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The Effect of a Penicillin Allergy Algorithm on Perioperative Antibiotic Choice
Abstracts AB37
J ALLERGY CLIN IMMUNOL VOLUME 137, NUMBER 2
The Effect of Penicillin Allergy Testing on Future Healthcare Utilization and Morbidity: A CaseControl Study
Eric M. Macy, MD, FAAAAI1, Yu-Hsiang Shu, MS, PhD2; 1SCPMG Department of Allergy, 2Kaiser Permanente Southern California. RATIONALE: The effect outpatient penicillin allergy testing has on future healthcare utilization (HU) and morbidity is unknown. METHODS: HU and morbidity in 500 penicillin allergic cases, only 8 penicillin allergy test-positive, seen from 6-8-2010 to 3-29-2012, were compared to non-tested controls. Five penicillin allergic controls were matched to each case by gender, age, weighted Charlson comorbidity index (CCI), and outpatient office visits during a 2-year lead-in period. Hospital days, new drug allergies, and antibiotic exposures were determined over a 36 to 62 month follow-up period. RESULTS: Cases had a mean (95% CI) lead-in CCI of 1.65 (1.44–1.87) and 13.73 (12.76–14.7) outpatient visits per year of healthplan coverage (YHC). Controls had a mean lead-in CCI of 1.7 (1.6–1.8) and 12.08 (11.69–12.47) outpatient visits per YHC. For cases, hospital days per YHC increased significantly less than for control subjects, 1.62 (1.13–2.11) to 2.16 (1.00–3.31) [133%] versus 0.73 (0.59–0.87) to 2.02 (1.43–2.61) [277%], (p < 0.0001). Antibiotic courses per year fell significantly more in cases, - 0.85 versus -0.62, (p 5 0.0212). Cases had significantly fewer new drug allergies at the end of the follow-up period, +0.044 versus +0.18, (p < 0.0001). The top 5 antibiotics cases were exposed to were penicillins, 1st generation cephalosporins, quinolones, tetracyclines, and macrolides versus macrolides, quinolones, clindamycin, 1stgeneration cephalosporins, and tetracyclines for controls. CONCLUSIONS: Penicillin allergy testing was associated with a smaller increase in hospital days, a greater fall in antibiotic usage, fewer new drug allergies, and significantly less macrolide, quinolone, and clindamycin exposure over the next 3 to 5 years.
116
The Effect of a Penicillin Allergy Algorithm on Perioperative Antibiotic Choice
Joseph A. Grillo, MD1, Karen Ravin, MD2, Magee L. DeFelice, MD3; 1 Nemours A.I. du Pont Hospital for Children, Wilmington, DE, 2Nemours/A.I. duPont Hospital for Children, 3Nemours/A.I duPont Hospital for Children, Wilmington, DE. RATIONALE: Cephalosporins are the preferred medications for perioperative antimicrobial prophylaxis. Due to the potential risk of crossreactivity between penicillins and cephalosporins, alternatives such as clindamycin are often administered to patients who report penicillin allergy. Clindamycin has potential to cause adverse hemodynamic effects when used in the perioperative setting, and lacks gram negative coverage. METHODS: The Nemours/A.I. duPont Hospital for Children developed an algorithm to evaluate penicillin allergic patients who present to the operating room. The algorithm recommends use of cephalosporins in select patients based on the clinical history of the penicillin reaction. The perioperative antibiotics administered to penicillin allergic patients who were screened using the protocol from May to June of 2015 were compared to a historical cohort from May to June of 2014. RESULTS: Fifty-four penicillin allergic patients (male to female ratio of 1:1) were screened using the algorithm. There were 46 penicillin allergic patients (male to female ratio of 2:3) in the pre-intervention group. When the algorithm was employed, clindamycin use decreased from 32.6% (15/46) to 9.3% (5/54) and the use of 1st or 2ndgeneration cephalosporins increased from 67.3% (31/46) to 88.8% (48/54). CONCLUSIONS: In the preoperative setting, a penicillin allergy algorithm increased cephalosporin and decreased clindamycin use. Preoperative penicillin skin testing for penicillin allergy has also been shown to increase the use of cephalosporins, however, skin testing in this setting may not always be practical. A penicillin allergy algorithm is an effective and efficient screening tool that could be expanded institutionwide and implemented at other tertiary care centers.
