Understanding Penicillin Allergy, Cross-reactivity, and Antibiotic Selection in the Preoperative Setting

Abstract Background Beta-lactam (BL) antibiotics are first-line agents for most patients receiving antimicrobial prophylaxis in surgical procedures. Despite evidence showing low cross-reactivity between classes of BLs, patients with allergies commonly receive vancomycin as an alternative to avoid allergic reaction. The objective of this study was to identify potentially inappropriate use of vancomycin surgical prophylaxis among patients with reported BL allergies. Methods Adult patients (≥18 years) receiving vancomycin for surgical prophylaxis with a reported penicillin and/or cephalosporin allergy at our institution between August 2017 to July 2018 were retrospectively evaluated for potential eligibility for penicillin allergy testing and/or receipt of standard prophylaxis. Surgery type and allergy history were extracted from the electronic medical record. Per our institution’s penicillin-testing protocol, patients with IgE-mediated reactions < 10 years ago were eligible for penicillin skin testing (PST), mild reactions or IgE-mediated reaction > 10 years ago were eligible for direct oral amoxicillin challenge, and severe non-IgE mediated allergies were ineligible for penicillin allergy evaluation or BL prophylaxis. Results Among 830 patients who received vancomycin for surgical prophylaxis, 196 reported BL allergy and were included in the analysis (155 with penicillin allergy alone; 21 with cephalosporin allergy; 20 with both cephalosporin and penicillin allergy). Approximately 40% of surgeries were orthopedic. Six patients were ineligible for BL prophylaxis. Per institutional protocol, 73 of 155 patients (48%) may have qualified for PST; 81 of 155 (52%) patients may have received a direct oral amoxicillin challenge. Only 3 of 22 patients with history of methicillin-resistant Staphylococcus aureus appropriately received additional prophylaxis with vancomycin and a BL. Conclusion Patients with BL allergies often qualify for receipt of a first-line BL antibiotic. An opportunity exists for improved BL allergy assessment as an antimicrobial stewardship intervention. Future studies should evaluate outcomes associated with BL allergy evaluation and delabeling in patients receiving surgical prophylaxis. Disclosures All Authors: No reported disclosures

Download Full-text

The Basics of Penicillin Allergy: What A Clinician Should Know

Pharmacy ◽

10.3390/pharmacy7030094 ◽

2019 ◽

Vol 7 (3) ◽

pp. 94 ◽

Cited By ~ 2

Author(s):

Louis Lteif ◽

Lea S. Eiland

Keyword(s):

Antimicrobial Agents ◽

Adult Population ◽

The United States ◽

Cross Reactivity ◽

Penicillin Allergy ◽

Patient Specific ◽

Beta Lactam ◽

Clinically Significant ◽

Medication Allergy ◽

Specific Reactions

Antimicrobials in the penicillin class are first line treatments for several infectious diseases in the pediatric and adult population today. In the United States, patients commonly report having a penicillin allergy, with penicillin being the most frequent beta-lactam allergy. However, very few patients experience a clinically significant immune-mediated allergic reaction to penicillin. If a true penicillin allergy exists, cross-reactivity to other beta-lactam antimicrobials may occur. Mislabeling patients with penicillin allergy can lead to a higher utilization of second line antimicrobial agents, potentially increasing costs and resistance due to a larger spectrum of activity. Pharmacists play an essential role in inquiring about patient specific reactions to presumed medication allergies and developing a further assessment plan, if needed, to determine if the medication allergy is real.

Download Full-text

Cephalosporins: A Focus on Side Chains and β-Lactam Cross-Reactivity

Pharmacy ◽

10.3390/pharmacy7030103 ◽

2019 ◽

Vol 7 (3) ◽

pp. 103 ◽

Cited By ~ 9

Author(s):

Saira B. Chaudhry ◽

Michael P. Veve ◽

Jamie L. Wagner

Keyword(s):

