cefazolin allergy was identified in 44 participants with a history of penicillin allergy, resulting in a dual allergy meta-analytical frequency of 0.7% (95% credible interval [CrI], 0.1%-1.7%; I 2 = 74.9%). Such frequency was lower for participants with unconfirmed (0.6%; 95% CrI, 0.1%-1.3%; I 2 = 54.3%) than for those with confirmed penicillin allergy (3.0%; 95% CrI, 0.01%-17.0%; I 2 = 88.2%). Thirteen studies exclusively assessed surgical patients (n = 3884), among whom 0.7% (95% CrI, 0%-3.3%; I 2 = 85.5%) had confirmed allergy to cefazolin. Low heterogeneity was observed for studies of patients with unconfirmed penicillin allergy who had been exposed to perioperative cefazolin (0.1%; 95% CrI, 0.1%-0.3%; I 2 = 13.1%). Penicillin allergy was confirmed in 16 participants with a history of cefazolin allergy, resulting in a meta-analytical frequency of 3.7% (95% CrI, 0.03%-13.3%; I 2 = 64.4%). The frequency of penicillin allergy was 4.4% (95% CrI, 0%-23.0%; I 2 = 75%) for the 8 studies that exclusively assessed surgical patients allergic to cefazolin.CONCLUSIONS AND RELEVANCE These findings suggest that most patients with a penicillin allergy history may safely receive cefazolin. The exception is patients with confirmed penicillin allergy in whom additional care is warranted.

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Outcomes from an inpatient beta-lactam allergy guideline across a large US health system

Cited by 48 publications

References 39 publications

Acute care beta-lactam allergy pathways: approaches and outcomes

Acute care beta-lactam allergy pathways: approaches and outcomes

Reaction Risk to Direct Penicillin Challenges

Assessment of the Frequency of Dual Allergy to Penicillins and Cefazolin

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