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Old but not forgotten: Antibiotic allergies in General Medicine (the AGM Study)

Jason A Trubiano, Rekha Pai Mangalore, Yi-Wei Baey, Duy Le, Linda V Graudins, Patrick GP Charles, Douglas F Johnson and Ar Kar Aung
Med J Aust 2016; 204 (7): 273. || doi: 10.5694/mja15.01329

Summary

Objectives: To determine the nature, prevalence and description accuracy of recorded antibiotic allergy labels (AALs) in a cohort of general medical inpatients, and to assess the feasibility of an oral antibiotic re-challenge study.

Design: Multicentre cross-sectional study.

Setting and participants: All patients admitted to the general medical units of Austin Health and Alfred Health, 18 May – 5 June 2015.

Main outcome measures: Baseline demographics, medical and allergy history, infection diagnoses and antibiotic prescribing data for general medical inpatients were collected. A questionnaire was administered to clarify AAL history, followed by correlation of responses with electronic and admissions record descriptions. A hypothetical oral re-challenge in a supervised setting was offered to patients with low risk allergy phenotypes (non-immediate reaction, non-severe cutaneous adverse reaction, or unknown reaction more than 10 years ago).

Results: Of the 453 inpatients, 107 (24%) had an AAL (median age, 82 years; interquartile range, 74–87 years); 160 individual AALs were recorded, and there was a mismatch in AAL description between recording platforms in 25% of cases. Most patients with an AAL were women (64%; P < 0.001), and more presented with concurrent immunosuppression than those without an AAL (23% v 8%; P < 0.001). β-Lactam penicillins were employed less frequently in patients with an AAL (16% v 35%; P = 0.02), while ceftriaxone (32% v 20%; P = 0.02) and fluoroquinolones (6% v 2%; P = 0.04) were used more often. Fifty-four per cent of patients with AALs were willing to undergo oral re-challenge, of whom 48% had a low risk allergy phenotype.

Conclusions: AAL prevalence in general medical inpatients was 24%, and was associated with excessive use of broad spectrum antibiotics. Allergies in a large proportion of patients with AALs were incorrectly documented, and were non-immune-mediated and potentially amenable to oral re-challenge. A direct oral re-challenge study in carefully selected patients with low risk allergy phenotypes appears feasible.

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  • Jason A Trubiano1,2
  • Rekha Pai Mangalore1
  • Yi-Wei Baey3
  • Duy Le1
  • Linda V Graudins4
  • Patrick GP Charles1
  • Douglas F Johnson1
  • Ar Kar Aung4

  • 1 Austin Health, Melbourne, VIC
  • 2 University of Melbourne, Parkville, VIC
  • 3 Monash Medical Centre, Melbourne, VIC
  • 4 Alfred Health, Melbourne, VIC


Competing interests:

No relevant disclosures.

