Risk-stratified Management to Remove Low-Risk Penicillin Allergy Labels in the ICU

Stone, Cosby A.; Stollings, Joanna L.; Lindsell, Christopher J.; Dear, Mary Lynn; Buie, Reagan; Rice, Todd W.; Phillips, Elizabeth

doi:10.1164/rccm.202001-0089le

Cited by 53 publications

(44 citation statements)

References 13 publications

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“…[15,31] For instance the vast majority of patients who are labeled as having a penicillin allergy were typically labeled much earlier in childhood. [32][33][34] Studies in allergy practice show that >95% of these individuals that undergo validated skin testing and challenge will tolerate penicillin, in part due to waning of this allergic response over time. [31] Therefore, our analysis did not consider the possibility of patients having lost their allergic tendency and being delabeled for a drug allergy, and our results should be explained as 'ever or never' reported an adverse reaction to a drug.…”

Section: Plos Geneticsmentioning

confidence: 99%

High-throughput framework for genetic analyses of adverse drug reactions using electronic health records

et al. 2021

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Understanding the contribution of genetic variation to drug response can improve the delivery of precision medicine. However, genome-wide association studies (GWAS) for drug response are uncommon and are often hindered by small sample sizes. We present a high-throughput framework to efficiently identify eligible patients for genetic studies of adverse drug reactions (ADRs) using “drug allergy” labels from electronic health records (EHRs). As a proof-of-concept, we conducted GWAS for ADRs to 14 common drug/drug groups with 81,739 individuals from Vanderbilt University Medical Center’s BioVU DNA Biobank. We identified 7 genetic loci associated with ADRs at P < 5 × 10−8, including known genetic associations such as CYP2D6 and OPRM1 for CYP2D6-metabolized opioid ADR. Additional expression quantitative trait loci and phenome-wide association analyses added evidence to the observed associations. Our high-throughput framework is both scalable and portable, enabling impactful pharmacogenomic research to improve precision medicine.

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Section: Plos Geneticsmentioning

confidence: 99%

High-throughput framework for genetic analyses of adverse drug reactions using electronic health records

et al. 2021

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“…For example, antihistamines do not prevent anaphylaxis and are not necessarily a contraindication to an oral challenge, 8 and an isolated urticarial reaction after 6 hours of receiving a medication can be considered a low-risk symptom. 12,13 Second, broadening the hospital environment beyond the pediatric floors will increase access to low-risk patients. The ICU, 13 preoperative and perioperative settings, 14,15 and emergency department 12 are areas of high benefit in which patients can be safely evaluated.…”

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confidence: 99%

“…12,13 Second, broadening the hospital environment beyond the pediatric floors will increase access to low-risk patients. The ICU, 13 preoperative and perioperative settings, 14,15 and emergency department 12 are areas of high benefit in which patients can be safely evaluated. Third, the authors note that a "nudge" from their oversight team was an effective intervention.…”

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confidence: 99%

“…For example, incorporating pharmacists into the delabeling workflow can be extremely valuable. 12,13 Fourth, one effective intervention in this study was EHR identification of the allergy, ordering of oral challenge, and documentation support. Validated pediatric-based allergy assessments incorporate the allergy reaction alone or, for certain reactions such as urticaria, timing of symptoms relative to medication exposure.…”

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Breaking the Mold: Safely Delabeling Penicillin Allergies in Hospitalized Children

Antoon

Grisso

Stone

2021

Hospital Pediatrics

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Children are often reported to have antibiotics allergies, with up to 35 million people, or 10% of the US population, labeled as allergic to an antibiotic. 1 In fact, 75% of children with reported antibiotic allergies are identified before the age of 3 years. 2 Recent studies have revealed that the majority of symptoms reported as an allergy by parents are non-immunoglobulin E-mediated adverse reactions or symptoms of a viral illness, such as rash, abdominal pain, vomiting, diarrhea, or other benign symptoms. 3,4 Additionally, .90% of patients with a reported penicillin allergy have negative skin testing results. 1,5,6 Several studies in adults and children reveal risk-stratified management, wherein those at low risk for a true allergy skip skin testing in favor of direct oral challenge, is safe and effective. 7 Delabeling penicillin allergies in children without true allergies is critical because penicillin allergy labels are associated with worse clinical outcomes, increased adverse drug events, more multidrug-resistant infections, and increased health care costs. [7][8][9] Although risk-stratified management of drug allergies is now standard of care, 7,8 implementation of this best practice in the hospital setting is lacking.In this issue of Hospital Pediatrics, researchers report a single-center, hospital-based quality improvement (QI) project aimed at performing risk stratification of penicillin allergies, with subsequent delabeling of children who do not have a true allergy. They used a multidisciplinary clinical care pathway, with several important interventions, including provider incentives, education initiatives, electronic health record (EHR) support, and oversight team encouragement of allergy evaluation at the provider level. The QI project achieved their preset goal, and the proportion of penicillin-allergy delabeling increased almost fivefold.In addition to the overall increased proportion of penicillin-allergy delabeling, the authors present several interesting findings. First, of those deemed low risk for true allergy, .50% received a penicillin antibiotic before discharge. Although this is likely due to the prioritization of delabeling efforts by providers in patients with immediate antibiotic selection needs, the high rate of penicillin prescribing in those admitted with a penicillin allergy is striking and emphasizes the short-term benefits of allergy delabeling programs. Second, 38% of delabeling occurred without an oral challenge. Many children are unnecessarily deemed "allergic" due to

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“…Because most PAL is labeled in childhood and >80% of patients will undergo surgery after their penicillin index reaction 8 , this avoidance affects most PAL patients. This information is helpful in guiding risk stratification for delabeling by history or testing 9 to improve perioperative antibiotic use and post-operative outcomes.…”

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Penicillin allergy labels drive perioperative prophylactic antibiotic selection in orthopedic procedures

Coleman

Stone

Wei

et al. 2020

The Journal of Allergy and Clinical Immunology: In Practice

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This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Risk-stratified Management to Remove Low-Risk Penicillin Allergy Labels in the ICU

Cited by 53 publications

References 13 publications

High-throughput framework for genetic analyses of adverse drug reactions using electronic health records

High-throughput framework for genetic analyses of adverse drug reactions using electronic health records

Breaking the Mold: Safely Delabeling Penicillin Allergies in Hospitalized Children

Penicillin allergy labels drive perioperative prophylactic antibiotic selection in orthopedic procedures

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