Access the full text.
Sign up today, get DeepDyve free for 14 days.
original article Allergo J Int (2020) 29:174–180 https://doi.org/10.1007/s40629-020-00135-5 Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project Christiane Querbach · Tilo Biedermann · Dirk H. Busch · Rüdiger Eisenhart-Rothe · Susanne Feihl · Christiane Filser · Friedemann Gebhardt · Markus Heim · Helmut Renz · Kathrin Rothe · Christoph D. Spinner · Melanie Starzner · Christian Suren · Monika Trojan · Knut Brockow Received: 29 April 2020 / Accepted: 18 June 2020 / Published online: 27 August 2020 © The Author(s) 2020 Summary (1) BLA allergy excluded, (2) benign delayed reaction, Background Beta-lactam antibiotics (BLA) are the (3) immediate reaction, and (4) severe cutaneous and treatment of choice for a large number of bacterial extracutaneous drug reaction. Recommendations infections. Putative BLA allergies are often reported strictly depend on this classiﬁcation and range from by patients, but rarely conﬁrmed. Many patients do use of full-dose BLA or use of BLA under certain con- not receive BLA due to suspected allergy. There is no ditions (e.g., two-stage dose escalation, non-cross- systematic approach to risk stratiﬁcation in the case reactive BLA only) to prohibiting all BLA and the use of a history of suspected BLA allergy. of alternative non-BLA. In case of suspected immedi- Methods Using the available stratiﬁcation programs ate or delayed allergic reactions, there is an additional and taking current guidelines into account, an algo- recommendation regarding subsequent allergy testing rithm for risk stratiﬁcation, including recommenda- during a symptom-free interval. tions on the use of antibiotics in cases of compellingly Conclusion Triage of patients with suspected BLA indicated BLA despite suspected BLA allergy, was for- is urgently required. While allergy testing, including mulated by the authors for their maximum care uni- provocation testing, represents the most reliable so- versity hospital. lution, this is not feasible in all patients due to the Results The hospital is in great need of recommen- high prevalence of BLA allergies. The risk stratiﬁ- dations on how to deal with BLA allergies. Patient- cation algorithm developed for the authors’ hospital reported information in the history forms the basis represents a tool suitable to making a contribution to for classifying the reactions into four risk categories: rational antibiotic therapy. C. Querbach · C. Filser · H. Renz · M. Starzner · M. Trojan C. D. Spinner Pharmacy Department, School of Medicine, University Department of Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Hospital rechts der Isar, Technical University of Munich, Munich, Germany Munich, Germany C. Querbach · D. H. Busch · S. Feihl · C. Filser · F. Gebhardt · D. H. Busch · S.Feihl ·F. Gebhardt·K. Rothe M. Heim ·H.Renz · K.Rothe · M.Starzner ·M. Trojan Institute for Medical Microbiology, Immunology, and Antibiotic Stewardship Unit, School of Medicine, University Hygiene, Technical University of Munich, Munich, Germany Hospital rechts der Isar, Technical University of Munich, R. Eisenhart-Rothe · C. Suren Munich, Germany Department of Orthopedics and Sports Orthopedics, School T. Biedermann · Prof. Dr. K. Brockow () of Medicine, University Hospital rechts der Isar, Technical Department of Dermatology and Allergology am University of Munich, Munich, Germany Biederstein, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany firstname.lastname@example.org M. Heim Department of Anesthesiology, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany 174 Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project K original article Keywords Beta-lactam antibiotics · Penicillin · into account current German and European recom- Risk stratiﬁcation · Checklist · Algorithms · Acute mendations, the authors formulated an algorithm, as treatment well as the following recommendations on the use of antibiotics in compelling indications, for their 1161- bed, maximum-care university hospital in order to Introduction stratify the risk of BLA allergy in the patient history. Beta-lactam antibiotics (BLA) are not only the drugs of choice for the treatment of numerous bacterial infec- Methods