  • 1. Picard M, Begin P, Bouchard H, et al. Treatment of patients with a history of penicillin allergy in a large tertiary-care academic hospital. J Allergy Clin Immunol Pract 2013; 1: 252-257.
  • 2. Lee CE, Zembower TR, Fotis MA, et al. The incidence of antimicrobial allergies in hospitalized patients: implications regarding prescribing patterns and emerging bacterial resistance. Arch Intern Med 2000; 160: 2819-2822.
  • 3. Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin “allergy” in hospitalized patients: A cohort study. J Allergy Clin Immunol 2014; 133: 790-796.
  • 4. Trubiano JA, Leung VK, Chu MY, et al. The impact of antimicrobial allergy labels on antimicrobial usage in cancer patients. Antimicrob Resist Infect Control 2015; 4: 23.
  • 5. Abbo LM, Beekmann SE, Hooton TM, et al. Management of antimicrobial allergies by infectious diseases physicians. JAMA Intern Med 2013; 173: 1376-1378.
  • 6. Fehily SR, Stuart RL, Horne K, et al. Who really knows their patients’ penicillin adverse drug reaction status? A cross-sectional survey. Intern Med J 2015; 45: 113-115.
  • 7. Moskow JM, Cook N, Champion-Lippmann C, et al. Identifying opportunities in EHR to improve the quality of antibiotic allergy data. J Am Med Inform 2015; doi: 10.1093/jamia/ocv139 [Epub ahead of print].
  • 8. Trubiano J, Phillips E. Antimicrobial stewardship’s new weapon? A review of antibiotic allergy and pathways to ‘de-labeling’. Curr Opin Infect Dis 2013; 26: 526-537.
  • 9. Ressner RA, Gada SM, Banks TA. Antimicrobial stewardship and the allergist: reclaiming our antibiotic armamentarium. Clin Infect Dis 2015; 62: 400-401.
  • 10. Blumenthal KG, Shenoy ES, Hurwitz S, et al. Effect of a drug allergy educational program and antibiotic prescribing guideline on inpatient clinical providers’ antibiotic prescribing knowledge. J Allergy Clin Immunol Pract 2014; 2: 407-413.
  • 11. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis 1987; 40: 373-383.
  • 12. Rawlins MD, Thompson JW. Pathogenesis of adverse drug reactions. In: Davies DM, editor. Textbook of adverse drug reactions. Oxford: Oxford University Press, 1977; pp 10-31.
  • 13. Pichler WJ, editor. Drug hypersensitivity. Basel: Karger, 2007.
  • 14. Roujeau JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med 1994; 331: 1272-1285.
  • 15. Centers for Disease Control and Prevention. CDC/NHSN surveillance definitions for specific types of infections. 2016. http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf (accessed Jan 2016).
  • 16. Sundvall PD, Stuart B, Davis M, et al. Antibiotic use in the care home setting: a retrospective cohort study analysing routine data. BMC Geriatr 2015; 15: 71.
  • 17. Trubiano JA, Cairns KA, Evans JA, et al. The prevalence and impact of antimicrobial allergies and adverse drug reactions at an Australian tertiary centre. BMC Infect Dis 2015; 15: 572.
  • 18. Petz LD. Immunologic cross-reactivity between penicillins and cephalosporins: a review. J infect Dis 1978; 137 Suppl: S74-S79.
  • 19. Kolodny MH, Denhoff E. Reactions in penicillin therapy. JAMA 1946; 130: 1058-1061.
  • 20. Gadde J, Spence M, Wheeler B, et al. Clinical experience with penicillin skin testing in a large inner-city STD clinic. JAMA 1993; 270: 2456-2463.
  • 21. Caubet JC, Kaiser L, Lemaitre B, et al. The role of penicillin in benign skin rashes in childhood: a prospective study based on drug rechallenge. J Allergy Clin Immunol 2011; 127: 218-222.
  • 22. Bourke J, Pavlos R, James I, et al. Improving the effectiveness of penicillin allergy de-labeling. J Allergy Clin Immunol Pract 2015; 3: 365-374.e1.
  • 23. Vezir E, Dibek Misirlioglu E, Civelek E, et al. Direct oral provocation tests in non-immediate mild cutaneous reactions related to beta-lactam antibiotics. Pediatr Allergy Immunol 2016; 27: 50-54.
  • 24. Blumenthal KG, Shenoy ES, Varughese CA, et al. Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy. Ann Allergy Asthma Immunol 2015; 115: 294-300.e292.
  • 25. Li M, Krishna MT, Razaq S, et al. A real-time prospective evaluation of clinical pharmaco-economic impact of diagnostic label of ‘penicillin allergy’ in a UK teaching hospital. J Clin Pathol 2014; 67: 1088-1092.
  • 26. Chua KY, Grayson ML, Burgess AN, et al. The growing burden of multidrug-resistant infections among returned Australian travellers. Med J Aust 2014; 200: 116-118. <MJA full text>
  • 27. Macy E, Contreras R. Adverse reactions associated with oral and parenteral use of cephalosporins: a retrospective population-based analysis. J Allergy Clin Immunol 2015; 135: 745-752.e745.
  • 28. Rice LB, Hutton-Thomas R, Lakticova V, et al. β-Lactam antibiotics and gastrointestinal colonization with vancomycin-resistant enterococci. J Infect Dis 2004; 189: 1113-1118.
  • 29. Vesteinsdottir I, Gudlaugsdottir S, Einarsdottir R, et al. Risk factors for Clostridium difficile toxin-positive diarrhea: a population-based prospective case–control study. Eur J Clin Microbiol Infect Dis 2012; 31: 2601-2610.
  • 30. Gordon D, Young LR, Reddy S, et al. Incidence of Clostridium difficile infection in patients receiving high-risk antibiotics with or without a proton pump inhibitor. J Hosp Infect 2015; 92: 173-177.
  • 31. Rive CM, Bourke J, Phillips EJ. Testing for drug hypersensitivity syndromes. Clin Biochem Rev 2013; 34: 15-38.

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