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Powell N, Blank M, Luintel A, Elkhalifa S, Bhogal R, Wilcock M, Wakefield M, Sandoe J. Narrative review of recent developments and the future of penicillin allergy de-labelling by non-allergists. NPJ ANTIMICROBIALS AND RESISTANCE 2024; 2:18. [PMID: 39843524 PMCID: PMC11721385 DOI: 10.1038/s44259-024-00035-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/11/2024] [Indexed: 01/24/2025]
Abstract
This article outlines recent developments in non-allergist delivered penicillin allergy de-labelling (PADL), discusses remaining controversies and uncertainties and explores the future for non-allergist delivered PADL. Recent developments include national guidelines for non-allergist delivered PADL and validation of penicillin allergy risk assessment tools. Controversies remain on which penicillin allergy features are low risk of genuine allergy. In the future genetic or immunological tests may facilitate PADL.
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Affiliation(s)
- Neil Powell
- Pharmacy Department, Royal Cornwall Hospital Trust, Truro, Cornwall, UK.
| | | | - Akish Luintel
- Institute of Global Health Innovation, Imperial College London, London, UK
| | - Shuayb Elkhalifa
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Allergy and Immunology Department, Respiratory Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Rashmeet Bhogal
- The School of Pharmacy and Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Michael Wilcock
- Pharmacy Department, Royal Cornwall Hospital Trust, Truro, Cornwall, UK
| | - Michael Wakefield
- Respiratory Department, Harrogate and District NHS Foundation Trust, Harrogate, UK
| | - Jonathan Sandoe
- Healthcare associated infection group, Leeds institute of medical research, university of Leeds, Leeds, UK
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Antimicrobial Stewardship in Total Joint Arthroplasty: Outcomes of a Collaborative Program Implementation. J Am Acad Orthop Surg 2022; 30:e1327-e1336. [PMID: 36200821 DOI: 10.5435/jaaos-d-21-00722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 04/26/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Antimicrobial stewardship has been cited as a crucial component of orthopaedic surgical care; however, limited high-quality data exist to guide antibiotic use across the total joint arthroplasty continuum. Antimicrobial stewardship program (ASP) implementation and evaluation is needed in this space. METHODS We pursued a prospective, sequential cohort study of an interprofessional ASP for total joint arthroplasty (TJA) formed in late 2017 at the study institution. Twelve total evidence-based recommendations for protocol change were issued, with 11 accepted and implemented across three project phases spanning March 2018 to December 2019. The primary study outcome was the rate of optimal preoperative intravenous antibiotic selection as assessed for Baseline versus Postintervention time periods. Secondary outcomes included individual antibiotic utilization rates. Descriptive statistics were pursued for institutional surgical site infection (SSI) and postoperative acute kidney injury (AKI) rates across the affected time frame. A cost-benefit analysis of the ASP was estimated from the institutional perspective. RESULTS The rate of optimal preoperative antibiotic selection increased from 64.9% in the Baseline Period (February 2018, n = 57) to 95.4% in the Postimplementation period (June 2018 to December 2019, n = 1,220) (P < 0.001). The rates of second-line preoperative antibiotics and total perioperative antibiotic exposures decreased. Total SSI and AKI rates in primary elective TJA seemed to decrease from calendar year 2018 to 2019 (deep SSI 1.00% to 0.22%, superficial SSI 0.66% to 0.00%, and AKI 1.97% to 1.03%). The institution realized an estimated $197,050 cost savings per 1000 TJA procedures. DISCUSSION A comprehensive ASP for TJA was associated with an increased use of optimal preoperative antibiotic selection, decreased total antibiotic exposures, and cost savings, without apparent detriment to SSI or AKI rates.
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Suresh NV, Shah VN, Fritz CG, Griff JR, Shah S, Watane A, Parikh RS, Nicolli EA. Medical malpractice litigation involving otolaryngology residents and fellows: A case-based 30-year review. World J Otorhinolaryngol 2022; 9:1-11. [DOI: 10.5319/wjo.v9.i1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/09/2022] [Accepted: 08/18/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Errors, misdiagnoses, and complications can occur while trainees are involved in patient care. Analysis of such events could reveal areas for improvement by residency and fellowship programs.
AIM To examine lawsuits tried at the state and federal level involving otolaryngology trainees.