tions, but also the most frequent triggers of drug aller- gies and fatal drug-related anaphylaxis [1, 2]. Approx- Between March 2019 and July 2019, members of the imately 3–10% of all patients or parents of affected Antibiotic Stewardship (ABS) Unit (hospital pharmacy, children in the population and up to 19% of all hospi- medical microbiology, intensive medicine), Infectiol- talized patients report a BLA allergy [1, 2]. Since sus- ogy and Allergology at the Klinikum rechts der Isar, pected hypersensitivity can be conﬁrmed by allergy Munich, drew up an algorithm in an interdisciplinary testing in only less than 10% , failure to take into approach on how to proceed in the case of suspected account allergies reported in the patient history is of BLA allergy when the use of a BLA is compellingly in- no consequence in many cases. Parainfectious exan- dicated (primarily in severe or acute infection). They thems or acute urticaria are frequently misinterpreted analyzed the guidelines and position papers that were as cutaneous drug reactions. The high number of BLA available or in preparation, as well as the respective allergies reported in patient histories hampers the se- literature [1–15]. Recommendations were made on the lection of a suitable antibiotic. The possible conse- basis of a risk assessment that takes into account pos- quences of incorrectly classiﬁed BLA allergies in the sible cross reactions between BLA and classiﬁes these patient history include the following: increased use of reactions into putative underlying pathomechanisms. broad-spectrum antibiotics, ineffective treatment of The pathomechanisms are suspected on the basis of bacterial infections, a high number of sick days and clinical symptoms reported in the patient history and hospitalization days, the induction of bacterial mul- recorded using a checklist. tiresistance and high costs. Healthcare providers urgently need a systematic Results approach to risk stratiﬁcation in the case of sus- pected BLA allergy in the patient’s history. Of all the Situations in which antibiotic use is compellingly in- strategies to investigate assumed BLA allergies, con- dicated for severe or acute infection in the setting of sultation by an allergologist, including skin testing a concomitant history of BLA allergy arise in almost followed by provocation testing, is the most reliable, 10% of patients at the authors’ hospital. These pa- but also the most time- and resource-consuming ap- tients need to be triaged with regard to the further ap- proach. However, in view of the millions of patients proach according to a risk stratiﬁcation system, either affected, additional instruments for systematic eval- receiving direct administration of alternative non-BLA uations are needed in order to offer low-risk patients and a recommendation for later allergy testing during faster treatment options. The preferred protocol to a symptom-free interval, or direct use of BLA under investigatetrueBLA allergy should besimpletoper- certain conditions (e.g., two-stage dosing) and taking form and yield as few false-positive results as possible into account possible cross-reactivity. . Clinical symptoms reported in the patient’s history In recent years, algorithms referred to as “de-label- form the basis for the classiﬁcation into pathomecha- ing strategies”, which are proven to reduce antibiotic nisms. The information needs to be rapidly recorded use and improve treatment outcomes, have been de- in clinical routine, but must also include all aspects scribed in the US , Australia , New Zealand relevant to the BLA allergy. , Great Britain [11, 13], and Germany . Algo- Relevant data on the suspected BLA allergy is col- rithms such as these, some of which are computer- lected using a targeted short patient history that is assisted, attempt to classify the most likely mecha- structured as a three-part checklist (Fig. 1). Examples nism of hypersensitivity reaction on the basis of clin- of possible alternatives are provided, and applicable ical manifestations of BLA allergy in the patient’s his- information can be underlined or ticked. Although tory. The further procedure is determined according this short patient history cannot replace the differen- to the