The Impact of Reported Beta-Lactam Allergy in Hospitalized Patients With Hematologic Malignancies Requiring Antibiotics

Huang, Kuan-Hsiang Gary; Cluzet, Valerie; Hamilton, Keith; Fadugba, Olajumoke

doi:10.1093/cid/ciy037

Cited by 104 publications

(99 citation statements)

References 34 publications

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“…60,61 Patients with penicillin allergy labels are also at greater risk for multidrug-resistant infections and use of inappropriate antimicrobials during treatment. It has been shown across several countries and healthcare systems that patients with penicillin allergy labels experience increased rates of infection with multidrug-resistant organisms such as Clostridioides difficile, 32,33,55,58,62 methicillin-resistant Staphylococcus aureus (MRSA), 32,33 and vancomycin-resistant Enterococcus species. 33,62 This increase is likely mediated by use of alternative broad-spectrum antimicrobials that favor selection of these organisms.…”

Section: Imp Ortant Neg Ative Con S Equen Ce S Of Peni Cillin Allermentioning

confidence: 99%

The challenge of de‐labeling penicillin allergy

Stone

Trubiano

Coleman

et al. 2019

Allergy

186

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: Imp Ortant Neg Ative Con S Equen Ce S Of Peni Cillin Allermentioning

confidence: 99%

The challenge of de‐labeling penicillin allergy

Stone

Trubiano

Coleman

et al. 2019

Allergy

186

160

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“…A recent retrospective chart review of 4671 American patients with hematologic malignancy evaluated the differences in clinical outcomes between 660 patients who reported β‐lactam allergy and those who did not . Overall, patients with self‐reported β‐lactam allergy had increased median lengths of stay after the first dose of antibiotic therapy and a lower probability of discharge at any given time relative to their counterparts, even after adjusting for potential confounders including neutropenia, leukemia, and severity of illness.…”

Section: Introductionmentioning

confidence: 99%

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

Modi

Majhail

Rybicki

et al. 2019

Transplant Infectious Dis

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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.

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“…Avoidance of BL antibiotics in lieu of NPAs has been shown to increase health care costs . Documentation of BL allergies leads to a longer duration of hospital stay and increased mortality . Specifically, the use of definitive treatment for methicillin‐susceptible Staphylococcus aureus (MSSA) with a BL antibiotic instead of vancomycin is associated with a 35% reduction in mortality .…”

Section: Introductionmentioning

confidence: 99%

“…Specifically, the use of definitive treatment for methicillin‐susceptible Staphylococcus aureus (MSSA) with a BL antibiotic instead of vancomycin is associated with a 35% reduction in mortality . In addition, patients with documented BL allergies are at a higher risk of developing Clostridioides difficile , methicillin‐resistant S. aureus (MRSA), and vancomycin‐resistant Enterococcus (VRE) compared with patients who had no reported BL allergy . The cumulative effect on mortality, morbidity, cost, and drug resistance emphasizes the importance of appropriate BL allergy labeling, as unverified, poorly documented, or inappropriate assessment of BL allergies can lead to suboptimal treatment selection.…”

Section: Introductionmentioning

confidence: 99%

“…5 Documentation of BL allergies leads to a longer duration of hospital stay and increased mortality. 6,7 Specifically, the use of definitive treatment for methicillin-susceptible Staphylococcus aureus (MSSA) with a BL antibiotic instead of vancomycin is associated with a 35% reduction in mortality. 8 In addition, patients with documented BL allergies are at a higher risk of developing Clostridioides difficile, methicillin-resistant S. aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) compared with patients who had no reported BL allergy.…”

mentioning

confidence: 99%

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Pharmacy driven assessment of appropriate antibiotic selection in patients with reported beta‐lactam allergy

Holmes

Bennett

Berry

2019

J Am Coll Clin Pharm

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Background Reported beta‐lactam (BL) antibiotic allergies lead to the avoidance of BL antibiotics. Despite that less than 10% of patients reporting have a true allergy, the documentation often leads to an increased use of alternative antibiotics. These nonpreferred antibiotics (NPA) have a significant impact on cost, clinical outcomes, and antimicrobial resistance. Objective The primary objective of this study was to assess the impact of a pharmacy‐driven assessment on the prescribing frequency of penicillin or cephalosporin antibiotics in patients with a reported BL allergy. Methods This retrospective cohort analysis evaluated the effect of a best practice alert (BPA) and subsequent allergy assessment on BL use in patients with reported allergies at an integrated health system. The BPA notified pharmacy staff that a patient with a documented BL allergy was receiving a NPA. Pharmacy staff assessed previous BL tolerance and clarified reaction, severity, and timing of the documented allergy. Patients were identified for analysis if they had a documented BL allergy within the electronic medical record and received at least one antibiotic during the study period. Results A total of 418 patients were included in this analysis (180 preimplementation, 238 postimplementation). In the pharmacy‐driven assessment group, BL antibiotic use increased by 12.9% (P = .008) in patients with a previously documented BL allergy with the largest use increase in 3rd/4th generation cephalosporins (P = .045). Days of therapy for NPAs decreased in the postimplementation group, including aztreonam (P = .006) and vancomycin (P = .009). Conclusions Our data suggests that a pharmacy‐driven allergy assessment using a BPA can increase appropriate use of BL antibiotics for hospitalized patients.

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The Impact of Reported Beta-Lactam Allergy in Hospitalized Patients With Hematologic Malignancies Requiring Antibiotics

Abstract: In hospitalized patients with hematologic malignancy, patients with reported BL allergy had worse clinical outcomes and higher healthcare cost than those without BL allergy label.

Cited by 104 publications

References 34 publications

The challenge of de‐labeling penicillin allergy

The challenge of de‐labeling penicillin allergy

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

Pharmacy driven assessment of appropriate antibiotic selection in patients with reported beta‐lactam allergy

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