scholarly journals 250. An Assessment of the Penicillin Allergy Label in Patients Undergoing Orthopedic Procedures at a VA Medical Center

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S232-S233
Author(s):  
Sherin Meledathu ◽  
MacKenzie Firek ◽  
Angelike P Liappis ◽  
Pratish C Patel
Keyword(s):  
Medical Center ◽  
Skin Testing ◽  
Group Versus ◽  
Retrospective Chart Review ◽  
Penicillin Allergy ◽  
Orthopedic Procedures ◽  
Secondary Outcome ◽  
Washington Dc ◽  
Hospital Stays ◽  
Alternative Antibiotic

Abstract Background Approximately 10% of the population is labeled as penicillin (PCN) allergic, while only 1% of these individuals have a true IgE mediated allergy. This label influences the prescription of the most appropriate antibiotic and ultimately leads to antimicrobial resistance, hospital readmission, increased length of hospital stays, use of critical care beds, and greater healthcare costs. Post-surgical complications in patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA) are also increased when patients receive an alternative antibiotic due to PCN allergy. Methods A retrospective chart review identified patients who underwent a TKA or THA during the 2018-2020 calendar years at the Washington DC VA Medical Center. Multiple operations at different times on the same patient were regarded as separate events. The primary outcome was patients who were evaluable for penicillin allergy de-labeling and the secondary outcome was perioperative antibiotic choice. Results Patients in both groups were predominantly male, Black, and over the age of 60. Of a total of 317 procedures performed, we identified 28 procedures in which patients carried a PCN allergy label (PAL) and received a β-lactam alternative antibiotic for surgical prophylaxis. No patients in the PAL group received cefazolin for prophylaxis, compared to 87% of the non-PAL group who were appropriately given cefazolin. In the group carrying the PAL, 62% of patients received vancomycin and 29% of patients received clindamycin for pre-operative prophylaxis. Only one of these patients had a formal allergy consult note, but the PCN allergy was not addressed during that visit. Fewer patients (4%) required ICU admission during their hospitalization in the non-PAL group versus 10% of patients in the PAL group. Table 1. Patient Demographics and Procedure Detail Conclusion The use of alternative antibiotics in pre-procedural prophylaxis can contribute to adverse events associated with high-risk broader spectrum antimicrobials as well as increased costs associated with antimicrobials such as vancomycin. Our facility began implementation of a penicillin de-labeling program in 2018 via skin testing and direct oral challenge in collaboration with colleagues from Allergy and Immunology. Removal of PAL in this population can increase rates of appropriate prophylaxis. Disclosures All Authors: No reported disclosures

scholarly journals Group Versus Individual Physical Therapy for Veterans With Knee Osteoarthritis: Randomized Clinical Trial

2016 ◽  
Vol 96 (5) ◽  
pp. 597-608 ◽  
Author(s):  
Kelli D. Allen ◽  
Dennis Bongiorni ◽  
Hayden B. Bosworth ◽  
Cynthia J. Coffman ◽  
Santanu K. Datta ◽  
...  
Keyword(s):  
Physical Therapy ◽  
Knee Osteoarthritis ◽  
Outcome Measure ◽  
Medical Center ◽  
Group Versus ◽  
Secondary Outcome ◽  
Home Exercise ◽  
Secondary Outcome Measure ◽  
Knee Oa ◽  
The Individual