respective classiﬁcation, ranging from complete tiated allergy history taken by a specialist physician avoidanceof the substance class in thefutureto skin during allergy diagnostics, it is sufﬁcient to provide testing plus/minus provocation testing to no restric- an acute assessment in the majority of cases. tions whatsoever. The ﬁrst questions on the checklist cover informa- In 2019, this topic was discussed intensively in the tion regarding known allergies and tolerance of other German BLA allergy guideline , as well as in the antibiotic substance classes, the timing of the reac- EAACI European position paper . Therefore, on tion(s), the suspected BLA, the duration of use prior to the onset of the reaction, the time interval between the basis of existing stratiﬁcation programs and taking K Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project 175 original article Date Full name, date of birth / patient label Physician in charge Part 1: Checklist short medical history Please underline as appropriate Date of allergy? 0-6 mo ago / 6-12 mo ago / 1-10 yrs ago / >10 yrs ago / N/A Suspected antibiotic (dose, mode of application)? e.g. Amoxicillin 1g p.o. tid e.g. symptoms on Duration of medication use until onset of symptoms? single dose / 1-7 days / >7 days / N/A day 7 of therapy or Time interval between onset of symptoms and last symptoms within within 1 hr / after 1-6 hrs / after 6 hrs until few days / N/A administration 5min after 1st dose Duration of symptoms? min up to few hrs / few days up to weeks / N/A Allergy testing / drug allergy pass available? yes / no / N/A Other known allergies? Well tolerated antibiotics known? Manifestations / Symptoms (examples) Measures taken mild moderate life-threatening after onset of manifestations / symptoms Please check off (multiple selections possible) Please check off (multiple selections possible) Pruritus Discontinuation of beta-lactam antibiotic Rhinoconjunctivitis Switch to alternative antibiotic Dizziness, headache Antihistamines iv / po / topical Corticosteroids iv / po / topical Urticaria Adrenaline iv / Adrenaline auto-injector im First signs of anaphylaxis Tachycardia Hospitalisation (ICU, normal ward) Mild dyspnoea and cough Other: Angioedema / laryngeal edema Other: Wheezing / severe dyspnoea Other: Drop in blood pressure Other: Unconsciousness Other: Cardiovascular- and/or respiratory arrest In ca. 60% of cases: Maculopapular exanthem rare: DRESS syndrome Continue to part 2: rare: Hemolytic anemia/cytopenia Recommendations on - Antibiotic therapy with compelling indication rare: Acute nephritis or hepatitis - Allergy testing rare: Most severe bullous skin reactions e.g. SJS/TEN Other reactions Non-allergic Diarrhea (eg. antibiotic-associated, C. difficile) ADRs Gastrointestinal reactions (nausea, vomiting ) 1 Beta-lactam allergy is reported in approx. 15% of all hospitalized patients, but not confirmed in > 80% via allergy testing; allergic reaction occur: iv > po administration, penicillins > cephalosporins, highest incidence at age 20-50 yrs; one anaphylaxis per approx. 10,000 applications of penicillins iv / im (for cephalosporins: case reports only), mortality: approx. 1/32,000 applications of penicillin 2 Immediate reaction (type I reaction, IgE-mediated): particularly cephalosporins 3 Delayed reaction (type IV reaction or not-IgE-mediated): particularly aminopenicillins 4 Differentation urticaria (angioedema) versus maculopapular exanthem: see "Antiinfektiva-Leitfaden", AiD Klinik 5 Burning/tingling of tongue or palate, metallic taste, burning sensation on palms of hands/soles of feet or in genitals, flushing, agitation, redness of large areas of skin 6 To be differentiated anaphylactic reactions grade 2 up to grade 4 abbr.: N/A information not available, ADRs adverse drug reactions, mo months, hr(s) hour(s), min minutes, ICU intensive care unit, iv intravenous, po per os, im intramuscular, DRESS Drug Rash with Eosinophilia and Systemic Symptoms, SJS Stevens-Johnson syndrome, TEN Toxic epidermal necrolysis Fig. 1 Procedure for suspected beta-lactam antibiotic allergy/adverse drug reactions (penicillin [derivatives], cephalosporins, carbapenems) 176 Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project K Immediate