Adherence to antibiotic guidelines and reported penicillin allergy: pooled cohort data on prescribing and allergy documentation from two English National Health Service (NHS) trusts

Abstract

ObjectiveTo investigate documentation of antimicrobial allergy and to determine prescribing adherence to local antibiotic guidelines for inpatients with and without reported penicillin allergy treated for infection in a National Health Service (NHS) context.SettingData were collected at two English hospital NHS trusts over two time-periods: June 2016 and February 2017.DesignCohort study. Trust 1 data were sourced from prospective point prevalence surveys. Trust 2 data were extracted retrospectively from an electronic report.ParticipantsInpatients treated for urinary tract infection (UTI), community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and skin and soft tissue infection (SSTI). Data on allergy were collected, and antibiotic selection assessed for adherence to trust guidelines with differences between groups presented as adjusted ORs.ResultsA total of 1497 patients were included, with 2645 antibiotics orders. Patients were treated for CAP (n=495; 33.1%), UTI (407; 27.2%), HAP (330; 22%) and SSTI (265; 17.7%). There were 240 (16%) patients with penicillin allergy. Penicillin allergy was recorded as allergy (n=52; 21.7%), side effect (27; 11.3%) and no documentation (161; 67.1%). Overall, 2184 (82.6%) antibiotic orders were guideline-adherent. Adherence was greatest for those labelled penicillin allergy (453 of 517; 87.6%) versus no allergy (1731 of 2128; 81.3%) (OR 0.52 (95% CI 0.37 to 0.73) p<0.001). Guideline-adherence for CAP was higher if penicillin allergy (151 of 163; 92.6%) versus no allergy (582 of 810; 71.9%) (OR 0.20 (95% CI 0.10 to 0.37) p<0.001). There was no difference in adherence between those with and without penicillin allergy for UTI, HAP or SSTI treatment.ConclusionsA relatively high proportion of patients had a penicillin allergy and two thirds of these had no description of their allergy, which has important implications for patient safety. Patients with penicillin allergy treated for CAP, received more guideline adherent antibiotics than those without allergy. Future studies investigating the clinical impact of penicillin allergy should include data on adherence to antibiotic guidelines.

Patient Adherence to Written Instructions following Complete Allergological Evaluation for Suspected Beta-Lactam Allergy: A Tertiary Hospital Study in Greece

“…Notably, almost 65% expressed a willingness to consume the delabelled drugs in the subsequent follow-up survey. While not statistically significant, psychiatric comorbidities were observed in 43% of this cohort, aligning with prior research indicating that anxiety and depression may contribute to an increased number of allergy labels [12,13]. These factors are likely influential in determining compliance rates.…”

“…These factors are likely influential in determining compliance rates. Furthermore, the presence of a genuine penicillin allergy label has demonstrated a significant association with greater adherence to antibiotic guidelines in two English National Health Service (NHS) trusts, as compared to non-allergy labels [13].…”

The impact of antibiotic allergy labels on antibiotic exposure, clinical outcomes, and healthcare costs: A systematic review

“…Notably, 1 study, which examined guideline adherence in penicillin allergic patients, found that there was increased adherence to guidelinerecommended therapy when an allergy label was present. 18 Additionally, 7 of 10 studies examining inpatients (70%) found that antibiotic allergy labels significantly increased the number of antibiotics administered. 2,[19][20][21][22][23][24] The other 3 studies reported equivocal results.…”

“…Philips et al, 2019 18 Reported penicillin allergy increased overall adherence to antimicrobial guidelines (OR, 0.61; 95% CI, 0.46-0.82; P < .001), even after adjustment (OR, 0.52; 95% CI, 0.37-0.73; P < .001).…”

Surgical Antibiotic Prophylaxis in an Era of Antibiotic Resistance: Common Resistant Bacteria and Wider Considerations for Practice

“…A recent multicentre UK study of hospitalised patients with common infections found that two-thirds of those patients with documented penicillin allergy had no details recorded on their purported allergy. 82 Similarly, in the perioperative setting, a UK study of over 21,000 elective surgical patients found that 27% of those with an allergy label were likely suitable for a direct provocation test. 83 A US study by Blumenthal et al of 8385 patients undergoing arthroplasty, gastrointestinal surgery, cardiovascular surgery, and hysterectomy found those listed with a penicillin allergy to have a 50% increased SSI risk which was largely due to patients receiving second-line agents for SAP.…”