METHODS The LexisNexis database, an online legal research database containing state and federal case records from across the United States, was retrospectively reviewed for malpractice cases involving otolaryngology residents or fellows from January 1, 1990 to December 31, 2020. Case data collected: Plaintiff/trainee/defendant characteristics, allegations, medical outcomes, and legal outcomes.
RESULTS Over the study period, 20 malpractice lawsuits involving otolaryngology trainees were identified. Plaintiffs raised numerous allegations including procedural error (n = 12, 25.5%), incorrect diagnosis and/or treatment (n = 8, 17.0%), and lack of knowledge of trainee involvement (n = 6, 12.8%). Nine cases (45%) had verdicts in favor of the plaintiff, whereas 5 cases (25%) had verdicts in favor of the defense. Six cases (30%) ended in a settlement. Awards to plaintiffs were heterogenous, with a median of $617,500 (range $32K-17M) for settled cases and verdicts favoring plaintiffs.
CONCLUSION The findings enclosed herein represent the first published analysis of trainee involvement in otolaryngology malpractice cases held at the state/federal level. Otolaryngology trainees can be involved in lawsuits for both procedural and nonprocedural events. This study highlights the importance of education specifically in the domains of procedural errors, informed consent, proper diagnosis/management, and clear communication within patient care teams. Training programs should incorporate these study findings into effective simulation courses and didactic sessions. Educating trainees about common pitfalls holds the promise of decreasing healthcare systems costs, reducing trainee burnout, and, most importantly, benefiting patients.
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Affiliation(s)
- Neeraj V Suresh
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA 19107, United States
| | - Viraj N Shah
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, United States
| | - Christian G Fritz
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA 19107, United States
| | - Jessica R Griff
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, United States
| | - Shreni Shah
- Morsani College of Medicine, University of South Florida, Tampa, FL 33612, United States
| | - Arjun Watane
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, CT 06510, United States
| | - Ravi S Parikh
- Department of Ophthalmology, NYU Grossman School of Medicine, New York, NY 10016, United States
| | - Elizabeth A Nicolli
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, United States
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DesBiens MT, Calderwood MS, Reigh EL. Expanding Penicillin Allergy Evaluation in Hospitalized Patients. Am J Med 2022; 135:958-963.e13. [PMID: 35339433 DOI: 10.1016/j.amjmed.2021.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/08/2021] [Accepted: 12/08/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Martha T DesBiens
- Department of Medicine, Section of Infectious Disease, Nuvance Health, Southbury, Conn; The Robert Larner M.D. College of Medicine at The University of Vermont, Burlington; Department of Medicine, Section of Infectious Disease & International Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - Michael S Calderwood
- Department of Medicine, Section of Infectious Disease & International Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Erin L Reigh
- Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Medicine, Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Covington EW, Durham SH, Bland CM, Bookstaver PB, Chahine EB, Cho JC, Diggs F, Jones BM, Kyle JA, Stover KR, Wagner JL, Hughes PJ. A Continuing Education Activity Durably Addressed Knowledge Gaps Related to Penicillin Allergies Among Pharmacists and Pharmacy Technicians. J Pharm Technol 2021; 38:18-25. [DOI: 10.1177/87551225211051015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Penicillin allergy is one of the most frequent self-reported allergies; however, only about 10% of reported allergies are accurate. Objectives: Through the creation of a continuing pharmacy education (CPE) activity, we sought to assess knowledge gaps and comfort levels in the management of penicillin allergies. Methods: A 1-hour enduring-content CPE activity was offered as an interactive course from September 20, 2019, to September 20, 2020. Participants completed 3 surveys (pre-survey, post-survey, and follow-up survey). Participants were pharmacists and pharmacy technicians who completed, at a minimum, the