Original Article

CME Article: Impact of β-Lactam Allergies on Antimicrobial Selection in an Outpatient Setting

Authors: Rachel A. Ness, PharmD, BCPS, Jessica G. Bennett, PharmD, Whitney V. Elliott, PharmD, BCPS, BCGP, Amanda R. Gillion, PharmD, BCPS, Debendra N. Pattanaik, MD, MBBS, FACR, FAAAI

Abstract

Objective: The primary objective of this study was to determine whether patients prescribed nonpreferred antibiotics received appropriate alternative antibiotics.

Methods: This was a retrospective observational analysis of military veteran patients with a β-lactam allergy treated in an outpatient clinic or emergency department for an infection during a 5-year span. Antibiotic regimens were first stratified as preferred or nonpreferred based on infection-specific guidelines. The nonpreferred regimens were then evaluated for appropriateness based on allergy history and culture and sensitivity reports.

Results: Of 445 fills of antibiotics evaluated, 269 met inclusion criteria, comprising 253 unique infections in 80 patients. Patients received nonpreferred antibiotics for their infection type in 57% of cases. Of the nonpreferred antibiotics, 56% were inappropriate based on guideline-recommended alternatives, allergy history, and culture and sensitivity data. Of the 88 allergies, 97% were historical/self-reported and 48% were cutaneous. In addition, 39% of patients safely received β-lactam antibiotics after documentation of their allergy.

Conclusions: Patients with documented β-lactam allergies are at high risk of receiving nonpreferred and inappropriate antibiotics, and many reactions likely do not reflect true allergies. These data emphasize the negative impact of the “β-lactam allergy” label and the importance of reassessing allergies.
Posted in: Allergy and Immunology2

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Lee CE, Zembower TR, Fotis MA, et al. The incidence of antimicrobial allergies in hospitalized patients: implications regarding prescribing patterns and emerging bacterial resistance. Arch Intern Med 2000;160:2819-2822.
2. Park M, Markus P, Matesic D, et al. Safety and effectiveness of a preoperative allergy clinic in decreasing vancomycin use in patients with a history of penicillin allergy. Ann Allergy Asthma Immunol 2006;97:681-687.
3. Barlam TF, Cosgrove SE, Abbo LM, et al. 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:e51-e77.
4. McDanel JS, Perencevich EN, Diekema DJ, et al. Comparative effectiveness of beta-lactams versus vancomycin for treatment of methicillin-susceptible Staphylococcus aureus bloodstream infections among 122 hospitals. Clin Infect Dis 2015;61:361-367.
5. Blumenthal KG, Shenoy ES, Varughese CA, et al. Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy. Ann Allergy Asthma Immunol 2015;115:294-300.e2.
6. Blumenthal KG, Parker RA, Shenoy ES, et al. Improving clinical outcomes in patients with methicillin-sensitive Staphylococcus aureus bacteremia and reported penicillin allergy. Clin Infect Dis 2015;61:741-749.
7. Jeffres MN, Narayanan PP, Shuster JE, et al. Consequences of avoiding β-lactams in patients with β-lactam allergies. J Allergy Clin Immunol 2016;137:1148-1153.
8. Charneski L, Deshpande G, Smith SW. Impact of an antimicrobial allergy label in the medical record on clinical outcomes in hospitalized patients. Pharmacotherapy 2011;31:742-747.
9. Macy 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;133:790-796.
10. Blumenthal KG, Lu N, Zhang Y, et al. The increased risk of methicillin-resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy. J Allergy Clin Immunol 2018; 141( suppl ):AB88.
11. Harris AM, Hicks LA, Qaseem A. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med 2016;164:425-434.
12. Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD 2017 global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. https://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd. Published 2017. Accessed September 14, 2019.
13. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012;55:1279-1282.
14. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012;54:e72-e112.
15. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015; 152( 2 suppl ):S1-S39.
16. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44( suppl 2 ):S27-S72.
17. Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg 2014;150( 1 suppl ):S1-S24.
18. Harmes KM, Blackwood RA, Burrows HL, et al. Otitis media: diagnosis and treatment. Am Fam Physician 2013;88:435-440.
19. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116:1736-1754.
20. Chow AW. Infections of the oral cavity, neck, and head. In: Bennett JE, Dolin R, Blaser MJ, eds, Mandell, Douglas, and Bennett’ Principles and Practices of Infectious Diseases , 8th ed, vol 1. Philadelphia: Elsevier Churchill Livingstone; 2015:789.
21. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014;59:e10-e52.
22. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012;54:e132-e173.
23. Zouboulis CC, Desai N, Emtestam L, et al. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermal Venereol 2015;29:619-644.
24. Cohen PR. Community-acquired methicillin-resistant Staphylococcus aureus skin infections: implications for patients and practitioners. Am J Clin Dermatol 2007;8:259-270.
25. Laureano AC, Schwartz RA, Cohen PJ. Facial bacterial infections: folliculitis. Clin Dermatol 2014;32:711-714.
26. van Bijen EM, Paget WJ, den Heijer CD, et al. Primary care treatment guidelines for skin infections in Europe: congruence with antimicrobial resistance found in commensal Staphylococcus aureus in the community. BMC Fam Pract 2014;15:175.
27. Nicolle LE. Complicated urinary tract infection in adults. Can J Infect Dis Med Microbiol 2005;16:349-360.
28. Schaeffer AJ, Nicolle LE. Urinary tract infections in older men. N Engl J Med 2016;374:562-571.
29. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52:e103-e120.
30. Centers for Disease Control and Prevention. 2015 sexually transmitted diseases treatment guidelines: epididymitis. https://www.cdc.gov/std/tg2015/epididymitis.htm. Published June 4, 2015. Accessed September 14, 2019.
31. Sharp VJ, Takacs EB, Powell CR. Prostatitis: diagnosis and treatment. Am Fam Physician 2010;82:397-406.
32. Jacobs DO. Diverticulitis. N Engl J Med 2007;357:2057-2066.
33. Chey WD, Leontiadis GI, Howden CW, et al. ACG clinical guideline: treatment of Helicobacter pylori infection. Am J Gastroenterol 2017;112: 212-239.
34. Surawicz CM, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol 2013;108:478-499.
35. Wolf JS, Jr Bennett CJ, Dmochowski RR, et al. Best practice statement: urologic surgery antimicrobial prophylaxis. https://www.auanet.org/guidelines/archived-documents/antimicrobial-prophylaxis-best-practice-statement. Published 2008. Accessed September 14, 2019.
36. Salmeron Escobar JI, Fernandez de Velasco AA. Antibiotic prophylaxis in oral and maxillofacial surgery. Med Oral Patol Oral Cir Bucal 2006;11:E292-E296.
37. Venkatesan AM, Kundu S, Sacks D, et al. Practice guidelines for adult antibiotic prophylaxis during vascular and interventional radiology procedures. J Vasc Interv Radiol 2010;21:1611-1631.
38. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013;70:195-283.
39. Blanca M, Torres MJ, Garcia JJ, et al. Natural evolution of skin test sensitivity in patients allergic to beta-lactam antibiotics. J Allergy Clin Immunol 1999;103( 5 Part 1 ):918-924.
40. Sullivan TJ, Wedner HJ, Shatz GS, et al. Skin testing to detect penicillin allergy. J Allergy Clin Immunol 1981;68:171-180.