reaction Delayed reaction within minutes up to 1 hr (in rare cases up to 6 hrs), > 6 hrs up to few then persisting for several hours days, then persisting few days up to weeks Occurrence in varying sequence/combination severe anaphylactic reaction up to anaphylactic shock original article Table 1 Criteria for diagnosis of skin rash following an- mediate use of a BLA. Reactions are classiﬁed into tibiotic administration four risk categories on the basis of the temporal se- Urticaria/(angioedema) Maculopapular exanthem quence reported in the patient history in immediate please check off please check off and delayed reactions and the severity of the symp- Time interval be- Within 1 hour (up to >6 hours up to few toms. The color coding of severity is taken from the tween onset of 6hours) days short patient’s history (Fig. 1). If a BLA allergy is ruled symptoms and out based on the reported occurrence of non-allergic last administra- adverse drug reactions that are predictable and not tion? severe, no allergy testing is required and BLA can be Duration of symp- Hours (angioedema Days up to approxi- toms? up to 2 days) mately 2 weeks administered. In cases of reported clinical manifes- Appearance and Red or white raised Often measles-like tations suspicious for mild, benign delayed reactions distribution of lesions with red environ- (type IV) without a severe cutaneous drug reaction, cutaneous ment non-cross-reactive BLA can be directly administered reaction? Localized any- Widespread on at full dosage. If an immediate allergy (type I) with where on the body (an- trunk > extremities severe anaphylaxis is reported in the patient’s history, gioedema: usually face: the administration of a non-BLA is recommended. In eyelids, lips, tongue) the case of a suspected immediate allergy (type I) with Course of Start with redness Red spots cutaneous no severe anaphylaxis in the patient’s history, a non- Then wheals (similar In some cases small reaction? cross-reactive BLA can be given in fractions (starting as after contact with raised papules: sym- stinging nettles): wheals metrical, increase at the with one tenth of the single dose, followed by the full migrate and increase beginning, may become single dose 2 h later) with acceptable risk. However, conﬂuent an allergy specialist should always be consulted be- Heal within 24 hours, Do not migrate, heal fore drug administration in order to establish whether but new lesions may after days prior allergy testing, e.g., skin testing, is necessary. appear on the body Any exposure to BLA, even non-cross-reactive BLA, in Concomitant Pruritus Pruritus symptoms? suspected allergy requires the patient to provide in- Deep Desquamation common formed consent and to be monitored. In the case of swelling = angioedema in later clearing phase suspected severe cutaneous and extracutaneous ad- Systemic involve- Rare: systemic involve- ment: anaphylaxis ment verse drug reaction in the patient’s history, a non- BLAisgiven, since reactionsofthiskind are not pre- dictable, cannot be adequately treated with drugs, and last use and the reaction, duration of symptoms, and may follow a severe course. allergy testing already performed. The algorithm also provides recommendations on The second part of the checklist relates to symp- alternative treatment options and the evaluation of toms in the patient’s history following the use of allergy testing, cross references to other important in- BLA (Fig. 1). Typical examples of cutaneous, res- ternal hospital documents (e.g., anti-infective guide- piratory, systemic, hematological, neurological, and lines, emergency cards), as well as contact details for renal manifestations or symptoms of the immediate the relevant points of contact (allergology, ABS unit, reaction and of the delayed reaction are given and infectiology) and information on allergy documenta- categorized by color into levels of severity, i.e., “mild”, tion in patient records (e.g., de-labeling). “moderate,” and “life-threatening”. Non-allergic reac- tions, e.g., gastrointestinal reactions such as nausea Discussion and vomiting that did not occur in the setting of an anaphylactic reaction, are clearly distinguished Due to the disadvantages of treatment with non-BLA from