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Published on: August 30, 2018
Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship
Kimberly G Blumenthal1, Paige G Wickner2, Shelley Hurwitz3
1Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and the Massachusetts General Professional Organization, Boston, Mass; Harvard Medical School, Boston, Mass.
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 3 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 Web site views; 112 users (38%) completed clinical decision support. Although ST period patients did not have increased odds of penicillin or cephalosporin use overall (adjusted odds ratio [aOR] 1.3; 95% CI, 0.8-2.0), we observed 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 APP and ST-when completed-increased the 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.
Insights
Addressing inpatient penicillin allergies with computerized guidelines or skin testing significantly increases the use of penicillin and cephalosporin antibiotics. These interventions improve antibiotic selection for patients with reported allergies.
Area of Science:
- Infectious Diseases
- Clinical Pharmacology
- Health Informatics
Background:
- Reported penicillin allergies often do not reflect true intolerance.
- Failure to accurately assess penicillin allergies leads to increased broad-spectrum antibiotic use and adverse events.
Purpose of the Study:
- To determine the optimal approach for managing penicillin allergies in hospitalized patients.
- To evaluate the effectiveness of penicillin skin testing and computerized decision support in improving antibiotic selection.
Main Methods:
- A study comparing three periods: standard of care (SOC), penicillin skin testing (ST), and computerized guideline application with decision support (APP).
- Inclusion of internal medicine inpatients reporting penicillin allergy.
- Primary outcome measured was the use of penicillin or cephalosporin, analyzed using multivariable logistic regression.
Main Results:
- The computerized guideline application (APP) period showed a significant increase in penicillin or cephalosporin use (aOR, 1.8).
- Penicillin skin testing (ST), when completed, demonstrated a substantial increase in penicillin or cephalosporin use in a per-protocol analysis (aOR, 5.7).
- Overall, both APP and ST interventions increased the use of preferred antibiotics compared to SOC.
Conclusions:
- Computerized guidelines and penicillin skin testing effectively increase the use of penicillin and cephalosporin antibiotics in inpatients with reported allergies.
- The computerized guideline approach was readily implemented and significantly improved antibiotic selection overall.
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