Risk Factors ◽

Clinical Practice ◽

Antimicrobial Stewardship ◽

Clinical Utility ◽

Cross Reactivity ◽

Penicillin Allergy ◽

Side Chain ◽

Safety And Efficacy ◽

History Of

Cephalosporins are among the most commonly prescribed antibiotic classes due to their wide clinical utility and general tolerability, with approximately 1–3% of the population reporting a cephalosporin allergy. However, clinicians may avoid the use of cephalosporins in patients with reported penicillin allergies despite the low potential for cross-reactivity. The misdiagnosis of β-lactam allergies and misunderstanding of cross-reactivity among β-lactams, including within the cephalosporin class, often leads to use of broader spectrum antibiotics with poor safety and efficacy profiles and represents a serious obstacle for antimicrobial stewardship. Risk factors for cephalosporin allergies are broad and include female sex, advanced age, and a history of another antibiotic or penicillin allergy; however, cephalosporins are readily tolerated even among individuals with true immediate-type allergies to penicillins. Cephalosporin cross-reactivity potential is related to the structural R1 side chain, and clinicians should be cognizant of R1 side chain similarities when prescribing alternate β-lactams in allergic individuals or when new cephalosporins are brought to market. Clinicians should consider the low likelihood of true cephalosporin allergy when clinically indicated. The purpose of this review is to provide an overview of the role of cephalosporins in clinical practice, and to highlight the incidence of, risk factors for, and cross-reactivity of cephalosporins with other antibiotics.

Download Full-text

1531. Antibiotic Selection for Neisseria gonorrhoeae among Penicillin Allergic Patients in the Emergency Department

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1711 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S766-S766

Author(s):

Matthew J McGuinness ◽

Jonathan Mccoy ◽

Tanaya Bhowmick

Keyword(s):

Emergency Department ◽

Statistical Significance ◽

Demographic Data ◽

Penicillin Allergy ◽

Physician Education ◽

Beta Lactam ◽

Transmitted Infection ◽

Antibiotic Selection ◽

Selection For ◽

To Receive

Abstract Background While penicillin (PCN) allergies are commonly reported, their cross-reactivity with beta-lactam antibiotics is minimal. First line treatment of gonorrheal infections includes a cephalosporin (CPH). In an emergency department (ED) environment, physicians must consider potential allergies when selecting antibiotics for a patient with symptoms concerning for sexually transmitted infection (STI). Methods A retrospective chart review on adult patients with symptoms concerning for STI presenting to an urban ED from January 2014 through June 2019 was performed. Chart discovery was performed using search terms of “STI”, “STD”, “urethritis”, “vaginitis”, and “gonorrhea”. Information abstracted included patient symptoms, type of care provider, and antibiotics prescribed or administered in the ED. The primary outcome was prevalence of allergy to PCN and CPH in patients evaluated for STI symptoms and secondary outcomes included prescribed antibiotic treatments. Chi-square and Fischer-exact tests were utilized to examine for statistical significance, with p values < 0.05 as statistically significant. Results A total of 603 patients met the inclusion criteria, of which 31 reported allergies to PCN, and another 3 reported allergies to CPH. Patients reporting PCN allergy were found to be less likely to receive a CPH antibiotic (p=0.0035). Patients reporting a non-anaphylactic allergy to PCN received a CPH at a rate of 92.3%. Attending physicians in particular were less likely to prescribe a CPH antibiotic to a patient reporting allergy compared with both resident physicians and PAs (p=0.00019). Patients reporting a PCN allergy were more likely to receive alternative antibiotics beyond CPH or azithromycin (p=0.046); the most frequently given antibiotics were metronidazole, doxycycline, and levofloxacin. Demographic Data Antibiotic Prescriptions by Type of Penicillin Allergy Antibiotic Prescriptions for Penicillin Allergy vs. No Allergy Conclusion Patients with PCN allergies represent a recurring challenge for ED physicians when faced with antibiotic selection for STI symptoms concerning for gonorrheal infection. Those with PCN allergies are significantly less likely to receive a CPH antibiotic, though these remain the only universal treatment for gonorrheal infections. These findings highlight the significant need for further physician education on allergies and antibiotic selection. Disclosures All Authors: No reported disclosures

Download Full-text

Cephalosporin graded challenges approach in community–acquired pneumonia patient with a history of penicillin allergy

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20212533 ◽

2021 ◽

Vol 9 (7) ◽

pp. 2106

Author(s):

Ketut Suryana

Keyword(s):

