Evaluation of a pharmacist-led penicillin allergy de-labelling ward round: a novel antimicrobial stewardship intervention

Devchand, Misha; Kirkpatrick, Carl M.; Stevenson, Wendy; Garrett, Kent; Perera, Dhineli; Khumra, Sharmila; Urbancic, Karen; Grayson, M. Lindsay; Trubiano, Jason A

doi:10.1093/jac/dkz082

Cited by 72 publications

(64 citation statements)

References 19 publications

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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%

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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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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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“…5,9,33 Paper and computer-based stratification tools have been developed and employed at various stages of the patient's journey by clinicians and pharmacists in hospitalised patients and for preoperative testing. 5,[34][35][36][37] Application of these tools results in 1 of 3 possible outcomes: removal of spurious PenA label; referral to specialist allergy assessment services for those deemed to be high risk; or confirmation of PenA status.…”

Section: Pena Delabelling Methodsmentioning

confidence: 99%

“…Recent studies of newer approaches of direct PenA delabelling using structured review and algorithms have primarily focussed on safety and clinical effectiveness (see Table ). Those conducted in hospital settings have involved a multidisciplinary team as a part of AMS programmes; and outpatient delabelling has mainly involved allergy specialist clinics . Patient partnership is key to the success of direct Pen‐A delabelling, however, some patients do not consent to participate and even when they do, are not comfortable with re‐exposure …”

Section: Introductionmentioning

confidence: 99%

Sustaining and spreading penicillin allergy delabelling: A narrative review of the challenges for service delivery and patient safety

Jani¹,

Williams

Krishna

2020

Brit J Clinical Pharma

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Many patients report allergies to penicillin, although in over 90% of these the label of penicillin allergy is shown to be incorrect following comprehensive testing. Inappropriate and inaccurate penicillin allergy labelling is a barrier to antimicrobial stewardship and can lead to patient harm. This review assesses an emergent evidence base and trend favouring delabelling using direct oral penicillin challenges following a stratified risk assessment of the likelihood and existence of true penicillin allergy, to identify and make recommendations for key components for implementation in standard practice. Research to date has focussed on the feasibility and clinical and financial outcomes of these direct delabelling strategies. There is a paucity of studies exploring the views and engagement of patients and healthcare professionals, and a gap in the evidence for prerequisites to safely deliver, sustain and spread the implementation of such services across health systems.

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“…It has subsequently been used by hospital pharmacists and nurses to assess betalactam allergy labels. 35 This tool classifies penicillin allergies into colour-coded risk groups and suggests an appropriate method for de-labelling: 34,36 • no risk -direct 'de-label'…”

Section: Risk Assessmentmentioning

confidence: 99%

Penicillin allergy: a practical approach to assessment and prescribing

Devchand

Trubiano

2019

Aust Prescr

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Penicillin allergies are not always lifelong. Approximately 50% are lost over five years. A reaction to penicillin during a childhood infection is unlikely to be a true allergy. Only 1-2% of patients with a confirmed penicillin allergy have an allergy to cephalosporins. In patients with a low risk of severe allergic reactions, cephalosporins are a relatively safe treatment option. Patients with a history of delayed non-severe reactions, such as mild childhood rashes that occurred over 10 years ago, may be suitable for an oral rechallenge with low-dose penicillin. This should be done in a supervised hospital environment. In many cases, with appropriate assessment and allergy testing, it may be possible to remove the penicillin allergy label. stay, 3 hospital readmission rates, 10 surgical site infections, 14 and admissions to intensive care units. 15 Similarly in general practice, penicillin allergy labels are associated with an increased risk of death and MRSA infection or colonisation. 16 Impermanent allergy It has been demonstrated that more than 90% of patients labelled as having a penicillin allergy would be able to tolerate penicillins following appropriate assessment and allergy testing. 17-19 Even penicillin allergies confirmed by skin tests can wane over time. Half the patients who have a positive skin test for penicillins will lose that reactivity after five years. 13,20 There is therefore interest in penicillin allergy 'de-labelling'. This is the removal of the allergy label following either allergy history reconciliation or testing (oral provocation or skin testing). What is true penicillin allergy? The classification of a patient-reported penicillin allergy label is the first important step in appropriate care (Table 1). Before prescribing, ask patients about their allergies, as not all allergies may have been documented in their medical records. Conversely, some reactions labelled as allergic may be other types of adverse events. Ask about the clinical features of suspected reactions. Allergic cross-reactivity The beta-lactam antibiotics include penicillins, cephalosporins, carbapenems and monobactams.

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Evaluation of a pharmacist-led penicillin allergy de-labelling ward round: a novel antimicrobial stewardship intervention

Cited by 72 publications

References 19 publications

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

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

Sustaining and spreading penicillin allergy delabelling: A narrative review of the challenges for service delivery and patient safety

Penicillin allergy: a practical approach to assessment and prescribing

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