The Use of Penicillin Skin Testing to Assess the Prevalence of Penicillin Allergy in an Emergency Department Setting

Raja, Ali S.; Lindsell, Christopher J.; Bernstein, Jonathan A.; Codispoti, Christopher D.; Moellman, Joseph J.

doi:10.1016/j.annemergmed.2008.12.034

Cited by 78 publications

(59 citation statements)

References 23 publications

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“…Although electronic health systems could do more to encourage providers to better characterize drug reactions (e.g., requiring characterization of a rash as urticarial, if known), this may be of limited utility, given that patient self-reporting of penicillin allergies has poor predictive value when assessed by subsequent skin testing. 9,10 Nonetheless, separating side effects, drug sensitivities, and allergic symptoms would likely aid medical decision making when antibiotic choices need to be made in the presence of a prior reaction, especially when clinical decision support related to medication prescribing is involved. Second, there was a substantial prevalence of providers electing to administer an alternative antibiotic rather than the indicated cephalosporin even in the face of reactions that have no immunologic basis.…”

Section: Discussionmentioning

confidence: 99%

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Prophylactic Antibiotic Management of Surgical Patients Noted as “Allergic” to Penicillin at Two Academic Hospitals

et al. 2016

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We studied prophylactic antibiotics administered at 2 academic medical centers during a 6-year period where a cephalosporin was indicated but an "allergy" to penicillin was noted. Another drug (typically vancomycin or clindamycin) was substituted approximately 80% of the time; this occurred frequently even when symptoms unrelated to acute hypersensitivity were listed. In >50% of cases, the reaction was either omitted or vague (e.g., simply "rash"). Given the estimated 1% cross-reactivity between penicillins and cephalosporins with similar R1 side chains, many of these patients could have received either the prescribed cephalosporin or another cephalosporin with a different R1 side chain.

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Section: Discussionmentioning

confidence: 99%

“…8 Furthermore, in 93.1% of self-reported penicillin allergy, skin tests were negative. 9 With a vague history of a reaction, 85.4% of skin tests were negative. 10 Thus, avoiding cephalosporins in the face of an unproven penicillin allergy usually is unnecessary.…”

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confidence: 99%

Prophylactic Antibiotic Management of Surgical Patients Noted as “Allergic” to Penicillin at Two Academic Hospitals

et al. 2016

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“…19 In our study, approximately 12% of the patients received a beta-lactam alternative antibiotic regimen, a prevalence consistent with the self-reported PCN allergy described in the literature. 20 It is important to remember that cephalosporin cross-reactivity shown in skin testing is present in only 10% of patients with a true PCN allergy. 19,21 Patients with negative results on PCN skin testing and those without a history of anaphylactic reaction to PCN can safely receive cephalosporin.…”

Section: Discussionmentioning

confidence: 99%

Prophylactic Antibiotic Choice and Risk of Surgical Site Infection After Hysterectomy

Uppal

Harris

Al-Niaimi

et al. 2016

Obstetrics & Gynecology

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OBJECTIVE To evaluate associations between prophylactic preoperative antibiotic choice and surgical site infection rates after hysterectomy. METHODS A retrospective cohort study was performed of patients in the Michigan Surgical Quality Collaborative undergoing hysterectomy from July 2012 to February 2015. The primary outcome was a composite outcome of any surgical site infection (superficial surgical site infections or combined deep–organ space surgical site infections). Preoperative antibiotics were categorized based on the recommendations set forth by the American College of Obstetricians and Gynecologists and the Surgical Care Improvement Project. Patients receiving a recommended antibiotic regimen were categorized into those receiving beta-lactam antibiotics and those receiving alternatives to beta-lactam antibiotics. Patients receiving non-recommended antibiotics were categorized into those receiving overtreatment (excluded from further analysis) and those receiving non-standard antibiotics. Multivariable logistic regression models were developed to estimate the independent effect of antibiotic choice. Propensity score matching analysis was performed to validate the results. RESULTS The study included 21,358 hysterectomies. The overall rate of any surgical site infection’ was 2.06% (N=441). Unadjusted rates of ‘any surgical site infection’ were 1.8%, 3.1% and 3.7% for beta-lactam, beta-lactam alternatives and non-standard groups, respectively. After adjusting for patient and operative factors within clusters of hospitals, compared to the beta-lactam antibiotics (reference group), the risk of ‘any surgical site infection’ was higher for the group receiving beta-lactam alternatives (OR 1.7, CI 1.27–2.07) or the non-standard antibiotics (OR 2.0, CI 1.31–3.1). CONCLUSION Compared to women receiving beta lactam antibiotic regimens, there is a higher risk of surgical site infection after hysterectomy among those receiving a recommended beta lactam alternative or non-standard regimen.

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“…1–4 Compared to beta-lactam antibiotics, these drugs are less effective in some clinical circumstances, 5–8 more toxic, 4,9 more costly, 10,11 and generally cover a broader antimicrobial spectrum. When a beta-lactam antibiotic is the preferred inpatient antibiotic, but not administered due to alleged allergy, patients experience more treatment failures and adverse events.…”

Section: Introductionmentioning

confidence: 99%

Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship

Blumenthal

Wickner

Hurwitz

et al. 2017

Journal of Allergy and Clinical Immunology

128

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Background Reported penicillin allergy rarely reflects penicillin intolerance. Failure to address inpatient penicillin allergies results in more broad-spectrum antibiotic use, treatment failures, and adverse drug events. Objective We aimed to determine the optimal approach to penicillin allergies among medical inpatients. Methods We evaluated internal medicine inpatients reporting penicillin allergy in three periods: (1) standard of care (SOC), (2) penicillin skin testing (ST), and (3) computerized guideline application with decision support (APP). The primary outcome was use of a penicillin or cephalosporin, comparing interventions to SOC using multivariable logistic regression. Results There were 625 patients: SOC 148, ST 278, and APP 199. Of 278 ST patients, 179 (64%) were skin test eligible; 43 (24%) received testing and none were allergic. In the APP period, there were 292 unique website views; 112 users (38%) completed clinical decision support. While ST period patients did not have an increased odds of penicillin or cephalosporin use overall (aOR 1.3 [95% CI 0.8, 2.0]), we observed a significant increased odds of penicillin or cephalosporin use overall in the APP period (aOR 1.8 [95% CI 1.1, 2.9]), and in a per protocol analysis of the skin tested subset (aOR 5.7 [95% CI 2.6, 12.5]). Conclusions Both the computerized guideline with decision support and penicillin skin testing – when completed – increased use of penicillin and cephalosporin antibiotics among inpatients reporting penicillin allergy. While the skin tested subset showed an almost 6-fold impact, the computerized guideline significantly increased penicillin or cephalosporin use overall nearly 2-fold and was readily implemented.

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The Use of Penicillin Skin Testing to Assess the Prevalence of Penicillin Allergy in an Emergency Department Setting

Cited by 78 publications

References 23 publications

Prophylactic Antibiotic Management of Surgical Patients Noted as “Allergic” to Penicillin at Two Academic Hospitals

Prophylactic Antibiotic Management of Surgical Patients Noted as “Allergic” to Penicillin at Two Academic Hospitals

Prophylactic Antibiotic Choice and Risk of Surgical Site Infection After Hysterectomy

Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship

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