scholarly journals De-labelling penicillin allergy in acutely hospitalized patients: a pilot study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Linde Steenvoorden ◽  
Erik Oeglaend Bjoernestad ◽  
Thor-Agne Kvesetmoen ◽  
Anne Kristine Gulsvik
Keyword(s):  
Antibiotic Use ◽  
Hospitalized Patients ◽  
Low Risk ◽  
Penicillin Allergy ◽  
Environmental Benefit ◽  
Medical Department ◽  
Norwegian Population ◽  
Risk Patients ◽  
History Of ◽  
Clinically Significant

Abstract Background Penicillin allergy prevalence is internationally reported to be around 10%. However, the majority of patients who report a penicillin allergy do not have a clinically significant hypersensitivity. Few patients undergo evaluation, which leads to overuse of broad-spectrum antibiotics. The objective of this study was to monitor prevalence and implement screening and testing of hospitalized patients. Methods All patients admitted to the medical department in a local hospital in Oslo, Norway, with a self-reported penicillin allergy were screened using an interview algorithm to categorize the reported allergy as high-risk or low-risk. Patients with a history of low-risk allergy underwent a direct graded oral amoxicillin challenge to verify absence of a true IgE-type allergy. Results 257 of 5529 inpatients (4.6%) reported a penicillin allergy. 191 (74%) of these patients underwent screening, of which 86 (45%) had an allergy categorized as low-risk. 54 (63%) of the low-risk patients consented to an oral test. 98% of these did not have an immediate reaction to the amoxicillin challenge, and their penicillin allergy label could thus be removed. 42% of the patients under treatment with antibiotics during inclusion could switch to treatment with penicillins immediately after testing, in line with the national recommendations for antibiotic use. Conclusions The prevalence of self-reported penicillin allergy was lower in this Norwegian population, than reported in other studies. Screening and testing of hospitalized patients with self-reported penicillin allergy is a feasible and easy measure to de-label a large proportion of patients, resulting in immediate clinical and environmental benefit. Our findings suggest that non-allergist physicians can safely undertake clinically impactful allergy evaluations.

scholarly journals The Penicillin Allergy Delabeling Program: A Multicenter Whole-of-Hospital Health Services Intervention and Comparative Effectiveness Study

2020 ◽  
Author(s):  
Kyra Y L Chua ◽  
Sara Vogrin ◽  
Susan Bury ◽  
Abby Douglas ◽  
Natasha E Holmes ◽  
...  
Keyword(s):  
Health Services ◽  
Propensity Score Analysis ◽  
Antibiotic Use ◽  
Low Risk ◽  
Penicillin Allergy ◽  
Index Admission ◽  
Relative Risk Ratio ◽  
Antibiotic Prescribing ◽  
Narrow Spectrum ◽  
Oral Penicillin

Abstract Background Penicillin allergies are associated with inferior patient and antimicrobial stewardship outcomes. We implemented a whole-of-hospital program to assess the efficacy of inpatient delabeling for low-risk penicillin allergies in hospitalized inpatients. Methods Patients ≥ 18 years of age with a low-risk penicillin allergy were offered a single-dose oral penicillin challenge or direct label removal based on history (direct delabeling). The primary endpoint was the proportion of patients delabeled. Key secondary endpoints were antibiotic utilization pre- (index admission) and post-delabeling (index admission and 90 days). Results Between 21 January 2019 and 31 August 2019, we assessed 1791 patients reporting 2315 antibiotic allergies, 1225 with a penicillin allergy. Three hundred fifty-five patients were delabeled: 161 by direct delabeling and 194 via oral penicillin challenge. Ninety-seven percent (194/200) of patients were negative upon oral penicillin challenge. In the delabeled patients, we observed an increase in narrow-spectrum penicillin usage (adjusted odds ratio [OR], 10.51 [95% confidence interval {CI}, 5.39–20.48]), improved appropriate antibiotic prescribing (adjusted OR, 2.13 [95% CI, 1.45–3.13]), and a reduction in restricted antibiotic usage (adjusted OR, 0.38 [95% CI, .27–.54]). In the propensity score analysis, there was an increase in narrow-spectrum penicillins (OR, 10.89 [95% CI, 5.09–23.31]) and β-lactam/β-lactamase inhibitors (OR, 6.68 [95% CI, 3.94–11.35]) and a reduction in restricted antibiotic use (OR, 0.52 [95% CI, .36–.74]) and inappropriate prescriptions (relative risk ratio, 0.43 [95% CI, .26–.72]) in the delabeled group compared with the group who retained their allergy label. Conclusions This health services program using a combination of direct delabeling and oral penicillin challenge resulted in significant impacts on the use of preferred antibiotics and appropriate prescribing.

