4.7 Article

Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship

Journal

JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY
Volume 140, Issue 1, Pages 154-+

Publisher

MOSBY-ELSEVIER
DOI: 10.1016/j.jaci.2017.02.005

Keywords

Stewardship; skin test; test dose; decision support; computerized guideline

Funding

  1. Brigham Care Redesign Incubator and Start-Up Program (BCRISP)
  2. Harvard Catalyst \ The Harvard Clinical and Translational Science Center (the National Center for Research Resources, National Institutes of Health [NIH]) [UL1 TR001102]
  3. Harvard Catalyst \ The Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, National Institutes of Health [NIH]) [UL1 TR001102]
  4. Harvard University
  5. NIH [K01AI125631-01]
  6. American Academy of Allergy Asthma and Immunology Foundation
  7. Steven and Deborah Gorlin MGH Research Scholars Award

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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.

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