117
Safety of Two-Step Graded Challenges to BetaLactams Using a Single-Blinded PlaceboControlled Protocol
Melissa Iammatteo, MD1, Denisa Ferastraoaru, MD, MSc2, Santiago Alvarez Arango, MD3, Niharika Thota, MD3, Ayobami Akenroye, MD, MPH3, Elina Jerschow, MD, MSc1; 1Albert Einstein College of Medicine/ Montefiore Medical Center, Bronx, NY, 2Albert Einstein/Montefiore Medical Center, Bronx, NY, 3Albert Einstein College of Medicine, Bronx, NY. RATIONALE: Graded challenges are performed to exclude immediate hypersensitivity reactions. We aimed to validate the safety of two-step graded challenges (test doses) by comparing the reaction rate of two-step challenges with placebos in patients with a negative skin test to beta-lactams. METHODS: We performed a five-year retrospective chart review of all patients who underwent single-blinded placebo-controlled two-step challenges to beta-lactams in an outpatient setting. RESULTS: Between 2010 and 2015, 154 patients underwent 162 challenges to beta-lactams. The majority of patients was female (81.2%) with a mean age of 51.4 years (SE 61.5). All challenges were preceded by negative skin testing and most (98%) were preceded by placebo. Reactions to placebo occurred in 11.3% of challenges (n518) and to beta-lactams in 6.2% (n510). Patients who reacted to placebos were female (100%, p50.04) and more likely to have a history of multiple reported drug allergies: 4.6 (SE 60.9) vs. 2.5 (SE 60.5) drug allergies in those who reacted to medication (SE 60.5) vs. 2.4 (SE 60.1) drug allergies in those who had no reaction (p<0.01). The majority of all reactions was mild and subjective (n524/28, 86%) with spontaneous resolution (n5 25/28, 89%). Reactions to placebos included pruritus (n512), sensation of throat tightness (n52), and hives (n51). Reactions to medications included pruritus (n54), tingling (n53), and fatigue (n53). No anaphylactic reactions occurred. CONCLUSIONS: This study validates the safety of two-step challenges to beta-lactams. Since a greater number of reactions occurred to placebo rather than to beta-lactams, it is likely that some reactions are not due to drugs.
118
Amoxicillin Challenges in Reporting Penicillin Allergy
Marine
Recruits
Jeremy D. Waldram, MD1, Mark H. Tucker, MD2; 1Scripps Clinic, San Diego, CA, 2Naval Branch Health Clinic, Bonita, CA. RATIONALE: Marine recruits commonly report a beta lactam allergy upon arriving to boot camp. This has significant implications during and after recruit training, but logistics typically prevent evaluation. METHODS: Over a 13 month period, 244 Marine recruits in San Diego, CA were evaluated for beta lactam allergy. They reported being allergic to these medications on their intake paperwork. Data regarding reaction history, exposure since reaction, and additional medical history was obtained prior to evaluation. Seventy-five recruits underwent penicillin skin testing followed by oral challenge to amoxicillin 250mg if skin test negative, while 169 recruits had oral challenge without skin testing. Recruits with negative oral challenges went on to receive intramuscular penicillin G per standard recruit prophylaxis protocol. RESULTS: All 75 recruits who underwent penicillin skin testing had negative skin tests and negative oral challenges to amoxicillin. Of the 169 recruits that proceeded directly to oral challenge, 168 (99.4%) had a negative challenge. A single recruit developed neck erythema, globus, and throat itching after oral challenge. The symptoms responded rapidly to intramuscular epinephrine and diphenhydramine. All of the 243 recruits having had negative amoxicillin challenges successfully received their routine prophylactic intramuscular penicillin G injection without reaction. CONCLUSIONS: Oral beta lactam challenge without prior penicillin skin testing may be an efficient, safe, and cost-reducing method of evaluating military recruits with reported beta lactam allergy. The views expressed herein are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government
SATURDAY
115
J ALLERGY CLIN IMMUNOL VOLUME 137, NUMBER 2