scholarly journals First pediatric electronic algorithm to stratify risk of penicillin allergy

2020 ◽  
Vol 16 (1) ◽  
Author(s):  
Hannah Roberts ◽  
Lianne Soller ◽  
Karen Ng ◽  
Edmond S. Chan ◽  
Ashley Roberts ◽  
...  
Keyword(s):  
Health Care Professionals ◽  
Pediatric Population ◽  
Skin Testing ◽  
Low Risk ◽  
Penicillin Allergy ◽  
Oral Drug ◽  
Beta Lactam ◽  
Paper Version ◽  
Pediatric Study ◽  
Risk Patients

AbstractBeta-lactam allergy is reported in 5–10% of children in North America, but up to 94–97% of patients are deemed not allergic after allergist assessment. The utility of standardized skin testing for penicillin allergy in the pediatric population has been recently questioned. Oral drug challenges when appropriate, are preferred over skin testing, and can definitively rule out immediate, IgE-mediated drug allergy. To our knowledge, this is the only pediatric study to assess the reliability of a penicillin allergy stratification tool using a paper and electronic clinical algorithm. By using an electronic algorithm, we identified 61 patients (of 95 deemed not allergic by gold standard allergist decision) as low risk for penicillin allergy, with no false negatives and without the need for allergist assessment or skin testing. In this study, we demonstrate that an electronic algorithm can be used by various pediatric clinicians when evaluating possible penicillin allergy to reliably identify low risk patients. We identified the electronic algorithm was superior to the paper version, capturing an even higher percentage of low risk patients than the paper version. By developing an electronic algorithm to accurately assess penicillin allergy risk based on appropriate history, without the need for diagnostic testing or allergist assessment, we can empower non-allergist health care professionals to safely de-label low risk pediatric patients and assist in alleviating subspecialty wait times for penicillin allergy assessment.

scholarly journals DALES - a prospective cross-sectional study of incidence of penicillin allergy labels, risk of true allergy and attitudes of patients and anaesthetists to de-labelling strategies

2020 ◽  
Author(s):  
L Savic ◽  
C Thomas ◽  
D Fallaha ◽  
Michelle Wilson ◽  
PM Hopkins ◽  
...  
Keyword(s):  
Population Level ◽  
Cross Sectional Study ◽  
Low Risk ◽  
Penicillin Allergy ◽  
Risk Category ◽  
Sectional Study ◽  
Cross Sectional ◽  
Allergy Testing ◽  
Risk Patients ◽  
Provocation Testing

AbstractBackgroundDirect drug provocation testing (DPT) in patients with low-risk penicillin allergy labels would allow population-level ‘de-labelling’. We sought to determine the incidence and nature of penicillin allergy labels in a large UK surgical cohort and to define patient and anaesthetist attitudes towards penicillin allergy testing.MethodsA prospective cross-sectional study was performed in 213 UK hospitals. ‘Penicillin allergic’ patients were interviewed and risk-stratified. Knowledge and attitudes around penicillin allergy were defined in patients and anaesthetists, determining potential barriers to widespread testing.FindingsOf 21,281 patients 12% self-reported penicillin allergy and 67% of these were potentially suitable for direct DPT (stratified low or intermediate risk). Irrespective of risk category 62% wanted allergy testing. Of 4,978 anaesthetists 40% claimed to routinely administer penicillin when they judge the label to be low-risk; 64% would then tell the patient they had received penicillin. Only 47% of all anaesthetists would be happy to administer penicillin to a patient previously de-labelled by an allergy specialist using direct DPT; the commonest reason not to administer penicillin was perceived lack of support from their hospital. On the study days, 13% of low-risk patients requiring penicillin received it, and 6 patients with high-risk labels received it. There were no adverse events in any of this group. However, 1 patient who received an alternative antibiotic suffered suspected anaphylaxis to this.InterpretationThe majority of patients with a penicillin allergy label may be suitable for direct DPT and demand for testing is high among patients. Anaesthetists demonstrate inconsistent, potentially unsafe prescribing in patients labelled as penicillin allergic. More than half of anaesthetists are not reassured by a negative DPT undertaken by a specialist. Significant knowledge gaps may prevent widespread de-labelling being effectively implemented in surgical patients.FundingThe National Institute of Academic Anaesthesia.

