Controversies in Drug Allergy: Drug Allergy Pathways
2018; Elsevier BV; Volume: 7; Issue: 1 Linguagem: Inglês
10.1016/j.jaip.2018.07.037
ISSN2213-2201
AutoresAnca Mirela Chiriac, Aleena Banerji, Rebecca S. Gruchalla, Bernard Yu‐Hor Thong, Paige G. Wickner, Paul‐Michel Mertès, Ingrid Terreehorst, Kimberly G. Blumenthal,
Tópico(s)Food Allergy and Anaphylaxis Research
ResumoDrug allergy pathways are standardized approaches for patients reporting prior drug allergies with the aim of quality improvement and promotion of antibiotic stewardship. At the International Drug Allergy Symposium during the 2018 American Academy of Allergy, Asthma, and Immunology/World Allergy Organization Joint Congress in Orlando, Florida, drug allergy pathways were discussed from international perspectives with a focus on beta-lactam allergy pathways and pragmatic approaches for acute care hospitals. In this expert consensus document, we review current pathways, and detail important considerations in devising, implementing, and evaluating beta-lactam allergy pathways for hospitalized patients. We describe the key patient and institutional factors that must be considered in risk stratification, the central feature of pathway design. We detail shared obstacles to widespread beta-lactam allergy pathway implementation and identify potential solutions to address these challenges. Drug allergy pathways are standardized approaches for patients reporting prior drug allergies with the aim of quality improvement and promotion of antibiotic stewardship. At the International Drug Allergy Symposium during the 2018 American Academy of Allergy, Asthma, and Immunology/World Allergy Organization Joint Congress in Orlando, Florida, drug allergy pathways were discussed from international perspectives with a focus on beta-lactam allergy pathways and pragmatic approaches for acute care hospitals. In this expert consensus document, we review current pathways, and detail important considerations in devising, implementing, and evaluating beta-lactam allergy pathways for hospitalized patients. We describe the key patient and institutional factors that must be considered in risk stratification, the central feature of pathway design. We detail shared obstacles to widespread beta-lactam allergy pathway implementation and identify potential solutions to address these challenges. This article is one of a series of international consensus documents developed from the International Drug Allergy Symposium held at the Joint Congress of the American Academy of Allergy, Asthma & Immunology/World Allergy Organization on March 1, 2018, in Orlando, Florida, USA. The symposium was sponsored by The Journal of Allergy and Clinical Immunology, The Journal of Allergy and Clinical Immunology: In Practice, and The World Allergy Organization Journal and chaired by Mariana Castells, MD, PhD, and Pascal Demoly, MD, PhD. This article is one of a series of international consensus documents developed from the International Drug Allergy Symposium held at the Joint Congress of the American Academy of Allergy, Asthma & Immunology/World Allergy Organization on March 1, 2018, in Orlando, Florida, USA. The symposium was sponsored by The Journal of Allergy and Clinical Immunology, The Journal of Allergy and Clinical Immunology: In Practice, and The World Allergy Organization Journal and chaired by Mariana Castells, MD, PhD, and Pascal Demoly, MD, PhD. Drug allergy pathways are standardized algorithms used by a group of providers with the aim of quality improvement for patients with previously reported drug allergies. There are 4 primary methods in which health care improvements are broadly achieved: (1) standardization, (2) coordination, (3) improving treatment decisions, and (4) prevention.1Trimble C. How Physicians Can Fix Health Care: One Innovation at a Time. American Association for Physician Leadership, Tampa, Fla2015Google Scholar Drug allergy pathways target improvements in patient care using more than one of these methods. Users of drug allergy pathways may be allergists who have, for example, standardized their internal approach to drug allergy. However, larger scale drug allergy pathways target a diverse