The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk

Blumenthal, Kimberly G.; Ryan, Erin; Liu, Yu; Lee, Hang; Kuhlen, James L.; Shenoy, Erica S.

doi:10.1093/cid/cix794

Cited by 331 publications

(224 citation statements)

References 64 publications

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“…Patients with penicillin allergy labels have been shown to have an increased mortality risk from coexisting hematologic malignancies and infections from penicillin susceptible organisms such as methicillin‐susceptible Staphylococcus aureus (MSSA) . Blumenthal et al have identified that penicillin allergy labels put patients at greater risk of postoperative surgical site infections, mediated by use of alternative antibiotics. Preoperative evaluation of penicillin allergy leads to increased utilization of appropriate antimicrobials, theoretically lowering surgical site infection risk .…”

Section: Important Negative Consequences Of Penicillin Allergy Labelsmentioning

confidence: 99%

“…A retrospective study from a Canadian tertiary center by Picard et al demonstrated greater expenditures per penicillin allergy patient during a one‐year period due to the use of non–beta‐lactam antibiotics. Prolongations of hospitalizations, surgical site infections, and treatment failures are costly outcomes that are increased in the context of a penicillin allergy label. Huang et al report that patients with penicillin allergy labels and hematologic malignancies incur around $50,000 USD in additional costs during their hospitalizations …”

Section: Important Negative Consequences Of Penicillin Allergy Labelsmentioning

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: Important Negative Consequences Of Penicillin Allergy Labelsmentioning

confidence: 99%

Section: Important Negative Consequences Of Penicillin Allergy Labelsmentioning

confidence: 99%

The challenge of de‐labeling penicillin allergy

Stone

Trubiano

Coleman

et al. 2019

Allergy

176

160

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“…Unfortunately, inaccurate or unconfirmed penicillin or B‐lactam allergy and misconceptions surrounding cephalosporin cross‐reactivity mean that many patients do not receive optimum prophylaxis, or it is avoided . In one adult study, patients with a penicillin allergy label had a 50% increased risk of SSI attributed to using the recommended penicillin alternative antibiotics . However, it is known that many of these patients are falsely labeled.…”

Section: Discussionmentioning

confidence: 99%

Allergy alerts — The incidence of parentally reported allergies in children presenting for general anesthesia

Sommerfield

Schilling

et al. 2018

Pediatric Anesthesia

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Summary Background and aim Pediatric patients increasingly report allergies, including allergies to food and medications. We sought to determine the incidence and, nature of parent‐reported allergies in children presenting for surgery and its significance for anesthetists. Methods We prospectively collected data on admissions through our surgical admission unit over a 2‐month period at a pediatric tertiary care teaching hospital. Data collected included patient demographics, history of atopy, with more comprehensive information collected if an allergy was reported. A clinical immunologist and an anesthetist reviewed the documentation of all patients reporting an allergy. Results We reviewed 1001 pediatric patients, 158 (15.8%) patients with parent‐reported allergies; to medications/drugs (n = 73), food (n = 66), environmental allergens (dust/grasses, n = 35), tapes/dressings (n = 27), latex (n = 4), and venom (eg, bee, wasp, n = 9). Forty‐one patients reported antibiotic allergies, with Beta‐lactam antibiotics being the most common, with the majority presenting with rash alone (57%). Ten patients reported allergies to nonsteroidal anti‐inflammatory drugs and eight to opioids. Twenty‐four patients reported egg and/or peanut allergy. Only 3/1001 (0.3%) patients were deemed to have evidence of likely IgE‐mediated drug allergy. Of the reported allergies, only 60 (38.2%) had been investigated prior, most likely to be followed up were food (53%) and environmental allergies (44.4%). Only 4/73 (5.5%) reported medication allergies had further follow‐up. Just four patients (0.4% of the entire cohort) had drug sensitivities/allergies that were likely to majorly alter anesthesia practice. Conclusion Only the minority of parent‐reported allergies in pediatric surgical patients were specialist confirmed and likely to be clinically relevant. Self‐reported food allergy is commonly specialist verified whereas reactions to medications were generally not. Over‐reporting of allergies is increasingly common and limits clinician choice of medications. Better education of patients and their families and more timely verification or dismissal of parent‐reported reactions is urgently needed.

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“…The use of alternative drugs (clindamycin, vancomycin, gentamycin) in patients reporting penicillin allergy can result in increased SSIs because concentration‐response relationships or dosing are less well defined than for penicillin. Adult patients with a reported penicillin allergy had a 50% increased odds of SSI, attributable to the receipt of second‐line perioperative antibiotics …”

Section: Perioperative Antibiotic Prophylaxismentioning

confidence: 99%

Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures

Morse

Blackburn

Hannam

et al. 2018

Pediatric Anesthesia

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Postoperative wound infections represent an important source of morbidity and mortality in children. Perioperative antibiotic prophylaxis has been shown to decrease the risk of developing infections and hospital guidelines surrounding antibiotic use exist to standardize patient care. Despite supporting evidence, rates of compliance with guidelines vary. Quality improvement initiatives have been introduced to improve compliance with intraoperative antibiotic guidelines. Thorough infection surveillance, including antibiotic provision in presurgical checklists, computerized voice antibiotic administration prompts, and national feedback systems are now increasingly common. Few studies have been conducted investigating the effectiveness of prophylactic antibiotics in children. Outcome measures such as morbidity and mortality and return to the operating room can be used to examine the relationship between antibiotic use and patient outcome but these measures are limited in that they occur infrequently or are subjective and difficult to measure. Metrics such as days alive out of hospital and length of hospital stay may be useful alternatives for ongoing monitoring of infections and identifying improvements in patient outcomes. Guidelines on antibiotic prophylaxis have facilitated an increase in the correct provision of perioperative antibiotics and a reduction in the incidence of postoperative infection. Measures of patient outcome such as days alive out of hospital and length of hospital stay are easy to collect and calculate but further work is needed to confirm the utility of these measures for monitoring infection rates.

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The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk

Abstract: Patients with a reported penicillin allergy had a 50% increased odds of SSI, attributable to the receipt of second-line perioperative antibiotics. Clarification of penicillin allergies as part of routine preoperative care may decrease SSI risk.

Cited by 331 publications

References 64 publications

The challenge of de‐labeling penicillin allergy

The challenge of de‐labeling penicillin allergy

Allergy alerts — The incidence of parentally reported allergies in children presenting for general anesthesia

Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures

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