scholarly journals The Risk of Stroke Using CHA2 DS2 -VASc Score in Hemodialysis Patients at a Tertiary Hospital in Riyadh, Saudi Arabia

2019 ◽  
Vol 4 (7) ◽  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Stroke Risk ◽  
Hemodialysis Patients ◽  
Low Risk ◽  
High Risk Patients ◽  
Stroke Risk Factors ◽  
Increased Risk ◽  
Risk Patients ◽  
History Of

Introduction: Patients undergoing hemodialysis are at increased risk of stroke. However, less known about the impact of some of the stroke risk factors, and the value of stroke risk scores in determining the risk in those patients. Our main goal. To assess the risk factors for stroke in hemodialysis patients and the use of the new CHA2DS2-VASc score for stroke assessment. Methods: Single center, retrospective cohort study of 336 patients undergoing hemodialysis from June 24, 2018, to September 6, 2018, was recruited. Baseline demographics, clinical, and laboratory data were collected. We calculated the CHA2 DS2 -VASc score for stroke assessment in all patients and categorized them into high, moderate and low risk patients according to CHA2 DS2 - VASc score and subcategorized them to two groups atrial fibrillation (AFib) and Non- Atrial fibrillation (Non AFib) patients. Results: 336 patients were included in our study; the majority of patients were at high risk with a CHA2 DS2 -VASc Score mean of 2.9± 1.5, although history of stroke was observed only in 15 patients (4.46%). According to CHA2 DS2 - VASc score, 280 patients were at high risk, 172 (51.19%) were high-risk patients on treatment (anticoagulant or antiplatelet) and 108(32.14%) patients were high risk patients not on treatment 48 were at moderate risk (14.28%) and 8 were at low risk (2.38 %). Patients were divided into subgroups as non-AFib and AFib. In non-AFib patients 320 (95.23%), high-risk patients 103 (32.18%) were not treated; high-risk patients with treatment are 162 (50.62%), moderate patients were 47 (14.68%), 8(2.5%) was in low risk. AFib patients were 16 with a mean CHA2 DS2 -VASc score of 4.4±1.1. Patients with AFib were all at high risk except 1 was at moderate risk (6.25%). There were 11 (68.75%) patients on treatment and 5 (31.25%) patients not on treatment. The risk factors for stroke that were statistically significant in increasing score risk for all patients were: age > 65 (95% CI, -2.04– -1.29; p = 0.000), being female (95% CI, -1.36– -0.68; p = 0.000) hypertension (95% CI, -2.59– -1.37; p = 0.000), diabetes (95% CI, -2.10– -1.50; p = 0.000), CVD (95% CI, -2.07– -1.24; p=0.000), history of stroke or TIA (95% CI, -3.70– -2.03; p = 0.000), CHF or LVEF (95% CI, -2.28– - 0.91; p = 0.000). Conclusions: The risk of stroke in hemodialysis patients is significant according to the use of CHA2 DS2 -VASc score in Non-AFib hemodialysis patients shows supportive evidence of increased risk of stroke in those patients, which suggest the importance of close monitoring of patients with stroke risk factors by the nephrologist and the stroke team which will lead to the initiation of early prophylaxis in those patients.

scholarly journals 30. Implementation of the PEN-FAST Penicillin Allergy Screening Tool in the Emergency Department During Medication Reconciliation

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S137-S138
Author(s):  
Satwinder Sony Kaur ◽  
David T Adams ◽  
Brittany Parker
Keyword(s):  
Emergency Department ◽  
Screening Tool ◽  
Healthcare Providers ◽  
Low Risk ◽  
Penicillin Allergy ◽  
Secondary Outcome ◽  
Beta Lactam ◽  
Decision Tool ◽  
Allergy Test ◽  
Risk Patients

