De-labeling of β-lactam allergy reduces intraoperative time and optimizes choice in antibiotic prophylaxis

Moussa, Yara; Shuster, Joseph; Matte, Gilbert; Sullivan, Andrew; Goldstein, Robert H.; Cunningham, Dayle; Ben‐Shoshan, Moshe; Baldini, Gabriele; Carli, Francesco; Tsoukas, Christos

doi:10.1016/j.surg.2018.03.004

Cited by 41 publications

(25 citation statements)

References 37 publications

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“…Patient and physician misconceptions surrounding penicillin allergy and cross reactivity with cephalosporins are prevalent, 13 and interventions are urgently needed for clinicians to accurately assess a reported allergy and to determine whether they can safely receive cefazolin. Interventions such as β-lactam skin testing [14][15][16][17][18][19] and oral provocation challenges [18][19][20] have been used in the perioperative setting but have been limited in their scalability and sustainability due to resource requirements. It is now recognized that the cephalosporin cefazolin is non-cross-reactive with penicillin due to a structurally dissimilar side chain, 2 which suggests that the decision to administer cefazolin preoperatively could theoretically be achieved with a clinical history alone.…”

Section: Discussionmentioning

confidence: 99%

Self-reported beta-lactam allergy and the risk of surgical site infection: A retrospective cohort study

Lam

Tarighi

Elligsen

et al. 2020

Infect. Control Hosp. Epidemiol.

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Objective:To assess whether a self-reported β-lactam allergy is associated with an increased risk of surgical site infection (SSI) across a broad range of procedures and to determine whether this association is mediated by the receipt of an alternate antibiotic to cefazolin.Design:Retrospective cohort study.Participants:Surgical procedures sampled by an institutional National Surgical Quality Improvement Program database over an 18-month period (January 2017 to June 2018) from 7 surgical specialties.Setting:Tertiary-care academic hospital.Results:Of the 3,589 surgical procedures included in the study, 369 (10.3%) were performed in patients with a reported β-lactam allergy. Those with a reported β-lactam allergy were significantly less likely to receive cefazolin (38.8% vs 95.5%) or metronidazole (20.3% vs 26.1%) and were more likely to receive clindamycin (52.0% vs 0.2%), gentamicin (3.5% vs 0%), or vancomycin (2.2% vs 0.1%) than those without allergy. An SSI occurred in 154 of 3,220 procedures (4.8%) in patients without reported allergy and 27 of 369 (7.3%) with reported allergy. In the multivariable regression model, a reported β-lactam allergy was associated with a statistically significant increase in SSI risk (adjusted odds ratio [aOR], 1.61; 95% confidence interval [CI], 1.04–2.51; P = .03). This effect was completely mediated by receipt of an alternate antibiotic to cefazolin (indirect effect aOR, 1.68; 95% CI, 1.17–2.34; P = .005).Conclusions:Self-reported β-lactam allergy was associated with an increased SSI risk mediated through receipt of alternate antibiotic prophylaxis. Safely increasing use of cefazolin prophylaxis in patients with reported β-lactam allergy can potentially lower the risk of SSIs.

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Section: Discussionmentioning

confidence: 99%

Self-reported beta-lactam allergy and the risk of surgical site infection: A retrospective cohort study

Lam

Tarighi

Elligsen

et al. 2020

Infect. Control Hosp. Epidemiol.

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“…• 2016-2018-More recent articles on penicillin and cephalosporin cross-reactivity highlight specific R1 cross-reactivity patterns and very low rate of cross-reactivity based on beta-lactam ring (<2%) 35,36 • 2016-2018-Impact of penicillin labels on time to antibiotic administration 37,38 • 2017-Impact of penicillin over-labeling on antibiotic resistance 40…”

Section: Acqu Is Iti On Of Peni Cillin Allergy L Ab El Smentioning

confidence: 99%

The challenge of de‐labeling penicillin allergy

Stone

Trubiano

Coleman

et al. 2019

Allergy

172

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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“…These patients would not have been identified through our inclusion criteria search as the BL allergy would no longer be listed on their profile. Recent studies have reported positive effects of BL allergy de‐labeling including decreased use of NPAs and increased utilization of BLs . During the development of our BPA, removing allergies that were deemed intolerances or nonsignificant allergies was discussed.…”

Section: Discussionmentioning

confidence: 99%

“…Recent studies have reported positive effects of BL allergy de- labeling including decreased use of NPAs and increased utilization of BLs. [19][20][21] During the development of our BPA, removing allergies that were deemed intolerances or nonsignificant allergies was discussed.…”

Section: Discussionmentioning

confidence: 99%

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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De-labeling of β-lactam allergy reduces intraoperative time and optimizes choice in antibiotic prophylaxis

Cited by 41 publications

References 37 publications

Self-reported beta-lactam allergy and the risk of surgical site infection: A retrospective cohort study

Self-reported beta-lactam allergy and the risk of surgical site infection: A retrospective cohort study

The challenge of de‐labeling penicillin allergy

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

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