activity and both pre- and post-surveys. The primary outcome was the percentage of participants scoring >80% on knowledge-based questions on the post-survey compared with the pre-survey. Secondary outcomes included pre-post comparisons on knowledge-based questions, participants’ self-report of an allergy, and comfort levels dispensing cephalosporins in a patient with a self-reported penicillin allergy. Results: A total of 389 participants completed the CPE activity, with 176 included for analysis. Significantly more participants scored >80% on knowledge-based questions on the post-survey compared with the pre-survey (71.6% vs 22.7%, P < .001). There was no significant difference between the percentage of participants scoring >80% on the post-survey and the follow-up survey (71.6% vs 65%, P = .119). The majority of participants (74%) felt comfortable dispensing a cephalosporin in a patient with a penicillin allergy on the pre-survey, with similar percentages on the post- and follow-up surveys (77% and 90%, respectively). Conclusion: A targeted continuing education program improved overall knowledge, which was sustained for up to 2 months.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce M. Jones
- St. Joseph’s/Candler Health System, Inc, Savannah, GA, USA
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Macy E. Why Was There Ever a Warning Not to Use Cephalosporins in the Setting of a Penicillin "Allergy"? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3929-3933. [PMID: 34303019 DOI: 10.1016/j.jaip.2021.06.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/23/2021] [Accepted: 06/30/2021] [Indexed: 12/20/2022]
Abstract
It is now well-established that avoiding β-lactam antibiotics, when they are the drugs of choice, results in significantly worse long-term global outcomes for patients. Much of this avoidable morbidity has been caused by widespread warnings in electronic health care record systems not to use cephalosporins in the setting of penicillin allergy. High rates, up to 1000-fold higher than now seen, of immunologically mediated reactions were associated with early impure penicillin preparations. This instilled a rational fear of β-lactam-associated anaphylaxis in generations of physicians. In the late 1970s, several editorial comments regarding a potential increased risk to patients given cephalosporins who had a history of a penicillin allergy resulted in the warning that became imbedded in the culture of medicine. Over the past 40 years, compelling data have been developed that refute this warning and showed that the risks of avoiding cephalosporins outweighed the benefits. In late 2017, Kaiser Permanente Southern California completely removed all warnings not to use cephalosporins in the setting of a penicillin allergy. The results have recently been published in JAMA Network Open. This Rostrum article provides some of the backstory on the establishment and removal of this warning for physicians who trained over the past 30 years.
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Affiliation(s)
- Eric Macy
- Allergy Department, Kaiser San Diego Medical Center, Permanente Southern California, San Diego, Calif.
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Penicillin Allergy Delabeling: A Multidisciplinary Opportunity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2858-2868.e16. [PMID: 33039010 DOI: 10.1016/j.jaip.2020.04.059] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022]
Abstract
The penicillin allergy label has been consistently linked with deleterious effects that span the health care spectrum, including suboptimal clinical outcomes, the emergence of bacterial resistance, and increased health care expenditures. These risks have recently motivated professional organizations and public health institutes to advocate for the implementation of penicillin allergy delabeling initiatives; however, the burden of delabeling millions of patients is too expansive for any one discipline to bear alone. This review presents the unique perspectives and roles of various stakeholder groups involved in penicillin allergy diagnosis, assessment, and delabeling; we emphasize opportunities, barriers, and promising areas of innovation. We summarize penicillin allergy methods and tools that have proven successful in delabeling efforts. A multidisciplinary approach to delabeling patients with reported penicillin allergy, bolstered by evidence-based clinical practices, is recommended to reduce the risks that associate with the penicillin allergy label.