Abstract Background The purpose of this study is to implement the PEN-FAST Penicillin Allergy Screening Tool in the emergency department to identify low risk patients with inappropriate penicillin-related allergies to transition them to a beta-lactam. Newly published, validated, penicillin allergy clinician decision tool (PEN-FAST) allows healthcare providers to identify low risk penicillin allergies with a negative predictive value of 96%. This quick, five question clinical decision tool allows healthcare providers and antimicrobial stewardship programs to identify patients who would also test negative if a formal penicillin allergy test was performed, making the process to confidently identify inappropriately labeled penicillin-related allergies more efficient. Methods During routine medication reconciliations, pharmacists will identify patients who have a documented penicillin-related allergy in the EMR and use the PEN-FAST screening tool. Patients meeting inclusion criteria will have their penicillin-related allergy updated in the EMR based upon their assessed risk of very low, low, moderate, or high. The primary outcomes for this study are the percentage of patients screened that were classified as “very low and low risk” and percentage penicillin-related allergies updated. The secondary outcomes are the percentage of patients that required antibiotic therapy (post-allergy update) that were transitioned to a beta-lactam, inpatient broad-spectrum antibiotic usage before and after allergy update, and time spent interviewing each patient. Results A total of 59 patients were interviewed using the PEN-FAST Tool. The results for the primary outcomes indicate 92% (n=54) of patient allergies updated in the EMR, 24% (n=13) of patients classified as “very low risk” and 34% (n=18) of patients classified as “low risk”. Results for the secondary outcome showed out of the 36 patients that were on non-beta lactams during allergy update, 72% (n=26) of those patients were transitioned to a beta-lactam. The average time to complete the PEN-FAST Tool was 4.2 minutes. Conclusion The results of this study support the use of the PEN-FAST Tool in efficiently updating patient’s allergies in the EMR and identifying low risk patients who may be eligible for beta-lactam therapy. Disclosures All Authors: No reported disclosures

Diagnosis and Treatment of Essential Thrombocythemia: Assessment of Current Clinical Practice.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 1903-1903
Author(s):  
Vivian H Y Lee ◽  
Erica Peterson ◽  
Leslie Zypchen ◽  
Lynda M Foltz
Keyword(s):  
Bone Marrow ◽  
Clinical Practice ◽  
High Risk ◽  
Diagnostic Criteria ◽  
Bone Marrow Biopsy ◽  
Jak2 V617f ◽  
Low Risk ◽  
Cytoreductive Treatment ◽  
Risk Patients ◽  
History Of

