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Infect Control Hosp Epidemiol. 2019 May;40(5):528-535. doi: 10.1017/ice.2019.50. Epub 2019 Mar 27.

Outcomes from an inpatient beta-lactam allergy guideline across a large US health system.

Author information

Division of Rheumatology, Allergy, and Immunology, Department of Medicine,Massachusetts General Hospital, Boston, Massachusetts.
University of Pittsburgh School of Medicine,Pittsburgh, Pennsylvania.
Harvard Medical School,Boston, Massachusetts.
Department of Pharmacy,Newton-Wellesley Hospital,Newton, Massachusetts.
Partners HealthCare System, Quality, Safety, and Value, Boston, Massachusetts.
Division of Allergy and Clinical Immunology, Jewish General Hospital,McGill University,Montreal, Quebec, Canada.
Division of Rheumatology, Allergy and Immunology, Department of Medicine,Brigham and Women's Hospital, Boston,Massachusetts.
Department of Pharmacy,Massachusetts General Hospital, Boston, Massachusetts.
Division of Infectious Diseases, Department of Medicine,North Shore Medical Center,Salem, Massachusetts.
Pharmacy Department,North Shore Medical Center,Salem, Massachusetts.
Pharmacy Department,Brigham and Women's Faulkner Hospital,Boston, Massachusetts.



To assess the safety of, and subsequent allergy documentation associated with, an antimicrobial stewardship intervention consisting of test-dose challenge procedures prompted by an electronic guideline for hospitalized patients with reported β-lactam allergies.


Retrospective cohort study.


Large healthcare system consisting of 2 academic and 3 community acute-care hospitals between April 2016 and December 2017.


We evaluated β-lactam antibiotic test-dose outcomes, including adverse drug reactions (ADRs), hypersensitivity reactions (HSRs), and electronic health record (EHR) allergy record updates. HSR predictors were examined using a multivariable logistic regression model. Modification of the EHR allergy record after test doses considered relevant allergy entries added, deleted, and/or specified.


We identified 1,046 test-doses: 809 (77%) to cephalosporins, 148 (14%) to penicillins, and 89 (9%) to carbapenems. Overall, 78 patients (7.5%; 95% confidence interval [CI], 5.9%-9.2%) had signs or symptoms of an ADR, and 40 (3.8%; 95% CI, 2.8%-5.2%) had confirmed HSRs. Most HSRs occurred at the second (ie, full-dose) step (68%) and required no treatment beyond drug discontinuation (58%); 3 HSR patients were treated with intramuscular epinephrine. Reported cephalosporin allergy history was associated with an increased odds of HSR (odds ratio [OR], 2.96; 95% CI, 1.34-6.58). Allergies were updated for 474 patients (45%), with records specified (82%), deleted (16%), and added (8%).


This antimicrobial stewardship intervention using β-lactam test-dose procedures was safe. Overall, 3.8% of patients with β-lactam allergy histories had an HSR; cephalosporin allergy histories conferred a 3-fold increased risk. Encouraging EHR documentation might improve this safe, effective, and practical acute-care antibiotic stewardship tool.

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