Point-of-Care β-Lactam Allergy Skin Testing by Antimicrobial Stewardship Programs: A Pragmatic Multicenter Prospective Evaluation

Leis, Jerome A; Palmay, Lesley; Ho, Grace; Raybardhan, Sumit; Gill, Suzanne; Kan, Tiffany; Campbell, Jackie; Kiss, Alex; McCready, Janine; Das, Pavani; Minnema, Brian; Powis, Jeff; Walker, Sandra A N; Ferguson, Heather; Wong, Benny; Weber, Elizabeth

doi:10.1093/cid/cix512

Cited by 51 publications

(46 citation statements)

References 13 publications

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“…Once risk is assessed, pathways will lead toward direct provocation challenges in low‐risk patients or skin testing in higher risk patients. One inpatient multi‐center ASP‐led beta‐lactam allergy testing service has already been shown to improve beta‐lactam usage . A multidisciplinary ASP‐led approach in Australia was able to remove a penicillin allergy label in 83% of patients and increase narrow‐spectrum beta‐lactam (aOR, 3.54; 95% CI, 1.98‐6.33) and appropriate antibiotic usage (aOR, 12.27; 95% CI, 5.00‐30.09) up to 90‐day post‐testing .…”

Section: Current Approaches To Penicillin Allergy Labels and Penicillmentioning

confidence: 99%

The challenge of de‐labeling penicillin allergy

Stone

Trubiano

Coleman

et al. 2019

Allergy

187

160

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Background Even though 8%‐25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de‐labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. Methods We performed an evidence‐based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de‐labeling. Over the period 1928‐2018 in Pubmed and Medline, search terms used included “penicillin allergy” or “penicillin hypersensitivity” alone or in combination with “adverse events,” “testing,” “evaluation,” “effects,” “label,” “de‐labeling,” “prick or epicutaneous,” and “intradermal” skin testing, “oral challenge or provocation,” “cross‐reactivity,” and “antimicrobial stewardship”. Results Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. Conclusions Operationalizing penicillin allergy de‐labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de‐labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.

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Section: Current Approaches To Penicillin Allergy Labels and Penicillmentioning

confidence: 99%

The challenge of de‐labeling penicillin allergy

Stone

Trubiano

Coleman

et al. 2019

Allergy

187

160

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“…allergy pathway conducted in Australia were led by infectious diseases physicians. 20,54 Pharmacist Pharmacists, particularly infectious diseases or ASP pharmacists, were instrumental to most beta-lactam allergy pathways. 32,33,37,38,[45][46][47] Pharmacists designed and led interventions.…”

Section: Infectious Diseasesmentioning

confidence: 99%

“…29 Two PST-based pathways reported that their approach saved approximately 50 doses of vancomycin. 39,41 Other PST-based pathways reported carbapenem and fluoroquinolone reduction (28% to 13%), 20 and aztreonam reduction (2.54 to 1.47 administrations per 1000 patient-days). 48 In the initial MGH pathway study, vancomycin, aztreonam, aminoglycosides, and fluoroquinolones were switched to beta-lactams using test doses.…”

Section: Infectious Diseasesmentioning

confidence: 99%

“…18,19 Prescribing beta-lactam antibiotics to patients with beta-lactam allergy histories occurs in approximately 5% of all US hospital patients, considering that 15% of hospital patients report a penicillin allergy, 40% to 50% require antibiotics, and 75% of hospital infections should be treated with a beta-lactam. 8,20 In this review, we identified a variety of acute care beta-lactam allergy pathways by intervention type, with a focus on unifying themes important to the intervention process and outcome measures considered central to antibiotic stewardship, quality improvement, and patient safety.…”

Section: Introductionmentioning

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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“…[15][16][17] This recommendation is based on the high negative predictive value of skin tests reported by American studies in which bencylpenicillin and penicillin V were predomi nantly prescribed. 18 However, more recent Eu ropean studies reported that between 8.4% and 30.7% of patients with negative results reacted to drug challenge.…”

mentioning

confidence: 99%

Using beta-lactam antibiotics in patients with a history of beta-lactam allergy: current concepts

Moreno¹,

Laffond²,

Muñoz-Bellido³

et al. 2017

Polish Archives of Internal Medicine

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ABSTRACTβ-lactams are the most widely used antibiotic family, but they are also the most common cause of drug-induced hypersensitivity reactions. The estimated prevalence of reported penicillin allergy ranges between 9% and 12%, although a high percentage of patients with a history of penicillin allergy have no subsequent reactions on reexposure to β-lactams. A self-reported penicillin allergy has been associated with antimicrobial resistance, increased cost, intensive care admission, and death, making it essential to establish an accurate diagnosis. In addition to a thorough clinical history, diagnostic methods include skin tests, in vitro tests, and drug-challenge tests. In this review, the diagnosis and management of patients with self-reported penicillin allergy is discussed, including the recently introduced antimicrobial stewardship strategy.REVIEW ARTICLE Use of β-lactam antibiotics in patients with a history of β-lactam allergy 541Antigenic determinants of β-lactams Penicillins and βlactams are generally considered immuno logically haptens and need to bind to carrier mol ecules to acquire complete immunogenic poten cy. The binding of the antibiotic to amino groups of autologous proteins induces a conformational modification that causes the immune system to recognize them as strange. The βlactam rings and the side group are all potentially immunogenic.Penicillins have been the most studied antibiot ics. The βlactam ring is intrinsically reactive and does not need prior metabolism. The instability of its structure makes it open quickly, allowing the carbonyl groups to form amidetype linkages with the amino groups of the lysine residues of the nearby proteins. 26 As approximately 95% of the penicillin molecules are bound to proteins in this manner, the antigenic determinant formed, benzylpenicilloyl (BPO), has been known as the major antigenic determinant of penicillin. BPO has been attached to a weakly immunogenic car rier molecule, called polylysine, to form benzyl penicilloyl polylysine (BPOPPL), which is used in making skin tests. The remaining part of the penicillin molecule degrades to a range of deriv atives which can also act as haptens. 27 These are minor determinants accounting for allergic reac tions in approximately 10% to 20% of patients. 23 The minor determinant mixture (MDM) has been also used in skin tests.The progressive increase in the consumption of amoxicillin (AX) has led to an increase in the detection of patients allergic to AX who tolerate benzylpenicillin (BP).28 These reactions are called selective reactions to AX. The major antigenic de terminant of AX is the amoxicilloyl amide, which results from the opening of the βlactam ring by amino groups. 29 Although the structure of the possible antigen ic elements of cephalosporins is not well known, different experimental studies have proved that they can generate structures able to provoke spe cific immune response. 30 IgE antibodies that re act with cephalosporins have been shown to de tect a wide range of specificities, although the f...

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Point-of-Care β-Lactam Allergy Skin Testing by Antimicrobial Stewardship Programs: A Pragmatic Multicenter Prospective Evaluation

Abstract: The use of BLAST at the point of care across 3 hospital ASPs resulted in greater use of preferred β-lactam therapy without increasing the risk of adverse drug reactions. Longer-term studies are needed to better assess the safety and clinical impact of this ASP intervention.

Cited by 51 publications

References 13 publications

The challenge of de‐labeling penicillin allergy

The challenge of de‐labeling penicillin allergy

Acute care beta-lactam allergy pathways: approaches and outcomes

Using beta-lactam antibiotics in patients with a history of beta-lactam allergy: current concepts

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