Penicillin skin testing as an antimicrobial stewardship initiative

Jones, Bruce M; Bland, Christopher M.

doi:10.2146/ajhp160233

Cited by 41 publications

(42 citation statements)

References 6 publications

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“… Level of evidence evaluated using the GRADE scoring system: A “1” represents a strong recommendation, while a “2” represents weak recommendations/suggestions. “a, b, c” represent the levels of available evidence, with “a” representing consistent evidence from well‐performed randomized, controlled trials or overwhelming evidence of some other form.…”

Section: Current Approaches To Penicillin Allergy Labels and Penicillmentioning

confidence: 99%

“…if a 2nd or 3rd line antibiotic is avoided. 79 Vyles et al estimated the hospital savings of removing inaccurate penicillin allergy diagnosis for a pediatric emergency room with 67 000 annual visits at $192 223 USD. 41,42 Penicillin allergy label removal has been found to be cost effective, even in more expensive inpatient care settings.…”

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

confidence: 99%

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The challenge of de‐labeling penicillin allergy

Stone

Trubiano

Coleman

et al. 2019

Allergy

176

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: Current Approaches To Penicillin Allergy Labels and Penicillmentioning

confidence: 99%

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

176

160

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“…20,54 Pharmacist Pharmacists, particularly infectious diseases or ASP pharmacists, were instrumental to most beta-lactam allergy pathways. 32,33,37,38,[45][46][47] Pharmacists designed and led interventions. 22e25,27 In the PHS pathway, a PHS community site had a pharmacist clinical champion.…”

Section: Infectious Diseasesmentioning

confidence: 99%

“…The PST-based pathways reported the frequency with which the test was positive, negative, and indeterminate. 20,34,36e48 Other assessed outcomes included length of stay, 21 mortality, 29 cost, 25,28,38,39,41,43,[46][47][48]51 and allergy documentation. 21,32,38,40,47,48,54 Antibiotic Use…”

Section: Infectious Diseasesmentioning

confidence: 99%

“…Studies with less patient selection for PST reported lower beta-lactam usages. Although some beta-lactams used after negative PST in some studies were later-generation cephalosporins, broad-spectrum penicillins (eg, piperacillin-tazobactam), and carbapenems, 39,47 the PST-based pathways nonetheless described penicillin use doubling (from 0.32 to 0.71 administrations per patient day) 48 and tripling (from 11% to 32%). 20 More modest changes were observed in the observational studies that used multivariable adjustment or matching.…”

Section: Infectious Diseasesmentioning

confidence: 99%

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Acute care beta-lactam allergy pathways: approaches and outcomes

Wolfson

Huebner

Blumenthal

2019

Annals of Allergy, Asthma & Immunology

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Acute care beta-lactam allergy pathways are coordinated allergy assessment programs for hospitalized patients as an antibiotic stewardship tool, which can be based on the allergy history alone, or use the allergy history to guide procedures such as drug challenges and/or penicillin skin testing. Pathways commonly targeted patients likely to benefit from acute care penicillin allergy evaluations: patients on specific broadspectrum antibiotics, referred from Infectious Diseases specialists, and/or patients with specific infections or bacterial culture results. Acute care beta-lactam pathways were safe and report decreased alternative antibiotic use and increased beta-lactam antibiotic use. Instructions Credit can now be obtained, free for a limited time, by reading the review article and completing all activity components. Please note the instructions listed below: Review the target audience, learning objectives and all disclosures. Complete the pre-test. Read the article and reflect on all content as to how it may be applicable to your practice. Complete the post-test/evaluation and claim credit earned. At this time, physicians will have earned up to 1.0 AMA PRA Category 1 Credit TM. Minimum passing score on the post-test is 70%. Overall Purpose Participants will be able to demonstrate increased knowledge of the clinical treatment of allergy/asthma/immunology and how new information can be applied to their own practices. Learning Objectives At the conclusion of this activity, participants should be able to: Identify the benefits of inpatient beta-lactam allergy assessments. Describe different approaches to beta-lactam allergy pathways including the methods used to identify patients.

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Evaluation and Management of Penicillin Allergy

Shenoy

Macy²,

Rowe

et al. 2019

JAMA

567

531

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IMPORTANCE β-Lactam antibiotics are among the safest and most effective antibiotics. Many patients report allergies to these drugs that limit their use, resulting in the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance and adverse events.OBSERVATIONS Approximately 10% of the US population has reported allergies to the β-lactam agent penicillin, with higher rates reported by older and hospitalized patients. Although many patients report that they are allergic to penicillin, clinically significant IgE-mediated or T lymphocyte-mediated penicillin hypersensitivity is uncommon (<5%). Currently, the rate of IgE-mediated penicillin allergies is decreasing, potentially due to a decreased use of parenteral penicillins, and because severe anaphylactic reactions to oral amoxicillin are rare. IgE-mediated penicillin allergy wanes over time, with 80% of patients becoming tolerant after a decade. Cross-reactivity between penicillin and cephalosporin drugs occurs in about 2% of cases, less than the 8% reported previously. Some patients have a medical history that suggests they are at a low risk for developing an allergic reaction to penicillin. Low-risk histories include patients having isolated nonallergic symptoms, such as gastrointestinal symptoms, or patients solely with a family history of a penicillin allergy, symptoms of pruritus without rash, or remote (>10 years) unknown reactions without features suggestive of an IgE-mediated reaction. A moderate-risk history includes urticaria or other pruritic rashes and reactions with features of IgE-mediated reactions. A high-risk history includes patients who have had anaphylaxis, positive penicillin skin testing, recurrent penicillin reactions, or hypersensitivities to multiple β-lactam antibiotics. The goals of antimicrobial stewardship are undermined when reported allergy to penicillin leads to the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance, including increased risk of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Broad-spectrum antimicrobial agents also increase the risk of developing Clostridium difficile (also known as Clostridioides difficile) infection. Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories. Moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95% and approaches 100% when combined with amoxicillin challenge. Clinicians performing penicillin allergy evaluation need to identify what methods are supported by their available resources.CONCLUSIONS AND RELEVANCE Many patients report they are allergic to penicillin but few have clinically significant reactions. Evaluation of penicillin allergy before deciding not to use penicillin or other β-lactam antibiotics is an important tool for antimicrobial stewardship.

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Penicillin skin testing as an antimicrobial stewardship initiative

Cited by 41 publications

References 6 publications

The challenge of de‐labeling penicillin allergy

The challenge of de‐labeling penicillin allergy

Acute care beta-lactam allergy pathways: approaches and outcomes

Evaluation and Management of Penicillin Allergy

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