BackgroundEfficient approaches are needed for delivering nonpharmacological interventions for management of knee osteoarthritis (OA).ObjectiveThis trial compared group-based versus individual physical therapy interventions for management of knee OA.Design and MethodsThree hundred twenty patients with knee OA at the VA Medical Center in Durham, North Carolina, (mean age=60 years, 88% male, 58% nonwhite) were randomly assigned to receive either the group intervention (group physical therapy; six 1-hour sessions, typically 8 participants per group) or the individual intervention (individual physical therapy; two 1-hour sessions). Both programs included instruction in home exercise, joint protection techniques, and individual physical therapist evaluation. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range=0–96, higher scores indicate worse symptoms), measured at baseline, 12 weeks, and 24 weeks. The secondary outcome measure was the Short Physical Performance Battery (SPPB; range=0–12, higher scores indicate better performance), measured at baseline and 12 weeks. Linear mixed models assessed the difference in WOMAC scores between arms.ResultsAt 12 weeks, WOMAC scores were 2.7 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% confidence interval [CI]=−5.9, 0.5; P=.10), indicating no between-group difference. At 24 weeks, WOMAC scores were 1.3 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% CI=−4.6, 2.0; P=.44), indicating no significant between-group difference. At 12 weeks, SPPB scores were 0.1 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% CI=−0.5, 0.2; P=.53), indicating no difference between groups.LimitationsThis study was conducted in one VA medical center. Outcome assessors were blinded, but participants and physical therapists were not blinded.ConclusionsGroup physical therapy was not more effective than individual physical therapy for primary and secondary study outcomes. Either group physical therapy or individual physical therapy may be a reasonable delivery model for health care systems to consider.

scholarly journals 177. Implementation of Pharmacist-Driven Penicillin Allergy Evaluation and Testing with a Focus on Bypassing Penicillin Skin Testing at an Academic Medical Center

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S95-S96
Author(s):  
YoungYoon Ham ◽  
Shyam Joshi ◽  
Ellie Sukerman ◽  
Kendall J Tucker ◽  
Diana Yu ◽  
...  
Keyword(s):  
Medical Center ◽  
Skin Testing ◽  
Academic Medical Center ◽  
Penicillin Allergy ◽  
Patient Interview ◽  
Academic Medical ◽  
Number Of Patients ◽  
The Us ◽  
Graded Challenge ◽  
Negative Health Outcomes

Abstract Background Penicillin allergies are reported by approximately 10% of the US population; however, studies reveal that >90% of those patients can tolerate penicillins. Penicillin allergies are associated with negative health outcomes, both clinical and financial, due to reduced efficacy and increased adverse effects of alternative antibiotics. Patient interview, penicillin skin testing (PST) and/or an oral graded challenge can be used to evaluate penicillin allergies. Different facilities use various algorithms for testing. The objective of this project was to determine whether a pharmacist-driven penicillin allergy evaluation and testing protocol which largely bypasses PST could safely de-label patients. Methods Adult patients (≥18 years) admitted with a penicillin allergy were evaluated for eligibility between September 2019 and June 2020. Pregnant patients, critically-ill patients, and patients receiving test-invalidating medication were excluded. Patients were evaluated and tested using institutional protocols, which allowed for the majority of patients to be challenged without PST. Allergies were removed with standardized documentation, and patients were given a pamphlet and counseled to discourage relabeling. Data collected included but were not limited to, the number of patients challenged and de-labeled, number of patients who were relabeled, and number of patients whose change in allergy status resulted in change of therapy. Results Forty-eight patients were interviewed and evaluated. One patient was evaluated by PST and oral graded challenge while 27 patients underwent an oral graded challenge only. Twenty patients were de-labeled as a result of patient interview. One patient failed oral challenge with minor itching that did not require any treatment, while 27 patients passed. Forty-seven allergies were removed or modified. Two patients who were de-labeled were relabeled with no record of a new reaction. Of de-labeled patients, 50% received a penicillin following removal of the allergy. Conclusion Penicillin allergies can be evaluated and removed using a pharmacy-driven algorithm that prioritizes direct challenges when appropriate. Risks of a reaction are low, and removal leads to change in treatment in a significant portion of patients. Disclosures All Authors: No reported disclosures

Effect of baseline medications on response to immunotherapy in hepatocellular carcinoma.

