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J Allergy Clin Immunol. 2017 Jul;140(1):154-161.e6. doi: 10.1016/j.jaci.2017.02.005. Epub 2017 Feb 28.

Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship.

Author information

1
Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and the Massachusetts General Professional Organization, Boston, Mass; Harvard Medical School, Boston, Mass. Electronic address: kblumenthal1@partners.org.
2
Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass.
3
Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Hospital, Boston, Mass.
4
University of Minnesota Medical School, Minneapolis, Minn.
5
New York Medical College, Valhalla, NY.
6
Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Infection Control Unit, Massachusetts General Hospital, Boston, Mass.
7
Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Mass.

Abstract

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.

KEYWORDS:

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

PMID:
28254470
PMCID:
PMC5496780
DOI:
10.1016/j.jaci.2017.02.005
[Indexed for MEDLINE]
Free PMC Article

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