The Effect of Penicillin Allergy Testing on Future Healthcare Utilization and Morbidity: A CaseControl Study
Eric M. Macy, MD, FAAAAI1, Yu-Hsiang Shu, MS, PhD2; 1SCPMG Department of Allergy, 2Kaiser Permanente Southern California. RATIONALE: The effect outpatient penicillin allergy testing has on future healthcare utilization (HU) and morbidity is unknown. METHODS: HU and morbidity in 500 penicillin allergic cases, only 8 penicillin allergy test-positive, seen from 6-8-2010 to 3-29-2012, were compared to non-tested controls. Five penicillin allergic controls were matched to each case by gender, age, weighted Charlson comorbidity index (CCI), and outpatient office visits during a 2-year lead-in period. Hospital days, new drug allergies, and antibiotic exposures were determined over a 36 to 62 month follow-up period. RESULTS: Cases had a mean (95% CI) lead-in CCI of 1.65 (1.44–1.87) and 13.73 (12.76–14.7) outpatient visits per year of healthplan coverage (YHC). Controls had a mean lead-in CCI of 1.7 (1.6–1.8) and 12.08 (11.69–12.47) outpatient visits per YHC. For cases, hospital days per YHC increased significantly less than for control subjects, 1.62 (1.13–2.11) to 2.16 (1.00–3.31) [133%] versus 0.73 (0.59–0.87) to 2.02 (1.43–2.61) [277%], (p < 0.0001). Antibiotic courses per year fell significantly more in cases, - 0.85 versus -0.62, (p 5 0.0212). Cases had significantly fewer new drug allergies at the end of the follow-up period, +0.044 versus +0.18, (p < 0.0001). The top 5 antibiotics cases were exposed to were penicillins, 1st generation cephalosporins, quinolones, tetracyclines, and macrolides versus macrolides, quinolones, clindamycin, 1stgeneration cephalosporins, and tetracyclines for controls. CONCLUSIONS: Penicillin allergy testing was associated with a smaller increase in hospital days, a greater fall in antibiotic usage, fewer new drug allergies, and significantly less macrolide, quinolone, and clindamycin exposure over the next 3 to 5 years.
116
The Effect of a Penicillin Allergy Algorithm on Perioperative Antibiotic Choice
Joseph A. Grillo, MD1, Karen Ravin, MD2, Magee L. DeFelice, MD3; 1 Nemours A.I. du Pont Hospital for Children, Wilmington, DE, 2Nemours/A.I. duPont Hospital for Children, 3Nemours/A.I duPont Hospital for Children, Wilmington, DE. RATIONALE: Cephalosporins are the preferred medications for perioperative antimicrobial prophylaxis. Due to the potential risk of crossreactivity between penicillins and cephalosporins, alternatives such as clindamycin are often administered to patients who report penicillin allergy. Clindamycin has potential to cause adverse hemodynamic effects when used in the perioperative setting, and lacks gram negative coverage. METHODS: The Nemours/A.I. duPont Hospital for Children developed an algorithm to evaluate penicillin allergic patients who present to the operating room. The algorithm recommends use of cephalosporins in select patients based on the clinical history of the penicillin reaction. The perioperative antibiotics administered to penicillin allergic patients who were screened using the protocol from May to June of 2015 were compared to a historical cohort from May to June of 2014. RESULTS: Fifty-four penicillin allergic patients (male to female ratio of 1:1) were screened using the algorithm. There were 46 penicillin allergic patients (male to female ratio of 2:3) in the pre-intervention group. When the algorithm was employed, clindamycin use decreased from 32.6% (15/46) to 9.3% (5/54) and the use of 1st or 2ndgeneration cephalosporins increased from 67.3% (31/46) to 88.8% (48/54). CONCLUSIONS: In the preoperative setting, a penicillin allergy algorithm increased cephalosporin and decreased clindamycin use. Preoperative penicillin skin testing for penicillin allergy has also been shown to increase the use of cephalosporins, however, skin testing in this setting may not always be practical. A penicillin allergy algorithm is an effective and efficient screening tool that could be expanded institutionwide and implemented at other tertiary care centers.
