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Journal For Healthcare Quality :...Penicillin allergy is the most commonly reported drug allergy in the United States. Patients labeled with penicillin allergy are at risk of receiving broad-spectrum...
INTRODUCTION
Penicillin allergy is the most commonly reported drug allergy in the United States. Patients labeled with penicillin allergy are at risk of receiving broad-spectrum antibiotics for surgical site infection prophylaxis, which can lead to increased antibiotic resistance, higher morbidity, suboptimal antibiotic therapy, and higher medical costs. This study aimed to determine the true prevalence of penicillin allergy among surgical patients and to decrease the unnecessary use of broad-spectrum antibiotics.
METHODS
A retrospective chart review was performed of patients who underwent urogynecologic surgery in 2017. In 2018, a quality initiative was started, and all patients reporting penicillin allergies were offered antibiotic allergy testing as part of their preoperative testing.
RESULTS
In 2017, 15% of patients reported penicillin allergy and 52% of them received surgical prophylaxis with broad-spectrum antibiotics. In 2018, 463 patients underwent surgery, 55 of whom reported penicillin allergy and were offered penicillin allergy testing. 35 (64%) agreed to proceed with testing, and of those tested, 33 (94%) tested negative for penicillin allergy.
CONCLUSIONS
94% of patients with stated penicillin allergy who consented to allergy testing proved to have negative test. Penicillin allergy testing should be considered as part of preoperative management.
Topics: Humans; Penicillins; Retrospective Studies; Anti-Bacterial Agents; Drug Hypersensitivity; Hypersensitivity
PubMed: 37428901
DOI: 10.1097/JHQ.0000000000000395 -
Current Opinion in Allergy and Clinical... Aug 2023The aim of this study was to review the practice of general practitioners (GPs) in regard to the diagnosis and management of drug hypersensitivity reactions (DHRs) to...
PURPOSE OF REVIEW
The aim of this study was to review the practice of general practitioners (GPs) in regard to the diagnosis and management of drug hypersensitivity reactions (DHRs) to identify major challenges and to facilitate the development of decision support tools to GPs confronted with DHRs patients.
RECENT FINDINGS
DHRs are still a challenge in the GPs clinical practice, which implies difficulties in clinical decisions and referral to allergy specialists.
SUMMARY
DHRs can range from mild to severe and even life-threatening. Drugs are the main cause of anaphylaxis deaths in most countries. Most DHRs are firstly seen by GPs, paediatricians or emergency doctors. However, our systematic review demonstrated difficulties in differentiating DHRs from other drug side effects. Most DHRs epidemiological data are from hospital and emergency departments, which may not reflect the real-life experience in primary care. GPs should be aware of the alert signs of DHRs: the involvement of other systems beyond the skin and/or atypical skin/ mucosal involvement, which mandated immediate referral to an emergency department. Data still stress difficulties in the recognition of DHRs clinical manifestations and highlight the need for decision aids to support their management by GPs. Structured clinical history and clinical examination are key diagnostic tools. Reasons for referring to allergy specialists based on the literature are to investigate cause, to undergo specific procedure, such as desensitization and to identify well tolerated, alternative drugs.
Topics: Humans; Quality Improvement; Drug Hypersensitivity; Anaphylaxis; Delivery of Health Care; Primary Health Care
PubMed: 37357792
DOI: 10.1097/ACI.0000000000000924 -
Hospital Pediatrics Sep 2023Penicillin allergy is the most common medication allergy, and the penicillin allergy label is commonly over-applied without adequate reaction history inquiry or...
BACKGROUND AND OBJECTIVES
Penicillin allergy is the most common medication allergy, and the penicillin allergy label is commonly over-applied without adequate reaction history inquiry or documentation. Because penicillin allergy labels are often applied in childhood and carried into adulthood, we sought to increase the completeness of reaction history documentation from 20% to 70% for pediatric hospital medicine patients and from 20% to 50% for all other pediatric inpatients within 12 months. As a secondary outcome, we also aimed to increase the proportion of delabeling unnecessary penicillin labels to 20% for all pediatric inpatients.
METHODS
To address our aims, our quality improvement initiative included education for pediatric faculty and staff, development and implementation of a clinical pathway for allergy risk stratification, and electronic health record optimizations. Statistical process control charts were used to track the impact of the interventions facilitated by an automated dashboard.