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Yang J, Wang L, Phadke NA, Wickner PG, Mancini CM, Blumenthal KG, Zhou L. Development and Validation of a Deep Learning Model for Detection of Allergic Reactions Using Safety Event Reports Across Hospitals. JAMA Netw Open 2020; 3:e2022836. [PMID: 33196805 PMCID: PMC7670315 DOI: 10.1001/jamanetworkopen.2020.22836] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Although critical to patient safety, health care-related allergic reactions are challenging to identify and monitor. OBJECTIVE To develop a deep learning model to identify allergic reactions in the free-text narrative of hospital safety reports and evaluate its generalizability, efficiency, productivity, and interpretability. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed hospital safety reports filed between May 2004 and January 2019 at Brigham and Women's Hospital and between April 2006 and June 2018 at Massachusetts General Hospital in Boston. Training and validating a deep learning model involved extracting safety reports using 101 expert-curated keywords from Massachusetts General Hospital (data set I). The model was then evaluated on 3 data sets: reports without keywords (data set II), reports from a different time frame (data set III), and reports from a different hospital (Brigham and Women's Hospital; data set IV). Statistical analyses were performed between March 1, 2019, and July 18, 2020. MAIN OUTCOMES AND MEASURES The area under the receiver operating characteristic curve and area under the precision-recall curve were used on data set I. The precision at top-k was used on data sets II to IV. RESULTS A total of 299 028 safety reports with 172 854 patients were included. Of these patients, 86 544 were women (50.1%) and the median (interquartile range [IQR]) age was 59.7 (43.8-71.6) years. The deep learning model achieved an area under the receiver operating characteristic curve of 0.979 (95% CI, 0.973-0.985) and an area under the precision-recall curve of 0.809 (95% CI, 0.773-0.845). The model achieved precisions at the top 100 model-identified cases of 0.930 in data set II, 0.960 in data set III, and 0.990 in data set IV. Compared with the keyword-search approach, the deep learning model reduced the number of cases for manual review by 63.8% and identified 24.2% more cases of confirmed allergic reactions. The model highlighted important words (eg, rash, hives, and Benadryl) in prediction and extended the list of expert-curated keywords through an attention layer. CONCLUSIONS AND RELEVANCE This study showed that a deep learning model can accurately and efficiently identify allergic reactions using free-text narratives written by a variety of health care professionals. This model could be used to improve allergy care, potentially enabling real-time event surveillance and guidance for medical errors and system improvement.
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Affiliation(s)
- Jie Yang
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Liqin Wang
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Neelam A. Phadke
- Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| | - Paige G. Wickner
- Harvard Medical School, Boston, Massachusetts
- Division of Allergy and Clinical Immunology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Christian M. Mancini
- Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| | - Kimberly G. Blumenthal
- Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Silva Espinosa DL, Rojas Mejía DV, Ramírez Zuluaga LF, Olaya Hernández M, Serrano Reyes CD. Descriptive analysis of a simplified approach to low-risk drug hypersensitivity reactions. Ann Allergy Asthma Immunol 2020; 126:162-167. [PMID: 32896639 DOI: 10.1016/j.anai.2020.08.396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/26/2020] [Accepted: 08/31/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Evaluation of drug allergy is intricate because of nonstandardized testing and challenge method variability. OBJECTIVE To determine the clinical and epidemiologic characteristics of a large group of patients with suspected drug allergies who underwent 1 or more provocation tests (PT), and to establish whether performing this test in fewer steps is safe and effective. METHODS A cross-sectional descriptive study was conducted in patients with suspected drug allergies who underwent a provocation test at the allergy service of Fundación Valle del Lili, Cali, Colombia, from January 2011 to August 2017. RESULTS A total of 508 patients underwent 615 PTs; the median age was 34.5 years (range, 1-87 years) and 332 were women (65.3%). The most frequently implicated drugs were nonsteroidal anti-inflammatory drugs in 362 patients (58.9%), followed by beta-lactam antibiotics in 170 (27.6%), and non-beta-lactam antibiotics in 21 (3.4%). The most typically described manifestations were cutaneous urticaria in 282 patients (45.8%) and angioedema in 220 (35.7%). Most patients underwent the PT without performing other previous tests, which were done in only 92 patients (18.3%). Skin prick tests and intradermal reaction tests were performed in 81 patients (15%); all results were negative. In 519 patients (84.3%), the PT was performed in 2 steps without a placebo. Of the PTs performed in 2 steps, 492 (94.8%) had negative results. In addition, PT was performed in 195 patients (37.6%) in whom 2 equal doses of the drug was administered; 186 patients (95.4%) had negative results. CONCLUSION Performing an open PT (without previous tests) in 2 steps among patients with low-risk drug reactions is safe. However, every case must be analyzed individually in terms of the risk-benefit ratio.