Abstract Abstract 1903 Poster Board I-926 Introduction: The discovery of the JAK2 V617F gene mutation has significantly altered the clinical diagnostic approach to the myeloproliferative neoplasms, reflected in the revised 2008 WHO diagnostic criteria. Both the 2001 and 2008 diagnostic criteria for essential thrombocythemia (ET) require a bone marrow biopsy showing megakaryocytic proliferation to make a diagnosis of ET. Published expert opinion based on clinical studies suggests that ET patients > 60 years old or with history of thrombosis should be characterized as high risk and treated with hydroxyurea. It is unclear whether physicians in clinical practice utilize the WHO diagnostic criteria or follow expert treatment recommendations for ET. Methods: We conducted a retrospective chart review of all patients with a clinical diagnosis of ET made by a hematologist who were seen in clinic from 2006 to 2008 at two university teaching hospitals in Vancouver, Canada. Data collected included demographic information, thrombosis history, diagnostic tests performed and treatment administered. Testing for JAK2 V617F became locally available in 2006, so for assessment of diagnostic tests performed, patients were divided into cohorts of diagnosis pre-2006 and 2006–2008. Patients were characterized as high risk if > 60 y or history of thrombosis at the time of diagnosis. All other patients were considered low risk. Results: Diagnostic information was available for 116 patients diagnosed prior to the availability of testing for JAK2 V617F. 65% (75/116) of patients in this cohort had a bone marrow biopsy performed (table 1). 44 patients received a new diagnosis of ET from 2006–2008. Only 48% (21/44) patients in this cohort had a bone marrow biopsy performed, significantly less than in the historical cohort (p = 0.019). 41/44 had JAK2 V617F testing performed: 41% (17/41) were JAK2 V617F negative, 56% (23/41) positive and 1 equivocal. Bone marrow biopsy was performed in 59% (10/17) of JAK2 V617F negative patients and 39% (9/23) of JAK2 V617F positive patients (p = 0.055) (table 1). Bone marrow biopsy was also performed in 1 patient with equivocal JAK2 V617F testing and 1 patient not tested for JAK2 V617F. 170 patients diagnosed with ET were seen in follow up 2006–2008. 64% (109/170) were high risk due to age > 60 y or history of thrombosis. The remaining 36% (61/170) were considered low risk. Hydroxyurea was used preferentially over anagrelide for treatment of ET (table 2). Only 76% of high risk patients were receiving cytoreductive treatment. 23% of low risk patients received cytoreductive treatment. ASA was prescribed to 89% of high risk and 79% of low risk patients. Conclusion: Despite the requirement for a bone marrow biopsy to meet the WHO criteria for ET, hematologists performed a bone marrow biopsy in less than half of patients they diagnosed with ET since 2006. Hematologists performed bone marrow biopsy less frequently after JAK2 V617F testing became available, particularly in JAK2 V617F positive patients. A substantial portion of high risk patients (24%) were receiving no cytoreductive therapy, contrary to expert recommendation. Further study is required to understand the barriers to implementing treatment recommendations in clinical practice. This study highlights the challenges in translating published diagnostic criteria and treatment guidelines into changes in patient care. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Clinically significant prostate cancer detection and segmentation in low-risk patients using a convolutional neural network on multi-parametric MRI

2020 ◽  
Vol 30 (12) ◽  
pp. 6582-6592
Author(s):  
Muhammad Arif ◽  
Ivo G. Schoots ◽  
Jose Castillo Tovar ◽  
Chris H. Bangma ◽  
Gabriel P. Krestin ◽  
...  
Keyword(s):  
Neural Network ◽  
Prostate Cancer ◽  
Active Surveillance ◽  
Deep Neural Network ◽  
Low Risk ◽  
Targeted Biopsy ◽  
Risk Patients ◽  
Clinically Significant ◽  
Systematic Biopsy ◽  
Group 1

Abstract Objectives To develop an automatic method for identification and segmentation of clinically significant prostate cancer in low-risk patients and to evaluate the performance in a routine clinical setting. Methods A consecutive cohort (n = 292) from a prospective database of low-risk patients eligible for the active surveillance was selected. A 3-T multi-parametric MRI at 3 months after inclusion was performed. Histopathology from biopsies was used as reference standard. MRI positivity was defined as PI-RADS score ≥ 3, histopathology positivity was defined as ISUP grade ≥ 2. The selected cohort contained four patient groups: (1) MRI-positive targeted biopsy-positive (n = 116), (2) MRI-negative systematic biopsy-negative (n = 55), (3) MRI-positive targeted biopsy-negative (n = 113), (4) MRI-negative systematic biopsy-positive (n = 8). Group 1 was further divided into three sets and a 3D convolutional neural network was trained using different combinations of these sets. Two MRI sequences (T2w, b = 800 DWI) and the ADC map were used as separate input channels for the model. After training, the model was evaluated on the remaining group 1 patients together with the patients of groups 2 and 3 to identify and segment clinically significant prostate cancer. Results The average sensitivity achieved was 82–92% at an average specificity of 43–76% with an area under the curve (AUC) of 0.65 to 0.89 for different lesion volumes ranging from > 0.03 to > 0.5 cc. Conclusions The proposed deep learning computer-aided method yields promising results in identification and segmentation of clinically significant prostate cancer and in confirming low-risk cancer (ISUP grade ≤ 1) in patients on active surveillance. Key Points • Clinically significant prostate cancer identification and segmentation on multi-parametric MRI is feasible in low-risk patients using a deep neural network. • The deep neural network for significant prostate cancer localization performs better for lesions with larger volumes sizes (> 0.5 cc) as compared to small lesions (> 0.03 cc). • For the evaluation of automatic prostate cancer segmentation methods in the active surveillance cohort, the large discordance group (MRI positive, targeted biopsy negative) should be included.