RESULTS
Within 12 months of interventions, the completeness of allergy labels improved from 20% to 64% among patients admitted to the pediatric hospital medicine service and improved from 20% to 45% for all other pediatric inpatients. The frequency of penicillin allergy delabeling remained unchanged; however, 98 patients were risk stratified and 34 received outpatient allergy referrals for further testing. The number of adverse drug reactions to penicillin, a balancing measure, did not change during the study period.
CONCLUSIONS
We increased the completeness of penicillin allergy documentation using a standardized workflow facilitated by a multidisciplinary clinical pathway. With ongoing efforts, more penicillin delabeling in low-risk patients is anticipated.
Topics: Humans; Child; Documentation; Penicillins; Anti-Bacterial Agents; Drug Hypersensitivity; Drug Labeling; Quality Improvement
PubMed: 37565275
DOI: 10.1542/hpeds.2022-006730 -
The World Allergy Organization Journal Mar 2024The majority of viral rashes occurring during an antibiotic therapy are considered as a drug hypersensitivity reaction (DHR). Differentiating a viral rash versus a DHR... (Review)
Review
The majority of viral rashes occurring during an antibiotic therapy are considered as a drug hypersensitivity reaction (DHR). Differentiating a viral rash versus a DHR is difficult or even impossible. In delayed DHRs the interplay between viruses and drugs is summarized according to the recent literature. The question is if the same reaction will again occur in case of drug re-exposure in absence of the concomitant viral infection because of persistent immune reactivity. Epstein Barr Virus (EBV) and Human Herpes virus 6 (HHV-6) models are analyzed in case of maculopapular exanthemas (MPEs) and drug reaction with eosinophilia and systemic symptoms (DRESS) over a course of drug therapy. MPEs are the most common skin manifestation during a viral infection and a concomitant drug therapy. In type IVb reactions to drugs a hapten/pro-hapten mechanism and a pharmacological interaction (p-i mechanism) are described as the 2 major ways to make T cells response functional. Rarely the altered repertoire model is involved. The Human Leukocyte Antigen (HLA) predisposition is an additional essential factor that can facilitate DHR. In MPEs rarely a DHR is confirmed by allergy testing. Severity and duration of MPEs, the presence of eosinophilia and systemic symptoms make more reliable the persistent nature of the reaction. Research on this topic is needed in order to provide the clinicians with instruments to decide when to suspect future reactions upon drug re-exposure even in the absence of a viral infection, because those patients should be investigated by a complete drug allergy work up.
PubMed: 38361746
DOI: 10.1016/j.waojou.2024.100877 -
Current Opinion in Allergy and Clinical... Aug 2023Perioperative anaphylaxis (POA) is rare but is associated with significant morbidity and mortality. Patients are referred to the allergist to identify the mechanism of... (Review)
Review
PURPOSE OF REVIEW
Perioperative anaphylaxis (POA) is rare but is associated with significant morbidity and mortality. Patients are referred to the allergist to identify the mechanism of the reaction, the causative agent and make recommendations regarding subsequent anaesthesia. Despite a well conducted allergological evaluation, the causative agent is not found in 30-60% of these reactions, leaving patients without a well established diagnosis.
RECENT FINDINGS
Several mechanisms can induce POA. In addition to the well known IgE-mediated reactions, IgG-mediated reaction, MRGPR-X2-related reaction or nonspecific histamine release may be involved. These situations are not easily assessed by the allergological workup.
SUMMARY
When the allergological workup is negative, the situation should be reassessed with the team present at the time of the reaction to confirm the reality of the hypersensitivity reaction and to search for a possible differential diagnosis. If POA is confirmed, the allergological evaluation should be repeated, ensuring proper execution according to current guidelines and including the search for hidden allergens. Specific IgE assays or basophil activation tests may be of interest. In case of negative results, a closely monitored drug challenge test, in coordination with the anaesthesia teams, may be useful to avoid the exclusion of any drug injected during the reaction.
Topics: Humans; Anaphylaxis; Drug Hypersensitivity; Skin Tests; Allergens; Immunoglobulin E
PubMed: 37357801
DOI: 10.1097/ACI.0000000000000912 -
Journal of the American Medical... Nov 2023A scoping review identified interventions for optimizing hospital medication alerts post-implementation, and characterized the methods used, the populations studied, and... (Review)
Review
OBJECTIVES
A scoping review identified interventions for optimizing hospital medication alerts post-implementation, and characterized the methods used, the populations studied, and any effects of optimization.