2020 ◽  
Vol 38 (4_suppl) ◽  
pp. 484-484
Author(s):  
Tomi Jun ◽  
Sirish Dharmapuri ◽  
Thomas Urban Marron ◽  
Max W. Sung ◽  
Celina Ang
Keyword(s):  
Hepatocellular Carcinoma ◽  
Medical Center ◽  
Academic Medical Center ◽  
Retrospective Chart Review ◽  
Histamine Receptor ◽  
Experimental Models ◽  
Secondary Outcome ◽  
Advanced Hepatocellular Carcinoma ◽  
Racially Diverse ◽  
Academic Medical

484 Background: Immunotherapy (IO) response rates in advanced hepatocellular carcinoma (HCC) are less than 20%. The microbiome has been shown to mediate IO response in experimental models, and clinical studies have observed that antibiotics, especially prior to IO initiation, are associated with reduced IO response. We reasoned that commonly prescribed antacid medications, such as proton pump inhibitors (PPIs) and histamine receptor antagonists (H2RAs), which are known to influence the microbiome, may also influence IO response. Methods: This is a retrospective chart review-based study of 95 patients with advanced HCC treated with IO at a single academic medical center. The primary outcome was overall survival (OS). The secondary outcome was overall response rate (ORR). The primary predictors were antibiotic or antacid exposure in the 60 days prior to IO. A secondary predictor was antibiotic or antacid exposure in the 30 days prior to IO. Results: The cohort was predominantly male (84%), was racially diverse (31% White, 23% Black, 23% Asian, 13% Hispanic), and had a median age of 65 years. There were 49 deaths with a median follow up of 0.96 years. The most common underlying liver diseases were HCV (49%), HBV (31%), and NASH (11%). The majority of patients had cirrhosis (80%), with a median Child Pugh score of 6. Within 60 days before IO, 25 patients received antibiotics, 40 received PPIs and 5 received H2RAs. Most patients receiving antibiotics also received a PPI (92%). The median duration of antibiotics was 5 days. Neither antibiotic nor antacid exposure within 60 or 30 days prior to IO was significantly correlated with OS in univariate or multivariate analyses, nor were they correlated with ORR. Conclusions: No significant associations between baseline exposure to antibiotics and antibiotics and OS or ORR were identified in this single-institution study. Larger observational studies or mechanistic studies are needed to clarify interactions between medications, the microbiome, and IO response. [Table: see text]

Subtotal Cholecystectomy versus Total Cholecystectomy in Complicated Cholecystitis

2012 ◽  
Vol 78 (7) ◽  
pp. 814-817 ◽  
Author(s):  
Brian Davis ◽  
Gino Castaneda ◽  
Jose Lopez
Keyword(s):  
Medical Center ◽  
El Paso ◽  
Group Versus ◽  
Retrospective Chart Review ◽  
Arterial Injury ◽  
Subtotal Cholecystectomy ◽  
Bile Duct Injuries ◽  
Time Period ◽  
Number Of Patients ◽  
Duodenal Injuries

Complicated cholecystitis can make dissections around the triangle of Calot difficult with a higher risk of duct and arterial injury. We reviewed a series of patients with cholecystitis receiving either partial or subtotal cholecystectomies and compared it with total cholecystectomies with respect to complications. A retrospective chart review was performed on all subtotal cholecystectomies performed for cholecystitis at University Medical Center of El Paso from June 2004 to December 2010. A similar number of patients who had total cholecystectomies for cholecystitis were selected as a comparison group from that same time period. A total of 116 patients who had subtotal and total cholecystectomies were reviewed (58 patients in each group). There were seven postoperative complications noted in the subtotal cholecystecomy (SC) group versus 14 for the total cholecystectomy (TC) group. Three patients in the SC group had cystic duct leaks, all successfully treated by endoscopic retrograde cholangiopancreatography with biliary stenting. There were two patients who had common bile duct injuries in the TC group and none in the SC group. Two patients had duodenal injuries in the TC group. Subtotal cholecystectomy is a viable alternative to total cholecystectomy in cases of complicated cholecystitis