the symptoms of the immediate reaction and in suspected BLA allergy and the high number of un- the delayed reaction [4, 15]. To enable better clinical conﬁrmed cases of suspected allergy, a systematic ap- differentiation between an immediate reaction in- proach to risk stratiﬁcation is urgently required, not volving urticaria or angioedema and maculopapular only for the authors’ university hospital. Since a risk exanthem, which can also resemble urticaria in the stratiﬁcation algorithm of this kind has not be de- ﬁrst few days , a differentiation aid was developed scribed in Germany yet, the authors formulated rec- (Table 1). ommendations on how to proceed in patients with The third part lists the measures that had been suspected BLA allergy (Figs. 1 and 2). Reichel et al. taken following onset of the reaction with suspected took a similar approach using ﬁve partially subdivided BLA allergy in order to collect further information on questions to estimate the probability of BLA allergy the severity. For example, parenteral drug administra- and then recommend direct de-labeling or the use of tion, in particular adrenaline, or hospital admission an alternative antibiotic . A hospital-wide basic suggest a high severity level. patient’s history record is expected to be integrated Figure 2 provides recommendations on how to pro- in the electronic medical records of inpatients at the ceed if there is a compelling indication for the im- end of 2020, which will enable, among other things, K Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project 177 original article 178 Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project K Part 2: Recommendation for compelling indication Exclusion of beta-lactam antibiotic Manifestation of suspected severe Manifestation of suspected mild, benign delayed reaction (type IV), allergy because of non-allergic adverse Manifestation of suspected immediate reaction (type I), e.g. cutaneous and extracutaneous drug no severe cutaneous drug reaction, e.g. drug reactions, e.g. reaction, e.g. Antibiotic-associated diarrhea Pruritus Angioedema / laryngeal edema DRESS syndrome 1 1 Clostridium difficile infection Maculopapular exanthem Urticaria Acute nephritis and hepatitis Gastrointestinal reactions Wheezing / severe dyspnoea Hemolytic anemia/cytopenia (nausea, vomiting) Drop in blood pressure / unconsciousness SJS Cardiovascular- and/or respiratory arrest TEN Unclear reaction without mucosal involvement / blistering / organ participation If necessary, symptomatic therapy of ADR If necessary, acute medical treatment If necessary, symptomatic therapy of adverse drug reactions If necessary, emergency phone numbers see emergency card C. diff: see "Antiinfektiva-Leitfaden", AiD Klinik and and and and Administration of non-beta-lactam antibiotics: alternative treatment options - See relevant internal guidelines (see "Antiinfektiva-Leitfaden", AiD Klinik) or - Consultation of Antibiotic Stewardship Team (phone xxx) or Department of Infectious Diseases (phone xxx) or or or in case of no severe anaphylaxis and after prior consultation of Department only for vital indication of Allergology (senior consultant, phone xxx) 3 3 if triggering penicillin (-derivative) clearly identified if triggering penicillin (-derivatives) clearly identified Administration of beta-lactam antibiotics 4 4 Non-cross-reactive 3rd-5th generation cephalosporins Non-cross-reactive 3rd-5th generation cephalosporin if medically indicated Selection and administration of with full-dose with starting dose 1/10th, then 2 hours later full-dose appropriate beta-lactam antibiotics after 3 3 if triggering cephalosporin clearly identified if triggering cephalosporin clearly identified prior consultation with Department of 5 5 Non-cross-reactive penicillins Non-cross-reactive penicillins Allergology (senior consultant, phone with full-dose with starting dose 1/10th, then 2 hours later full-dose xxx) 3 3 if triggering beta-lactam antibiotic not clearly identified if triggering beta-lactam antibiotic not clearly identified 6 6 Carbapenems Carbapenems and with full-dose with starting dose 1/10th, then 2 hours later full-dose consultation of Antibiotic Stewardship and and and Team (phone xxx) or Department of Appointment for allergy testing (anaphylaxis/urticaria: phone xxx, exanthem: phone xxx; e-mail email@example.com) with test after being free of symptoms for approx. 