group of providers in large institutions or health systems. Devising, implementing, and evaluating drug allergy pathways for patients with reported beta-lactam allergies is becoming increasingly common, particularly for multidisciplinary teams tasked with improving antibiotic choices for patients with a beta-lactam allergy label. Standardization of drug allergy recommendations into pathways requires sufficient clinical data, and in general, drug allergy research has lagged other areas of investigation in the field of allergy and immunology. Although expert panels have previously been convened to set drug allergy clinical and research advancement agendas,2Ogese M.O. Ahmed S. Alferivic A. Betts C.J. Dickinson A. Faulkner L. et al.New approaches to investigate drug-induced hypersensitivity.Chem Res Toxicol. 2017; 30: 239-259Crossref PubMed Scopus (15) Google Scholar, 3Demoly P. Adkinson N.F. Brockow K. Castells M. Chiriac A.M. Greenberger P.A. et al.International consensus on drug allergy.Allergy. 2014; 69: 420-437Crossref PubMed Scopus (643) Google Scholar, 4Khan D.A. Solensky R. Drug allergy.J Allergy Clin Immunol. 2010; 125: S126-S137Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar, 5Wheatley L.M. Plaut M. Schwaninger J.M. Banerji A. Castells M. Finkelman F.D. et al.Report from the National Institute of Allergy and Infectious Diseases workshop on drug allergy.J Allergy Clin Immunol. 2015; 136: 262-271.e2Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar none have previously addressed drug allergy pathways or the translation of drug allergy assessments into acute care. At the International Drug Allergy Symposium, organized during the 2018 American Academy of Allergy, Asthma, and Immunology/World Allergy Organization (WAO) Joint Congress in Orlando, Florida, drug allergy pathways were discussed from diverse international perspectives, with a focus on beta-lactam allergy pathways and pragmatic approaches for acute care hospitals. This consensus paper summarizes the key messages from the group of international experts. Antibiotic use has increased 65% between 2000 and 2015, fueled by increased use in low- to middle-income countries.6Friedrich M.J. Antibiotic consumption increasing globally.JAMA. 2018; 319: 1973Google Scholar High-income countries, which have processes aimed at curbing antibiotic resistance (eg, antibiotic stewardship), experienced slower growth.6Friedrich M.J. Antibiotic consumption increasing globally.JAMA. 2018; 319: 1973Google Scholar Beta-lactam antibiotics, the first class of antibiotics discovered, include the commonly prescribed penicillins, cephalosporins, carbapenems, and monobactams. To date, penicillin and its derivatives remain effective and well-tolerated antibiotics indicated to treat common infections, including many of those that affect hospitalized patients, such as urinary tract infection, pneumonia, and bacteremia. Beta-lactam allergies, recorded in up to 15% of hospitalized populations,7van Dijk S.M. Gardarsdottir H. Wassenberg M.W. Oosterheert J.J. de Groot M.C. Rockmann H. The high impact of penicillin allergy registration in hospitalized patients.J Allergy Clin Immunol Pract. 2016; 4: 926-931Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar, 8Macy E. Roppe L.B. Schatz M. Routine penicillin skin testing in hospitalized patients with a history of penicillin allergy.Perm J. 2004; 8: 20-24PubMed Google Scholar lead to increased broad-spectrum antibiotic use unless clear institutional-level policies encourage allergy investigation at the time of antibiotic prescription. Most patients reporting a beta-lactam allergy are not allergic. From 1% to 30% of outpatients undergoing a comprehensive drug allergy evaluation have their allergy confirmed.3Demoly P. Adkinson N.F. Brockow K. Castells M. Chiriac A.M. Greenberger P.A. et al.International consensus on drug allergy.Allergy. 2014; 69: 420-437Crossref PubMed Scopus (643) Google Scholar, 9Sacco K.A. Bates A. Brigham T.J. Imam J.S. Burton M.C. Clinical outcomes following inpatient penicillin allergy testing: a systematic review and meta-analysis.Allergy. 