International Working Group Scores Predict Post-Transplant Outcomes In Patients with Myelofibrosis

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 3085-3085 ◽  
Author(s):  
Bart Lee Scott ◽  
Ted A. Gooley ◽  
Michael L. Linenberger ◽  
Brenda M. Sandmaier ◽  
David Myerson ◽  
...  
Keyword(s):  
High Risk ◽  
Working Group ◽  
Scoring System ◽  
Prognostic Model ◽  
Low Risk ◽  
Post Transplant ◽  
International Working Group ◽  
High Risk Disease ◽  
Risk Patients ◽  
History Of

Abstract Abstract 3085 The International Working Group (IWG) has determined that prognosis in myelofibrosis is predicted by a scoring system that includes the following parameters: age > 65 years, constitutional symptoms, hemoglobin < 10 g/dL, leukocyte count > 25 × 109/L and circulating peripheral blasts ≥ 1%. Based on these factors patients may be placed into 4 separate categories: low, intermediate-1, intermediate-2 or high risk. The median survivals of these 4 groups are 135, 95, 48 and 27 months, respectively. The IWG scoring system has been validated in a dynamic prognostic model. However, there have been no publications evaluating the use of the IWG prognostic model in patients with myelofibrosis who receive hematopoietic cell transplantation (HCT). We performed a retrospective review of 181 patients with a diagnosis of myelofibrosis who underwent HCT at the Fred Hutchinson Cancer Research Center between March, 1990 and November 2009. Twelve patients received an autologous transplant and 169 patients underwent an allogeneic transplant using an HLA-matched related (78), syngeneic (3), HLA-mismatched related (4), HLA-matched unrelated (66) or HLA-mismatched unrelated (18) donor. The median age at time of HCT was 51 (range: 12–78) years. Among the 169 patients who received allogeneic transplants, conditioning regimens consisted of oral busulfan, 16 mg/kg (136); oral busulfan, 7 mg/kg with TBI 12 Gy (9); TBI 12–13 Gy (4); Melphalan, 140 mg/kg (3); Fludarabine, 90 mg/m2 with TBI 2–4 Gy (16); and Treosulfan, 42 gm/m2 with Fludarabine, 150 mg/m2 (1). GVHD prophylaxis consisted of cyclosporin/methotrexate (99), tacrolimus/methotrexate (49), cyclosporin/mycophenolate (14) or tacrolimus/mycophenolate (4). We were able to obtain the full set of parameters involved in calculating the IWG score in all 181 patients. Historical records pre-transplant and arrival records prior to transplant were reviewed. Patients were assigned to the highest possible IWG score based on age at time of HCT, history of constitutional symptoms, hemoglobin < 10 g/dL or transfusion dependence at time of transplant, history of leukocyte counts > 25 × 109/L, and history of peripheral blasts ≥ 1%. Based upon these parameters, there were 21 patients with low risk, 48 patients with intermediate-1, 54 patients with intermediate-2, and 58 patients with high risk disease. The IWG score was highly predictive of survival in the post-transplant setting with a hazard ratio (HR) of 4.4 (95% CI 1.6–12.5, p=0.005) for mortality in high risk patients compared to low risk patients. Patients in the low risk category had a significantly lower risk of relapse HR=0 (95% CI 0, p=0.046) in comparison to patients with high risk disease. In addition, patients with high risk disease had a significantly greater risk of transplant related mortality HR=3.7 (95% CI 1.3–11, p=0.016) in comparison to patients with low risk disease. This is the first examination of post-transplant outcomes by the pre-transplant IWG score. This analysis suggests that patient and disease characteristics considered in the IWG score and shown to be of prognostic significance at diagnosis also predict post-transplant survival. These findings, with a follow-up extending to two decades, indicate that while transplantation was curative for a proportion of patients, it could not completely overcome the risk conveyed by pre-transplant risk factors. It is our hope that future studies will use this information to address the optimal timing of appropriate interventions including HCT. Disclosures: No relevant conflicts of interest to declare.

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