Impact of Dosing Conversion From Basal Insulin to Follow-On Insulin Glargine

2019 ◽  
pp. 089719001985395
Author(s):  
Marina L. Maes ◽  
Emily J. Ashjian ◽  
Kellie A. Kippes ◽  
Vince Marshall ◽  
Nada Rida ◽  
...  
Keyword(s):  
Insulin Glargine ◽  
Basal Insulin ◽  
Medical Center ◽  
Insulin Dose ◽  
Academic Medical Center ◽  
Retrospective Chart Review ◽  
Secondary Outcome ◽  
Real World Data ◽  
Insulin Requirements ◽  
Patients With Diabetes

Background: Several basal insulins have recently come to market including follow-on insulin glargine (Basaglar®). Currently, there is no real-world data published on the implications of conversion to Basaglar on dosing or glycemic control. Objective: To identify differences in basal insulin dosing requirements, hemoglobin A1c (HbA1c), and incidence of hypoglycemia or weight gain when converting a patient to Basaglar from another basal insulin. Methods: Single-center, retrospective chart review at an academic medical center. All patients prescribed Basaglar between December 15, 2016, and August 31, 2017 were included for review if converted from another basal insulin. Primary outcome: Difference in basal insulin requirements in both units/d and units/kilogram (kg)/d after conversion to Basaglar. Secondary outcome: Change in HbA1c and weight. Results: Mean basal insulin dose was 38.4 ± 26.3 units/d pre-conversion and 40.5 ± 29.8 units/d post-conversion (P = .031). Results were significant for patients with type 2 diabetes mellitus (T2DM; pre-conversion basal dose 34.6 ± 24.3 units/d; post-conversion basal dose 37.6± 29.0 units/d; P = .009). Weight-based dosing changed from 0.37 ± 0.25 units/kg/d pre-conversion to 0.39 ± 0.29 units/kg/d post-conversion (P = .056) and was significant for patients with T2DM (P = .040). A nonsignificant decrease in HbA1c was seen (−0.14% ± 1.24%; P = .142). There was no difference seen in weight (111.6 ± 46.3 kg vs 111.7 ± 46.9 kg; P = .662). Conclusion: Patients with diabetes require similar basal insulin doses upon conversion to Basaglar. Clinicians should monitor blood glucose closely during basal insulin transition.

scholarly journals 118. Feasibility of a Proactive Amoxicillin Oral Challenge Program for Inpatients with Penicillin Allergy at the Miami VAMC

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S173-S173
Author(s):  
Michael J Piazza ◽  
Paola Lichtenberger ◽  
Lauren Bjork ◽  
Alex Lazo-Vasquez ◽  
Minh Hoang ◽  
...  
Keyword(s):  
Medical Center ◽  
Beta Blockers ◽  
Skin Testing ◽  
Hospital Medicine ◽  
Low Risk ◽  
Oral Challenge ◽  
Penicillin Allergy ◽  
Total N ◽  
Stewardship Program ◽  
Patient Reported