6 Infectious Diseases (phone xxx) weeks No allergy testing needed Further administration of beta-lactam antibiotics: Approval by dermatology / negative allergy testing, first dose be given under medical supervision Patient record / medical report / allergy pass - Allergy to XY + type of reaction + date of last occurence, e.g. "Maculopapular exanthem after administration of amoxicillin po in April 2020" If necessary, correction of previously "Anaphylaxis (urticaria, shortness of breath, drop in blood pressure) after first dose of imipenem/cilastatin iv on 4 April 2020" documented information „Suspected exanthem (symptoms and suspected beta-lactam antibiotic not clearly remembered) 20 years ago, recommendation for allergy testing" - If necessary, correction of previously documented information - Medical report: In case of suspected beta-lactam allergy recommendation for allergy testing after beeing free of symptoms for approx. 6 weeks 1 Differentation urticaria (angioedema) versus maculopapular exanthem: see "Antiinfektiva-Leitfaden", AiD Klinik 2 Because of the high number of reported beta-lactam allergies patients often receive broad-spectrum antibiotics instead of antibiotics of first choice; for almost all patients appropriate beta-lactam antibiotics can be identified; penicillins often are antibiotics of first choice, administration of alternative antibiotics may be less effective in treating infections 3 Reliable identification by precise documentation in allergy pass, patient record, medical report Classification cephalosporins: see "Antiinfektiva-Leitfaden" on AiD Klinik 5 Non-cross-reactive penicillins are all non-aminopenicillines. Aminopenicillins (e.g. amoxicillin, ampicillin) are contraindicated. 6 Symptoms after taking carbapenems are very rare. abbr.: ADR adverse drug reaction, iv intravenous, po per os, DRESS Drug Rash with Eosinophilia and Systemic Symptoms, SJS Stevens-Johnson syndrome, TEN Toxic epidermal necrolysis Fig. 2 Recommendations on antibiotic therapy for compelling indications Documentation Recommendation original article Dear patient Your records describe a so-called “penicillin allergy”. An allergy test has not been performed yet or you do not carry an allergy pass. As a consequence of a “penicillin allergy“, penicillins may be avoided for the rest of your life, although the symptoms that have occurred may also be due to other causes. If penicillins are not used, sometimes an infection cannot be treated optimally. Our recommendation to you: For clarification, please have an allergy test carried out by your allergologist. o If you currently have any symptoms due to the penicillin allergy, wait approx. 6 weeks until the symptoms have disappeared. o You can make an appointment at the Klinikum rechts der Isar at any time: Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein Biedersteiner Straße 29 80802 München Phone xxx E-mail firstname.lastname@example.org o If the test shows that you have a penicillin allergy, get an allergy pass. Always present it to your physician in charge. o If the test shows that you do not have a penicillin allergy, inform your physician in charge as well. Fig. 3 Patient information leaflet “Recommendation for allergy tes ting in suspected beta-lactam antibiotics (BLA) allergy” centralized allergy documentation to be linked. The of patients is able to reliably answer targeted ques- algorithm discussed here can provide valuable assis- tions about antibiotics that have been tolerated in tance in drawing up these records. the past. Early experience using the algorithm in clinical rou- Problems were primarily encountered in the retro- tine shows that a history of BLA allergy signiﬁcantly spective description of cutaneous manifestations, hampers rational antibiotic therapy. This instrument in particular “urticaria/angioedema” versus “mac- shows clear clinical beneﬁts, meaning that more pa- ulopapular exanthem”. As an aid to differentiation, tients with suspected BLA allergy can be treated with picture cards (not shown) and bullet-point explana- BLA. However, obstacles