Diagnostic Test ◽

Clinical Manifestations ◽

Cross Reactivity ◽

Community Acquired Pneumonia ◽

Antimicrobial Treatment ◽

Penicillin Allergy ◽

History Of ◽

Pulmonary Parenchyma ◽

Graded Challenge ◽

Antimicrobial Treatments

Community-Acquired Pneumonia (CAP) is an acute pulmonary parenchyma infection that acquired in the community. Diagnosis based on clinical manifestations, chest X-ray (CXR) and microbiological diagnosis test (lung aspirates culture). Recently there was advance in antimicrobial treatments of CAP and a microbiological diagnostic test is essential to ensure antimicrobial treatments. In the other hand microbiological diagnostic test does not achieve all of the pneumonic cases. Therefore, antimicrobial treatment should be empirically performed to avoid the delay in establishing appropriate treatment related with the mortality. By administering combination antimicrobial will achieve a better outcome than a mono-therapy. For patients with history of penicillin allergy, though the risk of cephalosporin allergic cross-reactivity is low, a greater awareness is still needed, so a graded challenge approach could be considered. Herein we present a case report of a female, 20-year-old, hospitalized due to CAP, and also had a history of penicillin allergy. She was treated by levofloxacin 750 mg IV q 24 hour and cephalosporin (ceftriaxone) 1 g IV q 12 hour with a Graded challenge approach. Although it does not a novelty, we hope it would remind the health care that a Graded challenge could be considered as an approach of administering cephalosporin in patient who has an experiece of penicillin allergy.

Download Full-text

A novel approach to improving antibiotic selection in patients reporting penicillin allergy

Annals of Allergy Asthma & Immunology ◽

10.1016/j.anai.2015.07.001 ◽

2015 ◽

Vol 115 (4) ◽

pp. 257-258 ◽

Cited By ~ 4

Author(s):

Roland Solensky

Keyword(s):

Penicillin Allergy ◽

Antibiotic Selection ◽

Novel Approach

Download Full-text

PP43 Decision-Making Tool In Case Of Beta-Lactam Allergy: How To Help Clinicians?

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462319002034 ◽

2019 ◽

Vol 35 (S1) ◽

pp. 45-45

Author(s):

Sylvie Bouchard ◽

Geneviève Robitaille ◽

Fatiha Karam ◽

Jean-Marc Daigle ◽

Mélanie Tardif

Keyword(s):

Primary Care ◽

Meta Analysis ◽

Cross Reactivity ◽

Penicillin Allergy ◽

Initial Reaction ◽

Knowledge Mobilization ◽

Beta Lactam ◽

Skin Reactions ◽

Increased Risk ◽

Work Health

IntroductionBeta-lactams (BLs), especially penicillins, are the most commonly used antibiotics, particularly in primary care, and one of the most reported drug allergies. Fearing cross-reactivity, clinicians refrain from prescribing another BL (e.g., cephalosporin or carbapenem) to penicillin-allergic patients. This can have significant consequences for the patients and the health-care system (e.g., exposure to broad-spectrum antibiotics, increased risk adverse effects, and increased healthcare costs).MethodsTo assess the absolute cross-reactivity risk, two systematic reviews with meta-analysis were conducted. Then, an approach based on a knowledge mobilization framework considering scientific, contextual and experiential evidences was used. Focus groups with stakeholders, including primary care clinicians, pediatricians, infectious disease specialists and allergists/immunologists, were also held to meet the needs of all actors concerned.ResultsFollowing this work, it appears that true allergies to penicillin are very rare. Indeed, in patients with a history of penicillin allergy, very few are truly allergic and thus the risk of cross-reaction with another BL is even lower, varying according to structural and physicochemical similarities with alleged-penicillin. Moreover, the risk of having an anaphylactic reaction after penicillin exposure is very low, especially among children. As well, in patients with confirmed penicillin allergy, the observed reactions are usually delayed non-severe skin reactions. However, with a confirmed penicillin allergy, it is important to remain cautious when administering a new BL, especially if the initial reaction was serious or severe. Based on these key messages, a decision aid including an algorithm was developed. Likewise, individualized algorithms for common infections met in primary care were produced.ConclusionsFrom this work, health professionals non-specialized in allergology should be able to better manage the risks attributed to penicillin allergies. Therefore, patients should receive the most effective and safe antibiotics to treat their clinical conditions in primary care.

