Table 1.
History-based beta-lactam allergy pathways in acute care
| Study | Location | Setting | Patient Selection | Study Design | Intervention Description | Outcome(s) measured | |
|---|---|---|---|---|---|---|---|
| Swearingen (2016)21 | Knoxville, TN, US | Academic medical center | Patients with mild penicillin allergy histories treated with aztreonam | Pre/Post (117 orders pre-period and 63 orders in post-period) | Restriction of aztreonam to patients with penicillin anaphylaxis, accomplished by education of pharmacy and patient-specific multidisciplinary communication | Alternative ABX use | A significant decrease in median aztreonam DOT (4.0 vs 2.0) post-period and persisted 1-year post-intervention |
| BL use | 36 ABX changes to BLs: 9 to ceftazidime, 9 to meropenem, 7 to cefepime, 6 to ceftriaxone, 5 to non-BL agents | ||||||
| Hospital length of stay and mortality | No change | ||||||
| Caplinger (2016)22 | Boise, ID, USA | Veterans affairs medical center | Patients receiving an anti-pseudomonal carbapenem | Pre/Post considering all orders for carbapenems (not just in BL allergy) | Risk stratification related to BL cross-reactivity inserted into the computerized decision support system | Alternative ABX use | Reduced anti-pseudomonal carbapenem use, considering initiations per 1000 patient-days Carbapenem use in patients with documented No significant change in carbapenem use in BL allergy (60% vs 54%, p=0.59) |
| Safety | No adverse events | ||||||
| Estep (2016)23 | Jacksonville, FL, US | Academic medical center | Patients ordered for aztreonam without clinician-witnessed anaphylaxis, pregnancy, nursing, incarcerated, or enrolled in a clinical trial | Pre/Post (79 patients pre-period and 107 patients post-period) | Antimicrobial stewardship quality initiative “ASQI” that involved EHR review and patient/family interview if feasible regarding allergy, and pharmacy evaluation based on collected information | Alternative ABX use | Reduced median time to aztreonam discontinuation in hours (30.7 vs12.7 |
| BL use | 35% switched to BL post-implementation versus 23% pre-implementation | ||||||
| Safety | No adverse effects associated with BL | ||||||
| Cost | Annual savings of $28,134 considering acquisition cost | ||||||
| Sigona (2016)24 | Syracuse, NY, US | Academic medical center | Adult hospitalized patients with documented BL allergy and receiving non-penicillin ABX | Prospective interview of 32 patients, 24 candidates for a BL ABX recommendation | Pharmacist history of BL allergy and recommendations to change ABX | BL use | 21 patients (66%) were switched to a BL |
| Staicu (2016)25 | Rochester, NY, US | Community teaching hospital | Adult patients ordered for aztreonam | Pre/post (303 orders for 281 patients pre-period and 193 orders for 178 patients in post-period) | ASP team (ID physicians, ID pharmacists) developed history tool (“Penicillin Allergy Screening Tool,” PAST); disseminated electronically on ASP websites) and hard copy (posters). Education of pharmacist and providers, pharmacists mandatory pass-rate >80%. Modification of sepsis order set | Alternative ABX use | Reduced aztreonam DOT per 1000 patient-days (9.5 to 4.4); reduced mean rate of inappropriate aztreonam usage from 4.0 DOT to 0.8 DOT per 1000 patient-days |
| BL use | 84% switched to another ABX: 15% to penicillin, 47% to a cephalosporin, 1% to a carbapenem, and 28% to a fluoroquinolone | ||||||
| Safety | No serious HSRs; one patient grade 2 rash to cefepime | ||||||
| Cost | Estimated annual direct cost avoidance of $60,000-$100,000 | ||||||
| Krey (2017)26 | Green Bay, WI, US | Community teaching hospital | Inpatients with reported BL allergy who received ABX for more than 24 hours (excluding surgical prophylaxis) | Pre/Post (91 pre-period and 88 post-period) | Implementation of local practice guidelines reliant on a scripted BL allergy history tool for pharmacy technician use. Pharmacist documented allergies, screened patients for prior BL use, and recommended ABX to providers following guideline informed by AI andID physicians. Education of pharmacists and prescribers. | Alternative ABX use | No difference in use of non-BL ABX (87% vs 84%, p=0.61) |
| BL use | More transitions to BL ABX (26% vs 11%,p=0.02) Among patients discharged on ABX, BL ABX were more frequently prescribed (57% vs 36%, p=0.006) |
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| Phan (2018)27 | Jacksonville, FL, US | Community teaching hospital | Adult patients with self-reported penicillin allergy on aztreonam | Pre/Post (140 patients in each period) | Education of pharmacy, pharmacy interception of orders for aztreonam, penicillin allergy guidance pocket card. | Alternative ABX use | Rate of aztreonam and fluoroquinolone use decreased |
| BL use | Increased frequency of cephalosporin use from 56 of 140 patients (40%) on cephalosporins pre-intervention and 106/140 (76%) post-intervention | ||||||
| Safety | 4.3% of patients discontinued ABXs due to ADR in pre-implementation group compared to 0.0% discontinuation in post-implementation group | ||||||
| Clark (2018)28 | Jacksonville, FL, US | Community teaching hospital | Inpatients with self-reported BL allergy | Pre/Post (95 patients pre, 65 patients post) | Standardized BL allergy questionnaire implemented by pharmacist trainees. Electronically identified eligible patients (BL allergy, aztreonam orders) | Alternative ABX use | Reduced aztreonam: doses per 1000 patient-days (21.2 vs 9.1, p=0.003), DOT per 1000 patient-days (8.8 vs 4.2, p-0.016) |
| BL use | Of 24 patients on aztreonam in post-period, 22 had therapy changed, most commonly to BL (59%) | ||||||
| Safety | No reported adverse events | ||||||
| Cost | $12,889 saved in post-implementation period, estimated annual cost saving of $37,857 | ||||||
Abbreviations: ABX, antibiotics; DOT, days of therapy; BL, beta-lactam; EHR, electronic health record; ASP, antibiotic stewardship program; ID, infectious diseases; HSR, hypersensitivity reaction; ADR, adverse drug reaction