2017; 72: 1288-1296Crossref PubMed Scopus (132) Google Scholar, 10Bourke J. Pavlos R. James I. Phillips E. Improving the effectiveness of penicillin allergy de-labeling.J Allergy Clin Immunol Pract. 2015; 3: 365-374.e1Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, 11Macy E. Ngor E.W. Safely diagnosing clinically significant penicillin allergy using only penicilloyl-poly-lysine, penicillin, and oral amoxicillin.J Allergy Clin Immunol Pract. 2013; 1: 258-263Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar A recent meta-analysis showed that only 5% of patients with a documented penicillin allergy tested in acute care settings were allergic (ie, had penicillin-specific IgE antibodies).9Sacco K.A. Bates A. Brigham T.J. Imam J.S. Burton M.C. Clinical outcomes following inpatient penicillin allergy testing: a systematic review and meta-analysis.Allergy. 2017; 72: 1288-1296Crossref PubMed Scopus (132) Google Scholar Therefore, refraining from beta-lactam antibiotics based on the patient-reported clinical history is unnecessarily restrictive. More importantly, although avoidance of beta-lactams ensures that no potentially iatrogenic allergic reactions recur, other unfavorable iatrogenic consequences, such as more side effects and reduced efficacy against specific infections, may ensue.12Blumenthal K.G. Parker R.A. Shenoy E.S. Walensky R.P. Improving clinical outcomes in patients with methicillin-sensitive Staphylococcus aureus bacteremia and reported penicillin allergy.Clin Infect Dis. 2015; 61: 741-749Crossref PubMed Scopus (65) Google Scholar, 13Jeffres M.N. Narayanan P.P. Shuster J.E. Schramm G.E. Consequences of avoiding beta-lactams in patients with beta-lactam allergies.J Allergy Clin Immunol. 2016; 137: 1148-1153Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar Additionally worrisome, alternative antibiotics contribute to drug-resistant organisms and Clostridium difficile infections.14Macy E. Contreras R. Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: a cohort study.J Allergy Clin Immunol. 2014; 133: 790-796Abstract Full Text Full Text PDF PubMed Scopus (507) Google Scholar, 15Blumenthal K.G. Lu N. Zhang Y. Li Y. Walensky R.P. Choi H.K. Risk of meticillin resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy: population based matched cohort study.BMJ. 2018; 361: k2400Crossref PubMed Scopus (175) Google Scholar Addressing inaccurate or poorly documented beta-lactam allergies, while recently encouraged as part of antibiotic stewardship,16Centers for Disease Control and PreventionIs It Really a Penicillin Allergy?.https://peggyfoundation.org/wp-content/uploads/2016/03/getsmart-penicillin-fact-sheet-revised.pdfDate accessed: June 21, 2018Google Scholar, 17Barlam T.F. Cosgrove S.E. Abbo L.M. MacDougall C. Schuetz A.N. Septimus E.J. et al.Executive summary: implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.Clin Infect Dis. 2016; 62: 1197-1202Crossref PubMed Scopus (241) Google Scholar has been classically performed in outpatient settings by allergy specialists, following society recommendations.18Torres M.J. Romano A. Celik G. Demoly P. Khan D.A. Macy E. et al.Approach to the diagnosis of drug hypersensitivity reactions: similarities and differences between Europe and North America.Clin Transl Allergy. 2017; 7: 7Crossref PubMed Scopus (74) Google Scholar, 19NICE National Institute for Health and Care ExcellentPutting NICE Guidance into Practice. Guideline Algorithm: Diagnosis and Management of Drug Allergy; 2014.https://www.nice.org.uk/guidance/cg183/evidence/algorithm-pdf-485837965Date accessed: June 21, 2018Google Scholar, 20Mirakian R. Leech S.C. Krishna M.T. Richter A.G. Huber P.A. Farooque S. et al.Management of allergy to penicillins and other beta-lactams.Clin Exper Allergy. 2015; 45: 300-327Crossref PubMed Scopus (182) Google Scholar, 21Antibiotic Allergy Clinical Update. Australian Society of Clinical Immunology and Allergy.https://allergy.org.au/images/stories/hp/info/ASCIA_HP_Clinical_Update_Antibiotic_Allergy_2014.pdfDate accessed: July 10, 2018Google Scholar The typical diagnostic evaluation of drug allergy is often labor intensive, time consuming, resource dependent, and complex. At a minimum, allergy specialist investigation includes a thorough drug allergy history and in vivo testing (ie, skin testing, drug challenge, patch testing, as indicated). In some countries, in vitro tests (eg, specific IgE measurement) are also used.3Demoly P. Adkinson N.F. Brockow K. Castells M. Chiriac A.M. Greenberger P.A. et al.International consensus on drug allergy.Allergy. 