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Ann Allergy Asthma Immunol. 2015 Oct;115(4):294-300.e2. doi: 10.1016/j.anai.2015.05.011. Epub 2015 Jun 9.

Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy.

Author information

1
Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts. Electronic address: kblumenthal1@partners.org.
2
Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts.
3
Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts.
4
Harvard Medical School, Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
5
Harvard Medical School, Boston, Massachusetts; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts.
6
Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.

Abstract

BACKGROUND:

Self-reported penicillin allergy infrequently reflects an inability to tolerate penicillins. Inpatients reporting penicillin allergy receive alternative antibiotics that might be broader spectrum, more toxic, or less effective.

OBJECTIVE:

To develop and assess a clinical guideline for the general inpatient provider that directs taking a history and prescribing antibiotics for patients with penicillin or cephalosporin allergy.

METHODS:

A guideline was implemented to assist providers with assessing allergy history and prescribing antibiotics for patients with reported penicillin or cephalosporin allergy. The guideline used a standard 2-step graded challenge or test dose. A quasi-experimental study was performed to assess safety, feasibility, and impact on antibiotic use by comparing treatment 21 months before guideline implementation with 12 months after guideline implementation.

RESULTS:

Significantly more test doses to β-lactam antibiotics were performed monthly after vs before guideline implementation (median 14.5, interquartile range 13-16.25, vs 2, interquartile range 1-3.25, P < .001). Seven adverse drug reactions occurred during guideline-driven test doses, with no significant difference in rate (3.9% vs 6.1%, P = .44) or severity (P > .5) between periods. Guideline-driven test doses decreased alternative antimicrobial therapy after the test dose, including vancomycin (68.3% vs 37.2%, P < .001), aztreonam (11.5% vs 0.5%, P < .001), aminoglycosides (6.0% vs 1.1%, P = .004), and fluoro quinolones (15.3% vs 3.3%, P < .001).

CONCLUSION:

The implementation of an inpatient antibiotic prescribing guideline for patients with penicillin or cephalosporin allergy was associated with an almost 7-fold increase in the number of test doses to β-lactams without increased adverse drug reactions. Patients assessed with guideline-driven test doses were observed to have significantly decreased alternative antibiotic exposure.

PMID:
26070805
PMCID:
PMC4593731
DOI:
10.1016/j.anai.2015.05.011
[Indexed for MEDLINE]
Free PMC Article

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