Download Full-text

Allergic Cross-Sensitivity between Penicillin and Carbapenem Antibiotics

Journal of Pharmacy Technology ◽

10.1177/875512250502100506 ◽

2005 ◽

Vol 21 (5) ◽

pp. 271-275

Author(s):

Erica D Greanya ◽

Doson Chua

Keyword(s):

Data Extraction ◽

Skin Testing ◽

Drug Hypersensitivity ◽

Cross Reactivity ◽

Penicillin Allergy ◽

Cross Sensitivity ◽

Number Of Patients ◽

Clinical Consequences ◽

Minimal Data ◽

The Cross

Objective: To review the literature evaluating the cross-hypersensitivity between carbapenem and penicillin antibiotics. Data Sources: Primary literature was accessed through MEDLINE (1980–June 2004), EMBASE (1980–December 2004), International Pharmaceutical Abstracts, PubMed, and references of reviewed articles. Key search terms were carbapenem, imipenem, meropenem, ertapenem, drug hypersensitivity, and penicillin allergy. Study Selection and Data Extraction: All articles describing clinical studies involving the use of carbapenem antibiotics in patients allergic to penicillin were reviewed. Data Synthesis: Four studies assessed carbapenem hypersensitivity in penicillin-allergic patients. Original estimates deemed the cross-reactivity to be 50% based on skin testing in a small number of patients; however, 3 more recent retrospective analyses indicate the overall incidence to be approximately 10%. The retrospective nature and presence of confounding factors in the more recent studies make it difficult to apply the lower estimates of carbapenem cross-sensitivity to a general patient population. The majority of cross-reactivity reactions reported was the development of a rash or hives. Conclusions: With minimal data available, the incidence of allergic reaction to carbapenem antibiotics in patients with self-reported penicillin allergy is likely less than the original skin test–determined estimates of 50%. However, caution should be used in patients with previously reported anaphylactic reactions to penicillin. A detailed allergy history is important in determining the clinical consequences of the potential cross-reactivity of carbapenem antibiotics in penicillin-allergic patients.

Download Full-text

171. Effectiveness and Feasibility of Pharmacist-Driven Penicillin Allergy De-Labeling Pilot Program

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.215 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S93-S93

Author(s):

Youchan Song ◽

Zachary Nelson ◽

Krista Gens

Keyword(s):

Program Implementation ◽

Skin Testing ◽

Surgical Site Infections ◽

Cross Reactivity ◽

Adverse Outcomes ◽

Penicillin Allergy ◽

Beta Lactam ◽

Patient Interview ◽

Clostridioides Difficile ◽

Increased Risk

Abstract Background Prevalence of true hypersensitivity to penicillins is low (0.5–2%). Documented penicillin allergies have been associated with an increased risk of adverse outcomes, including methicillin resistant Staphylococcus aureus infections, Clostridioides difficile infections, and surgical site infections. “De-labeling” of inappropriately documented allergies can decrease the use of unnecessary broad-spectrum antibiotics and prevent negative outcomes, but labor-intensive skin testing and oral challenges can be a barrier to program implementation. The goal of this project is to assess the effectiveness and feasibility of a pharmacist-led penicillin allergy de-labeling process that does not involve skin testing or oral challenges. Methods Adult patients with penicillin allergies were identified using a report within the electronic health record during a 3-month pilot period. Patients identified were interviewed by an infectious diseases pharmacy resident, and an allergy history was assessed utilizing a standardized checklist. The patients’ answers determined the ability to de-label via pharmacist utilization of an evidence-based and standardized checklist developed for this project. All documentation included a detailed patient allergy history along with a beta-lactam cross-reactivity chart to help guide future antibiotic choices. Results 66 patients were interviewed during the pilot. 12 patients (18%) met criteria for de-labeling and consented to the removal of the allergy. 4 patients (6%) met criteria for de-labeling but declined the removal of the allergy. Average time spent during patient interview was 5.2 minutes per patient. 58.3% of patients (7/12) who were de-labeled were subsequently prescribed a beta-lactam, and 100% (7/7) were able to tolerate the agents. 1 out of 4 patients (25%) who declined de-labeling but had their allergy updated to reflect intolerance was prescribed beta-lactams and was able to tolerate the agents (1/1, 100%). Conclusion A pharmacist-led penicillin allergy de-labeling process utilizing a standardized checklist is an effective method for removing penicillin allergies in patients who do not have a true allergy to penicillins. This pharmacist-led process is a feasible method for sites unable to perform oral challenges or skin testing. Disclosures All Authors: No reported disclosures

Download Full-text