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Tripathi R, Ezaldein HH, Rajkumar K, Bordeaux JS, Scott JF. Characteristics of State and Federal Malpractice Litigation of Medical Liability Claims for Keratinocyte Carcinoma, 1968 to 2018. JAMA Dermatol 2020; 155:812-818. [PMID: 31090874 DOI: 10.1001/jamadermatol.2019.0430] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance The prevalence of keratinocyte carcinoma (KC) exceeds that of all other malignant neoplasms combined. Despite the steady rise of payments for medical malpractice liability claims over time, data regarding the characteristics of malpractice litigation for KC are scarce. Objective To identify state and federal appellate medical malpractice liability cases for KC and determine the factors associated with the verdicts. Design, Setting, and Participants This retrospective review of KC-related malpractice litigation under state or federal jurisdiction reviewed the LexisNexis Academic database of state and federal cases, legal reviews, and case law. All appellate medical malpractice cases at the state and federal levels involving basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) from January 1, 1968, through December 31, 2018, were identified. Main Outcomes and Measures Demographic characteristics of the cases and plaintiffs, verdict, health care specialty of the defendant, setting of the litigation, rationale for the lawsuit and verdict, factors associated with the case outcome, and monetary payout in cases won by the plaintiff. Results In total, 83 cases were included in our analysis (34 BCC cases and 49 SCC cases; 47 [57%] male plaintiffs). Sixty-two cases (75%) were decided in favor of the defendant. More KC-related malpractice cases were won by defendants in more recent years than were won by plaintiffs (mean year, 2004 [SD, 11 years] vs 1998 [SD, 14 years]; P = .03). Twenty-five cases (30%) each occurred in the Northeast and the South, and 45 (54%) involved private practices. Most cases involved KCs occurring on the face, head, and/or neck (39 [47%]), the genitalia (22 [27%]), or the extremities (15 [18%]). More than half of defendants were dermatologists (19 [23%]), family medicine physicians (15 [18%]), or oncologists (8 [10%]). Jurisprudence for KC-related malpractice cases most often occurred at the state level (49 [59%]). The most common causes of litigation were failure to diagnose (18 [22%]), misdiagnosis (18 [22%]), and delay in treatment (11 [13%]). More female than male plaintiffs won their malpractice cases (11 of 35 [31%] vs 5 of 43 [12%]; P = .03). More cases involving SCC than BCC led to a decision favoring the plaintiff (13 of 47 [28%] vs 3 of 31 [10%]; P = .05). In cases won by the plaintiff, the median monetary payout was $179 654 and the mean payout was $909 801 (range, $11 537-$5 320 161). Conclusions and Relevance This study sheds light on the characteristics and settings of KC malpractice litigation claims, which is vital information for discovering potential areas of quality improvement, patient safety initiatives, and education for patients and health care professionals.
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Affiliation(s)
- Raghav Tripathi
- Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Harib H Ezaldein
- Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Jeremy S Bordeaux
- Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jeffrey F Scott
- Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Abstract
PURPOSE OF REVIEW As drug allergy research aims to inform clinical practice, implementation of best practices may be influenced by financial resources required to incorporate new interventions and the resulting clinical and economic returns on those resource investments. The present review summarizes new insights into the economics of drug allergy over the past year. RECENT FINDINGS While considering economic implications of recent drug allergy research, many studies have addressed different contextual factors related to the setting, provider, or outcomes. Advances in technology have enabled specialized allergists to support remote settings through telemedicine consultation. Training opportunities and interdisciplinary approaches to address drug allergy challenges have enabled multiple provider types to play a role in screening, diagnosis, and management. Penicillin allergy testing has been a major focus for many institutions, with several studies focused on de-labeling strategies including confirmatory skin testing and direct oral challenges. SUMMARY Studies over the past year provide new opportunities for the field of drug allergy research. The focus of current research to capture direct health costs or savings associated with drug allergy interventions demonstrates opportunity for more cost-effective care delivery and opportunity to explore greater benefits to society.
