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Review
. 2017 May-Jun;5(3):616-625.e7.
doi: 10.1016/j.jaip.2017.02.019.

Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation

Kimberly G Blumenthal  1 , Erica S Shenoy  2 , Anna R Wolfson  3 , David N Berkowitz  4 , Victoria A Carballo  5 , Diana S Balekian  6 , Kathleen A Marquis  7 , Ramy Elshaboury  8 , Ronak G Gandhi  8 , Praveen Meka  9 , David W Kubiak  10 , Jennifer Catella  11 , Barbara B Lambl  12 , Joyce T Hsu  13 , Monique M Freeley  14 , Alana Gruszecki  15 , Paige G Wickner  13
Affiliations
Review

Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation

Kimberly G Blumenthal et al. J Allergy Clin Immunol Pract. 2017 May-Jun.

Abstract

Addressing inaccurate penicillin allergies is encouraged as part of antibiotic stewardship in the inpatient setting. However, implementing interventions targeted at the 10% to 15% of inpatients reporting a previous penicillin allergy can pose substantial logistic challenges. We implemented a computerized guideline for patients with reported beta-lactam allergy at 5 hospitals within a single health care system in the Boston area. In this article, we describe our implementation roadmap, including both successes achieved and challenges faced. We explain key implementation steps, including assembling a team, stakeholder engagement, developing or selecting an approach, spreading the change, establishing measures, and measuring impact. The objective was to detail the lessons learned while empowering others to be part of this important, multidisciplinary work to improve the care of patients with reported beta-lactam allergies.

Keywords: Adverse drug reaction; Allergy; Beta-lactam; Drug; Graded challenges; Guideline; Hypersensitivity; Penicillin; Policy; Quality improvement; Stewardship; Test dose.

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Figures

Figure 1
Figure 1
Assembling a Team This workgroup structure displays the teams assembled at each hospital site as well as the umbrella Partners HealthCare team structure. Each hospital team required an executive sponsor, a clinical champion (Allergy/Immunology, Infectious Diseases, or Internal Medicine), pharmacy lead, and nursing lead. Abbreviations: MGH, Massachusetts General Hospital; BWH, Brigham and Women’s Hospital; BWF, Brigham and Women’s Faulkner Hospital; NWH, Newton-Wellesley Hospital; NSMC, North Shore Medical Center
Figure 2
Figure 2
The Partners Penicillin and Cephalosporin Hypersensitivity Pathway These pathway structures were used by the electronic decision support tool for reported hypersensitivities to penicillins and cephalosporins. Recommendations made by the computerized guideline followed these pathways. (A) Penicillin hypersensitivity pathway. For penicillin allergy histories, the guideline recommended:

  1. Type II–IV hypersensitivity reaction, avoidance of beta-lactams

  2. Type I IgE-mediated hypersensitivity reaction or unknown reaction, 3rd/4th/5th generation cephalosporins can be used by test dose directly; to use 1st/2nd generation cephalosporins or penicillins, penicillin skin testing or desensitization and Allergy/Immunology follow up was recommended.

  3. Mild hypersensitivity reaction including electronic health record discrepancies and benign morbilliform rashes, 3rd/4th/5th generation cephalosporins can be used by full dose and 1st/2nd generation cephalosporins and penicillins can be used by test dose.

(B) Cephalosporin hypersensitivity pathway Abbreviations/Footnotes:​ HSR, hypersensitivity reaction * Requires Infectious Diseases approval § Alternative agents by microbial coverage: Gram positive coverage: Vancomycin, linezolid*, daptomycin*, clindamycin, doxycycline, TMP/SMX Gram negative coverage: Quinolones, sulfamethoxazole/trimethoprim, aminoglycosides, aztreonam*
Figure 2
Figure 2
The Partners Penicillin and Cephalosporin Hypersensitivity Pathway These pathway structures were used by the electronic decision support tool for reported hypersensitivities to penicillins and cephalosporins. Recommendations made by the computerized guideline followed these pathways. (A) Penicillin hypersensitivity pathway. For penicillin allergy histories, the guideline recommended:

  1. Type II–IV hypersensitivity reaction, avoidance of beta-lactams

  2. Type I IgE-mediated hypersensitivity reaction or unknown reaction, 3rd/4th/5th generation cephalosporins can be used by test dose directly; to use 1st/2nd generation cephalosporins or penicillins, penicillin skin testing or desensitization and Allergy/Immunology follow up was recommended.

  3. Mild hypersensitivity reaction including electronic health record discrepancies and benign morbilliform rashes, 3rd/4th/5th generation cephalosporins can be used by full dose and 1st/2nd generation cephalosporins and penicillins can be used by test dose.

(B) Cephalosporin hypersensitivity pathway Abbreviations/Footnotes:​ HSR, hypersensitivity reaction * Requires Infectious Diseases approval § Alternative agents by microbial coverage: Gram positive coverage: Vancomycin, linezolid*, daptomycin*, clindamycin, doxycycline, TMP/SMX Gram negative coverage: Quinolones, sulfamethoxazole/trimethoprim, aminoglycosides, aztreonam*
Figure 3
Figure 3
The Computerized Partners Penicillin and Cephalosporin Hypersensitivity Pathway The computerized guideline/website contained optional clinical decision support for taking a drug allergy history. After answering questions from the patient’s allergy history, the decision support would group immunologic reactions into one of three categories described in the Partners Penicillin and Cephalosporin Hypersensitivity Pathway in Figure 2. The computerized guideline/website also included links to education videos as well as research and guidelines supporting beta-lactam allergy evaluation. Abbreviations:​ DRESS, drug rash eosinophilia and systemic symptoms; PCN, penicillin
Figure 4
Figure 4
Monthly Dashboard for Monitoring Implementation and Impact This monthly dashboard uses data from various sources (website, Google analytics, EHR reporting) to enable evaluation of the intervention use and uptake. Abbreviations: MGH, Massachusetts General Hospital; BWH, Brigham and Women’s Hospital; BWF, Brigham and Women’s Faulkner Hospital; NWH, Newton-Wellesley Hospital; NSMC, North Shore Medical Center; EHR, electronic health record
See this image and copyright information in PMC

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