2014; 69: 420-437Crossref PubMed Scopus (643) Google Scholar, 22Mirakian R. Ewan P.W. Durham S.R. Youlten L.J. Dugue P. Friedmann P.S. et al.BSACI guidelines for the management of drug allergy.Clin Exper Allergy. 2009; 39: 43-61Crossref PubMed Scopus (186) Google Scholar Although outpatient drug allergy evaluations have benefits in terms of diagnostic accuracy and patient safety, the evaluation is difficult to translate into the acute care hospital bedside for an infected patient requiring immediate antibiotic treatment. Although beta-lactam allergy pathways have been developed, their use remains uncommon, especially outside the United States.23Mill C. Primeau M.N. Medoff E. Lejtenyi C. O'Keefe A. Netchiporouk E. et al.Assessing the diagnostic properties of a graded oral provocation challenge for the diagnosis of immediate and nonimmediate reactions to amoxicillin in children.JAMA Pediatr. 2016; 170: e160033Crossref PubMed Scopus (195) Google Scholar, 24Trubiano J.A. Thursky K.A. Stewardson A.J. Urbancic K. Worth L.J. Jackson C. et al.Impact of an integrated antibiotic allergy testing program on antimicrobial stewardship: a multicenter evaluation.Clin Infect Dis. 2017; 65: 166-174Crossref PubMed Scopus (72) Google Scholar, 25Tucker M.H. Lomas C.M. Ramchandar N. Waldram J.D. Amoxicillin challenge without penicillin skin testing in evaluation of penicillin allergy in a cohort of Marine recruits.J Allergy Clin Immunol Pract. 2017; 5: 813-815Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, 26Blumenthal K.G. Wickner P.G. Hurwitz S. Pricco N. Nee A.E. Laskowski K. et al.Tackling inpatient penicillin allergies: assessing tools for antimicrobial stewardship.J Allergy Clin Immunol. 2017; 140: 154-161.e6Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar To address the evolving and unmet needs of inpatients with reported beta-lactam allergies today, drug allergy pathways targeted toward providing proactive, practical guidance in acute therapeutic situations are needed. Such pathways would include focused beta-lactam allergy evaluations that are less resource intensive, but still ensure the safety of our patients. Most patients report low-risk allergy histories27Vyles D. Chiu A. Simpson P. Nimmer M. Adams J. Brousseau D.C. Parent-reported penicillin allergy symptoms in the pediatric emergency department.Acad Pediatr. 2017; 17: 251-255Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar and thus many beta-lactams are likely safe for use. Furthermore, pathways can be used by trained personnel beyond allergy specialists, including medical doctors from other specialties, advanced practitioners, and pharmacists,28Heil E.L. Bork J.T. Schmalzle S.A. Kleinberg M. Kewalramani A. Gilliam B.L. et al.Implementation of an infectious disease fellow-managed penicillin allergy skin testing service.Open Forum Infect Dis. 2016; 3: ofw155Crossref PubMed Scopus (46) Google Scholar, 29Chen J.R. Tarver S.A. Alvarez K.S. Tran T. Khan D.A. A proactive approach to penicillin allergy testing in hospitalized patients.J Allergy Clin Immunol Pract. 2017; 5: 686-693Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar to enable more and cost-effective hospital-based allergy evaluations.30Blumenthal K.G. Li Y. Banerji A. Yun B.J. Long A.A. Walensky R.P. The cost of penicillin allergy evaluation.J Allergy Clin Immunol Pract. 2018; 6: 1019-1027.e2Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar A commonly used beta-lactam allergy pathway in the United States, originally developed by Massachusetts General Hospital, has more recently been adapted for educational materials,31Vaisman A. McCready J. Powis J. Clarifying a "penicillin" allergy: a teachable moment.JAMA Intern Med. 2017; 177: 269-270Crossref PubMed Scopus (13) Google Scholar, 32Blumenthal KG, Solensky R. Choice of Antibiotics in Penicillin-Allergic Hospitalized Patients. In: Post TW, Ed. Waltham, Mass: UpToDate. Available from: https://www.uptodate.com/contents/choice-of-antibiotics-in-penicillin-allergic-hospitalized-patients. Accessed September 6, 2018.Google Scholar and spread in an electronic form with clinical decision support within a large northeastern health system (Figure 1, A).26Blumenthal K.G. Wickner P.G. Hurwitz S. Pricco N. Nee A.E. Laskowski K. et al.Tackling inpatient penicillin allergies: assessing tools for antimicrobial stewardship.J Allergy Clin Immunol. 