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Antibiotic Allergy Protocol
Thomas M File Jr. MD, MSc, MACP, FIDSA, FCCP Chair, Infectious Disease Division Summa Health System, Akron, Ohio; Professor of Internal Medicine, Chair ID Section Northeast Ohio Medical University Rootstown, Ohio
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DISCLOSURES Research Support: Nabriva, Pfizer Consultant/Scientific Advisory Board Allergan, Medicine’s Co., Meiji, Merck, MotifBio, Paratek, Shionogi, BioMerieux, Curetis,
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LEARNING OBJECTIVES At the end of this lecture, the learner will be able to: 1) Classify drug reactions 2) List implications of penicillin allergy labeling by patients 3) List approaches to evaluation and management of patients who have a history of penicillin
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Allergic Reaction Classification
Modified from Weiss ME, Adkinson NF. Clin Allergy 1988; 18: 515
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Drug Allergy Reported in 20-40% of patients Impact often negative
Frequently leads to less optimal or more toxic agents. Most common drug allergy: Best-lactams While a reaction related to drug allergy is an adverse event, avoidance of a more appropriate antimicrobial because of ‘fear’ of allergy can be associated with even worse effects Blumenthal KG, Shenoy ES. Clin Infect Dis. 2016; 63: y E,
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Impact of Antibiotic Allergy History
Increased Broad spectrum ABX Increased Cost Increased LOS Increased Adverse effects Delay in administration of AB Reported in 20-40% of patients (2X longer) Increased Mortality lee et al Ann Intern Med 2000;; Unger et al Pharmacotherapy 2013; Howlett et al. Eastern States Conf Pharmacy, 2011; Huagn K et al. AAAAI ,
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Implications of Antibiotic Allergy
Retrospective, controlled cohort study; 51,582 patients with ‘penicillin allergy’ label MORE ‘suboptimal’ antibiotics (p< ) Fluoroquinolones, Clindamycin, Vamcomycin MORE CDI by 23% MORE VRE INCREASED LOS (0.6 days) Macy E, Contreraa R. J Allergy Clin Immunol 2013
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Impact of Reported Beta-Lactam Allergy on Inpatient Outcomes
MacFadden DR et al. Clin Infect Dis. 2016
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Penicillin Allergy Penicillin allergy is reported by 8-25% of patients across inpatient and outpatient settings Only 10% of patients with reported penicillin allergy are skin test positive Most common reaction to penicillin is rash Prevalence of life-threatening anaphylactic reaction to penicillin is estimated between 0.02% and 0.04% Key Point – Among all patients with a reported allergy to penicillin, up to 90% are able to tolerate penicillins after complete evaluation either because they were never allergic or an earlier allergy has resolved Gonzalez-estrada A et al. Penicillin allergy: a practical guide for clinicians. Cleveland Clinic Journal of Medicine. 2015; 82(5): Drug Allergy: an updated practice parameter. Ann Allergy, Asthma Immunol 2010;105:
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Penicillin Allergy Protocol (SUMMA)
Protocol developed by Antimicrobial Stewardship Team, Pharmacy, and Anesthesiology Department Approved by P&T Committee in November 2016 Implementation system-wide
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Continue ciprofloxacin + metronidazole
Case #1 45 y/o female admitted with diverticulitis confirmed on CT. History of PCN allergy. Started empirically on ciprofloxacin + metronidazole. When questioned about her PCN allergy, she had diarrhea. Course of action? Continue ciprofloxacin + metronidazole Change therapy to piperacillin/tazobactam Change ciprofloxacin to ceftriaxone
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Vancomycin and aztreonam Vancomycin and ciprofloxacin
Case #2 70 y/o male presents from SNF for Pneumonia; recently treated with cipro for UTI. PCN allergy listed with reaction of rash which occurred 5 days after initiation of the antimicrobial. This occurred ~20 years ago. Course of action? Vancomycin and aztreonam Vancomycin and ciprofloxacin Vancomycin and cefepime
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Questions to ask patient/family
What were the characteristics of the reaction? IgE-mediated versus Non-IgE-mediated IgE-mediated (Type I): Urticaria (most common), angioedema, laryngeal edema, bronchospasm, shortness of breath, presyncope or syncope, hypotension, and cardiopulmonary collapse Non-IgE-mediated: Maculopapular eruptions, hemolytic anemia, serum sickness, Stevens-Johnson syndrome, drug rash with eosinophilia and systemic symptoms, acute interstitial nephritis and toxic epidermal necrolysis
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Questions to ask patient/family
If a rash is described, determine the characteristics of the rash. Types of rash include: Urticaria (IgE-mediated) - pruritic, raised and erythematous eruption with central pallor. Maculopapular or morbilliform (non-IgE-mediated) - begin in dependent areas and then generalize. Often pruritic and associated with mucous membrane erythema. When did rash occur in relation to start of antibiotic: Within minutes/hours More than a day (delayed)
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Questions to ask patient/family
How was the reaction managed? What was the outcome? Use of and response to epinephrine and antihistamines with resolution or significant improvement within a few hours may indicate an IgE-mediated How long after taking penicillin did the reaction occur? Immediate (IgE-mediated) versus delayed (Non-IgE-mediated) IgE-mediated (Type I): Immediate, usually occur within 1 hour of the first dose (occasionally take 2 hours if taken orally with food) Non-IgE-mediated: Delayed in onset, often occurring days after start of treatment Have you tolerated other forms of penicillin since the reaction?
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Questions to ask patient/family
How many years ago did the reaction occur? Most patients lose their sensitivity to penicillin over time. (50% within 5 years, ≥ 80% within 10 year What was the indication for penicillin? Many cutaneous reactions are a result of an underlying viral or bacterial infection or an interaction between the antimicrobial and the disease state (e.g. rash developing with ampicillin and infectious mononucleosis)
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Questions to ask patient/family ARTERY
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Allergy Protocol Evaluation (pilot)
Evaluated the safety and validity of the protocol Compared patients with listed B-lactam allergy who tolerated B-lactams after pharmacist evaluation Patients were admitted from 12 December 2016 through 15 February 2017 with listed B-lactam allergy and already received the first dose of a non-B-lactam antibiotic were included in the study Pharmacy resident performed patient interviews, and subsequently made antibiotic recommendations to the prescribers based on the developed antibiotic allergy protocol, clinical treatment guidelines and culture/susceptibility results Summa Health Sample Preso
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Allergy Protocol Evaluation (pilot)
84 patients were included in the study (Intervention: 29; Control: 55). % of patients with a listed B-lactam allergy who tolerated B-lactam in the intervention and control group was 75.9% and 55.4% respectively (P=0.078). The incidence of adverse reactions and length of hospital stay were similar between the groups. Total cost of antibiotics/day was $21.20 in the intervention arm, and $61.00 in the control group (P<0.001). Post-intervention change in cost of antibiotics per day per patient was -$13.07 (P=0.022). Conclusion: The utilization of a standardized antibiotic allergy assessment tool along with pharmacist intervention promoted the appropriate use of antibiotics in the health system, and significantly reduced the cost of antimicrobial expenditures.
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Antibiotic Allergy-Key points
A patient history of allergy is associated with worse clinical ourtcomes Leads to less optimal antimicrobial usage Increase AEs, cost, LOS, in some cases mortality Most patients with history of allergy are NOT allergic Asking appropriate questions (what reaction, how long ago) can provide clarification in majority of cases and allow better use of antimicrobials
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