117
Safety of Two-Step Graded Challenges to BetaLactams Using a Single-Blinded PlaceboControlled Protocol
Melissa Iammatteo, MD1, Denisa Ferastraoaru, MD, MSc2, Santiago Alvarez Arango, MD3, Niharika Thota, MD3, Ayobami Akenroye, MD, MPH3, Elina Jerschow, MD, MSc1; 1Albert Einstein College of Medicine/ Montefiore Medical Center, Bronx, NY, 2Albert Einstein/Montefiore Medical Center, Bronx, NY, 3Albert Einstein College of Medicine, Bronx, NY. RATIONALE: Graded challenges are performed to exclude immediate hypersensitivity reactions. We aimed to validate the safety of two-step graded challenges (test doses) by comparing the reaction rate of two-step challenges with placebos in patients with a negative skin test to beta-lactams. METHODS: We performed a five-year retrospective chart review of all patients who underwent single-blinded placebo-controlled two-step challenges to beta-lactams in an outpatient setting. RESULTS: Between 2010 and 2015, 154 patients underwent 162 challenges to beta-lactams. The majority of patients was female (81.2%) with a mean age of 51.4 years (SE 61.5). All challenges were preceded by negative skin testing and most (98%) were preceded by placebo. Reactions to placebo occurred in 11.3% of challenges (n518) and to beta-lactams in 6.2% (n510). Patients who reacted to placebos were female (100%, p50.04) and more likely to have a history of multiple reported drug allergies: 4.6 (SE 60.9) vs. 2.5 (SE 60.5) drug allergies in those who reacted to medication (SE 60.5) vs. 2.4 (SE 60.1) drug allergies in those who had no reaction (p<0.01). The majority of all reactions was mild and subjective (n524/28, 86%) with spontaneous resolution (n5 25/28, 89%). Reactions to placebos included pruritus (n512), sensation of throat tightness (n52), and hives (n51). Reactions to medications included pruritus (n54), tingling (n53), and fatigue (n53). No anaphylactic reactions occurred. CONCLUSIONS: This study validates the safety of two-step challenges to beta-lactams. Since a greater number of reactions occurred to placebo rather than to beta-lactams, it is likely that some reactions are not due to drugs.
118
Amoxicillin Challenges in Reporting Penicillin Allergy
Marine
Recruits
Jeremy D. Waldram, MD1, Mark H. Tucker, MD2; 1Scripps Clinic, San Diego, CA, 2Naval Branch Health Clinic, Bonita, CA. RATIONALE: Marine recruits commonly report a beta lactam allergy upon arriving to boot camp. This has significant implications during and after recruit training, but logistics typically prevent evaluation. METHODS: Over a 13 month period, 244 Marine recruits in San Diego, CA were evaluated for beta lactam allergy. They reported being allergic to these medications on their intake paperwork. Data regarding reaction history, exposure since reaction, and additional medical history was obtained prior to evaluation. Seventy-five recruits underwent penicillin skin testing followed by oral challenge to amoxicillin 250mg if skin test negative, while 169 recruits had oral challenge without skin testing. Recruits with negative oral challenges went on to receive intramuscular penicillin G per standard recruit prophylaxis protocol. RESULTS: All 75 recruits who underwent penicillin skin testing had negative skin tests and negative oral challenges to amoxicillin. Of the 169 recruits that proceeded directly to oral challenge, 168 (99.4%) had a negative challenge. A single recruit developed neck erythema, globus, and throat itching after oral challenge. The symptoms responded rapidly to intramuscular epinephrine and diphenhydramine. All of the 243 recruits having had negative amoxicillin challenges successfully received their routine prophylactic intramuscular penicillin G injection without reaction. CONCLUSIONS: Oral beta lactam challenge without prior penicillin skin testing may be an efficient, safe, and cost-reducing method of evaluating military recruits with reported beta lactam allergy. The views expressed herein are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government
SATURDAY
115