Abstract Background Ninety percent of patients who report penicillin (PCN) allergy are not truly allergic. Penicillin skin testing (PST) followed by oral challenge (OC) with amoxicillin (AMX) can evaluate unconfirmed PCN allergy. PST is taxing and requires trained staff, while OC is an acceptable alternative in patients with low-risk histories, who can safely undergo OC without PST. OC is performed in the outpatient Miami Veterans Affairs Medical Center (MVAMC) setting. Collaboration between Allergy, Antimicrobial Stewardship Program (ASP), and Hospital Medicine identified patients with low-risk histories and offered OC to inpatients. Methods A daily report of MVAMC inpatients with PCN allergy was reviewed for appropriateness of OC (Fig 1). Hospice patients and those medically unstable or unable to consent were excluded. Appropriate consenting patients were challenged with AMX 500mg PO and observed for 60 minutes. If no reaction resulted, the PCN allergy label was removed. Epinephrine and diphenhydramine were available in case of adverse reaction. Those who were not OC candidates were offered outpatient PST (Fig 1). Figure 1. Penicillin allergy history evaluation algorithm Results We evaluated 39 inpatients with PCN allergy from 3/10 - 5/27/21. Median age was 68 years; 94.9% were male (Table 1). The most common recorded reaction was unknown (Table 2). Thirteen (33.3%) did not qualify for OC, 7 (17.9%) refused, 2 (5.1%) were receiving a penicillin-derivative, 1 (2.6%) patient’s primary team refused consult, 2 (5.1%) patients were discharged prior to OC. Fourteen (38%) patients underwent OC with 0 adverse reactions; 0 patients required epinephrine or diphenhydramine. After OC, 5 patients had changes to their antibiotic regimen as a result of a negative OC. Limitations included 5 patients on beta-blockers, and 5 patients unable to consent. Table 1. Demographics of Evaluated Inpatients, N = 39 (%) Note that 1 patient out of the 39, underwent DPC with cefpodoxime 200mg PO instead of amoxicillin for a reported allergy to ceftriaxone. Table 2. Reported Reactions, N = 41 (%) Total N exceeds evaluated patient number as one patient reported multiple reactions to receiving penicillin. Conclusion Removing unnecessary PCN allergy labels using inpatient OC with AMX is safe and effective for those with low-risk allergy histories. Zero patients undergoing OC developed a reaction, suggesting that OC may be safely performed per our algorithm. Our protocol does not require specialized training and is reproducible in settings without an Allergy specialist. In the 3 months prior to this program there were 0 inpatient consults to evaluate PCN. Future plans include forming a multidisciplinary consult service. Disclosures All Authors: No reported disclosures

scholarly journals Adherence and Systemic Reaction Rates to Allergy Immunotherapy among Veterans

2016 ◽  
Vol 7 (3) ◽  
pp. ar.2016.7.0170 ◽  
Author(s):  
Joseph T. Ellenburg ◽  
Jay A. Lieberman ◽  
Debendra Pattanaik
Keyword(s):  
Medical Center ◽  
Group Versus ◽  
Systemic Reaction ◽  
Retrospective Chart Review ◽  
Reaction Rates ◽  
Veterans Affairs ◽  
Adherence Rate ◽  
Systemic Reactions ◽  
History Of ◽  
Facility Age

Background Although allergen immunotherapy (AIT) is effective and safe, nonadherence is common. Limited data exist regarding adherence to ATT, factors that affect adherence, and systemic reactions associated with ATT among veteran populations. Objective To evaluate adherence to AIT and the prevalence of reactions secondary to AIT among patients at the Veterans Affairs Medical Center, Memphis, Tennessee. Methods A retrospective chart review was performed of veterans who received AIT at a single Veterans Affairs facility. Age, race, sex, the total number of shots, travel distance, a diagnosis of posttraumatic stress disorder (PTSD), and the number of severe adverse reactions were compared between the veterans who were adherent and veterans who were nonadherent. Results The overall adherence rate was 60.9%. Factors associated with adherence were a chart diagnosis of PTSD (293% [adherent group] versus 13.6% [nonadherent group]; p = 0.03) and home residence being a further distance from the facility (21.9 miles / 35.2 kilometers [adherent group] versus 18.0 miles/28.9 kilometers [nonadherentgroup]; p = 0.03). Patients who were adherent received an average of more total injections compared with patients who were nonadherent. Age, sex, race, and history of systemic reactions during AIT displayed no statistically significant differences between the groups. There were a total of 20 systemic reactions, and the systemic reaction rate was 0.2% per AIT encounter and 0.1% per injection. Conclusion AIT adherence and systemic reaction rates among veterans at our facility was comparable with similar studies. Adherence was associated with a chart diagnosis of PTSD and home residence that was further away from the clinic.

