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Review
. 2019 Jul;123(1):16-34.
doi: 10.1016/j.anai.2019.04.009. Epub 2019 Apr 19.

Acute care beta-lactam allergy pathways: approaches and outcomes

Anna R Wolfson  1 , Emily M Huebner  2 , Kimberly G Blumenthal  3
Affiliations
Review

Acute care beta-lactam allergy pathways: approaches and outcomes

Anna R Wolfson et al. Ann Allergy Asthma Immunol. 2019 Jul.
No abstract available

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Conflict of interest statement

Conflict of Interest: Dr. Blumenthal reports a licensed clinical decision support tool used for beta-lactam allergy evaluations in hospitalized patients at Partners HealthCare System.

Figures

Figure 1.
Figure 1.
Partners HealthCare System (PHS) Penicillin Hypersensitivity Pathway (Boston, MA, USA) ,,- This penicillin allergy pathway algorithm was originally developed at MGH, modified and studied at BWH, and further adapted for use at community hospital sites of PHS including two without access to Allergy/Immunology or PST (2016, Figure 1A). The algorithm considers actions based on the generalist’s allergy history considering three groups: (1) Type II-IV HSR, (2) Type I, IgE-mediated HSR or unknown reaction, and (3) Mild reactions. The pathway applied to all adult and pediatric patients, including pregnant patients, but test doses were not considered appropriate for patients with unstable cardiac or respiratory status. After evaluating HSR frequencies, additional modifications were made to further promote antibiotic stewardship. These changes included full dose carbapenem use in Type I IgE penicillin allergy histories and full dose cephalosporin use in all mild penicillin allergy histories (2019, Figure 1B). There is a corresponding cephalosporin hypersensitivity pathway algorithm. Abbreviations: PHS, Partners HealthCare System; MGH, Massachusetts General Hospital; BWH, Brigham and Women’s Hospital; PST, Penicillin Skin Test; HSR, hypersensitivity reaction; PCN, penicillin * Denotes antibiotics restricted by antibiotic stewardship programs at PHS sites
Figure 1.
Figure 1.
Partners HealthCare System (PHS) Penicillin Hypersensitivity Pathway (Boston, MA, USA) ,,- This penicillin allergy pathway algorithm was originally developed at MGH, modified and studied at BWH, and further adapted for use at community hospital sites of PHS including two without access to Allergy/Immunology or PST (2016, Figure 1A). The algorithm considers actions based on the generalist’s allergy history considering three groups: (1) Type II-IV HSR, (2) Type I, IgE-mediated HSR or unknown reaction, and (3) Mild reactions. The pathway applied to all adult and pediatric patients, including pregnant patients, but test doses were not considered appropriate for patients with unstable cardiac or respiratory status. After evaluating HSR frequencies, additional modifications were made to further promote antibiotic stewardship. These changes included full dose carbapenem use in Type I IgE penicillin allergy histories and full dose cephalosporin use in all mild penicillin allergy histories (2019, Figure 1B). There is a corresponding cephalosporin hypersensitivity pathway algorithm. Abbreviations: PHS, Partners HealthCare System; MGH, Massachusetts General Hospital; BWH, Brigham and Women’s Hospital; PST, Penicillin Skin Test; HSR, hypersensitivity reaction; PCN, penicillin * Denotes antibiotics restricted by antibiotic stewardship programs at PHS sites
Figure 2.
Figure 2.
Penicillin Allergy History Algorithm (Rochester, NY, USA), This penicillin allergy history screening algorithm was used to screen hospitalized patients with a penicillin allergy (Figure 2A). The algorithm assesses and categorizes allergic reactions based on the Gell and Coombs classification scheme, time elapsed since the reported penicillin reaction, and whether a penicillin antibiotic had been subsequently tolerated. The algorithm did not apply to patients hospitalized in the cardiac, medical, or surgical intensive care unit, inability to provide informed consent, and pregnancy. There are structural similarities to the PHS pathways with recommendations: Avoidance, skin test, full dose penicillin, or allergy consultation (Figure 2B).
Figure 2.
Figure 2.
Penicillin Allergy History Algorithm (Rochester, NY, USA), This penicillin allergy history screening algorithm was used to screen hospitalized patients with a penicillin allergy (Figure 2A). The algorithm assesses and categorizes allergic reactions based on the Gell and Coombs classification scheme, time elapsed since the reported penicillin reaction, and whether a penicillin antibiotic had been subsequently tolerated. The algorithm did not apply to patients hospitalized in the cardiac, medical, or surgical intensive care unit, inability to provide informed consent, and pregnancy. There are structural similarities to the PHS pathways with recommendations: Avoidance, skin test, full dose penicillin, or allergy consultation (Figure 2B).
Figure 3.
Figure 3.
Proposed approach for specialist triage all inpatients with documented penicillin allergy (Bethesda, MD, US), This figure demonstrates the approach taken by a large military medical center and places the Allergy/Immunology consultants at the center of a broad penicillin allergy antibiotic stewardship initiative that identifies, assesses, and evaluates inpatients with a documented or reported allergy to penicillin or another beta-lactam.
See this image and copyright information in PMC

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