2017; 140: 154-161.e6Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 33Blumenthal K.G. Shenoy E.S. Wolfson A.R. Berkowitz D.N. Carballo V.A. Balekian D.S. et al.Addressing inpatient beta-lactam allergies: a multihospital implementation.J Allergy Clin Immunol Pract. 2017; 5: 616-625.e7Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 34Blumenthal K.G. Shenoy E.S. Huang M. Kuhlen J.L. Ware W.A. Parker R.A. et al.The impact of reporting a prior penicillin allergy on the treatment of methicillin-sensitive Staphylococcus aureus bacteremia.PLoS One. 2016; 11: e0159406Crossref PubMed Scopus (53) Google Scholar, 35Blumenthal K.G. Shenoy E.S. Varughese C.A. Hurwitz S. Hooper D.C. Banerji A. Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy.Ann Allergy Asthma Immunol. 2015; 115: 294-300.e2Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar A number of other US institutions have adopted a similar approach, including Dartmouth-Hitchcock Medical Center (personal communication, Erin L. Reigh, MD, July 7, 2018), Mayo Clinic Jacksonville,37Sacco K CB, Epps K, Tatari M, Sanchez Alvarez C, Gardner L, Gooch C, et al. Inpatient penicillin allergy evaluation safely increases utilization of beta lactams. Drug Hypersensitivity Meeting. Amsterdam, The Netherlands, April 19-21, 2018.Google Scholar University of Nebraska,38Wolfe M. Schoen J. Bergman S. May S. Van Schooneveld T. Penicillin Allergy Guidance Document.https://www.nebraskamed.com/sites/default/files/documents/for-providers/asp/penicillin-allergy-guidance.pdfDate accessed: June 21, 2018Google Scholar and Rush University Medical Center.39Ravindran S.B.M. Wang S. Bandi S. Hanson A. O'Driscoll T. Tobin M. The impact of reported penicillin allergy on patients with Streptococcus bacteremia at an urban community hospital.J Allergy Clin Immunol. 2018; 139: AB29Abstract Full Text Full Text PDF Google Scholar These collective experiences demonstrate this beta-lactam allergy pathway to be safe and beneficial in terms of optimizing clinical care.26Blumenthal K.G. Wickner P.G. Hurwitz S. Pricco N. Nee A.E. Laskowski K. et al.Tackling inpatient penicillin allergies: assessing tools for antimicrobial stewardship.J Allergy Clin Immunol. 2017; 140: 154-161.e6Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 34Blumenthal K.G. Shenoy E.S. Huang M. Kuhlen J.L. Ware W.A. Parker R.A. et al.The impact of reporting a prior penicillin allergy on the treatment of methicillin-sensitive Staphylococcus aureus bacteremia.PLoS One. 2016; 11: e0159406Crossref PubMed Scopus (53) Google Scholar, 35Blumenthal K.G. Shenoy E.S. Varughese C.A. Hurwitz S. Hooper D.C. Banerji A. Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy.Ann Allergy Asthma Immunol. 2015; 115: 294-300.e2Abstract Full Text Full Text PDF PubMed Scopus (127) Google ScholarFigure 1Drug allergy pathways that include both history tools and guidance on beta-lactam prescriptions. A, Partners HealthCare System (Boston, Mass): Penicillin (A1) and cephalosporin (A2) hypersensitivity pathways with optional computerized clinical decision support (A3) (Boston, Mass). These pathways were originally used with a history tool at Massachusetts General Hospital (Figure 2, A), with subsequent modification into an electronic app that is provider-facing and uses the patient-reported history and available patient records. This pathway is active throughout hospitals affiliated with Partners HealthCare System (PHS),33Blumenthal K.G. Shenoy E.S. Wolfson A.R. Berkowitz D.N. Carballo V.A. Balekian D.S. et al.Addressing inpatient beta-lactam allergies: a multihospital implementation.J Allergy Clin Immunol Pract. 