MATERIALS AND METHODS
A structured search was undertaken in the MEDLINE and Embase databases, from inception to August 2023. Articles providing sufficient information to determine whether an intervention was conducted to optimize alerts were included in the analysis. Snowball analysis was conducted to identify additional studies.
RESULTS
Sixteen studies were identified. Most were based in the United States and used a wide range of clinical software. Many studies used inpatient cohorts and conducted more than one intervention during the trial period. Alert types studied included drug-drug interactions, drug dosage alerts, and drug allergy alerts. Six types of interventions were identified: alert inactivation, alert severity reclassification, information provision, use of contextual information, threshold adjustment, and encounter suppression. The majority of interventions decreased alert quantity and enhanced alert acceptance. Alert quantity decreased with alert inactivation by 1%-25.3%, and with alert severity reclassification by 1%-16.5% in 6 of 7 studies. Alert severity reclassification increased alert acceptance by 4.2%-50.2% and was associated with a 100% acceptance rate for high-severity alerts when implemented. Clinical errors reported in 4 studies were seen to remain stable or decrease.
DISCUSSION
Post-implementation medication optimization interventions have positive effects for clinicians when applied in a variety of settings. Less well reported are the impacts of these interventions on the clinical care of patients, and how endpoints such as alert quantity contribute to changes in clinician and pharmacist perceptions of alert fatigue.
CONCLUSION
Well conducted alert optimization can reduce alert fatigue by reducing overall alert quantity, improving clinical acceptance, and enhancing clinical utility.
Topics: Humans; Medical Order Entry Systems; Medication Errors; Drug Interactions; Drug Hypersensitivity; Software; Decision Support Systems, Clinical
PubMed: 37812769
DOI: 10.1093/jamia/ocad193 -
Acta Dermato-venereologica Dec 2023
Topics: Humans; Everolimus; Drug Eruptions; Exanthema
PubMed: 38112207
DOI: 10.2340/actadv.v103.12197 -
Journal of the American Academy of... Jun 2024
Topics: Humans; Drug Hypersensitivity Syndrome; Female; Phenotype; Male; Middle Aged; Adult; Eosinophilia; Aged
PubMed: 37276931
DOI: 10.1016/j.jaad.2023.05.067 -
European Heart Journal May 2024Aspirin has been known for a long time and currently stays as a cornerstone of antithrombotic therapy in cardiovascular disease. In patients with either acute or chronic... (Review)
Review
Aspirin has been known for a long time and currently stays as a cornerstone of antithrombotic therapy in cardiovascular disease. In patients with either acute or chronic coronary syndromes undergoing percutaneous coronary intervention aspirin is mandatory in a dual antiplatelet therapy regimen for prevention of stent thrombosis and/or new ischaemic events. Aspirin is also currently a first-option antithrombotic therapy after an aortic prosthetic valve replacement and is occasionally required in addition to oral anticoagulants after implantation of a mechanical valve. Presumed or demonstrated aspirin hypersensitivity is a main clinical problem, limiting the use of a life-saving medication. In the general population, aspirin hypersensitivity has a prevalence of 0.6%-2.5% and has a plethora of clinical presentations, ranging from aspirin-exacerbated respiratory disease to anaphylaxis. Although infrequent, when encountered in clinical practice aspirin hypersensitivity poses for cardiologists a clinical dilemma, which should never be trivialized, avoiding-as much as possible-omission of the drug. We here review the epidemiology of aspirin hypersensitivity, provide an outline of pathophysiological mechanisms and clinical presentations, and review management options, starting from a characterization of true aspirin allergy-in contrast to intolerance-to suggestion of desensitization protocols.
Topics: Humans; Aspirin; Drug Hypersensitivity; Platelet Aggregation Inhibitors; Desensitization, Immunologic; Percutaneous Coronary Intervention; Cardiologists
PubMed: 38666370
DOI: 10.1093/eurheartj/ehae128 -
The Journal of Allergy and Clinical... Aug 2023
Topics: Humans; Deep Learning; Machine Learning; Decision Support Systems, Clinical; Drug Hypersensitivity
PubMed: 36931329
DOI: 10.1016/j.jaci.2023.03.004