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D’Errico S, Frati P, Zanon M, Valentinuz E, Manetti F, Scopetti M, Santurro A, Fineschi V. Cephalosporins' Cross-Reactivity and the High Degree of Required Knowledge. Case Report and Review of the Literature. Antibiotics (Basel) 2020; 9:209. [PMID: 32344946 PMCID: PMC7277108 DOI: 10.3390/antibiotics9050209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/14/2020] [Accepted: 04/23/2020] [Indexed: 12/30/2022] Open
Abstract
Antibiotic cross-reactivity represents a phenomenon of considerable interest as well as antibiotic resistance. Immediate reactions to cephalosporins are reported in the literature with a prevalence of only 1%-3% of the population, while anaphylactic reactions are rarely described (approximately 0.0001%-0.1%) as well as fatalities. Allergic reaction to cephalosporins may occur because of sensitization to unique cephalosporin haptens or to determinants shared with penicillins. Cross-reactivity between cephalosporins represents, in fact, a well-known threatening event involving cephalosporins with similar or identical R1- or R2-side chains. The present report describes the case of a 79-year-old man who suddenly died after intramuscular administration of ceftriaxone. Serum dosage of mast cell tryptase from a femoral blood sample at 3 and 24 hours detected values of 87.7μg/L and 93.5μg/L, respectively (cut-off value 44.3 μg/L); the serum-specific IgE for penicillins, amoxicillin, cephaclor and also for the most common allergens were also determined. A complete post-mortem examination was performed, including gross, histological and immunohistochemical examination, with an anti-tryptase antibody. The cause of death was identified as anaphylactic shock: past administrations of cefepime sensitized the subject to cephalosporins and a fatal cross-reactivity of ceftriaxone with cefepime occurred due to the identical seven-position side chain structure in both molecules. The reported case offers food for thought regarding the study of cross-reactivity and the need to clarify the predictability and preventability of the phenomenon in fatal events.
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Affiliation(s)
- Stefano D’Errico
- Department of Medicine, Surgery and Health, University of Trieste, 34149 Trieste, Italy; (S.D.); (M.Z.); (E.V.)
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (P.F.); (F.M.); (M.S.); (A.S.)
| | - Martina Zanon
- Department of Medicine, Surgery and Health, University of Trieste, 34149 Trieste, Italy; (S.D.); (M.Z.); (E.V.)
| | - Eleonora Valentinuz
- Department of Medicine, Surgery and Health, University of Trieste, 34149 Trieste, Italy; (S.D.); (M.Z.); (E.V.)
| | - Federico Manetti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (P.F.); (F.M.); (M.S.); (A.S.)
| | - Matteo Scopetti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (P.F.); (F.M.); (M.S.); (A.S.)
| | - Alessandro Santurro
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (P.F.); (F.M.); (M.S.); (A.S.)
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (P.F.); (F.M.); (M.S.); (A.S.)
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A Practical Guide for Managing Antibiotic Allergies in the Emergency Department. Adv Emerg Nurs J 2020; 41:306-315. [PMID: 31687994 DOI: 10.1097/tme.0000000000000264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Up to 30% of patients report at least one antibiotic allergy, but oftentimes these antibiotic allergies are misdiagnosed. In fact, of the 10% of patients reporting penicillin allergies, 90%-98% are not truly allergic. In an era of increasing antibiotic resistance coupled with a limited number of new antibiotics, evaluating antibiotic allergies is critical in providing optimal patient care. Differentiating adverse drug reactions from antibiotic allergies may seem like a daunting task for clinicians and providers, especially in the emergency department, where decisions are made quickly. However, a systemic approach, including medical record review coupled with patient and/or family interview, is vital in managing patients with antibiotic allergies. Inappropriate, alternative antibiotics are frequently chosen due to patient allergies, and data suggest higher rates of broad-spectrum antibiotic use, antibiotic resistance, and poor outcomes as a result. Herein, we review antibiotic selection in patients reporting antibiotic allergies in the emergency department.
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Castells M. New role for the modern allergist in drug allergy: Assess, diagnose, and de-label. Ann Allergy Asthma Immunol 2019; 121:515-516. [PMID: 30389081 DOI: 10.1016/j.anai.2018.09.455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 09/12/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Mariana Castells
- Drug Hypersensitivity and Desensitization Center, Mastocytosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Solensky R. Penicillin allergy and the law. Ann Allergy Asthma Immunol 2019; 121:517-518. [PMID: 30389082 DOI: 10.1016/j.anai.2018.09.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Roland Solensky
- Oregon State University/Oregon Health Science University College of Pharmacy.
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Controversies in Drug Allergy: Drug Allergy Pathways. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:46-60.e4. [PMID: 30573422 DOI: 10.1016/j.jaip.2018.07.037] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 12/16/2022]
Abstract
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.
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Macy E, Vyles D. Who needs penicillin allergy testing? Ann Allergy Asthma Immunol 2018; 121:523-529. [PMID: 30092265 DOI: 10.1016/j.anai.2018.07.041] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 07/20/2018] [Accepted: 07/30/2018] [Indexed: 01/02/2023]
Affiliation(s)
- Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, California.
| | - David Vyles
- Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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