are also apparent, for which tions (Table 1) were formulated, both for the physi- pragmatic solutions need to be developed and succes- cian’s use and for patients to use during history sively implemented in a multidisciplinary approach: taking. Patients often do not have their allergy pass with Collecting the required information from patient them (if they have one at all), often presenting these records and taking the patient history is time- and only when requested to do so and or with some de- staff-intensive. Due to the intensiﬁcation of work lay after initial antibiotic therapy has been started. for medical personnel, thetimefactorwilltakeon The urgent recommendation to promptly carry out considerable importance in the future. an outpatient investigation into a history of BLA al- Information regarding “penicillin allergy” is gener- lergy or animmediate reactionin the past is rarely ally based on the self-reported patient history. Once followed. Therefore, a patient information leaﬂet, this information has been entered in the patient “Recommendation for allergy testing in suspected record, it will not necessarily be questioned or in- BLA allergy,” was developed in ﬁve different lan- vestigated at subsequent contacts with the patient. guages (German, English, Turkish, Arabic, and Rus- Precise information on symptoms of a BLA allergy sian) (Fig. 3). This was given to patients with a his- are very rarely documented in patient records. It is tory of BLA allergy during allergy history taking. often not possible for patients to provide speciﬁc Inpatient allergy testing (skin testing plus/minus data regarding, in particular, symptoms and times provocation testing) as standard in patients with due to a lack of recalling the event often dating back equivocal BLA allergy in whom antibiotic therapy is to childhood. Patients frequently refer to the sus- compellingly indicated is only possible to a limited pected antibiotic in an undifferentiated manner, extent due to the spatial separation of the allergy using the umbrella term “penicillin”. Only a fraction department from the main hospital building. An K Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project 179 original article 4. Brockow K, Ardern-Jones MR, Mockenhaupt M, Aberer W, optimized approach is currently under multidisci- Barbaud A, Caubet JC, et al. EAACI position paper on how to plinary discussion. classify cutaneous manifestations of drug hypersensitivity. Allergy. 2019;74:14–27. Conclusion 5. Vaisman A, McCready J, Hicks S, Powis J. Optimizing pre- operative prophylaxis in patients with reported β-lactam Heightening the awareness of suspected or proven allergy: a novel extension of antimicrobial stewardship. J AntimicrobChemother. 2017;72:2657–60. beta-lactam antibiotic (BLA) allergies among treat- 6. Charneski L, Deshpande G, Smith SW. Impact of an an- ing physicians on the one hand and patients on the timicrobial allergy label in the medical record on clinical other is an essential task of the interdisciplinary an- outcomes in hospitalized patients. Pharmacotherapy. tibiotic stewardship team in collaboration with the 2011;31:742–7. allergy unit. In addition to addressing BLA allergies 7. Blumenthal KG, Shenoy ES, Wolfson AR, Berkowitz DN, in internal infection guidelines, training courses, and Carballo VA, Balekian DS, et al. Addressing inpatient beta- ABS (Antibiotic Stewardship) medical rounds, the lactamallergies: Amulti-hospitalimplementation. JAllergy Clin Immunol Pract. 2017;5:616–625.e7. risk stratiﬁcation algorithm developed at the authors’ 8. Blumenthal KG, Wickner PG, Hurwitz S, Pricco N, Nee AE, hospital represents a tool suited to making a con- Laskowski K, et al. Tackling inpatient penicillin allergies: tribution to rational antibiotic therapy. To ensure assessing tools for antimicrobial stewardship. J Allergy Clin successful implementation, hurdles need to be con- Immunol. 