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. 2021 May 3;4(5):e219820.
doi: 10.1001/jamanetworkopen.2021.9820.

Evaluation of a Pharmacist-Led Penicillin Allergy Assessment Program and Allergy Delabeling in a Tertiary Care Hospital

Nicholas A Turner  1   2 , Rebekah Wrenn  1   2 , Christina Sarubbi  3 , Renee Kleris  4 , Patricia L Lugar  4 , Christine Radojicic  4 , Rebekah W Moehring  1   2 , Deverick J Anderson  1   2
Affiliations

Evaluation of a Pharmacist-Led Penicillin Allergy Assessment Program and Allergy Delabeling in a Tertiary Care Hospital

Nicholas A Turner et al. JAMA Netw Open. .

Abstract

Importance: Penicillin allergies are frequently mislabeled, which may contribute to use of less-preferred alternative antibiotics.

Objective: To evaluate a pharmacist-led allergy assessment program's association with antimicrobial use and clinical outcomes.

Design, setting, and participants: A pharmacist-led allergy assessment program was launched in 2 phases (June 1, 2015, and November 2, 2016) at a single-center tertiary referral hospital. The longitudinal cross-sectional study included all study period adult admissions; hospitalwide outcomes were assessed by segmented regression. Individual outcomes were assessed within an embedded propensity score-matched case-control study of inpatients undergoing comprehensive allergy assessment following self-report of penicillin allergy. Analysis occurred from March 1, 2020, to February 29, 2020.

Exposures: The longitudinal study analyzed hospital-level outcomes over 3 periods: preintervention (15 months), phase 1 (structured allergy history alone, 16 months), and phase 2 (comprehensive assessment including penicillin skin testing, 52 months). The case-control study defined cases as individuals undergoing comprehensive allergy assessment.

Main outcomes and measures: Hospital-level outcomes included antibiotic days of therapy per 1000 patient-days and hospital-acquired Clostridioides difficile infection (CDI) incidence per 10 000 patient-days. Individual outcomes included antibiotic selection, overall survival, and CDI-free survival.

Results: Longitudinal analysis spanned 2014-2020 (median admissions, 46 416 per year; interquartile range [IQR], 46 001-50 091 per year). Hospitalwide, allergy histories were temporally associated with decreased use of nonpenicillin alternative antibiotics (rate ratio, 0.87; 95% CI, 0.79-0.97) and high-CDI-risk antibiotics (rate ratio, 0.91; 95% CI, 0.85-0.98). Penicillin skin testing was temporally associated with lower hospital-acquired CDI rates (rate ratio, 0.61; 95% CI, 0.43-0.86). The embedded case-control study included 272 cases and 819 controls. Median age was 63 years (interquartile range, 51-73 years), 553 (50.7%) patients were women, and 229 (21.0%) patients were Black. Allergy-assessed patients were less likely to receive high-CDI-risk antibiotics at discharge (odds ratio, 0.66; 95% CI, 0.44-0.98). Estimated reductions in mortality (hazard ratio, 0.77; 95% CI, 0.55-1.07) and hospital-acquired CDI risk (hazard ratio, 0.53; 95% CI, 0.18-1.55) were not statistically significant.

Conclusions and relevance: Pharmacist-led allergy assessments may be associated with reduced high-CDI-risk antibiotic use at both hospitalwide and individual levels. Although individual reductions in mortality and CDI risk did not achieve significance, divergence of survival curves suggest longer-term benefits of allergy delabeling warrant future study.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Radojicic reported receiving personal fees from serving on the CSL Behring, Takeda, and Biocryst advisory boards outside the submitted work. Dr Moehring reported receiving grants from the Centers for Disease Control and Prevention and grants from the Agency for Healthcare Research and Quality outside the submitted work. Dr Anderson reported receiving grants from the Centers for Disease Control and Prevention, the National Institutes of Health/National Institute of Allergy and Infectious Diseases, the Agency for Healthcare Research and Quality, and royalties from UpToDate for authorship outside the submitted work; Dr Anderson is co-owner of Infection Control Education for Major Sports, LLC. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Interrupted Time Series Analysis of Antibiotic Use by Antibiotic Class
Vertical dashed lines represent transitions between intervention phases. Points represent actual antibiotic use in days of therapy per thousand patient-days present. Horizontal dashed line represents modeled results from interrupted time series regression.
Figure 2.
Figure 2.. Interrupted Time Series Analysis of Hospital-Acquired Clostridioides difficile Infection (CDI) Rates
Vertical dashed lines represent transitions between intervention phases. Points represent actual hospital-acquired CDI incidence rates per 10 000 patient-days present. Horizontal dashed line represents modeled results from interrupted time series regression.
Figure 3.
Figure 3.. Cohort of Patients With Self-reported Penicillin Allergy Remaining Unassessed, Matched Unassessed, and Assessed
Figure 4.
Figure 4.. Overall and Hospital-Acquired Clostridioides difficile Infection (CDI)-Free Survival Curves
A, Overall survival, stratified by penicillin allergy assessment. B, Hospital-acquired CDI-free survival, stratified by penicillin allergy assessment.
See this image and copyright information in PMC

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