2017; 5: 616-625.e7Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar and has been adopted by other hospitals in the United States. The app uses patient-reported clinical history to group patients into 1 of the 3 reaction groups and is currently only available for use at PHS hospitals. Research studies on this pathway demonstrate its safety, and its association with an increase in beta-lactam antibiotic use and increase first-line therapies for some inpatient infections.26Blumenthal K.G. Wickner P.G. Hurwitz S. Pricco N. Nee A.E. Laskowski K. et al.Tackling inpatient penicillin allergies: assessing tools for antimicrobial stewardship.J Allergy Clin Immunol. 2017; 140: 154-161.e6Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 34Blumenthal K.G. Shenoy E.S. Huang M. Kuhlen J.L. Ware W.A. Parker R.A. et al.The impact of reporting a prior penicillin allergy on the treatment of methicillin-sensitive Staphylococcus aureus bacteremia.PLoS One. 2016; 11: e0159406Crossref PubMed Scopus (53) Google Scholar, 35Blumenthal K.G. Shenoy E.S. Varughese C.A. Hurwitz S. Hooper D.C. Banerji A. Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy.Ann Allergy Asthma Immunol. 2015; 115: 294-300.e2Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar PHS hospitals perform over 1000 drug challenges (test doses) per year with this infrastructure. *Antibiotic-stewardship program restricted antibiotics. PCN, penicillin. B, Computerized clinical decision support system (Birmingham, UK): This computerized clinical decision support system (CDSS, Birmingham, UK) begins with an electronic questionnaire that is available as an app to assist providers in taking the allergy history. The computer uses entered information to stratify patients into high- and low-risk allergy groups (B1) with subsequent suggested actions (B2). High risk included patient acuity, high-risk delayed reactions such as Stevens-Johnson syndrome and organ involvement, and (1) rash <1 hour after first dose; (2) isolated hypotension, (3) upper or lower airway involvement, or (4) clinical features of anaphylaxis. Low-risk patients are given direct amoxicillin challenge, with 1-hour observation.36Krishna M.T. Huissoon A.P. Li M. Richter A. Pillay D.G. Sambanthan D. et al.Enhancing antibiotic stewardship by tackling "spurious" penicillin allergy.Clin Exper Allergy. 2017; 47: 1362-1373Crossref PubMed Scopus (50) Google Scholar BP, blood pressure; BSACI, British Society for Allergy & Clinical Immunology; COPD, chronic obstructive pulmonary disorder; DRESS, drug rash with eosinophilia and systemic symptoms; GIT, gastrointenstinal; PEFR, peak expiratory flow rate; PenA, penicillin-binding protein 2 gene; SpO2, blood oxygen saturation. C, Australian Therapeutic Guidelines (Melbourne, Australia): Suggested management of patients reporting penicillin hypersensitivity in whom a beta-lactam antibiotic is definitely required (Therapeutic Guidelines, Melbourne, Australia).40Antimicrobial Hypersensitivity Australian Therapeutic Guidelines: Antibiotic, Version 15. Therapeutic Guidelines Limited, Melbourne2014https://www.clinicalguidelines.gov.au/portal/2406/therapeutic-guidelines-antibiotic-version-15Date accessed: June 25, 2018Google Scholar This is a national antibiotic prescribing document, available online for all physicians to reference in Australia. Most hospitals in Australia base their institutional guidelines on this national guideline. B1 and B2 reprinted with permission from Krishna MT, Huissoon AP, Li M, Richter A, Pillay DG, Sambanthan D, et al. Enhancing antibiotic stewardship by tackling "spurious" penicillin allergy. Clin Exper Allergy 2017;47:1362-73 (© 2017 John Wiley & Sons Ltd).36Krishna M.T. Huissoon A.P. Li M. Richter A. Pillay D.G. Sambanthan D. et al.Enhancing antibiotic stewardship by tackling "spurious" penicillin allergy.Clin Exper Allergy. 