Kimberly G. Blumenthal
Paige G. Wickner
Results from a retrospective cohort study demonstrated the safety of an antimicrobial stewardship intervention that uses guideline-directed beta-lactam antibiotic test-dose procedures in hospitalized patients with reported beta-lactam allergies.
“Having a reported penicillin allergy not only decreases the likelihood that patients will be prescribed a penicillin when indicated, but very often, a penicillin allergy history will decrease the chance that a patient will be prescribed other beta-lactam drugs,” Kimberly G. Blumenthal, MD, MSc, quality and safety officer for allergy at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School, told Infectious Disease News. “Together, this increases the risk of Clostridioides difficile infection, other hospital associated infections, and antibiotic resistance.”
Writing in Infection Control & Hospital Epidemiology, Blumenthal and colleagues explained that up to 15% of hospitalized patients report an allergy to beta-lactam antibiotics, which impacts acute-care antibiotic prescribing. Blumenthal noted that among the approximately 10% of patients in the United States who report a penicillin allergy, most will tolerate penicillin and related beta-lactams after evaluation.
Between April 2016 and December 2017, the researchers evaluated beta-lactam antibiotic test-dose outcomes within a large health care system that included two academic and three community acute-care hospitals.
“The intervention uses a guideline and clinical decision support tools to help nonspecialist providers perform test doses, a type of drug challenges where a drug is given under observation to demonstrate tolerance,” Blumenthal explained.
They assessed adverse drug reactions (ADRs), hypersensitivity reactions (HSRs) and EHR allergy record updates.
According to the study, Blumenthal and colleagues identified 1,046 test doses. Of those, 77% were identified as being to cephalosporins, 14% to penicillins and 9% to carbapenems. ADR signs and symptoms were reported by 7.5% of patients (95% CI, 5.9%-9.2%), and confirmed HSRs were reported for 3.8% (95% CI, 2.8%-5.2%). Most — 68% — of HSRs occurred at the second step of the test-dose procedure, when the patient received a full dose, the researchers reported. Of these, 58% required no treatment beyond discontinuing the drug, but three patients did require intramuscular epinephrine. The researchers found increased odds of HSR associated with a reported cephalosporin allergy history (OR = 2.96; 95% CI, 1.34-6.58).
“The guideline does not overly rely on penicillin skin testing — only 4% of test doses were
preceded by the penicillin skin test — which can be challenging to routinely perform in inpatients due to short length of stay and patient schedules,” study author Paige G. Wickner, MD, MPH, medical director of quality and safety at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School, told Infectious Disease News. “To date, this guideline has been used at nine Partners HealthCare-affiliated sites, including many with no staff allergy and immunology support.”
The researchers encouraged EHR documentation to “improve this safe, effective, and practical acute-care antibiotic stewardship tool.”
“Allergy documentation strategies to improve the effectiveness of acute-care beta-lactam allergy interventions are needed,” study author Erica Shenoy MD, PhD, assistant chief of infection control at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School, told Infectious Disease News. – by Marley Ghizzone
Disclosures: Blumenthal reports receiving royalties from UpToDate and honoraria from New England Society of Allergy, Dartmouth Medical School, and Vanderbilt Medical School, outside the submitted work. Blumenthal and Shenoy report a licensed clinical decision support tool for beta-lactam allergy evaluation that is used institutionally at Partners HealthCare System. Wickner reports no relevant financial disclosures.