Pathways to improved antibiotic allergy and antimicrobial stewardship practice: The validation of a beta-lactam antibiotic allergy assessment tool

Devchand, Misha; Urbancic, Karen; Khumra, Sharmila; Douglas, Abby; Smibert, Olivia C; Cohen, E. Suzanne; Sutherland, Michael; Phillips, Elizabeth; Trubiano, Jason A

doi:10.1016/j.jaip.2018.07.048

Cited by 79 publications

(76 citation statements)

References 13 publications

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“…39 A rational approach for future studies would be to combine direct ingestion challenges with screening criteria validated on previous skin testing or challenge studies, to identify patients at low risk of an immediate hypersensitivity reaction a priori. 93 Skin testing for penicillin allergy has long been known to add additional predictive utility for immediate hypersensitivity over clinical history alone. 17,100 In those with a history of highrisk reactions (eg, widespread immediate urticaria upon first dose, anaphylaxis), skin testing has been successfully deployed to improve point-of-care prescribing, including in the intensive that demonstrated an increase in penicillin utilization (9.9%-49%) and decrease in vancomycin and fluoroquinolone usage after skin testing.…”

Section: Patients With a Low-risk History Or A History Inconsistent Wmentioning

confidence: 99%

“…The most definitive test for de-labeling a penicillin allergy is tolerance of the drug on ingestion challenge. Tolerance of a graded two dose or single dose ingestion challenge is the gold standard to evaluate immediate hypersensitivity drug reactions.Penicillin allergy assessment by history alone utilizing validated point-of-care assessment tools93,94 can risk stratify patients and potentially directly de-label those with clearly non-immune-mediated reactions (20% of all reported penicillin allergies) 46. These approaches currently target inaccurate penicillin allergy labels placed for reasons such as nausea, vomiting, diarrhea alone, or a family history of allergy.…”

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confidence: 99%

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The challenge of de‐labeling penicillin allergy

Stone

Trubiano

Coleman

et al. 2019

Allergy

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176

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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: Patients With a Low-risk History Or A History Inconsistent Wmentioning

confidence: 99%

mentioning

confidence: 99%

The challenge of de‐labeling penicillin allergy

Stone

Trubiano

Coleman

et al. 2019

Allergy

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176

160

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“…[32][33][34] An example is the Antibiotic Allergy Assessment Tool. 34 This underwent multidisciplinary validation by nursing staff, pharmacists, junior and senior medical staff with no training in allergy. It has subsequently been used by hospital pharmacists and nurses to assess betalactam allergy labels.…”

Section: Risk Assessmentmentioning

confidence: 99%

“…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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“…In recent years, algorithms referred to as "de-labeling strategies", which are proven to reduce antibiotic use and improve treatment outcomes, have been described in the US [12], Australia [10], New Zealand [14], Great Britain [11,13], and Germany [16]. Algorithms such as these, some of which are computerassisted, attempt to classify the most likely mechanism of hypersensitivity reaction on the basis of clinical manifestations of BLA allergy in the patient's history.…”

Section: Introductionmentioning

confidence: 99%

Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project

et al. 2020

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Summary Background Beta-lactam antibiotics (BLA) are the treatment of choice for a large number of bacterial infections. Putative BLA allergies are often reported by patients, but rarely confirmed. Many patients do not receive BLA due to suspected allergy. There is no systematic approach to risk stratification in the case of a history of suspected BLA allergy. Methods Using the available stratification programs and taking current guidelines into account, an algorithm for risk stratification, including recommendations on the use of antibiotics in cases of compellingly indicated BLA despite suspected BLA allergy, was formulated by the authors for their maximum care university hospital. Results The hospital is in great need of recommendations on how to deal with BLA allergies. Patient-reported information in the history forms the basis for classifying the reactions into four risk categories: (1) BLA allergy excluded, (2) benign delayed reaction, (3) immediate reaction, and (4) severe cutaneous and extracutaneous drug reaction. Recommendations strictly depend on this classification and range from use of full-dose BLA or use of BLA under certain conditions (e.g., two-stage dose escalation, non-cross-reactive BLA only) to prohibiting all BLA and the use of alternative non-BLA. In case of suspected immediate or delayed allergic reactions, there is an additional recommendation regarding subsequent allergy testing during a symptom-free interval. Conclusion Triage of patients with suspected BLA is urgently required. While allergy testing, including provocation testing, represents the most reliable solution, this is not feasible in all patients due to the high prevalence of BLA allergies. The risk stratification algorithm developed for the authors’ hospital represents a tool suitable to making a contribution to rational antibiotic therapy.

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Pathways to improved antibiotic allergy and antimicrobial stewardship practice: The validation of a beta-lactam antibiotic allergy assessment tool

Cited by 79 publications

References 13 publications

The challenge of de‐labeling penicillin allergy

The challenge of de‐labeling penicillin allergy

Penicillin allergy: a practical approach to assessment and prescribing

Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project

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