scholarly journals Penicillin Allergy Skin Testing as an Antibiotic Stewardship Intervention in Hematopoietic Cell Transplant Recipients

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S266-S267 ◽  
Author(s):  
Christopher Kovacs ◽  
Vasilios Athans ◽  
David Lang ◽  
Ronald Sobecks ◽  
Lisa Rybicki ◽  
...  
Keyword(s):  
Antibiotic Stewardship ◽  
Skin Testing ◽  
Hematopoietic Cell ◽  
Penicillin Allergy ◽  
Cell Transplant ◽  
Transplant Recipients ◽  
Hematopoietic Cell Transplant ◽  
Allergy Skin Testing

scholarly journals 57. Evaluating the Utility of a Penicillin Allergy Reconciliation Program within an Infectious Diseases Consult Population in a Community Health System

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S49-S50
Author(s):  
Bruce M Jones ◽  
Emily Plauche ◽  
Susan E Smith ◽  
Christopher M Bland
Keyword(s):  
Infectious Diseases ◽  
Health System ◽  
Community Health ◽  
Intervention Program ◽  
Primary Outcome ◽  
Panel Member ◽  
Penicillin Allergy ◽  
Secondary Outcome ◽  
Research Support ◽  
Research Grant

Abstract Background Penicillin allergy reconciliation is an important aspect of antimicrobial stewardship with ~10% of the population reporting a penicillin allergy. Our facility utilizes a Penicillin Allergy Reconciliation Program (PARP) led by an Infectious Diseases (ID) Pharmacist and pharmacy students to identify patients with penicillin allergies to reconcile and intervene when necessary. Information is collected by interview, electronic medical record (EMR) review, prescription outpatient fill history. This study evaluated reconciliations with and without a PARP in patients in a community health system. Methods This was a retrospective study that compared reconciliations performed on adult patients admitted at least once in 2019 with a self-reported penicillin allergy and ID physician consult at a hospital with a PARP (Institution 1) and one without a formal evaluation and intervention program (Institution 2) within the same community health system with same ID physicians. The primary outcome was documented reconciliation of a patient’s penicillin allergy during an inpatient visit in 2019. Reconciliation was defined as an edit or clarification (updating the severity, reaction, or comments section, as well as deleting) to a patient’s penicillin allergy in the EMR. The secondary outcome evaluated the percentage of total and ID consult patients with a penicillin allergy. Results There were 245 patients who met criteria and were included in the study, 113 from Institution 1 and 132 from Institution 2. For the primary outcome, there were 82 (72.6%) reconciliations at Institution 1 and 15 (11.4%) reconciliations at Institution 2 (p < 0.001). Interventions at Institution 1 and 2 resulted in 74 EMR updates and 8 removals and 14 EMR updates and 1 removal, respectively. Reconciliation was performed on the same visit as the ID consult in 59/82 patients (72%) at Institution 1 and 11/15 patients (73.3%) at Institution 2. All reconciliations at Institution 2 were made by pharmacist (10) or nurses (5). For the secondary outcome, 10.9% of patients with an ID consult and 12.6% of all patients admitted in 2019 had a penicillin allergy (p=0.027). Conclusion A PARP led by an ID pharmacist and students was an effective method to perform penicillin allergy reconciliations, even in the presence of active ID consultation. Disclosures Bruce M. Jones, PharmD, BCPS, ALK-Abello (Research Grant or Support)Allergan/Abbvie (Speaker’s Bureau) Christopher M. Bland, PharMD, FCCP, FIDSA, BCPS, ALK Abello, Inc. (Grant/Research Support)Biomerieux (Consultant)Merck (Consultant, Grant/Research Support, Advisor or Review Panel member, Speaker’s Bureau)Tetraphase (Speaker’s Bureau)

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