Penicillin allergy skin testing as an antibiotic stewardship intervention reduces alternative antibiotic exposures in hematopoietic stem cell transplant recipients

Abstract

Background: Antibiotic allergy de-labeling using penicillin allergy skin testing (PAST) can reduce the use and cost of alternative, non-β-lactam antibiotics in general inpatient populations. This strategy's role in hematopoietic stem cell transplant (HSCT) recipients is unclear. Methods: This study aimed to determine the effect of a pre-transplant PAST protocol on antibiotic use, days of therapy (DOT), and cost in an immunocompromised population at a single center from 7/1/2010-2/1/2019. Patients who received chimeric antigen receptor (CAR) T-cell therapy and those who underwent transplantation in the outpatient setting were excluded. Results: Of 1560 patients who underwent inpatient HSCT during the study period, 208 reported β-lactam allergy (136/844 [16%] pre-and 72/716 [10%] post-implementation; P < .001). PAST was performed on 7% and 54% of HSCT recipients preand post-implementation, respectively. Only two positive PAST were noted. There were no adverse reactions to PAST. There were no significant differences in the disease and transplant characteristics between the two groups. Days of therapy and cost of alternative antibiotics significantly decreased post-implementation (mean 788 vs 627 days, P = .01; mean $24 425 vs $17 518, P = .009). Conclusion: Penicillin allergy skin testing adjudicates reported β-lactam allergy in HSCT recipients, lowering use, DOT, and cost of alternative antibiotics and promoting effective formulary agents to treat immunocompromised HSCT recipients.

Antibiotic allergy labels in immunocompromised populations

“…12 Modi et al reported 13% prevalence of BLA label among an American cohort of hematopoietic stem cell transplant (HSCT) candidates. 13 Another study investigated overall reports of antibiotic allergy with 29% of a combined transplant cohort (35% HSCT and 65% SOT) reporting an antibiotic allergy; 16% reported BLA, while 12%, 8.5%, and 5% reported penicillin, TMP-SMX antibiotic, and cephalosporin allergy label, respectively. 4 McLaughlin et al reported a similar rate of TMP-SMX allergy labels with 9.7% of American kidney transplant cohort acquiring this new allergy after being placed on TMP-SMX for Pneumocystis jirevicii pneumonia prophylaxis 14 ; however, Urbancic et al found higher prevalence of reported TMP-SMX allergy label in an Australian kidney transplant cohort with 35% reporting this allergy.…”

“…Modi et al. reported 13% prevalence of BLA label among an American cohort of hematopoietic stem cell transplant (HSCT) candidates 13 . Another study investigated overall reports of antibiotic allergy with 29% of a combined transplant cohort (35% HSCT and 65% SOT) reporting an antibiotic allergy; 16% reported BLA, while 12%, 8.5%, and 5% reported penicillin, TMP‐SMX antibiotic, and cephalosporin allergy label, respectively 4 .…”

“…Ninety‐six percent of those tested had negative skin test results; however, only 46% underwent OC; all those who underwent OC were delabeled 13 . This group found a significant decrease in use of restricted antibiotics, duration, and cost, with increased use of preferred antibiotic 13 . Another retrospective analysis evaluated outpatient penicillin allergy evaluations (ST followed by OC) in lung transplant candidates; 31 patients were tested with 30 patients tolerating OC (one positive skin test result) 31 .…”

Inpatient Antibiotic Stewardship Interventions in the Adult Oncology and Hematopoietic Stem Cell Transplant Population: A Review of the Literature

“…Finally, Modi et al 48 performed a retrospective chart review examining the use of non–β-lactam alternative antibiotics during pre-implementation and post-implementation of PST in HCT recipients. 48 Of 1560 patients who underwent inpatient autologous or allogenic HCT, 208 (13.3%) reported a β-lactam allergy. During the post-implementation period, 54% with allergies underwent PST, and no adverse events were observed.…”

The Impact of Reported β-Lactam Allergy on Clinical Outcomes and Antibiotic Use Among Solid Organ Transplant Recipients

“…In addition to a robust body of literature supporting the safety and efficacy of penicillin skin testing and direct challenges among immunocompetent hosts [ 5 , 19–22 ], BLA evaluation and de-labeling interventions targeting surgical patient populations have been demonstrated to be associated with increased use of first-line perioperative antibiotics [ 23–25 ]. Furthermore, data regarding the safe use of penicillin skin testing among immunocompromised hosts and transplant candidates have begun to accumulate in recent years [ 26–29 ]. As a result, considering the high proportion of SOT recipients with a BLA and the certainty that their posttransplant course will involve antibiotic exposures, pretransplant evaluation of BLAs should be a priority for this population.…”