2017; 47: 1362-1373Crossref PubMed Scopus (50) Google ScholarView Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 1Drug allergy pathways that include both history tools and guidance on beta-lactam prescriptions. A, Partners HealthCare System (Boston, Mass): Penicillin (A1) and cephalosporin (A2) hypersensitivity pathways with optional computerized clinical decision support (A3) (Boston, Mass). These pathways were originally used with a history tool at Massachusetts General Hospital (Figure 2, A), with subsequent modification into an electronic app that is provider-facing and uses the patient-reported history and available patient records. This pathway is active throughout hospitals affiliated with Partners HealthCare System (PHS),33Blumenthal K.G. Shenoy E.S. Wolfson A.R. Berkowitz D.N. Carballo V.A. Balekian D.S. et al.Addressing inpatient beta-lactam allergies: a multihospital implementation.J Allergy Clin Immunol Pract. 2017; 5: 616-625.e7Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar and has been adopted by other hospitals in the United States. The app uses patient-reported clinical history to group patients into 1 of the 3 reaction groups and is currently only available for use at PHS hospitals. Research studies on this pathway demonstrate its safety, and its association with an increase in beta-lactam antibiotic use and increase first-line therapies for some inpatient infections.26Blumenthal K.G. Wickner P.G. Hurwitz S. Pricco N. Nee A.E. Laskowski K. et al.Tackling inpatient penicillin allergies: assessing tools for antimicrobial stewardship.J Allergy Clin Immunol. 2017; 140: 154-161.e6Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 34Blumenthal K.G. Shenoy E.S. Huang M. Kuhlen J.L. Ware W.A. Parker R.A. et al.The impact of reporting a prior penicillin allergy on the treatment of methicillin-sensitive Staphylococcus aureus bacteremia.PLoS One. 2016; 11: e0159406Crossref PubMed Scopus (53) Google Scholar, 35Blumenthal K.G. Shenoy E.S. Varughese C.A. Hurwitz S. Hooper D.C. Banerji A. Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy.Ann Allergy Asthma Immunol. 2015; 115: 294-300.e2Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar PHS hospitals perform over 1000 drug challenges (test doses) per year with this infrastructure. *Antibiotic-stewardship program restricted antibiotics. PCN, penicillin. B, Computerized clinical decision support system (Birmingham, UK): This computerized clinical decision support system (CDSS, Birmingham, UK) begins with an electronic questionnaire that is available as an app to assist providers in taking the allergy history. The computer uses entered information to stratify patients into high- and low-risk allergy groups (B1) with subsequent suggested actions (B2). High risk included patient acuity, high-risk delayed reactions such as Stevens-Johnson syndrome and organ involvement, and (1) rash <1 hour after first dose; (2) isolated hypotension, (3) upper or lower airway involvement, or (4) clinical features of anaphylaxis. Low-risk patients are given direct amoxicillin challenge, with 1-hour observation.36Krishna M.T. Huissoon A.P. Li M. Richter A. Pillay D.G. Sambanthan D. et al.Enhancing antibiotic stewardship by tackling "spurious" penicillin allergy.Clin Exper Allergy. 2017; 47: 1362-1373Crossref PubMed Scopus (50) Google Scholar BP, blood pressure; BSACI, British Society for Allergy & Clinical Immunology; COPD, chronic obstructive pulmonary disorder; DRESS, drug rash with eosinophilia and systemic symptoms; GIT, gastrointenstinal; PEFR, peak expiratory flow rate; PenA, penicillin-binding protein 2 gene; SpO2, blood oxygen saturation. C, Australian Therapeutic Guidelines (Melbourne, Australia): Suggested management of patients reporting penicillin hypersensitivity in whom a beta-lactam antibiotic is definitely required (Therapeutic Guidelines, Melbourne, Australia).40Antimicrobial Hypersensitivity Australian Therapeutic Guidelines: Antibiotic, Version 15. Therapeutic Guidelines Limited, Melbourne2014https://www.clinicalguidelines.gov.au/portal/2406/therapeutic-guidelines-antibiotic-version-15Date accessed: June 25, 2018Google Scholar This is a national antibiotic prescribing document, available online for all physicians to reference in Australia. Most hospitals in Australia base their institutional guidelines on this national guideline. B1 and B2 reprinted with permission from Krishna MT, Huissoon AP, Li M, Richter A, Pillay DG, Sambanthan D, et al. Enhancing antibiotic stewardship by tackling "spurious" penicillin allergy. Clin Exp
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