2017;140:154–161.e6. tinuously identiﬁed and interventions implemented 9. Shenoy ES,MacyE,Rowe T,Blumenthal KG. Evaluation in a targeted manner. and management of penicillin allergy: a review. JAMA. 2019;321:188–99. Funding Open Access funding provided by Projekt DEAL. 10. Devchand M, Urbancic KF,Khumra S,Douglas AP,Smib- ertO,CohenE,etal. Pathwaystoimprovedantibioticallergy Conﬂict of interest C. Querbach, T. Biedermann, D.H. Busch, and antimicrobial stewardship practice: the validation of R. Eisenhart-Rothe, S. Feihl, C. Filser, F. Gebhardt, M. Heim, a beta-lactam antibiotic allergy assessment tool. J Allergy H. Renz,K.Rothe,C.D.Spinner, M. Starzner, C.Suren, M.Tro- Clin Immunol Pract. 2019;7:1063–1065.e5. jan and K. Brockow declare that they have no competing 11. MohamedOE,BeckS,HuissoonA,MelchiorC,HeslegraveJ, interests. Baretto R, et al. A retrospective critical analysis and Open Access This article is licensed under a Creative Com- risk stratiﬁcation of penicillin allergy delabelling in a UK mons Attribution 4.0 International License, which permits specialist regional allergy service. J Allergy Clin Immunol use, sharing, adaptation, distribution and reproduction in Pract. 2019;7:251–8. any medium or format, as long as you give appropriate credit 12. Kuruvilla M, Sexton M, Wiley Z, Langﬁtt T, Lynde GC, to the original author(s) and the source, provide a link to Wolf F. A streamlined approach to optimize perioperative the Creative Commons licence, and indicate if changes were antibiotic prophylaxis in the setting of penicillin allergy made. The images or other third party material in this article labels. J Allergy Clin Immunol Pract. 2020;8:1316–22. are included in the article’s Creative Commons licence, unless 13. Savic LC, Khan DA, Kopac P, Clarke RC, Cooke PJ, indicated otherwise in a credit line to the material. If material Dewachter P, et al. Management of a surgical patient is not included in the article’s Creative Commons licence and with a label of penicillin allergy: narrative review and con- your intended use is not permitted by statutory regulation or sensus recommendations. Br J Anaesth. 2019;123:e82–e94. exceeds the permitted use, you will need to obtain permis- 14. du Plessis T, Walls G, Jordan A, Holland DJ. Implemen- sion directly from the copyright holder. To view a copy of this tation of a pharmacist-led penicillin allergy de-labelling licence, visit http://creativecommons.org/licenses/by/4.0/. service in a public hospital. J Antimicrob Chemother. 2019;74:1438–46. 15. Brockow K, Przybilla B, Aberer W, Bircher AJ, Brehler R, Dickel H, et al. Guideline for the diagnosis of drug hyper- References sensitivity reactions: S2K-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI) and the 1. Wurpts G, Aberer W, Dickel H, Brehler R, Jakob T, Kreft B, et German Dermatological Society (DDG) in collaboration al. S2k Guideline: Diagnostics for suspected hypersensi- with the Association of German Allergologists (AeDA), the tivity to beta-lactam antibiotics. Guideline of the German German Society for Pediatric Allergology and Environ- Society for Allergology and Clinical Immunology (DGAKI) mental Medicine (GPA), the German Contact Dermatitis in collaboration with the Medical Association of German Research Group (DKG), the Swiss Society for Allergy and Allergologists (AeDA), German Society for Pediatric Aller- Immunology (SGAI), the Austrian Society for Allergology gology and Environmental Medicine (GPA), the Austrian and Immunology (ÖGAI), the German Academy of Aller- Society for Allergology and Immunology (ÖGAI), and the gology and Environmental Medicine (DAAU), the German Paul-Ehrlich Society for Chemotherapy (PEG). Allergo J Int. Center for Documentation of Severe Skin Reactions and the 2019;28:121–51. German Federal Institute for Drugs and Medical Products 2. Brockow K. Triage strategies for clarifying reported betalac- (BfArM). Allergo J Int. 2015;24:94–105. tamallergy. J Allergy Clin Immunol Pract. 2019;7:1066–7. 16. Reichel A, Röding K, Stoevesandt J, Trautmann A. De- 3. RomanoA,Atanaskovic-MarkovicM,BarbaudA,BircherAJ, labelling antibiotic allergy through ﬁve key questions. Clin Brockow K, Caubet JC, et al. Towards a more precise Exp Allergy. 2020;50:532–5. diagnosis of hypersensitivity to beta-lactams—an EAACI position paper. Allergy. 2019;75:1300–15. 180 Suspected penicillin allergy: risk assessment using an algorithm as an antibiotic stewardship project K
Allergo Journal International – Springer Journals
Published: Sep 1, 2020
Access the full text.
Sign up today, get DeepDyve free for 14 days.